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Mixed urinary incontinence—time to uncouple urgency from stress?

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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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.

Author information

Correspondence to Peter Emanuel Papa Petros.

Electronic supplementary material

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 [39]. Video 3 aims to explain the mechanism of neourgency after a midurethral sling.

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)

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 Control of DO

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 Causation of DO

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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Keywords

  • Mixed incontinence
  • Urinary urge incontinence
  • Urgency
  • Stress incontinence