Dr. Vivian Sung, a urogynecologist in the department of obstetrics and gynecology at Women & Infants Hospital and professor at the Warren Alpert Medical School of Brown University, recently oversaw a research trial that compared modes of treatment for women with mixed urinary incontinence.
Sung found that women who underwent surgery for the condition fared just as well as those who combined surgery with exercises or behavioral therapy. Contrary to current guidelines, which urge caution when it comes to surgery, Sung says turning to the procedure first may be the most effective treatment for mixed urinary incontinence.
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Sung said one in six women in the United States experiences moderate to severe urinary incontinence, and approximately 30% of these women have mixed urinary incontinence.
PBN: You recently had an article published in the Journal of the American Medical Association about a trial that evaluated the effectiveness of exercise combined with surgery for women experiencing urinary incontinence. What was the outcome of the trial?
SUNG: Our study included 480 women with two different types of urinary incontinence (stress and urgency incontinence). When these two occur together, it can be more severe and difficult to treat and can greatly impact a woman’s quality of life.
In this trial, we evaluated whether combining behavioral and pelvic floor muscle therapy with midurethral sling surgery was better than sling surgery alone for treating both types of incontinence.
We found that one year after treatment, both groups had significant improvements in both types of urinary incontinence symptoms without a large difference between the groups.
Adding behavioral and pelvic floor muscle therapy did provide some secondary benefits, including decreasing the number of leakage episodes, decreasing the chance of needing additional urinary treatment after surgery and improving quality of life related to urinary symptoms.
Overall, the adverse side effects in both groups was low at about 2.3%.
About 85% of women reported being much or very much better after either treatment.
PBN: We’ve heard over and over about the benefits of exercises and therapy to counteract many conditions. In this case, why did behavioral therapy not seem to help?
SUNG: It seems that the midurethral sling surgery is more effective than initially thought at treating both types of urinary conditions, which is likely why we did not see a difference between the two treatments in the large, overall study population. This was somewhat unexpected.
In some of our secondary analyses that are ongoing now, it does seem like there may be a specific sub-population of women that would benefit from adding the behavioral/pelvic floor muscle therapy to surgery, mainly women who start out with more-severe overactive bladder symptoms.
Additionally, our study only included women with moderate or severe mixed incontinence symptoms who were willing to have surgical treatment. Therefore, the findings may not apply to women who have mild symptoms or those who do not have mixed incontinence. It also does not apply to women who do not want surgery or who are not candidates for surgery.
It is also important to note that our study compared combined behavioral and surgical treatment with surgical treatment only. We did not include a group who had no surgery and only had behavioral/pelvic floor therapy. Therefore, the study does not conclude that behavioral/pelvic floor therapy does not help at all. It only concludes that combining it with surgery was not better compared to surgery alone in our study population.
PBN: Will your findings influence how you treat women with urinary incontinence in the future?
SUNG: This study has already started to influence the way we counsel women and has opened up options! In the past, guidelines warned that sling surgery in women with mixed incontinence could worsen urinary incontinence and cautioned that we should exhaust all conservative options first, which are not always “noninvasive.” But before this study, there were not high-quality data to support this recommendation. This trial finally provides data that we can use to improve the way we counsel women with mixed incontinence about expectations and outcomes should they choose to have surgery.
PBN: How important is it for physicians to have the chance to do research?
SUNG: Clinical research is critically important for several reasons. First, it is necessary for us to have the research data that we can use as clinicians to evolve and improve the quality of care we provide for patients. This is truly one of the most important ways to advance medical knowledge. Clinician-researchers help to improve the quality of clinical services by facilitating ideas between clinical and research aspects. They also help to implement evidence-based treatment approaches, which also improves the quality of clinical services. There also is rapid development of therapies and devices that need to be evaluated in clinical trials to determine their efficacy and safety once used clinically. Physicians are ideally positioned to lead these studies.
PBN: And does the research that Rhode Island doctors do benefit the state’s health care industry?
SUNG: The participation of Rhode Island doctors in research is critical to our state’s health care industry and here are some of the reasons. It really benefits patients, physicians, learners and health care organizations in Rhode Island. It offers opportunities and access to cutting-edge treatments for our patients that may otherwise not be available to Rhode Islanders. It plays an important role in improving the diagnosis and treatment of diseases and quality of life of our patients. External support for research can help our institutions maintain capacity and build new resources for such activities. It can help institutions stay at the cutting edge of health care and stay innovative. It provides opportunities to train the next generation of clinical researchers. Ultimately it helps our organizations retain talent, improve knowledge and skills, and stay competitive while improving the quality of our care and access to treatments for our patients.
Elizabeth Graham is a PBN staff writer. She can be reached at Graham@pbn.com.
