The statement also noted that the American Urogynecologic Society "supports an improved approval process for these devices – one that includes better and longer term randomized trials of new surgical devices and materials before going to market," as well as improved postmarket surveillance through registries and national databases.
• Retropubic urethropexy (Burch procedure). Head-to-head studies have found the Burch procedure to be equally effective, compared with the synthetic retropubic sling, "but it’s a little more invasive," Dr. Iglesia said. "It requires skin incisions from above, through which the bladder neck is sutured to a ligament by the pubic bone. The Burch has not been found to be more durable than the synthetic retropubic sling. That’s why the full-length synthetic slings have become the gold standard. But in the wrong hands, these synthetic mesh slings can become problematic, with bladder perforation, vaginal mesh exposure, voiding difficulty, worsening urgency, urinary tract infections, and pain being some potential complications. You want to make sure you refer your patients to someone who’s done a lot of these procedures and knows how to deal with potential complications."
Symptoms associated with stress incontinence may also respond to certain medications, including duloxetine, imipramine, and estrogen applied via cream or patch.
In addition to Botox and pelvic floor strengthening exercises, treatment options for urge incontinence include the following:
• Medications. According to a 2010 review from the Agency for Healthcare Quality and Research, options include the antimuscarinic drugs tolterodine, trospium, solifenacin, darifenacin, and fesoterodine. Drugs with mixed actions include oxybutynin, propiverine, and flavoxate. "There’s no one drug that’s been the best," Dr. Iglesia commented. "Many of the drugs have similar side effects, including constipation and dry mouth, and some of them are pricey. I’ll generally start with what is covered by the patient’s insurance, and I like medications that I can titrate up until I get the desired effect."
• Neuromodulation. InterStim Therapy by Medtronic is an implantable device which stimulates the sacral nerve with mild energy pulses. Typically reserved for patients who have not responded to medical therapy, this approach uses low-voltage electrical stimulation to downregulate nerves that are causing overactive bladder symptoms or urge incontinence. "Over 100,000 InterStim devices have been implanted worldwide with up to 80% improvement," Dr. Iglesia said. "There’s also a tampon-like stimulator [transvaginal electrical stimulation] that you can place in the vagina twice a day for about 12 weeks. You can also apply energy with posterior tibial nerve stimulation, which is a once-a-week treatment for 12 weeks."
Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate.
Dr. Iglesia disclosed that she was a member of the FDA Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee which met on Sept. 8-9.
Dr. Brubaker said that she had no relevant financial disclosures.