Abstract
The onset of de novo irritative voiding symptoms after anti-incontinence surgery for stress urinary incontinence is troubling to both patient and physician alike. At present, mechanisms responsible for the development of these symptoms are incompletely elucidated. Although bladder outlet obstruction may certainly be a cause, correct diagnosis and treatment of this condition in its more insidious manifestation may be difficult. In addition, alternative etiologic factors related to surgical technique during outlet enhancing surgery may play a role, prompting a rethinking of these procedures. In this discussion, we review changes in voiding physiology and mechanisms for voiding dysfunction after anti-incontinence surgery, emphasizing de novo urge syndrome and detrusor instability. In addition, we present our approach to the evaluation, diagnosis, and treatment of these challenging patients.
Similar content being viewed by others
References and Recommended Reading
Richter HE, Varner RE, Sanders E, et al.: Effects of pubovaginal sling procedure on patients with urethral hypermobility and intrinsic sphincteric deficiency: would they do it again? Am J Obstet Gynecol 2001, 184:14–19.
McGuire EJ, Letson W, Wang S: Transvaginal urethrolysis after obstructive urethral suspension procedures. J Urol 1989, 142:1037–1038.
Pope AJ, Shaw PJR, Coptcoat MJ, et al.: Changes in bladder function following a surgical alteration in ouflow resistance. Neurourol Urodyn 1990, 9:503–508.
Klutke JJ, Klutke CG, Bergman J, et al.: Bladder neck suspension for stress urinary incontinence: how does it work? Neurourol Urodyn 1999, 18:623–627.
Belair G, Tessier J, Bertrand PE, et al.: Retropubic cystourethropexy: is it an obstructive procedure? J Urol 1997, 158:533–538.
Cardozo LD, Stanton SL, Williams JE: Detrusor instability following surgery for genuine stress incontinence. Br J Urol 1979, 51:204–207.
Bump RC, Hurt WG, Elser DM, et al.: Understanding lower urinary tract function in women soon after bladder neck surgery. Neurourol Urodyn 1999, 18:629–637. Analyzing pre- and postoperative urodynamics in patients who underwent surgery for SUI, the authors found that anti-incontinence surgery achieves success by urethral obstruction and that degree of obstruction will determine clinical efficacy and risk for postoperative voiding dysfunction.
Kuo HC: Videourodynamic results after pubovaginal sling procedure for stress urinary incontinence. Urology 1999, 54:802–807. One of only a handful of studies evaluating patients undergoing pubovaginal sling surgery with videourodynamics in a prospective fashion. This paper demonstrated that a properly positioned pubovaginal sling tied without tension should not result in an increase in urethral resistance during normal voiding.
Weinberger MW, Ostergard DR: Long-term clinical and urodynamic evaluation of the polytetrafluroethylene suburethral sling for treatment of genuine stress incontinence. Obstet Gynecol 1995, 86:92–96.
Hilton P: A clinical and urodynamic study comparing the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence. Br J Obstet Gynaecol 1989, 96:213–220.
Nitti VW, Tu LM, Gitlin J: Diagnosing bladder outlet obstruction in women. J Urol 1999, 161:1535–1540. This paper describes a practical approach to correctly diagnosing the presence and anatomic location of BOO in women using videourodynamics.
Groutz A, Blaivas JG, Chaikin DC: Bladder outlet obstruction in women: definition and characteristics. Neurourol Urodyn 2000, 19:213–220.
Goldman HB, Rackley RR, Appell RA: The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction. J Urol 1999, 161:196–199.
Ulmsten U, Petros P: Intravaginal sling plasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol 1995, 29:75–82.
Wang AC: An assessment of the early surgical outcome and urodynamic effects of the tension-free vaginal tape (TVT). Int Urogynecol J Pelvic Floor Dysfunct 2000, 11:282–284.
Lo TS, Wang AC, Horng SG, et al.: Ultrasonographic and urodynamic evaluation after tension free vagina tape procedure (TVT). Acta Obstet Gynecol Scand 2001, 80:65–70.
Monga AK, Stanton SL: Urodynamics: prediction, outcome and analysis of mechanism for cure of stress incontinence by periurethral collagen. Br J Obstet Gynaecol 1997, 104:158–162.
Swami S, Batista JE, Abrams P: Collagen for female genuine stress incontinence after a minimum 2-year follow-up. Br J Urol 1997, 80:757–761.
Webster GD, Kreder KJ: Voiding dysfunction following cystourethropexy: evaluation and management . J Urol 1990, 144:670–673.
Brown K, Hilton P: The incidence of detrusor instability before and after colposuspension: a study using conventional and ambulatory urodynamic monitoring. BJU Int 1999, 84:961–965.
Couillard DR, Webster GD: Detrusor instability. Urol Clin North Am 1995, 22:593–612.
Harrison SCW, Hunnam GR, Farman P, et al.: Bladder instability and denervation in patients with bladder outflow obstruction. Br J Urol 1987, 60:519–522.
Speakman MJ, Brading AF, Guilpin CJ, et al.: Bladder outflow obstruction: a cause of denervation supersensitivity. J Urol 1987, 138:1461–1466.
Calvert RC, Thompson CS, Khan MA, et al.: Alterations in cholinergic and purinergic signaling in a model of the obstructed bladder. J Urol 2001, 166:1530–1533.
O’Reilly BA, Kosaka AH, Chang TK, et al.: A quantitative analysis of purinoceptor expression in the bladders of patients with symptomatic outlet obstruction. BJU Int 2001, 87:617–622.
Sutherland RS, Baskin LS, Kogan BA, et al.: Neuroanatomical changes in the rat bladder after bladder outlet obstruction. Br J Urol 1998, 82:895–901.
Chaikin DC, Rosenthal J, Blaivas JG: Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol 1998, 160:1312–1316.
Langer R, Ron-El R, Newman M, et al.: Detrusor instability following colposuspension for urinary stress incontinence. Br J Obstet Gynaecol 1988, 95:607–610.
Morgan TO, Westney LO, McGuire EJ: Pubovaginal sling: 4-year outcome analysis and quality of life assessment. J Urol 2000, 163:1845–1848.
Mills IW, Greenland JE, McMurray, et al.: Studies of the pathophysiology of idiopathic detrusor instability: the physiological properties of the detrusor smooth muscle and its pattern of innervation. J Urol 2000, 163:646–651.
Morley R, Cumming J, Weller R: Morphology and neuropathology of the pelvic floor in patients with stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996, 7:3–12.
Artibani W: Diagnosis and significance of idiopathic overactive bladder. Urology 1997, 50(Suppl 6A):25–32.
Nitti VW, Raz S: Obstruction following anti-incontinence procedures: diagnosis and treatment with transvaginal urethrolysis. J Urol 1994, 152:93–98.
Abrams PH, Blaivas JG, Stanton SL, Andersen JT: Standardization of terminology of lower urinary tract function. Neurourol Urodyn 1988, 7:403–427.
Chassagne S, Bernier PA, Haab F, et al.: Proposed cutoff values to define bladder outlet obstruction in women. Urology 1998, 51:408–411.
Lemack GE, Zimmern PE: Pressure flow analysis may aid in identifying women with outflow obstruction. J Urol 2000, 163:1823–1828. Using pressure-flow analysis, the authors propose cutoff values for diagnosing BOO in women, but indicate that these values must be used in conjunction with the overall clinical picture.
Axelrod SL, Blaivas JG: Bladder neck obstruction in women. J Urol 1987, 137:497–499.
Siegel SW, Catanzaro F, Dijkema HE, et al.: Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology 2000, 56(6 Suppl 1):87–91.
Phelan MW, Franks M, Somogyi GT, et al.: Botulinum toxin urethral sphincter injection to restore bladder emptying in men and women with voiding dysfunction. J Urol 2001, 165:1107–1110.
Foster HE, McGuire EJ: Management of urethral obstruction with transvaginal urethrolysis. J Urol 1993, 150:1448–1451.
Zimmern PE, Hadley HR, Leach GE, et al.: Female urethral obstruction after Marshall-Marchetti-Krantz operation. J Urol 1987, 138:517–520.
Liapis A, Bakas P, Pafiti A, et al.: Changes of collagen type III in female patients with genuine stress incontinence and pelvic floor prolapse. Eur J Obstet Gyncol Reprod Biol 2001, 97:76–79.
Falconer C, Ekman G, Malmstom A, et al.: Decreased collagen synthesis in stress incontinent women. Obstet Gynecol 1994, 84:583–586.
Stenzel A, Colleselli K, Poisel S, et al.: Rationale and technique of nerve sparing radical cystectomy before an orthotopic neo-bladder procedure in women. J Urol 1995, 154:2044–2049.
Lassman G: Muscle spindles and sensory nerve endings in the external urethral sphincter [in German]. Acta Neuropathol (Berlin)1984, 63:344–346.
de Groat WC, Booth AM, Yoshimura N: Neurophysiology of micturition and its modification in animal models of human disease. In The Autonomic Nervous System, vol 3. Edited by Maggi CA. London: Harwood Academic Publishers; 1993:227–290.
Mahony DT, Laferte RO, Blais DJ: Integral storage and voiding reflexes. Neurophysiologic concept of continence and micturition. Urology 1977, 9:95–106.
Jung SY, Fraser MO, Ozawa H, et al.: Urethral afferent nerve activity affects the micturition reflex: implication for the relationship between stress incontinence and detrusor instability. J Urol 1999, 162:204–212. This study provides experimental evidence linking urethral afferent activity to the modulation of reflex detrusor contractility. The authors’ findings imply a mechanism for the correction of DI via surgical treatment of stress incontinence, and emphasize the key role that urethral innervation may play in ultimate bladder function.
Serels SR, Rackley RR, Appell RA: Surgical treatment for stress urinary incontinence associated with valsalva induced detrusor instability. J Urol 2000, 163:884–887. The occurrence of postoperative de novo urge syndrome may be limited by utilizing a modified technique for pubovaginal sling surgery with preservation of the anatomic integrity of the endopelvic fascia.
Klutke JJ, Ramos S: Urodynamic outcome after surgery for severe prolapse and potential stress incontinence. Am J Obstet Gynecol 2000, 182:1378–1381.
Maher CF, Dwyer PL, Carey MP, Moran PA: Colposuspension or sling for low urethral pressure stress incontinence? Int Urogynecol J Pelvic Floor Dysfunct 1999, 10:384–389.
Maher C, Carey M, Dwyer P, et al.: Pubovaginal or vicryl mesh rectus fascia sling in intrinsic sphincter deficiency. Int Urogynecol J Pelvic Floor Dysfunct 2001, 12:111–116.
Mason RC, Roach M: Modified pubovaginal sling for treatment of intrinsic sphincteric deficiency. J Uro1 1996, 156:1991–1994.
Gilja I: Transvaginal needle suspension operation: the way we do it. Clinical and urodynamic study: long-term results. Eur Urol 2000, 37:325–330.
Holschneider CH, Solh S, Lebherz TB, et al.: The modified Pereyra procedure in recurrent stress urinary incontinence: a 15-year review. Obstet Gynecol 1994, 83:573–578.
Nguyen JK, Hall CD, Bhatia NN: Transvaginal bladder neck suspension to Cooper’s ligament: a review of the literature. Int Urogynecol J Pelvic Floor Dysfunct 2000, 11:320–324.
Klutke JJ, Bergman J, Klutke CG: Transvaginal bladder neck suspension with Cooper’s ligament fixation. Long-term urodynamic results. J Reprod Med 2000, 45:541–545.
Kaplan SA, Te AE, Young GP, et al.: Prospective analysis of 373 consecutive women with stress urinary incontinence treated with a vaginal wall sling: the Columbia-Cornell University experience. J Urol 2000, 164:1623–1627.
Juma S, Little NA, Raz S: Vaginal wall sling: four years later. Urology 1992, 39:424–428.
Vasavada SP, Rackley RR, Appell RA: In situ vaginal wall sling formation with preservation of the endopelvic fascia for treatment for stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1998, 9:379–384.
Smith DN, Appell RA, Winters JC, et al.: Collagen injection therapy for female intrinsic sphincteric deficiency. J Urol 1997, 157:1275–1278.
Haab F, Sananes S, Amarenco G, et al.: Results of the tensionfree vaginal tape procedure for the treatment of type II stress urinary incontinence at a minimum followup of 1 year. J Urol 2001, 165:159–162.
Moran PA, Ward KL, Johnson D, et al.: Tension-free vaginal tape for primary genuine stress incontinence: a two-centre follow-up study. BJU Int 2000, 86:39–42.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Kershen, R.T., Appell, R.A. De novo urge syndrome and detrusor instability after anti-incontinence surgery: Current concepts, evaluation, and treatment. Curr Urol Rep 3, 345–353 (2002). https://doi.org/10.1007/s11934-002-0075-7
Issue Date:
DOI: https://doi.org/10.1007/s11934-002-0075-7