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Impact of surgery for stress incontinence on morbidity: cohort study

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7121.1493 (Published 06 December 1997) Cite this as: BMJ 1997;315:1493
  1. Nick Black, professor of health services research (n.black{at}lshtm.ac.uk)a,
  2. Joanne Griffiths, research fellowa,
  3. Catherine Pope, research fellowa,
  4. Ann Bowling, senior lecturer in health services researcha,
  5. Paul Abel, reader in urologyb
  1. a Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. b Department of Surgery, Royal Postgraduate Medical School, London W12 0NN
  1. Correspondence to: Professor Black
  • Accepted 29 July 1997

Abstract

Objectives: To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications.

Design: Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery.

Setting: 18 hospitals in the North Thames region.

Subjects: 442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278.

Main outcome measures: Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures.

Results: Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously.

Conclusions: Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised.

Key messages

  • Although surgery improves stress incontinence in most women (87%), only 28% are continent one year later

  • The need for preoperative urodynamic testing should be reappraised

  • Urgency and urge incontinence should not be considered contraindications to surgery

  • Women considering surgery should receive more accurate information on the probability of an improvement in symptoms and possible complications

  • There is a need for a rigorous, pragmatic, randomised trial of surgery for stress incontinence

Footnotes

    • Accepted 29 July 1997
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