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JOGC

No. 248-Guidelines for the Evaluation and Treatment of Recurrent Urinary Incontinence Following Pelvic Floor Surgery

  • Danny Lovatsis
    Affiliations
    Toronto, ON
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  • William Easton
    Affiliations
    Scarborough, ON
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  • David Wilkie
    Affiliations
    Vancouver, BC
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  • Author Footnotes
    ∗ Urogynaecology Committee: Danny Lovatsis, MD, (Chair), Toronto, ON; Jens-Erik Walter, MD (Co-Chair), Montréal, QC; William Easton, MD, Scarborough, ON; Annette Epp, MD, Saskatoon, SK; Scott Farrell, MD, Halifax, NS; Lise Girouard, RN, Winnipeg, MB; Chander Gupta, MD, Winnipeg, MB; Marie-Andrée Harvey, MD, Kingston, ON; Annick Larochelle, MD, St-Lambert, QC; Magali Robert, MD, Calgary, AB; Sue Ross, PhD, Calgary, AB; Joyce Schachter, MD, Ottawa, ON; Jane Schulz, MD, Edmonton, AB; David Wilkie, MD, Vancouver, BC. Disclosure statements have been received from all members of the committee. The literature searches and bibliographic support for this guideline were undertaken by Becky Skidmore, Medical Research Analyst, The Society of Obstetricians and Gynaecologists of Canada.

      Abstract

      Objective

      To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery.

      Options

      Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions.

      Outcomes

      These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms.

      Evidence

      Published opinions of experts, and evidence from clinical trials where available.

      Values

      The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table).

      Recommendations

      • 1.
        Thorough evaluation of each patient should be performed to determine the underlying etiology of recurrent urinary incontinence and to guide management (II-3B).
      • 2.
        Conservative management options should be used as the first line of therapy (III-C).
      • 3.
        Patients with a hypermobile urethra, without evidence of intrinsic sphincter deficiency, may be managed with a retropubic urethropexy (e.g., Burch procedure) or a sling procedure (e.g., mid-urethral sling, pubovaginal sling) (II-2B).
      • 4.
        Patients with evidence of intrinsic sphincter deficiency may be managed with a sling procedure (e.g., mid-urethral sling, pubovaginal sling) (II-3B).
      • 5.
        In cases of surgical treatment of intrinsic sphincter deficiency, retropubic tension-free vaginal tape should be considered rather than transobturator tape (I-B).
      • 6.
        Patients with significantly decreased urethral mobility may be managed with periurethral bulking injections, a retropubic sling procedure, use of an artificial sphincter, urinary diversion, or chronic catheterization (III-C).
      • 7.
        Overactive bladder should be treated using medical and/or behavioural therapy (II-2B).
      • 8.
        Urinary frequency with moderate elevation of post-void residual volume may be managed with conservative measures such as drugs to relax the urethral sphincter, timed toileting, and double voiding. Intermittent self-catheterization may also be used (III-C).
      • 9.
        Complete inability to void with or without overflow incontinence may be managed by intermittent self-catheterization or urethrolysis (III-C).
      • 10.
        Fistulae should be managed by an experienced physician (III-C).

      Key Words

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