Most women have mixed incontinence even if stress incontinence is dominant. Sometimes it is useful to treat the OAB-DO first to see if a minor degree of stress incontinence is tolerable if the bladder is treated .Most often this does not work and surgery for the stress incontinence is required.
Treatment of OAB-DO is not at the moment very effective. In part this is due to the clinical trial of one or another agent where the underlying theme is 'my drug is as good as or better than yours.' As it happens no single agent works very well without some education of the patient and some idea of what the expected outcome might be. Patients expect that one pill daily will make them dry.
That usually does not happen, and part of the trouble is the random, sudden, pattern of the DO which is so quickly developed that the subject has no ability to prevent it.
Timed voiding on a rigid schedule helps to avoid this and more than one drug can be used with rather dramatic improvement in outcome. We use an anticholinergic agent, a trycyclic drug and/or an alpha blocking agent in combination for all and in resistant idiopathic incontinence.
Stress incontinence can be treated with pelvic floor exercise, with bulking agents and with surgery. I do not think pelvic floor exercises work for most people and I can not predict who will get better and who will not. Most woman want the leakage fixed. Bulking agents are fine for elderly patients who have minimal urethral mobility.
With the advent of new very effective synthetic materials for slings the entire field of stress incontinence has changed dramatically. Detrusor instability is the favorite diagnosis of academic types and was eliminated by effective sling procedures. On the other hand the swing has gone too far. Patients with straight forward stress incontinence, with urethral mobility, and prolapse conditions, can be well served by a TVT or TOT of some kind, but certain kinds of stress incontinence can’t be so treated.
These conditions include: post partum severe stress incontinence associated with minimal mobility and a very low leak point pressure, after failure of a bone anchor sling, erosion of any synthetic or fascial sling into the vagina or urethra, or bladder, and in cases of neurogenic incontinence associated with ISD.
These conditions require some sling compression of the urethra which is safest if achieved with an autologous fascia sling.
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