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SOGC CLINICAL PRACTICE GUIDELINE
SOGC Clinical Practice Guideline
No. 248, September 2010 (Replaces No. 74, July 1998) Guidelines for the Evaluation and Treatment
of Recurrent Urinary Incontinence Following
Pelvic Floor Surgery

Abstract
This clinical practice guideline has been prepared by the Objective: To provide general gynaecologists and urogynaecologists
Urogynaecology Committee and approved by the Executive and with clinical guidelines for the management of recurrent urinary Council of the Society of Obstetricians and Gynaecologists of incontinence after pelvic floor surgery.
Options: Evaluation includes history and physical examination,
PRINCIPAL AUTHORS
multichannel urodynamics, and possibly cystourethroscopy.
Management includes conservative, pharmacological, andsurgical interventions.
Outcomes: These guidelines provide a comprehensive approach
to the complicated issue of recurrent incontinence that is based UROGYNAECOLOGY COMMITTEE
on the underlying pathophysiological mechanisms.
Evidence: Published opinions of experts, and evidence from clinical
Jens-Erik Walter, MD (Co-Chair), Montreal QC Values: The quality of the evidence is rated using the criteria
described by the Canadian Task Force on Preventive Health Care Recommendations
1. Thorough evaluation of each patient should be performed to determine the underlying etiology of recurrent urinary incontinence and to 2. Conservative management options should be used as the first line 3. Patients with a hypermobile urethra, without evidence of intrinsic sphincter deficiency, may be managed with a retropubic urethropexy (e.g., Burch procedure) or a sling procedure (e.g., mid-urethral 4. Patients with evidence of intrinsic sphincter deficiency may be Disclosure statements have been received from all members of the managed with a sling procedure (e.g., mid-urethral sling, pubovaginal The literature searches and bibliographic support for this guideline 5. In cases of surgical treatment of intrinsic sphincter deficiency, were undertaken by Becky Skidmore, Medical Research Analyst, retropubic tension-free vaginal tape should be considered rather Society of Obstetricians and Gynaecologists of Canada.
6. Patients with significantly decreased urethral mobility may be managed with periurethral bulking injections, a retropubic slingprocedure, use of an artificial sphincter, urinary diversion, orchronic catheterization. (III-C) 7. Overactive bladder should be treated using medical and/or Key Words: Urinary incontinence, recurrent, surgery
8. Urinary frequency with moderate elevation of post-void residual volume may be managed with conservative measures such as drugs This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC.

l AUGUST JOGC AO T 2010
Guidelines for the Evaluation and Treatment of Recurrent Urinary Incontinence Following Pelvic Floor Surgery
Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force
on Preventive Health Care

Evidence obtained from at least one properly randomized A. There is good evidence to recommend the clinical preventive II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive II-2: Evidence from well–designed cohort (prospective or C. The existing evidence is conflicting and does not allow to retrospective) or case–control studies, preferably from more make a recommendation for or against use of the clinical preventive action; however, other factors may influencedecision-making II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in D. There is fair evidence to recommend against the clinical uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this E. There is good evidence to recommend against the clinical III: Opinions of respected authorities, based on clinical L. There is insufficient evidence (in quantity or quality) to make experience, descriptive studies, or reports of expert a recommendation; however, other factors may influence *The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force onPreventive Health Care.20†Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the The Canadian TaskForce on Preventive Health Care.20 to relax the urethral sphincter, timed toileting, and double voiding.
3. An intraoperative or postoperative complication of Intermittent self-catheterization may also be used. (III-C) 9. Complete inability to void with or without overflow incontinence may be managed by intermittent self-catheterization or 4. Surgery was inappropriate therapy or an inappropriate 10. Fistulae should be managed by an experienced physician. (III-C) 5. Pre-existing or de novo overactive bladder causing J Obstet Gynaecol Can 2010;32(9):893–898 INTRODUCTION
6. Urinary tract infection causing urgency incontinence.
Careful investigation and patient selection before 7. Voiding dysfunction causing urgency/frequency or primary pelvic surgery for prolapse and/or urinary incontinence will minimize the incidence of immediate or Long-term
Progressive
delayed failure.1 Conservative (i.e., non-surgical) or surgical Incontinence
intervention may be required when prior surgery has failed, 1. Deficiency of pelvic floor support either through although non-surgical options should first be considered.2 genetic predisposition or other medical condition.
Patients who complain of either de novo or recurrenturinary incontinence following reconstructive pelvic floor 2. Predisposing medical conditions (e.g., chronic obstructive pulmonary disease, obesity, chronic or incontinence surgery must undergo a thorough evalua- tion to identify the cause of this incontinence. The causes ofincontinence for most of these patients will fall into one 3. Urogenital aging and estrogen deficiency.
ASSESSMENT
Early Causes of Urinary Incontinence
Although some recurrent urinary incontinence may fit into 1. Surgical correction of stress incontinence either the category outlined in the 2003 SOGC guideline, “The Evaluation of Stress Incontinence Prior to Primary 2. Latent (occult) stress incontinence not recognized Surgery,”1 specialized evaluation, including urodynamics, preoperatively in a patient with pelvic organ prolapse.
will permit accurate diagnosis and measurement of SEPTEMBER JOGC SEPTEMBRE 2010 l
SOGC Clinical Practice Guideline
urodynamic variables that may significantly affect the The majority of surgical procedures used to treat stress management plan. Should a patient meet all the criteria on incontinence are designed to restore normal anatomic rela- the following list, then assessment may proceed as suggested tionships and re-establish extrinsic urethral support.
in the guideline1 without multichannel urodynamics.
Although the exact mechanism responsible for the restora- • No more than one prior surgery for incontinence tion of continence that results from successful surgery is • Symptoms of pure stress urinary incontinence uncertain3; the only consistent postoperative urodynamic finding is enhanced pressure transmission to the urethra.
This urodynamic change is probably a consequence of No symptoms of voiding dysfunction such as urinary better transmission of intra-abdominal pressure to the hesitancy, slow or interrupted stream, straining to void, newly supported urethra. It is also speculated that support of the mid-urethra results in some degree of kinking of the urethra when the proximal urethra and bladder descend Post-void residual urine volume < 100 mL during increased intra-abdominal pressure.4 Using this model, it is evident that in order for surgery to correct stress If any of the above requirements are not met, then a more incontinence, it must stabilize the urethra at an appropriate thorough evaluation is required, using multichannel anatomic level to allow pressure transmission to the urodynamics, and referral to a subspecialist may be indicated.
urethra. If this stability is not established at the time of the In all cases, the assessment must be designed to identify one operation or if it cannot be maintained over time, the or a combination of the following predisposing conditions.
1. Compromise to the urethral sphincter mechanism Repeated surgery may cause significant trauma to the urethra 2. Detrusor overactivity (overactive bladder) resulting in a poorly vascularized, scarred, rigid “drainpipe urethra” that has no sphincteric function (intrinsicsphincter deficiency).5 In this condition, the urethra is a poorly coapted conduit through which urine may leak with minimal increases in intra-abdominal pressure or on anearly continuous basis. Urethroscopy will reveal a smooth Recommendation
rigid tube which does not coapt. The urethrovesical junction is 1. Thorough evaluation of each patient should be per- open and can be visualized from any point along the formed to determine the underlying etiology of recurrent urethra. Videocystourethrography will confirm a urethra urinary incontinence and to guide management. (II-3B) which is immobile and open. Intrinsic sphincter deficiency Investigation of Urethral Sphincter Function
(ISD) may result after prior retropubic urethropexy(e.g., Burch procedure) or needle suspension (e.g., Pereyra Extrinsic support of the urethra is critical to continence, and procedure), or less frequently after prior anterior it is provided laterally by connective tissue attachment to colporrhaphy.6 The likelihood of ISD increases as the the pelvic side walls and posteriorly by the levator ani mus- cles. Urethral mobility should be assessed to evaluateextrinsic support. However, continence is maintained only Urethrovesical junction mobility can be assessed by Q-tip if extrinsic support is complemented by normal intrinsic ure- test,7 inspection and palpation of the distal anterior vaginal thral function, which consists of the following: wall during Valsalva manoeuvre, ultrasound examination, videocystourethrography, and urethroscopy. If recurrenthypermobility is found, it may be assumed that surgery has failed either to establish or to maintain urethral support. If 3. Normal smooth muscle sphincter function the urethra is maintained in an elevated retropubic position,then it can be assumed that the goal of surgery has been 4. Normal external striated sphincter function achieved and that failure is the result of ISD. A patient with ISD will require subspecialized evaluation and manage- devascularization, denervation, or disruption of muscular ment, including multichannel urodynamics. Urodynamic sphincters can result in marked impairment of intrinsic ure- variables consistent with ISD include a maximum urethral thral sphincter function. These problems may also arise closure pressure less than 20 cm of water or a leak point from prior trauma, surgery, or pelvic radiation. Some pressure less than 60 cm of water.6 The choice of any subse- quent surgical procedure will be determined by the degree hypermobility and deficiency of intrinsic urethral function.
of urethral fixation by scar, the patient’s medical condition, l SEPTEMBER JOGC SEPTEMBRE 2010
Guidelines for the Evaluation and Treatment of Recurrent Urinary Incontinence Following Pelvic Floor Surgery
and the degree to which detrusor and urethral function has retropubic sling procedure, use of an artificial sphincter, been compromised by denervation caused by previous urinary diversion, or chronic catheterization. (III-C) OVERACTIVE BLADDER
MANAGEMENT OF RECURRENT STRESS INCONTINENCE
Overactive bladder, a symptom complex consisting of Any decision to proceed with a specific treatment must urgency, frequency, nocturia, and urgency incontinence, is include an assessment of the severity of the patient’s caused by a failure of bladder inhibition and, if unrecog- symptoms, and a trial of conservative management must nized prior to surgery, may cause persistent incontinence be considered (as described in the SOGC guideline following surgery. De novo overactive bladder may develop “Conservative Management of Urinary Incontinence”).2 following surgery for stress incontinence,13 particularly if Conventional retropubic urethropexy (Burch procedure)9 extensive vaginal dissection has been performed or as a sec- has a higher rate of failure in cases of suspected ISD where ondary result after outlet obstruction. Patients will usually maximum urethral closure pressure is less than 20 cm of present with urinary urgency, frequency, nocturia, with or water. Tension-free vaginal tape has shown success rates of without urge incontinence. Cystoscopy may identify blad- 74% to 82% when performed as a repeat procedure, der pathology responsible for the urinary symptoms, such depending on the degree of ISD present.8 Some data indi- as suture or mesh penetrating the bladder or urethra.
cate that transobturator tape may not be as effective as Although a simple cystometrogram will identify most cases tension-free vaginal tape in cases where there is an element of overactive bladder, multichannel subtracted cystometry of ISD,10 particularly if the maximum urethral closure is indicated if the diagnosis is uncertain.
pressure is less than 40 cm of water,11 with success rates of The management of overactive bladder is medical or behav- only approximately 50%. Patients with significant ISD, ioural. Medical therapy typically uses anticholinergic/ such as a fixed drainpipe urethra, may also have persistent antimuscarinic medications.14 Behavioural therapy includes incontinence even if undergoing a urethral sling as the prompted voiding, bladder training, caffeine reduction, or repeat surgical technique. Referral to a subspecialist for a biofeedback, with or without electrostimulation.2 In some retropubic sling procedure with or without lysis of bladder instances, overactive bladder is a result of outlet obstruc- neck and paraurethral scar may provide continence under tion, (discussed in the next section), and urethrolysis may these circumstances. The risk of failure and urinary reten- tion may be increased. Periurethral bulking agents may alsobe injected.12 Consideration may be given to other Some patients may have mixed urinary incontinence.
“end-stage” options, such as placement of an artificial Although surgery is not contraindicated in cases of mixed sphincter, urinary diversion, or chronic catheterization.
urinary incontinence,16 conservative management options Patients with recurrent stress incontinence who opt for for both the stress and urgency incontinence should be surgical treatment should be managed according to the used, and benefits maximized before further surgery is Recommendations
Recommendation
2. Conservative management options should be used as the 7. Overactive bladder should be treated using medical 3. Patients with a hypermobile urethra, without evidence of VOIDING DYSFUNCTION
intrinsic sphincter deficiency, may be managed with aretropubic urethropexy (e.g., Burch procedure) or a sling Voiding dysfunction as a consequence of pelvic surgery procedure (e.g., mid-urethral sling, pubovaginal sling).
may develop for several reasons. In general, voiding dys- function is due to either urethral obstruction or detrusor 4. Patients with evidence of intrinsic sphincter deficiency underactivity. A patient with subclinical preoperative dys- may be managed with a sling procedure (e.g., mid-ure- functional voiding may not be able to empty her bladder after surgical stabilization of the urethrovesical junction.17Excessive elevation of the urethra in patients with a normal 5. In cases of surgical treatment of intrinsic sphincter defi- preoperative voiding mechanism may partially obstruct uri- ciency, retropubic tension-free vaginal tape should be nary outflow, causing voiding dysfunction. Mild degrees of considered rather than transobturator tape. (I-B) incomplete emptying will appear as urinary frequency, hesi- 6. Patients with significantly decreased urethral mobility tancy, and nocturia. More severe voiding compromise is may be managed with periurethral bulking injections, a manifested in urinary retention, bladder distension and SEPTEMBER JOGC SEPTEMBRE 2010 l
SOGC Clinical Practice Guideline
overflow incontinence, recurrent urinary tract infections, tomography with intravenous contrast (CT urogram) is indicated to identify possible upper tract damage.
uroflowmetry including measurement of peak flow rate and Urogenital fistula is a surgical problem that must be cor- post-void residual volume is sufficient to screen for voiding rected.19 The choice of procedure will depend on the sever- dysfunction.1 Post-void residual levels can be measured by ity and location of the fistula. Fistula and stress inconti- catheterization, ultrasound examination, or contrast radiog- nence can co-exist. If surgery is undertaken, it should cor- raphy. An intermittent voiding pattern on uroflowmetry, a rect all incontinence and pelvic floor prolapse disorders, decreased peak flow rate (< 15 mL/second), or a high either concomitantly or in stages, depending on individual post-void residual volume (> 150 mL) should prompt more sophisticated voiding studies, which may include voiding Recommendations
cystometry (simultaneous measurement of intravesical andabdominal pressures during voiding), urine flow rate, 10. Fistulae should be managed by an experienced physi- electromyogram, and urethral sphincter activity.15 Treatment should be individualized, and options include REFERENCES
1. Farrell SA, Epp A, Flood C, Lojoie F, MacMillan B, Mainprize T, Robert M.
catheterization, or urethrolysis. There are limited data on The evaluation of stress incontinence prior to primary surgery. SOGC the use of urethral relaxants (e.g., benzodiazepines, lioresal, Guideline No. 127, Apr. 2003. J Obstet Gynaecol Can 2003;25:313–8.
alpha-blockers). Detrusor stimulation using bethanecol is 2. Robert M, Ross S, Farrell SA, Easton WA, Epp A, Girouard L, et al.
Conservative management of urinary incontinence. SOGC Clinical Practice typically ineffective.18 Occasionally, voiding may be Guideline No. 186, December 2006. J Obstet Gynaecol Can improved by use of a pessary or surgery to correct a high cystocoele if present. If detrusor hypotonia is the cause, 3. Nager CW, Schulz JA, Stanton SL, Monga A. Correlation of urethral then sacral nerve stimulation can be used. Additional closure pressure, leak-point pressure and incontinence severity measures.
Int Urogynecol J Pelvic Floor Dysfunct 2001;12:395–400.
anti-incontinence operations for stress incontinence should 4. Lo TS, Wang AC, Horng SG, Liang CC, Soong YK. Ultrasonographic and be planned cautiously in patients with marked postopera- urodynamic evaluation after tension free vagina tape procedure (TVT).
Acta Obstet Gynecol Scand 2001;80:65–70.
5. GM Ghoniem, AN Elgamasy, R Elsergany, DS Kapoor. Grades of intrinsic Recommendations
sphincteric deficiency (ISD) associated with female stress urinary incontinence.
Int Urogynecol J Pelvic Floor Dysfunct 2002;13:99–05.
8. Urinary frequency with moderate elevation of post-void 6. McGuire EJ, Fitzpatrick CC, Wan J, Bloom D, Sanvordenker J, Ritchey M.
residual volume may be managed with conservative mea- Clinical assessment of urethral sphincter function. J Urol 1993;150:1452–4.
sures such as drugs to relax the urethral sphincter, timed 7. Karram MM, Bhatia NW. The Q-tip test: standardization of the technique and its interpretation in women with urinary incontinence. Obstet Gynecol1988;71:807–11.
self-catheterization may also be used. (III-C) 8. Rezapour M, Falconer C, Ulmsten U. Tension-free vaginal tape (TVT) in stress incontinent women with intrinsic sphincter deficiency (ISD)— 9. Complete inability to void with or without overflow a long-term follow-up. Int Urogynecol J Pelvic Floor Dysfunct 2001; self-catheterization or urethrolysis. (III-C) 9. Sand PK, Bowen LW, Panganiban R, Ostergard DR. The low pressure urethra as a factor in failed retropubic urethropexy. Obstet Gynecol1987;69:399–402.
UROGENITAL FISTULA
10. Schierlitz L, Dwyer PL, Rosamilia A. Effectiveness of tension-free vaginal Urogenital fistula following incontinence surgery is a rare tape compared with transobturator tape in women with stress urinaryincontinence and intrinsic sphincter deficiency. Obstet Gynecol complication. A fistula may exist between the vagina and the urethra, the bladder, the ureter, or a combination of 11. Guerette NL, Bena JF, Davila GW. Transobturator slings for stress these organs. Methylene blue solution may be instilled into incontinence: using urodynamic parameters to predict outcomes.
the bladder followed by speculum examination or place- Int Urogynecol J Pelvic Floor Dysfunct 2008;19:97–102.
ment of tampons in the vagina. Direct visualization of dye 12. Herschorn S. Current status of injectable agents for female stress urinary or staining of the tampon will confirm the presence of a incontinence. Can J Urol 2001;8:1281–9.
vesicovaginal fistula. Cystourethroscopy should permit the 13. Bombieri L, Freeman RM, Perkins EP, Williams MP. Why do women have identification of a fistula in either the urethra or the bladder, voiding dysfunction and de novo detrusor instability after colposuspension?BJOG 2002;109:402–12.
as well as assessment of the precise size, location, and num-ber of fistulae. Injection of intravenous indigo carmine fol- 14. JG Ouslander. Management of overactive bladder. N Engl J Med lowed by speculum examination or the tampon test may 15. Carr L, Webster G. Voiding dysfunction following incontinence surgery: identify a ureterovaginal fistula if a vesicovaginal fistula has diagnosis and treatment with retropubic or vaginal urethrolysis.
been ruled out. Intravenous pyelography or computed l SEPTEMBER JOGC SEPTEMBRE 2010
Guidelines for the Evaluation and Treatment of Recurrent Urinary Incontinence Following Pelvic Floor Surgery
16. Rezapour M, Falconer C, Ulmsten U. Tension-free vaginal tape (TVT) management protocols and the effect of bethanecol.
in women with mixed urinary incontinence—a long-term follow-up.
Int Urogynecol J Pelvic Floor Dysfunct 1990;1:132–5.
Int Urogynecol J Pelvic Floor Dysfunct 2001;Suppl 2:S15–18.
19. Miller EA, Webster GD. Current management of vesicovaginal fistulae.
17. Minassian VA, Al-Badr A, Drutz HP, Lovatsis D. Tension-free vaginal tape, Burch, and slings: are there predictors for early postoperative voidingdysfunction? Int Urogynecol J Pelvic Floor Dysfunct 2004;15:183–7.
20. Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W. Canadian Task 18. Farrell SA, Webster RD, Higgins LM, Steeves RA. Duration of postoperative Force on Preventive Health Care. New grades for recommendations from catheterization: a randomized, double-blind trial comparing two catheter the Canadian Task Force on Preventive Health Care. CMAJ 2003;169:207–8.
SEPTEMBER JOGC SEPTEMBRE 2010 l

Source: http://sogc.org/wp-content/uploads/2013/01/gui248CPG1009E_000.pdf

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