Recurrent stress incontinence with intrinsic sphincter deficiency after previous anterior repair
A 61-year-old woman, BMI 31, para 3, a smoker with chronic obstructive pulmonary disease and a winter cough, is referred with a five-year history of urine leakage on coughing and brisk walking that recurred after an anterior colporrhaphy performed six years ago. She also reports occasional urgency but no urge incontinence. She uses four pads a day, has restricted her social life and has stopped her daily walks. Examination shows a fixed, well-supported urethra, no significant prolapse (POP-Q stage I anteriorly), a positive cough stress test, and a post-void residual of 35 mL. Urodynamics show no detrusor overactivity, a maximum urethral closure pressure of 21 cmH2O and leakage at a Valsalva leak point pressure of 45 cmH2O. She has completed three months of supervised pelvic floor muscle training with a physiotherapist without meaningful improvement. She asks specifically for 'the tape operation' she read about, and is worried because a friend had a mesh erosion.
1. Interpret the urodynamic and clinical findings. What do they tell you about her likely surgical outcome, and what would you do before any operation?
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Interpretation
- This is urodynamic stress incontinence with intrinsic sphincter deficiency: a maximum urethral closure pressure of 21 cmH2O (below the conventional 20–25 threshold) and a low Valsalva leak point pressure of about 45 cmH2O, with a fixed, non-hypermobile urethra and no detrusor overactivity. Her occasional urgency is not urge incontinence and does not indicate overactive bladder requiring antimuscarinics on its own.
- Recurrence after an anterior repair means scarred, less mobile tissue at the bladder neck. Retropubic approaches generally outperform transobturator approaches in this setting, and cure rates overall are lower than in primary stress incontinence - realistic expectations are in the order of 70–85% 'dry' or greatly improved at one year, not 95%.
- The fixed urethra and low closure pressure also mean a simple transobturator tape may be relatively ineffective, and repeat vaginal dissection carries a risk of urethral or bladder injury.
Before surgery
- Confirm the diagnosis is reproduced on examination and that her symptoms are predominantly stress.
- Treat the reversible factors: smoking cessation (at least 6–8 weeks before surgery), optimisation of inhaled therapy for COPD, weight management, treatment of constipation and any chronic cough. An untreated chronic cough is a genuine mechanical threat to any anti-incontinence repair.
- Check for urinary tract infection, review the drug chart, ensure she is not on medications that worsen leakage, and confirm she understands that surgery may need to be delayed until her chest is optimised.
- Cystoscopy is worth considering, given previous pelvic surgery, to exclude suture material, fistula or urethral pathology.
- Discuss the alternatives with their evidence: continued supervised pelvic floor training (small additional benefit), a vaginal continence pessary (useful as a trial and as a bridge), and the surgical options.
2. Present the surgical options and your recommendation, together with the informed consent discussion about mesh. What would you tell her specifically about 'the tape'?
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Options
- Retropubic midurethral sling (TVT): the best-evidenced operation for intrinsic sphincter deficiency; cure rates above transobturator tapes in low-pressure urethras. Risks: bladder perforation (about 2–5%), voiding dysfunction and retention, tape erosion into the vagina or urethra, groin/suprapubic pain, dyspareunia.
- Transobturator tape (TOT/TVT-O): lower risk of bladder perforation but inferior results with a low maximum urethral closure pressure - not the best first choice for her.
- Autologous rectus fascial sling: avoids synthetic mesh entirely, good cure for sphincter deficiency, but adds a abdominal donor-site wound, longer operating time, more postoperative voiding dysfunction, and needs a surgeon who performs it regularly.
- Burch colposuspension: good, durable option for sphincter deficiency in a woman not planning pregnancy; longer recovery, higher rate of later prolapse and rectocele, needs open or laparoscopic expertise.
- Urethral bulking agents: less durable, useful mainly for frail patients or those wanting to avoid surgery; repeat injections often needed.
Recommendation: optimise her chest and weight first, then offer a retropubic midurethral sling as the default, with an autologous fascial sling or Burch colposuspension discussed as equally reasonable mesh-free alternatives. Her fixed, scarred urethra and prior repair should be done by a urogynaecologist in a centre with experience managing mesh complications.
Consent about mesh
- Synthetic mesh tapes are permanent implants; explain the real incidence of vaginal erosion (a few percent), the possibility of urethral erosion and chronic pain, and that management may need partial excision or further surgery.
- Mention that the implant should be recorded in the national implant registry with the lot number, and that she has the right to a copy of the record.
- Explain that mesh removal is specialist work and does not always resolve pain or voiding problems.
- Document the discussion, including that she specifically asked about her friend's erosion.
3. She decides she does not want any mesh. Outline a mesh-free management plan and the objective outcomes you would quote her, and describe how you would manage a later vaginal tape erosion in a woman who had previously been treated elsewhere.
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Mesh-free plan
- Continue supervised pelvic floor muscle training, with a realistic statement that after 3 months of failure the added benefit is modest but not zero, and address adherence, technique and constipation.
- Trial of a vaginal continence pessary fitted by a trained clinician, with a review at 2–4 weeks; this is a legitimate long-term option for women who decline surgery and gives a useful prediction of whether reducing urethral mobility helps.
- Aggressive modification of the cough: smoking cessation referral, inhaler review, physiotherapy for cough control. Weight loss of 5–10% improves leakage modestly; set a realistic target rather than an ideal BMI.
- Offer an autologous rectus fascial sling or Burch colposuspension as the mesh-free surgical options. Quote roughly: 80–85% objective cure at 1–5 years for fascial sling and Burch in competent hands, more voiding dysfunction and longer recovery than tape, and no mesh-related complications. Also note the lifetime risk of later prolapse surgery after Burch.
- Document that she declined synthetic mesh and was given a written record of the alternatives.
If a vaginal mesh erosion appears later (in a woman treated elsewhere)
- Assess: symptoms (discharge, pain, dyspareunia, partner discomfort), examination to define extent, and whether the erosion is vaginal, urethral or bladder; cystoscopy for suspected urinary tract involvement.
- Small asymptomatic vaginal exposures may be managed conservatively with vaginal oestrogen and review; symptomatic or enlarging exposure needs excision of the exposed portion by an experienced urogynaecologist, with antibiotic cover.
- Do not simply pull on the tape: traction can worsen urethral or bladder injury.
- Refer to a specialist mesh centre if there is urethral involvement, chronic pain or multiple previous attempts, and report the complication.