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JU INSIGHT: Bladder Outlet Obstruction in Women With Chronic Urinary Symptoms and History of Urethral Sling
By: James Ross, MD; Lidia Avvakoumova; Alaya Yassein, MD; Magdalene Payne, MD; Conrad Maciejewski, MD, MSc; Ranjeeta Mallick, PhD; Rodney H. Breau, MD, MSc; Humberto Vigil, MD, MSc; Duane Hickling, MD, MSc | Posted on: 16 Feb 2023
Ross J, Avvakoumova L, Yassein A, et al. Prevalence and predictors of bladder outlet obstruction in women with chronic urinary symptoms and a history of urethral sling surgery. J Urol. 2023;209(2):384-390.
Study Need and Importance
Bladder outlet obstruction is a recognized complication of urethral sling surgery for females with stress urinary incontinence. For women with acute de novo urinary symptoms with/without retention following sling placement, urgent sling revision is often indicated; however, the prevalence of obstruction in women with chronic urinary symptoms and a history of urethral sling surgery is unknown. Furthermore, clinical predictors of obstruction and appropriate workup and management of these patients remain poorly defined.
What We Found
A retrospective chart review was performed on 105 women with chronic urinary symptoms following urethral sling surgery (median age 61 years, median time since sling surgery 5 years). The prevalence of urodynamic obstruction within this cohort was 60% (63/105). A tight palpable suburethral band and increased post-void residual were significantly associated with increased odds of urodynamic obstruction (see Table). For patients undergoing sling revision surgery for obstruction, the cumulative incidence of improvement in storage and voiding symptoms at 6 months was 43% and 87%, respectively. The probability of being incontinence-free and free from redo sling surgery was 56% and 75% at 30 months post-revision, respectively.
Table. Logistic Regression Models for Clinical Predictors of Urodynamic/Fluoroscopic Bladder Outlet Obstruction
| Predictor | Odds ratio (95% CI) | P value |
|---|---|---|
| Time since surgery | 0.96 (0.86, 1.07) | .4 |
| LUTS Mixed symptoms Storage symptoms Voiding symptoms |
Reference 0.37 (0.09, 1.56) 1.48 (0.14, 16.2) |
.2 .5 |
| Tight suburethral band | 6.84 (1.30, 36.1) | .02 |
| Increased PVR by 50 mL | 1.35 (1.06, 1.72) | .02 |
| Abbreviations: CI, confidence interval; LUTS, lower urinary tract symptoms; PVR, post-void residual. | ||
Limitations
The study is a single-centered, nonrandomized, and retrospective review with a small sample size. Female bladder outlet obstruction remains poorly defined in the literature and results may vary if a different definition is used. Physical exam findings may be subject to inter-provider variability. No standardized questionnaires were used to assess patients’ symptoms.
Interpretation for Patient Care
Females with chronic urinary symptoms and a history of urethral sling surgery have a high prevalence of bladder outlet obstruction and should undergo thorough history, physical exam, and urodynamics to rule out obstruction. Sling revision may relieve obstruction; however, patients should be monitored for persistent storage symptoms and recurrent incontinence and counseled on the potential need for redo incontinence surgery.
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