Case 1: A 77 year old female with a history of prior prolapse repair with mesh, sacrospinous ligament fixation, with concomitant TOT sling presents with mixed urinary incontinence, using numerous pads per day. She claims her incontinence is stress predominant. She has recently noticed some vaginal bleeding, and was told she has mesh extrusion by an outside provider. On exam, the patient has anterior vaginal wall extrusion of mesh, her cough stress test is negative and her PVR in the office is 80 cc. UDS were then performed. On the tracing, she demonstrates two voids, with incomplete bladder emptying, leak with cough, and no significant DO. She has poorly sustained low amplitude contractions with low flow (Pdet max 8-10 cm H20). There is no evidence of obstruction from sling on FUDS. Her PVR on UDS was 415 cc.
Dr. De advocates for obtaining a repeat PVR. In her opinion, it is important to review prior operative notes for specifically what was done and the devices used. Since the patient has minimal urethral mobility, she may be a candidate for a urethral bulking agent, or placement of a more obstructing sling. Her UDS showed Valsalva voiding, so it is important to preserve the ability for her to continue to do this. She has a large bladder capacity on UDS (836 cc), she may recommend a focus on earlier voiding. With this patients management, she recommends to start the management conservatively, with pelvic floor physical therapy, double voiding, and relaxation strategies. She may try an alpha blocker with or without CIC. The ability to CIC remains a pivotal matter; if she becomes obstructed with a repeat sling, she will need to do this to manage her bladder. Dr. De advocates for urethral bulking agents; they are successful and less obstructing than a sling. If a repeat sling is placed, she recommends a MUS or obstructing pubovaginal sling. Another option is available, in the placement of an adjustable sling (retropubic), but there is not a lot of data to support this.
Dr. Zimmern states we must make several assumptions about this patient. She is a non-neurogenic patient with adequate hand function, and not morbidly obese, so that she would be able to perform CIC after treatment. We do not know her prior baseline condition before her original surgery, in the severity of SUI or MUI prior to POP repair and TOT. Her voiding diary is also unknown. We do not know if she is on hormonal therapy and we assume she has no recurrent POP. The absence of DO on UDS does not exclude DO as source of UI. You may consider a trial of OAB medication. Dr. Zimmern is convinced this is an outlet issue. He would recommend to this patient injectable agents (macroplastique,) and would avoid fascial sling placement unless the patient is amenable to CIC for life. The placement of artificial urinary sphincters is infrequent in this age group. The patient has limited options for bladder management. Medications available to her include bethanechol and Flomax. She may undergo sacral neurostimulation, but often an issue for the older patient due to inability to obtain body MRI’s. The detrusorplasty procedure has been largely abandoned. She may require future bladder drainage with CIC, foley, or SPT. He mentioned cystectomy as a final resort.
The case presented highlights that there is often a mismatch between patients primary symptoms and their UDS findings. It is of utmost importance how we approach these patients and counsel them regarding treatment options and expectations.
Presenter by: Elise J.B. De, MD, ICS Education Committee Chair Treat the Outlet, Philippe E. Zimmern, MD, FACS, FPMRS Treat the Bladder
Written by: Cristina Palmer, DO, Female Urology, Pelvic Reconstruction, Voiding Dysfunction Fellow, Department of Urology, UC Irvine Medical Center, Orange, California at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting (SUFU 2018), February 27-March 3, 2018, Austin, Texas