Stress Urinary Incontinence: Go Directly to Surgery?

Surgical Rounds®, August 2014,

Stress urinary incontinence has been associated with poor quality of life, social isolation, and depression. A new study compared the cost and cost effectiveness of 3 treatment strategies.

Stress urinary incontinence (SUI) is more than an annoying problem—it has been associated with poor quality of life, social isolation, and depression.

Conservative management has few risks and is reversible, but requires considerable effort on the patient’s part, which leads to high rates of abandonment and low success rates by the end of one year of treatment. Meanwhile, surgical therapy with midurethral slings (MUS) boasts success rates of 85% to 95% with few side effects, and many studies have reported superior results with MUS and good patient satisfaction. With no algorithm to guide treatment, which path balances cost and efficacy best?

A new study, published ahead of print in the American Journal of Obstetrics & Gynecology, indicates using surgical intervention earlier may be cost effective. The study describes a decision tree model developed by researchers at Stanford University School of Medicine in California.

The team compared the costs and cost effectiveness of 3 initial treatment strategies, delineating probabilities of SUI after 12 months of use of a continence pessary, pelvic floor muscle therapy (PFMT), and MUS. The researchers developed cost data using Medicare 2012 dollars.

Regardless of how inexpensive the treatment with a continence pessary, its effectivenees was always lower than MUS, and it was never a preferred approach.

The model acknowledged MUS-associated morbidities (mesh erosion, retention, de novo urge incontinence, and recurrent SUI). Regardless, compared to PFMT, initial treatment of SUI with MUS was the more cost-effective strategy with an incremental cost effectiveness ratio of $32,132/quality-adjusted life year.