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Management of postoperative complications, Quality of Life and palliation in females with stress urinary incontinence undergoing midurethral sling procedures

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Lucian Iorga1,6, Radu Anghel1,6, Dragos Marcu1,2,6, Bogdan Socea2,3, 4,5, Ovidiu Gabriel Bratu1,2,4,7, Dan Mischianu1,2,4,7

1 University Emergency Central Military Hospital „Dr. Carol Davila”, Bucharest, Romania, 2“Carol Davila” University of Medicine and Pharmacy, Bucharest România, 3“Sf. Pantelimon” Clinical Emergency Hospital, 4Academy of Romanian Scientists, Bucharest, Romania, 5 Surgery, 6MD, 7Urology

Recieved: 15.03.2018 • Accepted for publication: 29.03.2019

Abstract

Stress urinary incontinence is a common health issue affecting the quality of life of more than 50% of women at some point in their lifes, frequently associated with pelvic organ prolapse. It represents the involuntary leakage of urine through urethra with the increase of intraabdominal pressure. In terms of surgical management, midurethral sling procedures, such as the tension-free vaginal tape and transobturator midurethral slings, have started to replace other surgical treatments, being minimally invasive procedures.

In this paper we wanted to evaluate the impact of surgery on the quality of life, patient satisfaction and sexual function, and also postoperative pain management.

Keywords: incontinence, sling procedures, patient satisfaction, sexual function, palliation

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Introduction

Stress urinary incontinence (SUI) is a symptom, a clinical sign, and a urodynamic observation that represents the involuntary leakage of urine with increased abdominal pressure. In up to 80% of women with pelvic floor dysfunctions, SUI coexists with pelvic organ prolapse (POP) and prolapse repair can exacerbate existing SUI symptoms or unveil urinary incontinence in previously continent women (occult SUI) (1,2). Although mortality is rare due to this health issue, it is a disease that affects the body image and the quality of life of millions of women (3).

The prevalence of stress urinary incontinence among adult women is thought to be between 17-45%, with more than 50% of parous women having POP (4,5). The etiology is considered to be multifactorial, divided into intrinsic factors such as genetics, age, postmenopausal status, obesity and extrinsic (parity, history of hysterectomies, occupation, etc).

Management options for SUI include both conservative and surgical treatments. Conservative approaches for the management of SUI include the use of incontinence pessaries and pelvic floor muscle exercises. However, for women who have insufficient recovery following conservative therapy, or for those who decline this approach there are numerous surgical treatments.

In terms of surgical approaches, midurethral sling placement has replaced other surgical techniques such as retropubic colposuspension and bladder neck slings as the procedure of choice for many women (6). The tension-free vaginal tape (TVT), inserted through the retropubic space and exit through the abdominal wall in the suprapubic area, was the first synthetic retropubic midurethral sling. After the placement of a TVT a cystoscopy is recommended to check the bladder integrity (7). Another type of sling procedures used in the treatment of SUI in women is the transobturator midurethral slings (TOT), that are inserted through a groin incision, through the obturator foramen and exiting the vaginal incision (out-to-in), on in an in-to-out manner, through the vaginal incision, through the obturator foramen and exit through the skin of the groin area.

Regarding POP, countless surgical procedures have been developed over the years, but due to the success of mesh hernia repairs and the use of sling procedures in SUI, surgeons have started applying this method in a transvaginal manner and in 2002 the FDA has approved the first mesh product for POP management (8,9). In order to avoid the occult stress urinary incontinence that could appear after the surgical management of the genital prolapse it is recommended to perform  an anti-incontinence procedure, usually the TVT approach, during the surgery for POP (10).

Transobturator and retropubic slings appear to have similar efficacy, with retropubic slings having a slightly higher chance of success, but at the cost of greater rates of bladder perforation, bowel injury, major vascular injury and postoperative voiding dysfunction. However, short-term postoperative site pain, especially groin pain, is higher with transobturator slings as compared with retropubic slings (11,12).

Results

Quality of life and patient satisfaction after surgery

SUI is a global health issue with a significant negative impact on quality of life (QoL), therefore, QoL assessment is increasingly important in patient care and as an outcome in treatment trials. Patient satisfaction after SUI surgery can be determined by numerous factors, such as inherent patient-specific expectations, postoperative continence status and complications. Mallet et al stated that patients with inappropriate treatment expectations who receive SUI surgery are at a higher risk for dissatisfaction after surgery (13).

Larry T. Sirls et al analyzed the data from the cohort enrolled in the trial of midurethral slings (TOMUS) using two measures, the Incontinence Impact Questionnaire (IIQ) and International Consultation on Incontinence Questionnaire (ICIQ). The authors found that higher QoL was associated with treatment success, younger age, lower body mass index (BMI) and improvement in SUI symptom severity and bother, regardless of approach or QoL measure (14).

Wai et al, in their paper on 597 patients, compared retropubic with transobturator midurethral slings using the Incontinence Surgery Satisfaction Questionnaire. They stated that both treatment groups had a high level of satisfaction, at a follow-up of 12 months, regarding urine leakage (slightly higher level of satisfaction in the TOT group, 90% versus 85.9% in the TVT group), urgency to urinate, frequency of urination, capability of physical, sexual and social activity and from an emotional standpoint of view (15).

A study conducted on 330 patients with a median age of 55 years old, wanted to compare the long-term patient satisfaction after retropubic (128 patients) and transobturator midurethral slings (202 patients). After a median follow-up period of 12 years the ICIQ score droped from an average of 14 before surgery to 6 after surgery, with no notable difference between the two groups. Al-Zahrani et al also stated that the Global Response Assessment Scale showed a greater improvement in the retropubic sling group (66,4%), than in the transobturator approach (57,4%) and concluded that midurethral slings have good and durable long-term effects on patients satisfaction and quality of life (16).

In their follow-up after 24 months of 52 females who underwent transobturator midurethral sling for SUI, Waleed et al found that the global satisfaction rate was 79%, concluding that the transobturator approach (from outside to inside) is an effective treatment of SUI (17).

It should be comforting to surgeons and patients alike that, after midurethral sling surgery for SUI, many studies report an overall patient’s satisfaction and improvement in QoL of about 80%, sustained for at least 2 years. Meschia et al used the ICIQ to assess improvements in QoL of 231 women with primary stress urinary incontinence that were randomized to TVT (114) or TOT(117), also showing over 80% improvements in overall scores (18).

The impact of SUI surgery on sexual function

Sexual dysfunction related to SUI may result from decreased libido, dermatitis induced dyspareunia and fear of coital leakage has been reported by women (19). Although some authors stated that sexual function has improved after midurethral sling procedures, there are also reports on negative effects (20,21). Due to an erogenous area located on the anterior vaginal wall, extensive vaginal incision and paraurethral dissection in the sling procedure can affect sexual function, therefore different sling insertion techniques and the experience of the surgeon may lead to varying outcomes (22). Complete relief from coital incontinence, reduction in anxiety and avoidance of sex are the main reasons why sexual function may improve after SUI surgery, whereas the most common symptom related to worsened sexual activity is dyspareunia. Some authors recommend that women should be informed that their sexual function could remain unchanged and that dyspareunia may occur. Usually the recommended convalescence until recommencement of sexual intercourse was about 4 to 6 weeks.

A study conducted by Burak Aslan et al wanted to evaluate sexual function in women before and after surgery for SUI and to determine whether there was a difference in sexual function between classical TOT and modified TOT (m-TOT) procedures (without wide vaginal incision and paraurethral dissection) using Female Sexual Function Index (FSFI) questionnaire. They found that in m-TOT group the improvement in arousal, lubrication and orgasm domains were significantly higher, due to the fact of minimal tissue damage, with cure rate of urinary incontinence and complication rates being the same as the classical TOT. The only limitation of this study was that the follow-up was only for three months (23).

In their paper, F. Paul et al enrolled 34 sexually active women with SUI and evaluated them using the NSF-9 sexual scoring system questionnaire preoperative and at 3, 6 and 12 months after surgery. They found significant improvement in all domains of sexual function post-surgery. The frequency of intercourse improved in 70.5% patients, lubricity improved in 57.1% patients and orgasm improved in 67.1% patients. 80% of patients improved sexual satisfaction after surgery, while only 24% of patients had satisfactory intercourse prior to surgery [24]. On the other hand, a study conducted on 75 patients who underwent midurethral procedures for SUI found that there was no significant change in overall sexual function in women undergoing surgery using the FSFI questionnaire, but they pointed that patients experienced less pain during intercourse after the TVT than after the TOT procedure (25). Similar findings regarding pain during sexual activity in patients who underwent TOT surgery for SUI were found by Elsevier et al. and Jang et al (26,27). The same result, showing a negative impact on sexual function was found in a meta-analysis of eighteen studies that showed that sling surgery had negative impacts on 13.1% of patients and there was no change in symptoms for 55.5% (27).

Results of Simsek et al. and Abo El-Enen et al. papers also indicate an improvement in FSFI scores following midurethral slings placed in a transobturatory manner (28,29).

Pain management

Postoperative pain is one of the most worrisome complications after any pelvic operation. Pain is usually mild and self-limited after vaginal mesh surgery done for SUI or POP. Usually the pain resolves within a few days to weeks, and can be managed with application of ice, nonsteroidal anti-inflammatory medications or oral narcotics. Sometimes it can take the form of chronic pelvic pain and additional measures should be taken. Local anesthetic agents or local injections with steroids have been proposed (30,31,32).

If the pain persists for more than 6 weeks sling release or excision should be taken into consideration. If a sling excision in planned it is recommended that patients should be advised that removal of the mesh or a part of it may result in recurrent SUI (33).

Groin pain usually occurs with a higher incidence after midurethral slings placed in a transobturator manner. Authors report an estimated incidence of 12-16%, more likely to appear following inside-out placement of the sling and is usually located deep within the muscle, rather than superficial (34,35).

Some women report pain following a sling procedure under the form of dyspareunia, frequently following TOT, rather than TVT. Neuman et all in their prospective trial of 300 women who underwent TOT, reported 4 women with dyspareunia, all 4 managed with sling release, with complete resolution after the surgery and no recurrence of incontinence (36).

Activity restrictions after surgery

Due to the fact that the sling is initially held in place only by frictional tissue forces, patients must allow sufficient time to pass for tissue in-growth to occur before significant intraabdominal pressure is applied to the mesh.

It is recommended that patients must be advised to avoid activities that may increase intraabdominal pressure, heavy lifting or strenuous exercises for at least 4-6 weeks. However, ambulation is indicated (36).

Follow-up visits

It is recommended to do a routine follow-up at 4-6 weeks after surgery to evaluate that the incisions have adequately healed, to check for vaginal mesh erosion and to also measure a post void residual volume to determine whether the patient has been adequately emptying her bladder.

Patients are advised to call their surgeons if they experience any of the following: heavy vaginal bleeding, fever greater than 38 degrees, skin incision changes, foul-smelling, green, or dark yellow vaginal discharge, urinary retention, severe or persistent abdominal pain (36).

Conclusions

Stress urinary incontinence and pelvic organ prolapsed are important health issues, affecting more than 50% of women at one point in their life in terms of quality of life, body image and sexual function. In regard to quality of life and patient satisfaction after surgery, it is comforting to know that many authors report an overall patient’s satisfaction and improvement in QoL of about 80%, sustained for at least 2 years, regardless of the midurethral sling procedure. However, there are conflicting results concerning the effect of incontinence surgery on sexual function.

Postoperative pain is frequently mild and self-limited usually resolving in a few weeks with conservative treatment, but sometimes it can take the form of chronic pelvic pain. In this cases aditional measures should be taken into consideration. In terms of phisical activity restrictions, there is a consensus that women undergoing vaginal mesh surgery should avoid strenuous tasks and heavy lifting for 4 to 6 weeks. At the follow-up visits a thorough vaginal inspection should be done to check for vaginal mesh erosion and also a post-void residual volume should be measured.

All of these palliation measures are well known between uro-gynecologists and it is said that half of the procedures success lies in all mentioned above.

Conflict of interest: none
Acknowledgments: All authors contributed equally to this article
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