Skip to main content
Top
Published in: International Urogynecology Journal 8/2011

01-08-2011 | Clinical Opinion

Mixed urinary incontinence—time to uncouple urgency from stress?

Author: Peter Emanuel Papa Petros

Published in: International Urogynecology Journal | Issue 8/2011

Login to get access

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.
Appendix
Available only for authorised users
Literature
1.
go back to reference Abrams P, Cardozo L, Fall M et al (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International Continence Society. Neurourol Urodyn 21:167–178PubMedCrossRef Abrams P, Cardozo L, Fall M et al (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International Continence Society. Neurourol Urodyn 21:167–178PubMedCrossRef
2.
go back to reference Khullar V, Cardozo L, Dmochowski R (2010) Mixed incontinence: current evidence and future perspectives. Neurourol Urodyn 29:618–622PubMedCrossRef Khullar V, Cardozo L, Dmochowski R (2010) Mixed incontinence: current evidence and future perspectives. Neurourol Urodyn 29:618–622PubMedCrossRef
3.
go back to reference Lee J, Dwyer P, Rosamilia A, Lim Y, Polyakov A, Stav K (2011) Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis. BJOG. doi:10.1111/j.1471-0528.2011.02915.x Lee J, Dwyer P, Rosamilia A, Lim Y, Polyakov A, Stav K (2011) Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis. BJOG. doi:10.​1111/​j.​1471-0528.​2011.​02915.​x
4.
go back to reference Eboue C, Marcus-Braun N, von Theobald P (2010) Cystocele repair by transobturator four arms mesh: monocentric experience of first 123 patients. Int Urogynecol J 21:85–93PubMedCrossRef Eboue C, Marcus-Braun N, von Theobald P (2010) Cystocele repair by transobturator four arms mesh: monocentric experience of first 123 patients. Int Urogynecol J 21:85–93PubMedCrossRef
5.
go back to reference Petros PE, Ulmsten U (1993) The posterior fornix syndrome: a multiple symptom complex of pelvic pain and abnormal urinary symptoms deriving from laxity in the posterior fornix. Scand J Urol Nephrol 27:89–93, Supplement No 153-PART IVCrossRef Petros PE, Ulmsten U (1993) The posterior fornix syndrome: a multiple symptom complex of pelvic pain and abnormal urinary symptoms deriving from laxity in the posterior fornix. Scand J Urol Nephrol 27:89–93, Supplement No 153-PART IVCrossRef
6.
go back to reference Sivaslioglu AA, Gelisen O, Dolen I, Dede H, Dilbaz S, Haberal A (2005) Posterior sling (infracoccygeal sacropexy): an alternative procedure for vaginal vault prolapse. Aust NZ J Obstet Gynaecol 45:159–160CrossRef Sivaslioglu AA, Gelisen O, Dolen I, Dede H, Dilbaz S, Haberal A (2005) Posterior sling (infracoccygeal sacropexy): an alternative procedure for vaginal vault prolapse. Aust NZ J Obstet Gynaecol 45:159–160CrossRef
7.
go back to reference Farnsworth BN (2002) Posterior intravaginal slingplasty (infracoccygeal sacropexy) for severe posthysterectomy vaginal vault prolapse—a preliminary report on efficacy and safety. Int Urogynecol J Pelvic Floor Dysfunct 13:4–8PubMedCrossRef Farnsworth BN (2002) Posterior intravaginal slingplasty (infracoccygeal sacropexy) for severe posthysterectomy vaginal vault prolapse—a preliminary report on efficacy and safety. Int Urogynecol J Pelvic Floor Dysfunct 13:4–8PubMedCrossRef
8.
go back to reference Inoue H, Sekiguchi Y, Kohata Y, Satono Y, Hishikawa K, Tominaga T, Oobayashi M (2009) Tissue fixation system (TFS) to repair uterovaginal prolapse with uterine preservation: a preliminary report on perioperative complications and safety. J Obstet Gynaecol Res 35(2):346–353PubMedCrossRef Inoue H, Sekiguchi Y, Kohata Y, Satono Y, Hishikawa K, Tominaga T, Oobayashi M (2009) Tissue fixation system (TFS) to repair uterovaginal prolapse with uterine preservation: a preliminary report on perioperative complications and safety. J Obstet Gynaecol Res 35(2):346–353PubMedCrossRef
9.
go back to reference Petros PEP, Richardson PA (2010) TFS posterior sling improves overactive bladder, pelvic pain and abnormal emptying, even with minor prolapse. A prospective urodynamic study. Pelviperineology 29:52–55 Petros PEP, Richardson PA (2010) TFS posterior sling improves overactive bladder, pelvic pain and abnormal emptying, even with minor prolapse. A prospective urodynamic study. Pelviperineology 29:52–55
10.
go back to reference Petros PE (2010) Diagnosis. In: Petros PE (ed) The female pelvic floor, 3rd edn. Springer, Heidelberg, 84–93, 99–101CrossRef Petros PE (2010) Diagnosis. In: Petros PE (ed) The female pelvic floor, 3rd edn. Springer, Heidelberg, 84–93, 99–101CrossRef
11.
go back to reference Popper KR (1980) A survey of some fundamental problems. On the problem of a theory of scientific method. Theories. Falsifiability. The problem of the empirical basis. Degrees of testibility. Simplicity. The Logic of Scientific Discovery. Unwin and Hyman, London. 27–146 Popper KR (1980) A survey of some fundamental problems. On the problem of a theory of scientific method. Theories. Falsifiability. The problem of the empirical basis. Degrees of testibility. Simplicity. The Logic of Scientific Discovery. Unwin and Hyman, London. 27–146
12.
go back to reference Petros PE, Von Konsky B (1999) Anchoring the midurethra restores bladder-neck anatomy and continence. Lancet 354(9183):997–998PubMedCrossRef Petros PE, Von Konsky B (1999) Anchoring the midurethra restores bladder-neck anatomy and continence. Lancet 354(9183):997–998PubMedCrossRef
13.
go back to reference Petros PE, Ulmsten U (1993) Bladder instability in women: a premature activation of the micturition reflex. Neurourol Urodyn 12:235–239PubMedCrossRef Petros PE, Ulmsten U (1993) Bladder instability in women: a premature activation of the micturition reflex. Neurourol Urodyn 12:235–239PubMedCrossRef
14.
go back to reference Petros PE (1999) Detrusor instability and low compliance may represent different levels of disturbance in peripheral feedback control of the micturition reflex. Neurourol Urodyn 18:81–91CrossRef Petros PE (1999) Detrusor instability and low compliance may represent different levels of disturbance in peripheral feedback control of the micturition reflex. Neurourol Urodyn 18:81–91CrossRef
Metadata
Title
Mixed urinary incontinence—time to uncouple urgency from stress?
Author
Peter Emanuel Papa Petros
Publication date
01-08-2011
Publisher
Springer-Verlag
Published in
International Urogynecology Journal / Issue 8/2011
Print ISSN: 0937-3462
Electronic ISSN: 1433-3023
DOI
https://doi.org/10.1007/s00192-011-1449-5

Other articles of this Issue 8/2011

International Urogynecology Journal 8/2011 Go to the issue

Editorial

Plagiarism