Thursday, May 22, 2014

Stress Urinary Incontinence: ‏New ACOG Guidelines Laurie Barclay, MD May 21, 2014


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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