Overactive bladder symptoms after midurethral sling surgery in women: Risk factors and management

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1 Received: 4 January 2017 Accepted: 2 May 2017 DOI: /nau REVIEW ARTICLE Overactive bladder symptoms after midurethral sling surgery in women: Risk factors and management Tom Marcelissen Philip Van Kerrebroeck Department of Urology, Maastricht University Medical Center, Maastricht, The Netherlands Correspondence Tom Marcelissen, MD, PhD, Maastricht University Medical Center, PO BOX 5800 Maastricht, The Netherlands tmarcelissen@gmail.com Introduction: Overactive bladder syndrome (OAB) including urgency and urgency urinary incontinence (UUI) occurs frequently after stress urinary incontinence (SUI) surgery. It is important to identify the risk factors for the occurrence of OAB symptoms in order to adequately inform the patient before surgery. Furthermore, when facing OAB after sling surgery it is crucial to know how to manage these symptoms. Methods: We conducted a literature review in order to assess the risk factors and management of OAB symptoms after SUI surgery. We searched for relevant articles in PubMed that specifically addressed the topic of OAB symptoms after midurethral sling surgery. Results: The incidence of de novo and persistent urgency and UUI is reported around 15% and 30%, respectively. Several studies demonstrated that women with mixed incontinence who have a predominant urge component will have worse outcomes after surgery. Older age was also found to be a predictive factor in three studies. Furthermore, urodynamic signs of overactive bladder (eg, DO, low bladder capacity, elevated detrusor pressure) can predict postoperative urgency or UUI. The management of OAB symptoms after SUI surgery is essentially the same as in idiopathic OAB. However, before commencing therapy it is crucial to rule out other factors than can cause urgency, including bladder outlet obstruction, urinary tract infection, or sling erosion. Conclusions: OAB symptoms are frequently reported after sling surgery. Women with mixed incontinence and older women are at risk of developing post-operative OAB symptoms. We have proposed an algorithm for the treatment of these symptoms which can be useful in clinical practice. KEYWORDS midurethral sling, overactive bladder, stress urinary incontinence, urgency 1 INTRODUCTION Stress urinary incontinence (SUI) is a bothersome symptom that can have a serious impact on social and psychological David Ginsberg led the peer-review process as the Associate Editor responsible for the paper. well-being. 1 When conservative management with pelvic floor training fails, surgical treatment can be considered. Several surgical procedures have been proposed for the treatment of SUI. Although these procedures are often effective for the resolution of incontinence, symptoms of overactive bladder syndrome (OAB) including urgency, and urgency urinary incontinence (UUI) occur frequently after Neurourology and Urodynamics. 2018;37: wileyonlinelibrary.com/journal/nau 2017 Wiley Periodicals, Inc. 83

2 84 MARCELISSEN AND VAN KERREBROECK surgery. 2 Patients with mixed urinary incontinence (MUI) can experience persistence or even aggravation of OAB symptoms, whereas patient with pure SUI can develop de novo urgency. Although potentially reversible causes such as infection, bladder outlet obstruction (BOO), and foreign bodies (mesh or suture material) exist, the cause is unclear in many cases. 3 It is important to identify the risk factors for the occurrence of OAB symptoms in order to adequately inform the patient before surgery. Furthermore, when facing OAB after surgery it is crucial to know how to manage these symptoms. In this paper, we reviewed the literature concerning OAB symptoms after SUI. We searched for possible risk factors and proposed an algorithm for the management of postoperative OAB symptoms. 2 METHODS We conducted a literature review in order to assess the risk factors and management of OAB symptoms after SUI surgery. We searched for relevant articles in PubMed that specifically addressed the topic of OAB symptoms after SUI surgery. We used the terms urgency, overactive bladder, and storage in combination with the terms urinary stress incontinence, sling, TOT, TVT, or colposuspension, All existing trials that evaluated the efficacy and safety of SUI surgery were scrutinized. Relevant data from these articles were extracted and used for this review. 2.1 Incidence After any procedure for stress incontinence, patients with pure SUI may develop de novo OAB symptoms. It is known that UUI affects quality of life more than SUI. 1 Thus, women who develop OAB following stress incontinence surgery can experience worsening in quality of life compared to their status before surgery. It is therefore important to accurately assess the incidence of this complication. Stanford et al 4 reviewed the complications of suburethral sling procedures, including 20 studies with a total of 1950 patients. They found an overall incidence of de novo OAB symptoms of 15.4%. The reported incidence ranged from 1.7% to 42%. A possible reason for this wide range is the variety in tools that are used for measuring outcome. Both subjective (eg, questionnaires, voiding diaries) and objective (eg, urodynamics, pad test) tools are utilized for recording OAB symptoms, making comparison difficult. Furthermore, various questionnaires are used for subjective evaluation. These include the Urogenital distress inventory (UDI), Detrusor Instability Score (DIS), Incontinence-Overactive bladder (ICIQ/OAB) and Medical, Epidemiological, and Social Aspects of Aging (MESA) questionnaire. 5 7 Besides the different tools that are used, different definitions of de novo OAB symptoms are applied. Some studies only evaluate urgency or frequency symptoms (OAB dry), whereas others examine urgency urinary incontinence (OAB wet) or detrusor overactivity (DO). Inconsistent use of these definitions is confusing and makes it difficult to compare results. The use of different procedures or techniques for anti-incontinence surgery also makes comparison difficult. Another explanation for the discrepancy in the incidence of de novo urgency might be the duration of follow-up. In some patients, OAB symptoms can arise several years after surgery. 8 Kulseng-Hanssen et al 9 evaluated the long-term follow-up of retropubic midurethral tapes in 483 women. De novo UUI increased significantly from 4.1% 6-12 months after surgery to 14.9% at 10 years follow-up. Zyczynski et al 10 evaluated the data from three multicenter trials of women with stress predominant MUI. They showed that the initial improvement in OAB symptoms after SUI surgery seen during the 1st year gradually declined after 5 year followup. 10 Holmgren et al 11 reported an 60% cure rate of UUI up to 4 years after midurethral sling women with mixed incontinence. This improvement declined to 40% at 5 years and 30% at 4-8 years. Petri et al 8 analyzed the time interval between the tape insertion and time of treatment for complications. The majority of complications were seen between the 1st and 5th year of tape insertion. Moreover, up to 15% of complications occurred more than 5 years after tape insertion, emphasizing the need for long-term follow-up. A possible explanation for the late occurrence of OAB symptoms might be formation of fibrosis around the tape or mesh erosion. 12 Obviously, these symptoms could also be the result of physiological changes associated with ageing, since the prevalence of OAB increases with age. 13 Persistent urgency or UUI can occur in patients with MUI who undergo surgery for SUI. Lee et al 6 evaluated 754 women with SUI and urgency; and 514 women with SUI and UUI who underwent a synthetic midurethral sling procedure with a mean follow-up of 50 months. Of the women with SUI and urgency, 40% had persistent urgency at follow-up. 14 InwomenwithSUIandUUI,32%had persistent urgency incontinence. Kulseng-Hanssen et al 9 evaluated 1113 women with MUI undergoing a midurethral sling procedure. The results were analyzed according to the women s predominant bother: SUI, UUI, or both equally. Women with predominant SUI had significantly better results at both 7 and 38 months than those in the other groups, especially those predominantly bothered by UUI. Eleven per cent of the women experienced an increase in UUI 38 months after surgery. Padmanabhan et al 15 evaluated 718 patients with MUI who were treated with a synthetic or autologous fascial sling. Seventy-one

3 MARCELISSEN AND VAN KERREBROECK 85 percent of patients reported improvement of OAB symptoms following surgical intervention, whereas 3% reported worsening and 26% remained the same. There was a direct effect between change in QoL and change in postoperative urgency or UUI in both patient with synthetic and fascial slings. 2.2 Risk factors OAB symptoms are common after SUI surgery and can have a large impact on quality of life. Hence, it is important to identify which patients are likely to develop these symptoms. Several studies have investigated possible risk factors that are associated with the occurrence of urgency and UUI after surgery and various preoperative symptoms have been evaluated (Table 1). Four studies demonstrated that women who have predominant urgency component will have worse outcomes after surgery In line with this observation, a history of anticholinergic medication use has also been addressed as a predictive factor for postoperative OAB. 16,20 Interestingly, Richter et al 21 found that concomitant preoperative UUI was also associated with higher failure rates for SUI specific outcomes. Consequently, it is possible that patients with mixed incontinence have a higher disease severity or even different pathophysiology than patients with pure SUI. A history of prior incontinence surgery has also been proposed as a risk factor by several authors. 14,18 Different causative mechanisms can be postulated, including BOO, irritation due to previous sling surgery, or bladder denervation during extensive dissection. Older age was found to be a predictive factor in three studies. 18,22,23 Since OAB symptoms are more prevalent with increasing age, changes in the bladder urothelium or detrusor could be responsible for the higher incidence in this group. 24 Furthermore, ageing-induced neuronal dysfunction might also predispose to detrusor overactivity or UUI. 25 Holmgren et al 11 reported that increasing parity and delivery by caesarean section were more common in women who developed de novo urgency following a TVT procedure. 11 Urodynamic studies (UDS) have often been investigated as predictors for surgical outcomes. In most studies, urodynamic signs of overactive bladder (eg, DO, low bladder capacity, elevated detrusor pressure) have been found to be predictive for postoperative urgency or UUI. 14,16,17,23,26,27 Despite these findings, the presence of DO does not appear to significantly worsen the outcome of SUI. For example, Lai et al 28 found equal cure rates of SUI in patients with preoperative DO and patients without DO. And Kuo et al 29 found that patients with DO even had higher cure rates of SUI than patients without DO. Nevertheless, the satisfaction rate in this group was considerably lower due to the higher rate of postoperative UUI. This again shows that OAB symptoms can have a serious impact on quality of life, and stresses the importance of adequate patient counseling. 2.3 Management The first step in the management of OAB symptoms after SUI surgery is to rule out urinary tract infection and bladder outlet obstruction. Also, iatrogenic injury or a foreign body in the urethra can account for urgency symptoms. 3 Evaluation includes a history and physical examination, urinalysis, and post-void residual. Cystoscopy and urodynamics may help to rule out surgical complications. A foreign body or tape erosion can often be identified during cystoscopy. Urodynamics can sometimes be useful in distinguishing obstruction from dysfunctional voiding or to asses detrusor contractility. Once these factors have been excluded, OAB symptoms should be treated according to the AUA guideline as primary idiopathic OAB. 2 As most cases resolve, conservative measures are initially recommended. These include first TABLE 1 Risk factors for the occurrence of OAB symptoms after sling surgery Study N Follow-up Risk factors for OAB Holmgren years Older age, obesity, parity, history of caesarean section Barber months History of anticholinergic medication use, concurrent prolapse surgery Alperin weeks Increased preoperative frequency, elevated detrusor pressure Gamble months Older age, nocturia, lower max bladder capacity, higher detrusor pressures at DO Houwert months Absence of SUI on urodynamics, low bladder capacity Panayi months Opening detrusor pressure Lee months Baseline urgency symptoms, DO, older age, previous incontinence surgery Kenton months Preoperative urgency, DO, history of anticholinergic medication use Segal months History of incontinence surgery Chou months Preoperative urgency and UUI

4 86 MARCELISSEN AND VAN KERREBROECK and second line treatment with behavorial therapy and oral antimuscarinics. Fig. 1 provides an algorithm for the management. In a study by Cross et al 30 the effect of antimuscarinics was evaluated in 150 patients after pubovaginal sling surgery. Twenty-nine patients (19%) developed de novo UUI and were treated with antimuscarinics. After 3 months of treatment, 85% of these patients were cured and able to discontinue medical therapy. Serati et al 31 evaluated the benefit of solifenacin in 110 patients who had de novo urgency after TOT. The results were compared with a group of patients with idiopathic OAB who received the same treatment (both 5 mg solifenacin). After 3 months of treatment, the TOT patients reported a significantly lower improvement in urgency ( 1.1 vs 2.3) and UUI ( 0.2 vs 1.1) episodes compared to the idiopathic group. If insufficient effect is achieved or patients do not tolerate antimuscarinics, treatment with mirabegron can be attempted. Although there are currently no data on the use of mirabegron in this specific patient group, results for idiopathic OAB have been positive. 32 If first or second line treatments fail, third line treatments can be offered in any order, including sacral neuromodulation (SNM), onabotulinumtoxina (BoNT-A), or percutaneous tibial nerve stimulation (PTNS). Only limited data exists on the third-line treatment of OAB symptoms after SUI surgery. Sherman at el 33 performed a test stimulation with sacral neuromodulation in 34 women with refractory UUI after SUI surgery. Of these, 22 (65%) responded and underwent permanent implantation. There was no difference between responders and non-responders with respect to type of SUI surgery, incontinence severity or urodynamic parameters. A shorter duration between SUI surgery and test stimulation (less than 4 years) and younger age might be associated with a positive response. Starkman et al 34 evaluated the effect SNM in 25 women after urogynaecologic surgery (pubovaginal slings, retropubic suspension, pelvic prolapse repair). Twenty-two patients (88%) underwent implantation and after 6 months follow-up 20 patients maintained >50% improvement in clinical symptoms. Furthermore, eight patients underwent SNM after urethrolysis for idiopathic bladder outlet obstruction. Of these, six had a favorable response and underwent implantation. After 15 months follow-up, all patients significantly improved, with three being dry. Miotla et al 35 evaluated the efficacy of BoNT-A in 102 patients who had de novo or persistent OAB symptoms after MUS. After 12 weeks, 41 patients (40%) were completely dry. BoNT-A had a significant benefit in both groups regarding the daily number of voids and incontinence episodes. Urinary retention was observed in four patients. Urinary tract infections were observed in less than 4% of patients. FIGURE 1 Algorithm for the management of postoperative urgency after sling surgery

5 MARCELISSEN AND VAN KERREBROECK 87 3 SUMMARY AND CONCLUSIONS Urgency and UUI are prevalent symptoms after sling surgery for SUI and can have a significant impact on QoL. Women with mixed incontinence and older women are at risk of developing post-operative OAB symptoms. Urodynamic studies might aid the surgeon into identifying risk factors which can be used to adequately counsel patients before surgery. The management of OAB symptoms after SUI surgery is essentially the same as in idiopathic OAB. However, before commencing therapy it is crucial to rule out other factors than can cause urgency, including bladder outlet obstruction, urinary tract infection or sling erosion. REFERENCES 1. Schimpf MO, Patel M, O Sullivan DM, et al. Difference in quality of life in women with urge urinary incontinence compared to women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20: Dmochowski RR, Blaivas JM, Gormley EA, et al. 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6 88 MARCELISSEN AND VAN KERREBROECK 32. Warren K, Burden H, Abrams P. Mirabegron in overactive bladder patients: efficacy review and update on drug safety. Ther Adv Drug Saf. 2016;7: Sherman ND, Jamison MG, Webster GD, et al. Sacral neuromodulation for the treatment of refractory urinary urge incontinence after stress incontinence surgery. Am J Obstet Gynecol. 2005;193: Starkman JS, Wolter CE, Scarpero HM, et al. Management of refractory urinary urge incontinence following urogynecological surgery with sacral neuromodulation. Neurourol Urodyn. 2007;26: discussion Miotla P, Futyma K, Cartwright R, et al. Effectiveness of botulinum toxin injection in the treatment of de novo OAB symptoms following midurethral sling surgery. Int Urogynecol J. 2016;27: How to cite this article: Marcelissen T, Van Kerrebroeck P. Overactive bladder symptoms after midurethral sling surgery in women: Risk factors and management. Neurourology and Urodynamics. 2018;37: