Urogynaecology


MUI should be categorised on the basis of the predominant or the most bothersome symptom component and the treatment strategy should be tailored accordingly.12,13


The subcategorising can be based on questionnaires allowing a quantitative assessment of the severity of the individual incontinence component. Questionnaires such as the ICI-Q short form provide information about the type of incontinence, severity and bothersomeness. It is important to be aware that the presence of a complaint of urgency can be a coping mechanism of severe SI.13 Bladder diaries and frequency volume charts can also provide objective data about the number of episodes and hence the severity of the two components. Symptomatic MUI based on a single question has a low positive predictive value (0.4–0.5) as to the urodynamic condition of MUI.3


In order to improve the predictive value of cystometry there have been attempts to quantify the degree of DO in terms of ‘detrusor instability index’14


or ‘high-pressure instability’.15,16


Although there is no consensus at the moment regarding which questionnaire/score system is the most valuable to quantify severity and/or the role of urodynamic parameters, three categories can be described thus:


• group I – patients with predominant SI;


• group II – patients with equal stress and urgency incontinence; and •


group III – patients with predominant urge incontinence.


Data from the Norwegian national database showed that of 1,113 women with symptomatic MUI, 66% had predominant SI, 27% were equally bothered while 7% had predominant urge incontinence (UI).17 Urodynamic investigation of women with stress-predominant MUI has shown that 82% experienced urodynamic SI. In those with urge-predominant MUI, 64% had DO.18 a treatment strategy can be described.


Based on this subcategorising,


Incontinence pessaries have been found to be effective in women with stress-predominant MUI, but half of patients successfully fitted with a pessary had nevertheless discontinued use at six-month follow-up.21


Conservative and Pharmacological Treatment Vaginal devices have been shown to reduce stress as well as urgency UI.19,20


Pessaries will also reduce urgency symptoms in women with a prolapse.22


and few studies have looked specifically at MUI. Three randomised controlled trials applied pelvic floor muscle training to women with urodynamic SI or stress-predominant urodynamic MUI.25,26,27


Wells et al. found a 77% rate of subjective cure or improvement after six monthly visits with a nurse.25


Burns et al. found


Goode et al. compared four bi-weekly visits with a nurse versus a written self-help programme and found no significant difference between the two programmes, with only modest efficacy.27 Two randomised trials studied pelvic floor muscle training in women with urge-predominant MUI with urodynamic DO.28,29


60% subjective cure or improvement after eight weekly visits with a nurse, and this result was significantly better than a control group receiving no care.26


Both studies failed to show the efficacy of pelvic floor muscle training compared 62


The evidence on pelvic floor muscle training for UI shows considerable variation in interventions used, study populations and outcome measures,23,24


with either a drug (oxybutinin) or a self-help booklet. There is scant evidence on the long-term efficacy of pelvic floor muscle training, but the available evidence seems to indicate a deterioration of the effect with time.


In conclusion, women with MUI desiring a non-surgical option could be offered pelvic floor muscle training or a vaginal device or pessary, with appropriate follow-up scheduled to ensure continued care if therapy fails.


There is ample evidence to support the use of antimuscarinics in UI,30 but few studies have specifically targeted women with MUI. In a population of women with urge-predominant symptomatic MUI, Khullar et al. found a median reduction in incontinence episodes of 77% after eight weeks of treatment with extended-release once-daily (ER QD) tolterodine 4mg, which was significantly higher than the placebo response of 51%.31


sub-group analyses of studies on solifenacin and oxybutinin.32–34


Similar results were found in pooled There


is no good evidence on antimuscarinic therapy in women with symptomatic MUI and a urodynamic diagnosis. Side effects, especially dry mouth, are frequent with antimuscarinic therapy, and long-term adherence to therapy is poor.35


Duloxetine, a selective serotonin norepinephrine re-uptake inhibitor, has proven efficacy in women with stress urinary incontinence,36


but is


licensed for that indication in only a few markets. Duloxetine has been studied in a large randomised placebo-controlled study of 588 women with MUI.37


Validated questionnaires were used to classify women into three symptomatic subgroups: stress-predominant, balanced or urge-predominant MUI. Half of the women were randomised to additional urodynamic investigations to further qualify the diagnoses. Overall, incontinence episodes were significantly more reduced with duloxetine (60%) than with placebo (47%), and the reduction was seen in both UI and SI episodes. Decreases were significantly greater for patients with stress-predominant MUI, whether diagnosed by symptoms alone or qualified by invasive urodynamic investigations. Side effects, especially nausea, were very frequent with duloxetine. Long-term persistence of duloxetine for UI is poor.38,39


In conclusion, antimuscarinics can be offered to women with urge- predominant MUI and duoxetine to women with stress-predominant MUI. Adding urodynamic investigations to the diagnostic work-up does not seem to add prognostic value. Side effects are frequent with either pharmacological approach, and appropriate follow-up should be offered as long-term persistence is poor.


Surgical Treatment


Whether the subcategorising of MUI is based on symptom/bother score,17,40


voiding diary data (urge episodes)44 parameters,14–16 and/or urodynamic


there is a clear trend that the severity of the urgency component is inversely related to the outcome of conventional surgical therapy for SI (see Figure 1). Despite ambiguities in the definition of MUI and variations in the definition of cure rate, design of studies and length of follow-up, some crude conclusions can be drawn. The overall subjective cure/improvement rate for the stress component is around 85%, while the urgency component is cured/improved in approximately 60% of patients after short-term follow-up (one to three years).15,17,41,42


The problem is that the urge


component becomes worse in 5–10% of women and is unchanged after surgery in 10–20% of women.17,43


EUROPEAN OBSTETRICS & GYNAECOLOGY


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