Surgery shows first-line potential for stress urinary incontinence

The authors of a head-to-head study say that surgery should be considered as a first-line option for women with stress urinary incontinence, ahead of physiotherapy.

Women who underwent surgery for urinary incontinence, irrespective of whether they had some physiotherapy first, fared better than those who had pelvic floor training alone, the team reports in the New England Journal of Medicine.

“Our findings suggest that women with this condition should be counseled regarding both pelvic-floor muscle training and midurethral-sling surgery as initial treatment options,” say Julien Labrie (University Medical Center Utrecht, the Netherlands) and colleagues.

The team randomly assigned 460 women to undergo retropubic or transobturator midurethral-sling surgery, or physiotherapy (nine sessions over 9–18 weeks). The women had moderate or severe stress-predominant urinary incontinence, and had either not received treatment or had undergone physiotherapy more than 6 months ago.

After 12 months, women in the surgery group were significantly more likely to report improvement on the Patient Global Impression of Improvement than women in the physiotherapy group, at rates of 90.8% and 64.4%, respectively, while 85.6% and 65.5%, respectively, reported no symptoms. Subjective and objective cure rates were also significantly higher in the surgery group.

And, the benefits of surgery persisted when the authors performed a post hoc per-protocol analysis including the 99 women originally assigned to the physiotherapy group who chose to switch to surgery after a mean of 7.4 physiotherapy sessions.

Furthermore, while both groups experienced improvements in Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ) scores, improvements in incontinence and overactive bladder on the UDI were significantly greater in the surgery group, as were improvements in mobility and embarrassment scores on the IIQ.

Labrie and colleagues say that the results should encourage physicians to consider surgery as an immediate treatment option for women diagnosed with stress urinary incontinence.

Noting that all 65 adverse events were among women who underwent surgery, they conclude: “Information on expected outcomes with both interventions, as well as on the potential, albeit infrequent, complications of surgery, will allow for individualized decision making by each woman and her health care provider.”

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