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PAPERS: Nick Black, Joanne Griffiths, Catherine Pope, Ann Bowling, and Paul Abel Impact of surgery for stress incontinence on morbidity: cohort study BMJ 1997; 315: 1493-1498 [Abstract] [Full text]

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Diagnosis should precede treatment

Douglas G Tincello   (2 May 1998)

Diagnosis should precede treatment 2 May 1998
Douglas G Tincello, Specialist Registrar (Year 4) Urodynamic Department, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS Send response to journal: Re: Diagnosis should precede treatment	I am astonished that six months have gone by without any response to the article by Black et al [1] being published. The paper makes some challenging assertions. The authors state that previous studies have been of poor quality yet themselves report data from patients on the basis of symptoms alone. It is well established that urinary symptoms alone are of little value in reaching a diagnosis of either genuine stress incontinence (GSI) or detrusor instability (DI) [2]. Thus the patients included will contain a mixture of those with GSI, DI and other conditons and since roughly 65% of patients have GS the proportion of patients in the improved or not improved groups may well be different. The resulting bias will distort the results of both surgery and of the study, and therefore perhaps mask the risks of surgery in patients with DI. The authors continue by stating on the basis of this data that urgency is not a contraindication to surgery, and conclude by questioning the value of cystometry. We would argue strongly against these two assertions based upon data from such a poorly defined study, particularly where the authors show themselves to be unfamiliar with the difficulties of reaching diagnoses in these patients. We agree that the symptoms of urgency and urge incontinence are not contraindications to surgery since many patients with GSI will complain of these. However, a diagnosis of DI is certainly a relative contraindication to surgery [3] and, as previously stated, this cannot be diagnosed on history alone [2]. Cystometry will exclude instability in addition to providing important information on voiding flow rates and pressures, which is importance when trying to minimise postoperative retention. The benefit of reaching a proper diagnosis and of identifying potential voiding disturbances mean that preoperative cystometry is and should remain an essential investigation in the management of women with urinary complaints. 1. Black N, Griffiths J, Pope C, Bowling A, Abel P. Impact of surgery for stress incontinence on morbidity: cohort study. Br Med J 1997;315:1493-1498. 2. Sand PK, Hill RC, Ostergard DR. Incontinence history as a predictor of detrusor instability. Obstet Gynecol 1988;71:257-259. 3. Cardozo LD, Stanton SL. Genuine stress incontinence and detrusor instability: a review of 200 patients. Br J Obstet Gynaecol 1980;87:184-190. Douglas Tincello