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Surgical Treatment Called Effective
AMERICAN UROLOGICAL ASSOCIATION EXPERT PANEL ISSUES
TREATMENT GUIDELINES FOR FEMALE STRESS URINARY INCONTINENCE
WASHINGTON, D.C. (June 25)--Treating female stress urinary incontinence
initially with
surgery provides an effective long-term cure for most patients, according
to treatment
guidelines for this common urological disorder released here today by the
American Urological
Association (AUA) during the Fifth Annual Congress on Women's Health.
"These guidelines for the first time provide well documented data
regarding the effectiveness
of surgery to treat this common problem," says Dr. Gary E. Leach, who
chaired the AUA
panel of experts that developed the treatment guidelines. Dr. Leach is
director of the Tower
Urology Institute for Continence at the Cedars-Sinai Medical Center in
Los Angeles and
associate clinical professor of urology at the University of California
at Los Angeles.
According to AUA President Dr. Roy J. Correa, Jr., a urologist at the
Virginia Mason Clinic
in Seattle, urinary incontinence is defined as uncontrolled leakage of
urine.
"This is a widespread problem that affects an estimated 13 million
adults in the United
States," he points out. "Approximately 85 percent of those individuals
affected are women."
Dr. Correa explains that incontinence is categorized into four
different types:
1) stress
incontinence in which leakage occurs because of physical activity;
2)
urge incontinence in
which leakage occurs because of a sudden strong urge to urinate;
3) mixed
incontinence, which
is a combination of stress and urge incontinence; and
4) overflow
incontinence, in which
leakage occurs as a frequent or constant dribble.
"Since female urinary stress incontinence is by far the most common of
these categories, the
AUA guidelines specifically address surgical treatment options for this
disorder" says Dr.
Correa.
According to the Mayo Clinic's Dr. Joseph Segura, Jr., chair of the AUA
Practice
Parameters, Guidelines, and Standards Committee, a thorough review and
analysis of the peer-reviewed medical literature provided strong evidence
to support the use of surgery as an initial
therapy. The data also supports surgery as a secondary form of therapy
after failure of other
management options, Dr. Segura says.
"Although the U. S. Government Agency for Health Care Policy and
Research last year
released revised treatment guidelines for stress urinary incontinence,
its panel did not conduct
a detailed analysis of surgical procedures," Dr. Segura explains. "The
AUA felt that this was
an information void that needed to be addressed. Therefore, the scope of
the AUA treatment
guidelines report was designed to examine the effectiveness and
appropriateness of surgical
treatment."
According to Dr. Leach, stress incontinence is most often caused by
weakened pelvic
muscles that support the bladder, bladder neck, and urethra. These
muscles can weaken due
(more)
to pregnancy and childbirth, and prior pelvic surgery. With weakened
support, the bladder
neck and urethra may shift from their normal positions causing them to
drop momentarily. The
sphincter then is unable to maintain closure in the "dropped" position
when there is pressure
on the bladder from an activity, such as coughing. Stress incontinence
also can result from
weakened urethral sphincter muscles along with loss of the internal seal
mechanism in the
urethra that acts like a washer in a water faucet.
The AUA panel reviewed four categories of surgical procedures used to
treat female stress
urinary incontinence. They include retropubic suspensions, transvaginal
suspensions, sling
procedures, and anterior repairs.
Retropubic suspensions are performed through an incision in the lower
abdomen. In this
procedure, the urologist places sutures near the bladder neck and
urethra, securing them to a
pelvic bone or to surrounding supporting structures.
Transvaginal suspensions are done through the vagina and through a
small incision in the
lower abdomen. In this procedure, the urologist places sutures in the
tissue near the bladder
neck and urethra from the vaginal side, then transfers the sutures to the
abdominal incision,
through which they are tied either to the abdominal wall or to the pelvic
bone.
Sling procedures are performed partly through the vagina and partly
through a small incision
similar to the incision for a transvaginal suspension. This surgical
procedure creates
a hammock-like bolstering of the urethra. A supporting strip of material
is placed under the
urethra and bladder neck, and secured with permanent suture to the
abdominal wall or a pelvic
bone.
(more)
Retropubic suspensions, transvaginal suspensions, and sling procedures
seek to create support
for the urethra and bladder neck in order to prevent downward sag and
urine leakage during
physical activities. Anterior repairs address vaginal support of the
bladder base by using the
pubocervical fascia.
The AUA panel found that retropubic suspensions and slings are the most
efficacious
procedures for long-term success. However, the panel also found that
these procedures are
associated with slightly higher complication rates when compared to the
other two cited
surgical procedures. The complications mainly involve postoperative
voiding dysfunction and
a longer convalescence period.
The panel report states that "in patients who are willing to accept
slightly higher complication
rates for the sake of long-term cure, retropubic suspensions and slings
are
appropriate choices. In the patient for whom decreased hospital stay,
less likelihood of
morbidity and/or earlier return to work are paramount, transvaginal
suspensions are
appropriate procedures. Anterior repairs, in the panel's opinion, are
the least likely of the four
major procedure categories to be efficacious in the long term."
The AUA panel strongly recommends as a standard of care that
physicians' evaluation of a
woman who presents with symptoms of stress urinary incontinence should
include the
following components: a thorough history, including the impact of
symptoms on lifestyle; a
physical examination with an objective demonstration of stress
incontinence; a urinalysis; and
other appropriate diagnostic studies to assess symptom causes, frequency
and severity of
incontinent episodes, and patient expectations from treatment.
(more)
According to Dr. Leach, while the components of a diagnostic evaluation
are not the main
focus of the guidelines report, the panel created this standard because
an accurate preoperative
evaluation is obviously indispensable for the selection of a treatment
option.
Also cited as a standard of care by the panel is fully and clearly
informing each patient of the
available surgical alternatives, including estimated benefits and risks
of each procedure. The
panel states that the choice of treatment should be made between surgeon
and patient, taking
into consideration patient preferences, and the experience and judgment
of the surgeon.
Physicians can order the AUA's Management of Female Stress Urinary
Incontinence
Guidelines by contacting the American Urological Association Health
Policy Department at
(410) 223-4367. Patients and the general public can get information and
advice regarding
incontinence by contacting the American Foundation for Urologic Disease
at 1-800-242-2383.
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