How to manage urinary urgency in a 75-year-old female with a history of sacrocolpopexy?

Management of Urinary Urgency After Sacrocolpopexy in a 75-Year-Old Female

Bladder training should be the first-line treatment for urinary urgency in this 75-year-old female with a history of sacrocolpopexy, followed by pharmacologic therapy with mirabegron if behavioral therapy is unsuccessful. 1

Understanding Urgency in Post-Sacrocolpopexy Patients

Urinary urgency is defined as "a sudden, compelling desire to pass urine which is difficult to defer" 2. This symptom is particularly common following pelvic reconstructive surgeries like sacrocolpopexy, which can alter bladder and urethral anatomy.

Pathophysiology in Post-Surgical Patients

• Sacrocolpopexy can affect urethral position and function 3
• Changes in bladder neck position may contribute to urgency symptoms
• Urgency may develop de novo or persist from pre-surgical conditions

Diagnostic Approach

Before initiating treatment, consider these key factors:

• Determine if urgency is isolated or part of mixed incontinence
• Rule out urinary tract infection
• Assess for excessive post-void residual volume
• Consider whether symptoms represent de novo urgency after surgery

Treatment Algorithm

Step 1: Behavioral Therapy (First-Line)

• Bladder training is strongly recommended as first-line treatment for urgency urinary incontinence 1
• This involves scheduled voiding and gradually increasing intervals between voids
• Instruct patient to resist the urge sensation by using distraction and relaxation techniques
• Document voiding diary to track improvement

Step 2: Pharmacologic Therapy (If Bladder Training Fails)

If bladder training is unsuccessful after 4-6 weeks:

• Mirabegron (β3-adrenoceptor agonist) is recommended at 25mg daily, which can be increased to 50mg if needed 4

  • Advantages: Effective for urgency with fewer anticholinergic side effects
  • Clinical trials show significant reduction in urgency episodes and improvement in quality of life 4
  • Particularly suitable for elderly patients due to minimal cognitive effects

• Alternative: Antimuscarinic agents (if mirabegron is contraindicated)

  • Options include fesoterodine, which has flexible dosing and proven efficacy for urgency 2
  • Consider lower starting doses in elderly patients
  • Monitor for anticholinergic side effects (dry mouth, constipation, cognitive effects)

Step 3: Combination Therapy (For Refractory Cases)

• Consider combination of behavioral therapy with pharmacologic treatment
• If mixed incontinence is present, add pelvic floor muscle training 1

Special Considerations for Post-Sacrocolpopexy Patients

Studies have shown that:

• Sacrocolpopexy alone can improve some urinary symptoms by restoring normal anatomy 3
• Approximately 32-38% of women may experience urge incontinence after sacrocolpopexy 5
• Urodynamic evaluation may be helpful in complex cases 6

Monitoring and Follow-up

• Reassess symptoms after 4-6 weeks of initial therapy
• Monitor for treatment-related side effects
• For patients on mirabegron, no special monitoring is required unless on concurrent digoxin therapy 4
• Consider urodynamic testing if symptoms persist despite appropriate management

Cautions and Pitfalls

• Avoid systemic pharmacologic therapy if stress incontinence is the predominant symptom 1
• Be aware that antimuscarinic medications carry risk of cognitive side effects in elderly patients
• Recognize that post-surgical anatomy changes may affect treatment response
• Weight loss should be recommended if the patient is obese 1

By following this structured approach, urinary urgency following sacrocolpopexy can be effectively managed to improve quality of life and reduce morbidity in this 75-year-old patient.