Heidi S. Harvie

Background: Midurethral sling placement is often performed during prolapse repair to treat or prevent stress urinary incontinence. However, some women experience persistent or new-onset stress or urgency urinary incontinence after surgery. It is unclear how prolapse repair, with or without a concomitant midurethral sling, alters urethral morphology and support, and how these changes relate to urinary continence outcomes. Objectives: To compare postoperative urethral morphology (dimensions, angles, shape) and support (position, mobility) after transvaginal prolapse repair with vs without a concurrent midurethral sling, and to explore associations between postoperative urethral characteristics and urinary outcomes (stress, urgency symptoms). Study Design: This ancillary analysis used magnetic resonance imaging and urinary outcome data from the Defining Mechanisms of Anterior Vaginal Wall Descent Study conducted across 8 clinical sites within the United States Pelvic Floor Disorders Network. Eighty-two women (median age, 65 years) underwent transvaginal prolapse repair (vaginal mesh hysteropexy or vaginal hysterectomy with uterosacral ligament suspension) with or without a concurrent midurethral sling between April 2013 and February 2015. Postoperative imaging at rest and during strain was performed 30-42 months after surgery (or earlier if they chose reoperation) between June 2014 and May 2018. Prolapse recurrence, defined as descent beyond the vaginal introitus during strain, was recorded. The urethra was segmented from postoperative scans to create 3-dimensional models for measuring urethral diameters, length, surface area, volume, angles, shape (principal component scores from a statistical shape model), position, and mobility (rest-to-strain displacement). Preoperative and 24-48-month postoperative urinary continence outcomes were assessed using validated questionnaires: the Urogenital Distress Inventory, Urinary Impact Questionnaire, and the Incontinence Severity Index. Comparisons of urethral and urinary outcomes by (1) midurethral sling and (2) stress urinary incontinence were made using Wilcoxon rank-sum tests, principal component analysis, and multivariate models as appropriate. Associations between urethral and urinary outcomes were evaluated with Spearman’s rank correlation. Results: Forty-six women (22 hysteropexy, 24 hysterectomy) were in the sling group, and 36 (19 hysteropexy, 17 hysterectomy) were in the no-sling group. Among the 48 women without prolapse recurrence (28 sling, 20 no-sling), those with a sling (vs without) had larger urethral dimensions (all P<.03), a more anterior-superior position of the proximal urethra (indicating better bladder neck support) (P=.04), a straighter urethral shape (P=.006), and reported less bothersome postoperative stress incontinence (P=.02). Overall, 14 women (17%) experienced postoperative stress incontinence. Stress urinary incontinence was linked to a more acute proximal urethral sagittal angle (more aligned with axial plane) (P=.01), and a lower proximal urethra position (P=.04) and mid-urethra position (P=.03). Poorer stress and urgency urinary outcomes were associated with a shorter urethral length (P=.01), a more posterior-inferior urethral position (all P<.05), increased “C” or “S”-shaped urethral concavity (P=.008; P=.006), and smaller rest-to-strain displacement of the proximal (P=.03) and distal (P=.009) urethra. Conclusions: Urethral morphology and support differed with concomitant midurethral sling (vs no sling) and stress urinary incontinence after vaginal surgery. Urethral characteristics were also associated with postoperative urinary symptoms. Urethral configuration may influence urinary outcomes and could be considered during prolapse and stress urinary incontinence repairs. CONDENSATION PAGE: TWEETABLE STATEMENT: Vaginal prolapse repair with midurethral sling (vs without) was linked to a larger, straighter urethra, and better urinary outcomes. Poorer urinary outcomes were linked to a shorter, “C”- or “S”-shaped urethra. SHORT TITLE: Urethral Morphology Associated with Midurethral Sling and Postoperative Urinary Outcomes AJOG AT A GLANCE: A. Why was this study conducted?: Some women experience urinary incontinence after prolapse repair with or without a concomitant midurethral sling. It remains unclear how midurethral sling surgery alters urethral morphology and support, and how these changes relate to postoperative urinary symptoms. B. What are the key findings?: This magnetic resonance imaging study compared postoperative urethral characteristics (morphology, support) and urinary outcomes among women after vaginal prolapse repair with and without concomitant midurethral sling. Among women without prolapse recurrence, midurethral sling (vs no sling) was associated with larger urethral dimensions, a straighter, better-supported urethra, and superior urinary outcomes. Poorer urinary outcomes were associated with a shorter, curvier urethra and worse urethral support. C. What does this study add to what is already known?: Postoperative urethral morphology and support differ by midurethral sling and were associated with urinary outcomes after vaginal prolapse repair. Urethral configuration warrants surgical consideration in prolapse and urinary incontinence repairs.

Importance: Mixed urinary incontinence (MUI) is common and can be challenging to manage. Objectives: We present the protocol design and rationale of a trial comparing the efficacy of 2 procedures for the treatment of women with MUI refractory to oral treatment. The Midurethral sling versus Botulinum toxin A (MUSA) trial compares the efficacy of intradetrusor injection of 100 U of onabotulinimtoxinA (an office-based procedure directed at the urgency component) versus midurethral sling (MUS) placement (a surgical procedure directed at the stress component). Study Design: The MUSA is a multicenter, randomized trial of women with MUI electing to undergo procedural treatment for MUI at 7 clinical centers in the NICHD Pelvic Floor Disorders Network. Participants are randomized to either onabotulinumtoxinA 100 U or MUS. OnabotulinimtoxinA recipients may receive an additional injection between 3 and 6 months. Participants may receive additional treatment (including crossover to the alternative study intervention) between 6 and 12 months. The primary outcome is change from baseline in Urogenital Distress Inventory (UDI) at 6 months. Secondary outcomes include change in UDI at 3 and 12 months, irritative and stress subscores of the UDI, urinary incontinence episodes, predictors of poor treatment response, quality of life and global impression outcomes, adverse events, use of additional treatments, and cost effectiveness. Results: Recruitment and randomization of 150 participants is complete and participants are currently in the follow-up phase. Conclusions: This trial will provide information to guide care for women with MUI refractory to oral treatment who seek surgical treatment with either onabotulinumtoxinA or MUS.

Purpose:Sacral neuromodulation and intradetrusor onabotulinumtoxinA injection are therapies for refractory urgency urinary incontinence. Sacral neuromodulation involves surgical implantation of a d...

(Abstracted from JAMA 2019;322:1054–1065) Two surgical options for patients with uterovaginal prolapse are vaginal hysterectomy with suture apical suspension or transvaginal mesh hysteropexy, a uterine preservation procedure. An analysis of a US database from 2007 to 2011 estimated that 13% of women underwent pelvic organ prolapse surgery by the age of 80 years.

Purpose: Objective physical activity data for women with urinary incontinence are lacking. We investigated the relationship between physical activity, sedentary behavior, and the severity of urinary symptoms in older community-dwelling women with urinary incontinence using accelerometers. Materials and Methods: This is a secondary analysis of a study that measured physical activity (step count, moderate-to-vigorous physical activity time) and sedentary behavior (percentage of sedentary time, number of sedentary bouts per day) using a triaxial accelerometer in older community-dwelling adult women not actively seeking treatment of their urinary symptoms. The relationship between urinary symptoms and physical activity variables was measured using linear regression. Results: Our cohort of 35 community-dwelling women (median, age, 71 years) demonstrated low physical activity (median daily step count, 2168; range, 687–5205) and high sedentary behavior (median percentage of sedentary time, 74%; range, 54%–89%). Low step count was significantly associated with nocturia (P = 0.02). Shorter duration of moderate-to-vigorous physical activity time was significantly associated with nocturia (P = 0.001), nocturnal enuresis (P = 0.04), and greater use of incontinence products (P = 0.04). Greater percentage of time spent in sedentary behavior was also significantly associated with nocturia (P = 0.016). Conclusions: Low levels of physical activity are associated with greater nocturia and nocturnal enuresis. Sedentary behavior is a new construct that may be associated with lower urinary tract symptoms. Physical activity and sedentary behavior represent potential new targets for treating nocturnal urinary tract symptoms.