We recently read with great interest the article by Lee et al.1‘Persistence of urgency and urge urinary incontinence (UUI) in women with mixed urinary symptoms after midurethral slings: a multivariate analysis’. This study is of particular interest because the authors tried to identify the risk factors for persistence of urgency or UUI following surgical treatment. Knowing the risk factors for postoperative persistence of symptoms is relevant to the choice of the initial management of mixed urinary incontinence (MUI), and for providing adequate preoperative counselling to the patients.
However, we believe that the methodology of the study should be clarified in order to better understand the findings. Midurethral slings were used to treat MUI in all patients in the study but there is no evidence that they received conservative management prior to surgery. The first-line therapy for urinary incontinence includes patient education, physical therapies, scheduled voiding regimes, behavioural therapies and medications. Furthermore, patients with MUI should be initially treated for the predominant problem, and conservative management should be maintained for 8–12 weeks.2 Pelvic floor muscle training (PFMT) is considered to be the first-line conservative management of all types of incontinence, in particular for stress urinary incontinence (SUI) and MUI; in fact, women who receive PFMT have a higher likelihood to have improvements in symptoms, and report a better quality of life.3 Initial management could be combined with medical therapy, such as antimuscarinics, in particular in patients with urgency-predominant MUI or in those with detrusor overactivity (DO) as demonstrated by urodynamic study.2,4 Lee et al.1 included nine women with DO alone at urodynamic assessment and 273 women with urodynamic stress incontinence (USI) and DO. These patients could have benefited from antimuscarinic therapy before surgery; however, in the study there is no evidence that this therapy was provided. In the results, the authors stated that DO increases the risk of persistent urgency after surgery in patients with preoperative urgency or UUI. The finding may be biased by the fact that the patients did not receive conservative management before surgery; furthermore, in patients with DO the cure rates for USI treatment might be decreased and overactive bladder symptoms might not change or might even worsen.4
In addition, we would like to bring the Editor’s attention to the criteria used for inclusion in the study. As the title refers to patients with MUI symptoms, the authors should have included women with MUI symptoms independently from urodynamic findings. Alternatively, the study might have included only women with urodynamic findings suggestive of MUI: that is to say USI and DO, which we can call ‘mixed urodynamic incontinence’. No clear criteria were apparently used for inclusion in the study. If the authors aimed to include both patients with MUI symptoms and patients with MUI, it seems unlikely that no woman complained of just SUI and, at the urodynamic assessment, was found to have MUI.