The American
College of Obstetricians and Gynecologists has issued first-time guidelines
regarding the evaluation of uncomplicated stress urinary incontinence (SUI)
before surgical treatment in women.
"[SUI] is a condition of involuntary loss of urine on
effort, physical exertion, sneezing, or coughing that is often bothersome to
the patient and frequently affects quality of life," the committee writes
in an opinion published in the June issue of Obstetrics & Gynecology.
"It is estimated to affect 15.7% of adult women. Among women with SUI,
77.5% report their symptoms to be bothersome, and of this group 28.8% report
their symptoms to be moderately to extremely bothersome; the degree of bother
is associated with the severity of SUI."
Conservative
treatment options for SUI include pelvic muscle exercises prescribed alone or
with physical therapy, behavioral modification, continence-support pessaries,
and urethral inserts. Surgical options to treat incontinence include retropubic
urethropexies, autologous fascial slings, urethral bulking agents, and
synthetic midurethral slings.
Counseling
regarding treatment should first highlight conservative options, the authors
emphasize. Before performing primary midurethral sling surgery in women with
symptoms of SUI, clinicians should evaluate patients with a minimum of 6 steps:
Obtain history,
including urologic history, thorough medical and neurologic histories, and
medications, including nonprescription medications.
Perform
urinalysis to exclude urinary tract infection.
Perform a
physical examination to exclude confounding or contributing factors. These may
include urethral diverticulum, vaginal discharge, or extraurethral
incontinence. Pelvic organ prolapse is a form of complicated SUI because the
prolapse can cause a relative obstruction of the urethra, thereby hindering
bladder emptying.
Demonstrate
stress incontinence using the cough test.
Evaluate
urethral mobility using the cotton swab test, pelvic organ prolapse
quantification system, visualization, palpation, or ultrasonography.
Antiincontinence surgery is more successful in women with urethral mobility,
which indicates uncomplicated SUI and is defined as at least a 30 degree
displacement from the horizontal when the patient is in a supine lithotomy
position and straining.
Measure
postvoid residual urine volume. In women with uncomplicated SUI, this is less
than 150 mL. Elevated postvoid residual urine volume may indicate a
bladder-emptying abnormality or incontinence associated with chronic urinary
retention.
Adding
preoperative multichannel urodynamic testing to this basic evaluation does not
affect treatment outcomes for women with uncomplicated SUI who have not
responded to conservative treatment and who wish to undergo midurethral sling
surgery, according to available evidence. However, multichannel urodynamic
testing and other diagnostic tests before surgery or initiation of other treatment
may benefit women with complicated SUI.
"Clinical judgment should guide the health care provider's
decision to perform preoperative multichannel urodynamic testing or to refer to
a specialist with appropriate training and experience in female pelvic medicine
and reconstructive surgery," the committee writes.
Obstet Gynecol.
2014;123:1403-1407.
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