Abstract
Introduction
“Mixed incontinence” is defined as a combination of stress and urge symptoms. Over time, it has morphed into a single entity, encompassing etiology and treatment. My perspectives are: (a) Stress incontinence (SI) and urge incontinence (UI) are different symptoms with often different anatomical causation and so should be treated separately; (b) It is illogical to group urgency with SI. Urgency may also be associated with frequency, nocturia, abnormal emptying and pelvic pain in patients with no SI (“posterior fornix syndrome”); and (c) There is growing evidence that urgency may be cured by surgical correction of a cystocele and/or apical prolapse in up to 80% of patients who do not have SI. In this anatomical context, sensory urgency, urge incontinence and urodynamic detrusor overactivity may all be hypothesized as different manifestations of a prematurely activated micturition reflex, caused by a lax vagina’s inability to support bladder base stretch receptors. This statement can be tested with a simple clinical test, “simulated operations”, whereby digitally supporting in turn the midurethra, bladder base and posterior vaginal fornix may cause a significant decrease in the urgency felt by the patient.
Conclusions
The term “mixed incontinence” is only valid if both symptoms are caused by a lax pubourethral ligament. However, urgency may be caused by laxity in other parts of the vagina. Regarding stress and urge as separate entities will remove the confusion resulting from this definition, creating new directions for science and therapy.
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References
Abrams P, Cardozo L, Fall M et al (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International Continence Society. Neurourol Urodyn 21:167–178
Khullar V, Cardozo L, Dmochowski R (2010) Mixed incontinence: current evidence and future perspectives. Neurourol Urodyn 29:618–622
Lee J, Dwyer P, Rosamilia A, Lim Y, Polyakov A, Stav K (2011) Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis. BJOG. doi:10.1111/j.1471-0528.2011.02915.x
Eboue C, Marcus-Braun N, von Theobald P (2010) Cystocele repair by transobturator four arms mesh: monocentric experience of first 123 patients. Int Urogynecol J 21:85–93
Petros PE, Ulmsten U (1993) The posterior fornix syndrome: a multiple symptom complex of pelvic pain and abnormal urinary symptoms deriving from laxity in the posterior fornix. Scand J Urol Nephrol 27:89–93, Supplement No 153-PART IV
Sivaslioglu AA, Gelisen O, Dolen I, Dede H, Dilbaz S, Haberal A (2005) Posterior sling (infracoccygeal sacropexy): an alternative procedure for vaginal vault prolapse. Aust NZ J Obstet Gynaecol 45:159–160
Farnsworth BN (2002) Posterior intravaginal slingplasty (infracoccygeal sacropexy) for severe posthysterectomy vaginal vault prolapse—a preliminary report on efficacy and safety. Int Urogynecol J Pelvic Floor Dysfunct 13:4–8
Inoue H, Sekiguchi Y, Kohata Y, Satono Y, Hishikawa K, Tominaga T, Oobayashi M (2009) Tissue fixation system (TFS) to repair uterovaginal prolapse with uterine preservation: a preliminary report on perioperative complications and safety. J Obstet Gynaecol Res 35(2):346–353
Petros PEP, Richardson PA (2010) TFS posterior sling improves overactive bladder, pelvic pain and abnormal emptying, even with minor prolapse. A prospective urodynamic study. Pelviperineology 29:52–55
Petros PE (2010) Diagnosis. In: Petros PE (ed) The female pelvic floor, 3rd edn. Springer, Heidelberg, 84–93, 99–101
Popper KR (1980) A survey of some fundamental problems. On the problem of a theory of scientific method. Theories. Falsifiability. The problem of the empirical basis. Degrees of testibility. Simplicity. The Logic of Scientific Discovery. Unwin and Hyman, London. 27–146
Petros PE, Von Konsky B (1999) Anchoring the midurethra restores bladder-neck anatomy and continence. Lancet 354(9183):997–998
Petros PE, Ulmsten U (1993) Bladder instability in women: a premature activation of the micturition reflex. Neurourol Urodyn 12:235–239
Petros PE (1999) Detrusor instability and low compliance may represent different levels of disturbance in peripheral feedback control of the micturition reflex. Neurourol Urodyn 18:81–91
Acknowledgements
I gratefully acknowledge the permission from Dr. Monteiro, Portugal and Professor Palma, Brazil to use the videos which accompany this work.
Conflicts of interest
P.E. Petros is the author of the textbook The Female Pelvic Floor. He is also a consultant to TFS surgical.
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Videos
The aim of videos 1 and 2 is to provide further insights into the mechanisms for the surgical cure of stress, urge and DO as reported [3–9]. Video 3 aims to explain the mechanism of neourgency after a midurethral sling.
Video 1 Control of stress incontinence
Video 1 simulates how a midurethral sling can cure the SI component of mixed incontinence. Pressure at midurethra restores urethrovesical geometry and continence with effort [12] (by permission Professor Palma, Brazil) (M1V 4,364 kb)
Video 2 explains in the most direct way how a midurethral sling can cure the urge component, indeed, the DO of mixed incontinence. It also demonstrates that if there is sufficient support at bladder base, the stretch receptors can be prevented from firing off prematurely, supporting the concept of DO as a premature activation of the micturition reflex [13] (by permission Dr. Monteiro, Portugal) (MPG 10,349 kb)
Video 3 aims to provide some insights into the mechanism of neourgency after a midurethral sling. Excessive pressure applied on the vaginal membrane from below caused DO and urine loss, presumably by stimulation of the bladder base stretch receptors. There is a fine balance between the support of stretch receptors, video 2, and stimulation thereof, video 3 (by permission Dr. Monteiro, Portugal) (MOV 529 kb)
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Petros, P.E.P. Mixed urinary incontinence—time to uncouple urgency from stress?. Int Urogynecol J 22, 919–921 (2011). https://doi.org/10.1007/s00192-011-1449-5
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DOI: https://doi.org/10.1007/s00192-011-1449-5