What's the next step for a 56-year-old woman with new onset urgency and urgent incontinence after mid urethral (midurethral) sling placement?

Management of New Onset Urgency and Urgent Incontinence After Mid Urethral Sling

The next step for this 56-year-old woman with new onset urgency and urgent incontinence after mid urethral sling placement should be to initiate anticholinergic medication therapy, as urinalysis and pelvic exam are normal.

Diagnostic Considerations

When evaluating post-operative urgency and urgent incontinence after mid urethral sling placement, it's important to understand the underlying mechanisms and rule out complications:

1. Causes already ruled out:

   • Urinary tract infection (normal urinalysis)
   • Sling erosion or malposition (normal pelvic exam)

2. Potential mechanisms for post-operative urgency symptoms:

   • De novo detrusor overactivity (occurs in 5-25% of women after sling surgery) 1
   • Partial bladder outlet obstruction from overtightened sling
   • Urethral irritation from sling material

Management Algorithm

First-line Treatment

• Anticholinergic medications (e.g., tolterodine, oxybutynin)
  • Tolterodine 2mg twice daily has demonstrated efficacy in reducing urgency incontinence episodes 2
  • Oxybutynin is an alternative option, though may have more side effects 3

If symptoms persist after 4-6 weeks of medication therapy:

1. Perform cystoscopy to evaluate for:

   • Urethral erosion or injury 4
   • Sling position and potential obstruction
   • Bladder abnormalities

2. Consider urodynamic testing to assess for:

   • Detrusor overactivity
   • Bladder outlet obstruction
   • Reduced bladder capacity

For refractory symptoms:

• Sling revision or incision if obstruction is identified
• Advanced therapies for persistent detrusor overactivity:
  • Sacral neuromodulation
  • Botulinum toxin injections

Risk Factors and Prognosis

Research has identified several risk factors for persistent or de novo urgency after mid urethral sling:

• Age ≥66 years 5
• Pre-existing mixed incontinence 6
• Decreased bladder capacity 5
• Lower maximum urethral closure pressure 5
• Diabetes 5

Important Considerations

• Delayed treatment of post-operative urgency symptoms is associated with worse outcomes. Patients with urgency incontinence after sling placement are more likely to experience delays in treatment compared to those with obstructive symptoms 7.

• After sling revision for urgency symptoms, 76.5% of patients may have persistent symptoms, particularly those requiring anticholinergic medication pre-revision 7.

• The incidence of de novo urgency and urgency urinary incontinence is reported around 15% and 30%, respectively 6.

Pitfalls to Avoid

• Don't immediately assume sling needs revision without a trial of medication therapy first
• Don't overlook the possibility of urethral injury if symptoms persist despite medication
• Don't delay treatment as this can lead to worse outcomes 7
• Don't forget to counsel the patient about the possibility of persistent symptoms even after appropriate treatment

By following this algorithm, you can systematically address the patient's new onset urgency and urgent incontinence while minimizing complications and optimizing quality of life outcomes.