Treat or Wait? Natural Perioperative Course of Overactive Bladder Symptoms at the Time of Midurethral Sling Placement.

OBJECTIVE: The aims of this study were to describe the perioperative course of untreated overactive bladder (OAB) (urinary frequency [UF] and urgency urinary incontinence [UUI]) before and after isolated retropubic midurethral sling (MUS) and to identify the time point for spontaneous OAB symptom improvement in the most patients. METHODS: This is a prospective cohort study of women undergoing an isolated MUS. Women completed the Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7 preoperatively and weekly for 13 weeks postoperatively. Bothersome UF and UUI were defined as a response of "moderately" or "greatly" bothered on questions 1 and 2 of the Urogenital Distress Inventory. The treatment for OAB was deferred until 13 weeks after surgery. RESULTS: Fifty-four women were included with a mean ± SD age of 48 ± 9 years. Preoperatively, 41% of women reported both bothersome UF and UUI. Six weeks after surgery, only 15% and 6% reported bothersome UF and UUI (P < 0.001 and P < 0.001, respectively). Between 6 and 13 weeks, percentages of bothersome symptoms remained low (11.7% UF and 5.8% UUI). In addition, the impact of these urinary symptoms on activities, relationships, and feelings became consistently negligible (Incontinence Impact Questionnaire 7 median score <1) at 5 weeks postoperatively. Only 3 women desired treatment for UUI after the study period. CONCLUSIONS: Overactive bladder is common before and immediately after MUS. However, the majority of patients have spontaneous symptom resolution by 6 weeks after surgery; it may be reasonable to discontinue preoperatively initiated overactive bladder treatment or defer starting treatment until this time point.

Concurrent Retropubic Midurethral Sling and OnabotulinumtoxinA for Mixed Urinary Incontinence: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether retropubic midurethral sling combined with onabotulinumtoxinA is more effective than sling alone in improving mixed urinary incontinence symptoms. METHODS: We conducted a prospective, double-blind, randomized, controlled trial of women with mixed urinary incontinence, planning to undergo midurethral sling. Women were randomly assigned to receive 100 unites of intradetrusor onabotulinumtoxinA or placebo during surgery. Participants completed the PGI-S (Patient Global Impression of Severity), the UDI-6 (Urinary Distress Inventory, Short Form), and the PFIQ-7 (Pelvic Floor Impact Questionnaire-Short Form 7) before and 3 months after surgery, and the primary outcome, PGI-I (Patient Global Impression of Improvement), 3 months postoperatively. Primary outcome was PGI-I score at 3 months for overall incontinence. We considered women "improved" with answers of "very much better" or "much better" on the PGI-I. Assuming a PGI-I response of "improved" in 66% of placebo and 93% of onabotulinumtoxinA participants, 68 women were needed to show a significant difference with 80% power at 0.05 significance level. RESULTS: From March 2016 to November 2019, 78 women completed a 3-month follow-up (onabotulinumtoxinA: 41; placebo: 37). Mean age was 51 years (±10). On the PGI-I, the number who "improved" did not differ between groups at 3 months (83% vs 84%, P=1.0). The onabotulinumtoxinA group had less severe urgency symptoms as indicated by median urgency PGI-S scores (1 [interquartile range 1-2] vs 2 [interquartile range 1-3], P=.033) and greater improvement in urgency symptoms based on median urgency PGI-I score (1 [interquartile range 1-3] vs 2 [interquartile range 2-4], P=.028). At 3 months, median UDI-6, PFIQ-7, and PGI-S scores improved significantly from baseline in both groups. Similarly, UDI-6 and PFIQ-7 scores did not differ between groups. More women in the onabotulinumtoxinA arm initiated intermittent self-catheterization, (3% placebo; 12% onabotulinumtoxinA, P=.20) and experienced urinary tract infections (5% placebo; 22% onabotulinumtoxinA, P=.051), but these did not differ statistically. CONCLUSION: Concurrent intradetrusor onabotulinumtoxinA injection did not improve overall incontinence symptoms at 3 months compared with placebo among women with mixed urinary incontinence undergoing midurethral sling placement. Women with mixed urinary incontinence undergoing sling report significant improvement in overall incontinence symptoms, regardless of the addition of onabotulinumtoxinA injections, but those receiving concurrent onabotulinumtoxinA injections reported less urgency severity and greater improvement in urgency symptoms at 3 months. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02678377.

Recovering sexual satisfaction after prolapse surgery: a secondary analysis of surgical recovery.

INTRODUCTION AND HYPOTHESIS: We compared pre- and postoperative sexual function scores in sexually active women undergoing pelvic organ prolapse (POP) surgery. METHODS: Planned secondary analysis of women enrolled in the Restricted Convalescence: Outcomes Following Urogynecologic Procedures study, a randomized trial of postoperative activity after POP surgery. All participants could return to sexual activity at 6 weeks. Participants completed the Pelvic Floor Distress Inventory (PFDI), the Patient-Reported Outcomes Measurement Information System (PROMIS) profile, and the Golombok Rust Inventory of Sexual Satisfaction (GRISS) questionnaires at baseline and 3 months. GRISS is a validated 28-item survey for heterosexual couples that contains seven subscales to assess sexual function. Higher scores represent worse sexual function. RESULTS: Thirty-seven sexually active women were assessed. Mean age ± standard deviation (SD) was 56 ± 11, most of whom (92%) were Caucasian; 78% had undergone minimally invasive sacrocolpopexy, and the remainder had native tissue vaginal repairs. GRISS scores improved 3 months after surgery [4.5 ± 2.6 to 3.6 ± 2.2, p < 0.001; mean decrease of 0.9, 95% confidence interval (CI) 0.36-1.36]. PFDI scores improved from 122 ± 53 at baseline to 28 ± 31 at 3 months (p < 0.001). Higher GRISS scores were correlated with higher PFDI scores (Spearman's rho = 0.35, p = 0.03) at baseline and 3 months (Spearman's rho = 0.31, p = 0.03). Several GRISS subscales improved after surgery: partner avoidance (p = 0.01), vaginismus (p = 0.02), noncommunication (p = 0.01), dissatisfaction (p = 0.03), and anorgasmia (p = 0.001). However, sexual infrequency (p = 0.08) and nonsensuality (p = 0.4) did not change. Fifty-one percent had sexual dysfunction before surgery, which decreased to 32% after surgery (p = 0.04). CONCLUSION: Sexual function and satisfaction are significantly improved 3 months following POP surgery. Improved sexual function is correlated with improved pelvic floor symptoms.