Howard B. Goldman, MD
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Mixed urinary incontinence includes symptoms of stress incontinence (unintentional, activity-induced loss of urine) and overactive bladder (urgent and frequent urination and nocturia).
Women with mixed incontinence often expect that surgery intended to correct stress urinary incontinence also will improve their overactive bladder (OAB) symptoms, despite a lack of confirmatory studies.
A recent analysis by Cleveland Clinic and other institutions shows that most women with mixed, stress-predominant incontinence who underwent any of four types of SUI surgery initially experienced significant improvement of OAB symptoms.
The level of OAB improvement declined somewhat over time, regardless of the type of SUI surgery, although half to two-thirds of patients still reported significant relief five years after surgery.
Obesity lessened the likelihood of OAB improvement, the analysis found, and the degree of relief at one and five years varied to an extent, depending on which repair method was used.
Clinicians should take those findings into account and provide individualized, procedure-specific presurgical counseling to help patients set realistic expectations, the researchers concluded.
“Knowing what the outcomes can be for women with overactive bladder syndrome after surgery for stress urinary incontinence can help us counsel our patients and provide them with more accurate information,” says study co-author Howard B. Goldman, MD. Dr. Goldman is Vice Chair for Quality of Cleveland Clinic’s Glickman Urological & Kidney Institute and Professor of Surgery at Cleveland Clinic Lerner College of Medicine.
Probing SUI surgery’s effects on bladder symptoms
SUI surgery produces successful, durable stress-associated leakage-correction outcomes and good rates of patient satisfaction. In clinical practice, it also has been associated with secondary OAB symptom relief. However, the surgery’s precise effect on bladder storage symptoms is poorly understood, and postsurgical OAB outcomes have not been well-documented in medical literature.
Analyzing data from three large clinical trials involving more than 1,600 women, researchers from Cleveland Clinic and eight other U.S. medical institutions sought to assess how incontinence-correction surgical procedures affected OAB symptoms in mixed, stress-predominant incontinence patients one and five years postoperatively. They also looked for clinical, physiological or other characteristics that might predict postsurgical bladder symptom outcomes.
The researchers’ analysis, published recently in Obstetrics and Gynecology, found that a majority of patients who underwent either Burch colposuspension, autologous pubovaginal sling, or retropubic or transobturator midurethral sling surgeries, reported significant OAB symptom improvement. Significant improvement was defined as a positive change of 70 percent or more from baseline symptoms as measured by the Urinary Distress Inventory-Irritative subscale.
“Overall, about 60 percent of women in the study reported that their overactive bladder symptoms were improved one year after surgery, although this improvement tended to decline a bit when the women were followed up to five years postoperatively,” Dr. Goldman says. At five years, 46 percent to 65 percent of patients still reported significant OAB improvement.
Examining influence of surgery type and patient obesity
The researchers found that, after one year, more women who underwent Burch colposuspension reported OAB symptom improvement than did women who received an autologous pubovaginal sling (68 percent vs. 57 percent, p = .01). Patients who received either type of midurethral sling reported similar OAB symptom improvement (66 percent for retropubic compared to 71 percent for transobturator). Those relative differences were consistent throughout the five-year postoperative period.
Obesity is a known risk factor for development of OAB, and appears to be a complicating factor in resolution of OAB symptoms following SUI surgery. Obese women are 43 percent less likely to experience OAB symptom relief compared with women who are overweight or of normal weight. The analysis determined that women with a body mass index (BMI) of 30 kg/m2 or higher and more vaginal births were less likely to have OAB symptom improvement after SUI surgery than were women with BMIs between 25 and 30 kg/m2.
“We should strongly encourage women with a BMI greater than 30 who also have an overactive bladder to lose weight, as doing this, in general, helps improve their OAB symptoms,” explains Dr. Goldman. “Clearly, those patients with a BMI greater than 30 who have the SUI surgery have a lower rate of improvement in their OAB symptoms.”
Other patient parameters are not prognostic
Preoperative use of anticholinergics did not predict the level of OAB symptom improvement after surgery, according to the analysis. Neither did potentially relevant clinical factors such as age, smoking or the presence of pelvic organ prolapse, or urodynamic parameters such as detrusor overactivity or maximum cystometric capacity.
A significant number of mixed urinary incontinence patients who undergo SUI surgery show improvement in OAB symptoms and may no longer require medications for that condition. However, some patients’ OAB symptoms will not be resolved, Dr. Goldman says, “and we have to make these patients aware of this prospect to mitigate potential disappointment with the surgery outcome.”