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Urinary incontinence after hysterectomy

Published:November 14, 2016DOI:https://doi.org/10.1016/j.ajog.2016.11.1023
      To the Editors:
      We read with interest the article of Bohlin et al
      • Bohlin K.S.
      • Ankardal M.
      • Lindkvist H.
      • Milsom I.
      Factors influencing the incidence and remission of urinary incontinence after hysterectomy.
      about urinary incontinence (UI) after hysterectomy. Based on a large cohort study, the authors stated that several factors, including vaginal delivery, body mass index, and preoperative urgency, influenced the rate of UI after hysterectomy. However, the authors did not underline the confusion made between urge UI (UUI) and stress UI (SUI). It is mandatory to comment on this point, because the absence of distinction between UUI and SUI can be misleading for several reasons.
      First, distinguishing SUI and UUI (and their association, called mixed incontinence) is of importance because both are highly prevalent and often associated. The prevalence of overactive bladder (OAB), ie, urgency with or without incontinence, is estimated to be 11.8%,
      • Irwin D.E.
      • Milsom I.
      • Hunskaar S.
      • et al.
      Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study.
      varying from 1.8-30.5% in a recent article by Milsom et al.
      • Milsom I.
      • Coyne K.S.
      • Nicholson S.
      • Kvasz M.
      • Chen C.I.
      • Wein A.J.
      Global prevalence and economic burden of urgency urinary incontinence: a systematic review.
      Separating SUI and UUI would thus have led to groups of similar size based on patient characteristics and would have likely influence the results in a logistic regression analysis.
      Then, the pathophysiology of UUI and SUI is completely different, as are the therapeutic resources.
      • Norton P.
      • Brubaker L.
      Urinary incontinence in women.
      While SUI has a complex but known interaction with pelvic organ prolapse, UUI belongs to the field of OAB and has very unclear links with pelvic organ prolapse and other gynecologic disorders, based on low-level inconsistent evidence.

      Burkhard FC, Lucas MG, Berghmans LC, et al. European Association of Urology guidelines. Urinary incontinence. Available at: http://uroweb.org/guideline/urinary-incontinence/#4. Accessed Sept. 27, 2016.

      Lastly, the authors consider “daily urge” as a criterion in their logistic regression analysis. As a component of OAB, but not necessarily associated with UUI, this parameter cannot be interpreted correctly in the current context. Indeed, this category can reflect OAB without incontinence, that is idiopathic in the vast majority of cases and would not be impacted by hysterectomy. On the other hand, this category of “daily urge” surely includes all patients with UUI, but their proportion can only be postulated. Unfortunately, this “daily urge” status is not available in the postoperative setting. Furthermore, the absence of data regarding antimuscarinic therapy is also another important caveat.
      Not taking into account that UUI and SUI are 2 different diseases blurs the analysis and limits sound conclusions.

      References

        • Bohlin K.S.
        • Ankardal M.
        • Lindkvist H.
        • Milsom I.
        Factors influencing the incidence and remission of urinary incontinence after hysterectomy.
        Am J Obstet Gynecol. 2016;
        • Irwin D.E.
        • Milsom I.
        • Hunskaar S.
        • et al.
        Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study.
        Eur Urol. 2006; 50: 1306-1314
        • Milsom I.
        • Coyne K.S.
        • Nicholson S.
        • Kvasz M.
        • Chen C.I.
        • Wein A.J.
        Global prevalence and economic burden of urgency urinary incontinence: a systematic review.
        Eur Urol. 2014; 65: 79-95
        • Norton P.
        • Brubaker L.
        Urinary incontinence in women.
        Lancet. 2006; 367: 57-67
      1. Burkhard FC, Lucas MG, Berghmans LC, et al. European Association of Urology guidelines. Urinary incontinence. Available at: http://uroweb.org/guideline/urinary-incontinence/#4. Accessed Sept. 27, 2016.

      Linked Article

      • Factors influencing the incidence and remission of urinary incontinence after hysterectomy
        American Journal of Obstetrics & GynecologyVol. 216Issue 1
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          Studies on the influence of body mass index, smoking, and mode of delivery on the occurrence of urinary incontinence after hysterectomy are required to provide women with information about how these factors influence continence after a hysterectomy.
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      • Reply
        American Journal of Obstetrics & GynecologyVol. 216Issue 4
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          We thank Dr Jean-Nicolas Cornu and colleagues1 for their comments regarding our article entitled “Factors influencing the incidence and remission of urinary incontinence after hysterectomy”2 published in the American Journal of Obstetrics and Gynecology.
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