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Objectives To determine whether catheterization rates after intradetrusor onabotulinumtoxinA injection for nonneurogenic overactive bladder and urgency incontinence differ between women with urgency urinary incontinence only and women with urgency-predominant mixed urinary incontinence. Methods This was a retrospective cohort study of patients that underwent intradetrusor onabotulinumtoxinA injection of 100 U for nonneurogenic urgency urinary incontinence. The primary outcome was the difference in catheterization rates between women with urgency urinary incontinence alone compared with women with urgency-predominant mixed urinary incontinence. Descriptive statistics and multivariate logistic regression analysis were performed. Results Of the 177 women included in the final analysis, 105 had urgency urinary incontinence and 72 had urgency-predominant mixed urinary incontinence. The overall catheterization rate after onabotulinumtoxinA injection was 11.3%, with significantly fewer women with mixed urinary incontinence requiring catheterization when compared with women with urgency urinary incontinence alone (4.2% vs 16.2%; P = 0.03), despite an older population (P = 0.02). Patient-reported improvement (P = 0.37) and decision to continue onabotulinumtoxinA treatments (P = 0.89) were similar between groups. Multivariate logistic regression analysis revealed that women with mixed urinary incontinence had significantly lower odds of requiring catheterization after onabotulinumtoxinA injections than women with urgency urinary incontinence alone (odds ratio, 0.16; 95% confidence interval, 0.04-0.67; P = 0.01). Conclusions Findings suggest that the presence of symptomatic stress urinary incontinence is associated with lower rates of catheterization after intradetrusor onabotulinumtoxinA, but does not compromise efficacy of treatment for urgency-predominant mixed urinary incontinence.

INTRODUCTION AND OBJECTIVE:The definition of mixed urinary incontinence (MUI) of the International Continence Society assesses patient-reported symptoms without considering physical and urodynamic ...

INTRODUCTION AND OBJECTIVE:Mixed urinary incontinence (MUI) is a prevalent condition in women. Thirty-four percent of women with UI report MUI, while 49.8% and 15.9% report only stress urinary inco...

We evaluated urinary incontinence outcomes following synthetic suburethral sling removal in women.We reviewed a prospectively maintained database of 360 consecutive women who underwent transvaginal suburethral sling removal from 2005 to 2015. We excluded patients with neurogenic bladder, nonsynthetic or multiple slings, prior mesh for prolapse, concomitant surgery during sling excision, urethral erosion or fistula, postoperative retention or less than 6-month followup. Demographics, sling type, indications for removal, time to removal and patient reported outcomes were recorded. Outcomes were stratified by incontinence type, including stress predominant, urge predominant and mixed urinary incontinence. Subsequent management was evaluated, including observation, minimally invasive outpatient interventions (bulking agents, neuromodulation or onabotulinumtoxinA) or more invasive surgery (autologous fascial sling or bladder suspension). No patients elected to receive a subsequent synthetic sling. Success was defined by responses to UDI-6 (Urogenital Distress Inventory) questions 2 and 3, self-reported satisfaction with continence at the last visit and no further intervention.Of the 99 patients who met inclusion criteria 27 denied any subjective leakage after suburethral sling removal alone while 72 experienced some degree of incontinence after removal. Stress predominant urinary incontinence occurred in 26 patients, which was persistent in 7 and de novo in 19, urge predominant incontinence was noted in 14, which was persistent in 6 and de novo in 8, and mixed urinary incontinence occurred in 32, which was persistent in 13 and de novo in 19. Mean followup was 23 months (range 6 to 114). The success rate following a single minimally invasive intervention after suburethral sling removal was 81%, 86% and 75% in patients with stress predominant, urge predominant and mixed urinary incontinence, respectively.Patients who undergo suburethral sling removal may show urinary control, or de novo or persistent incontinence with a higher predilection for stress predominant or mixed urinary incontinence. However, after a single minimally invasive intervention following suburethral sling removal the success rate reached 75% to 86%.

UNLABELLED TVT-O placement has been associated with short-term cure/improvement of urgency (U) and urge urinary incontinence (UUI) in a significant proportion of patients. Further, the observed improvement in U/UUI is associated with improved quality of life (QOL). This study is a prospective continuation aimed to determine if the short-term benefit of TVT-O on U/UUI persists at 12 months postoperatively. METHODS Patients with stress-predominant mixed incontinence undergoing TVT-O placement were prospectively assessed using 3-day bladder diary and multiple validated incontinence questionnaires focusing on U (Urgency Perception Score), UUI (International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms), and QOL (Incontinence Impact Questionnaire, Short Form). RESULTS Eighty-seven patients achieved 12-month assessment, at which point improvements (versus baseline) in mean daily pad use (2.5-0.9) and mean incontinence episodes (3.6-0.7) were seen (P < 0.05, both comparisons). Seventy-eight percent of patients reported cure of stress incontinence. Questionnaire scores for UUI improved from 2.0(±1.1) to 1.0(±1.1) (P < 0.001), with 32% and 31% of patients reporting cure and improvement, respectively. Similarly, mean Urgency Perception Score improved from 10.1(±4.4) to 6.7(±4.5) (P < 0.001). Eighty-two percent of the patients did not require anticholinergics over the 12-month follow-up period. Furthermore, U outcomes are associated with improvements in QOL. CONCLUSIONS TVT-O placement is associated with cure/improvement of U and UUI in a significant proportion of patients with mixed urinary incontinence. Further, the observed improvements in U/UUI persist at 12 months and appear to have a durable positive association with QOL.

Introduction A vesicouterine fistula is a rare form of urogenital fistula, yet there is increasing prevalence in the United States because of the rising rate of cesarean deliveries. Vesicouterine fistulas have various presentations including menouria, hematuria, or urinary incontinence. Case presentation A 39-year-old multiparous woman presented with urine leakage after her third cesarean delivery. She had been treated for mixed urinary incontinence with overactive bladder medications and a midurethral sling with continued complaints of urine leakage. The patient noticed her symptoms of urine leakage improved during menses when she used a menstrual cup. After confirmation of vesicouterine fistula, the patient underwent robotic-assisted surgery and her symptoms of insensible urine leakage resolved. Conclusions When evaluating women with urinary incontinence and a history of cesarean deliveries, use of menstrual cup may aid in the diagnosis of vesicouterine fistula. Robotic-assisted laparoscopic repair with tissue interposition flap is an efficacious minimally invasive method for treatment of vesicouterine fistula.

PURPOSE OF REVIEW Deciding on an optimal therapy for mixed urinary incontinence (MUI) is challenging, as a single-treatment modality may be inadequate for alleviating both the urge and stress component. A MEDLINE search was conducted regarding English-language literature pertaining to the treatment for MUI focusing on literature within the last 18 months. RECENT FINDINGS Behavioral therapy and lifestyle modification, such as moderate weight loss and caffeine reduction, should be considered first-line options for all women with MUI. The addition of pelvic floor muscle therapy may have an additional salutary effect. Treatment of the urge component with antimuscarinics is effective; however, the stress component is likely to persist after therapy. Treatment with vaginal estrogen cream may help in the short-term, but long-term benefits are unknown. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI; however, it appears that women with MUI may have lower cure rates compared to women with pure stress urinary incontinence. SUMMARY The optimum treatment of MUI may often require multiple treatment modalities. Although surgery may often have a positive impact on both components, its routine implementation should be approached with caution and patients should be carefully selected and counseled.

OBJECTIVE : The objectives of the study were to estimate the severity of urge urinary incontinence (UUI) after surgery for stress incontinence and identify factors associated with symptom severity. METHODS : Four hundred thirty-eight women who underwent surgery for stress incontinence over a 10-year period completed a mailed questionnaire protocol that included validated instruments to assess lower urinary tract function and mental and physical well-being. Bivariate analysis and generalized linear models were used to identify factors associated with severity of UUI as measured by the urge incontinence domain of the Incontinence Symptom Index. RESULTS : Urge urinary incontinence was experienced daily by 35.9% of patients. Factors independently associated with higher UUI severity scores were preoperative mixed urinary incontinence (P = 0.006), depression (P < 0.001), aging (P < 0.001), and longer follow-up times (P = 0.01). Pubovaginal sling (P = 0.001) and urethral vaginal suspension (P = 0.04) had higher severity scores than Tension-Free Vaginal Tape. CONCLUSIONS : Daily episodes of UUI are experienced by slightly more than one third of women after surgery for stress incontinence. Identification of factors associated with UUI may help physicians to modify treatment and patient expectations.

Objective To evaluate the effects of pelvic floor muscle (PFM) training on urinary incontinence (UI) and quality of life in women diagnosed with stress or mixed UI. Design We completed a parallel group, randomized clinical trial evaluating the effectiveness of PFM training in women with stress or mixed UI. Settings and participants We recruited consecutive cases of women with stress or mixed UI from outpatient urology clinics attached to a county hospital and a university hospital in Izmir, Turkey. Methods After baseline evaluation, 41 women were randomly assigned to either the PFM training group or the control group. Muscle training included 3 sets of daily fast and slow contractions in lying, sitting, and standing positions. Participants were also taught the knack. The intervention period was 8 weeks, and the women in the exercise group telephoned once a week to provide motivation. The untreated control group had no contact during the intervention period. Outcome measures were Incontinence Quality of Life (I-QOL) Questionnaire, episodes of leakage in 3-day bladder diary, 1-hour pad test, and PFM strength. Results Thirty-four women completed the trial. The mean age of women was 41.82 +/- 8.65 years in the exercise group and 44.64 +/- 6.90 years in the control group. The 2 groups were statistically similar regarding key demographic and clinical characteristics. After 8 weeks, significant differences in the 1-hour pad test, episodes of leakage in 3-day bladder diary, PFM strength, and I-QOL scores (P = .01) were noted when participants in the PFM training group were compared to control group participants. Conclusion An 8-week trial of PFM training significantly increased PFM strength, improved quality of life, and reduced the frequency of UI episodes.

RESULTS: The patient was consented for elective diverticulectomy using a vaginal approach which was performed without complication. Technical points which are emphasized in the video include the following: 1) optimal vaginal exposure, 2) maximal ventral dissection of the diverticulum first to expose the bivalve surface, 3) meticulous dorsal dissection of the diverticulum to develop a periurethral plane, 4) circumferential demonstration of the extent of the lateral horns or extensions of the diverticulum, 5) complete removal, and 6) a tension-free multilayer closure of the surgical field. Following successful excision, our postoperative care pathway included discharge the following day and urethral catheter removal after three weeks. Final pathology was consistent with a urethral diverticulum with benign tissue showing acute and chronic inflammation. At three month follow up, history and pelvic exam revealed no evidence of incontinence or dyspareunia. CONCLUSIONS: Excision of urethral diverticula can be challenging, especially with a horseshoe shape or circumferential anatomy. The literature suggests that recurrence rates are higher with circumferential diverticula. Therefore, the goal of this video is to emphasize key technical points which may aid in ensuring complete excision without complications.

To evaluate a self-directed home biofeedback treatment system in a group of community dwelling, otherwise healthy women with symptoms of stress, urge, and mixed urinary incontinence (UI).Fifty-five women, aged 25 to 81 years, participated in the study.Initial evaluation included a self-reported continence assessment, a 24-hour bladder and fluid habits diary, severity indices for stress and urge UI, and assessment of pelvic floor strength using a pneumatic biofeedback device. Subjects completed a 16-week self-directed program. Assessment and severity index data were self-reported using a continence assessment form, a 24-hour bladder habit and fluid form, and stress and urge incontinence severity indices. Strength level of the trainer, number of digital bands lit on the screen during contraction, number of sessions, and program (starter, intermediate, advanced, or maintenance) were recorded on data sheets.The treatment system includes an 8-minute educational and motivational video; a journal for education, instructions, and daily documentation forms; and a home biofeedback trainer with pneumatic vaginal sensors that displays the strength of pelvic muscle contraction.Forty-four women completed the 16-week program. At the end of treatment, 19 (43%) were dry and 16 (36%) reported 50% or more improvement in number of leaks per day, number of voids per day, or both. Women with stress leakage experienced a significant reduction in the number of incontinent episodes per day and the mean severity index of incontinence (P.001). Participants with urge UI experienced a significant reduction in the mean number of voids per day and mean severity index for UI (P.001). Younger subjects were more likely to improve when compared with older participants, but no significant differences were found when comparing women who take estrogen with those who do not take estrogen or when comparing those with a history of bladder surgery with those who had no previous surgery.These data suggest that self-selected healthy women with symptoms of urge, stress, and mixed incontinence can improve their symptoms and lower their severity index with a minimal intervention, comprehensive, self-directed home biofeedback continence system.

INTRODUCTION AND OBJECTIVES: Mixed urinary incontinence (MUI) defined as the combination of stress and urge incontinence accounts for approximately 33% of all cases of incontinence in women. No consensus exist in literature either medical or surgical treatment has to be proposed first and the usual attitude to treat the dominant symptom first is not supported by any evidence and often disappointing. Our aim to determine the most effective strategy and sequence of therapy between surgery and anticholinergics in females suffering from mild to severe MUI. METHODS: 66 women were included in a prospective multicentre randomized study with an optimal cross over. In phase 1 of the study patients were randomized into two groups: TVT-O (J&J Women’s Health) procedure or Oxytrol patch (Paladin) 3.9 mg/Q3D for 12 weeks. In phase 2 patients not satisfied with the result of their initial treatment were offered a cross over. Our primary outcome was 24h pad test. Cure was defined by a 24-h pad test of 8 g or less. Improvement was defined by a reduction of pad weight 25% in comparison to base line and failure less 25% reduction of pad weight. The follow-up was 56 weeks. RESULTS: 66 patients were randomised and 62 patients completed the study. In phase 1, 31 patients received Oxytrol treatment and 31 patients TVT-O procedure. At 12 weeks, 64% (20/31) of patients having had TVT-O as first line were satisfied (80% (16/20) cured). Only 16% (5/31) patients having had Oxytrol as first line were satisfied (20% (1/5) cured). At 12 weeks, the odds ratio for subjects in TVT-O group to be satisfied and cured were respectively 11.57 times (11.57, 95% CI 2.93-45.67, p 0.05) and 8.03 times (8.03, 95% CI 2.93-45.67, p 0.05) higher than those in Oxytol group. At 12 weeks, 84% (26/31) of patients who started with Oxytrol crossed over to TVT-O and 61,5% (16/26) were cured at 56 weeks after surgical procedure. Only 35% (11/31) of patients who started with TVT-O crossed over to Oxytrol and 18% (2/11) were cured at 56 weeks. CONCLUSIONS: Patients with moderate to severe MUI treated surgically in first line have statistically better chance to be cured in comparison to a patient treated pharmacologically.