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Surgery ‘should be first-line treatment’ for stress incontinence

Surgery should be promoted in guidelines as a first-line treatment for stress incontinence as it is more likely to be successful than using physiotherapy, claim researchers.

The researchers made the claim after their study - published in the New England Journal of Medicine this month, found that 91% of patients with moderate-to-severe stress urinary incontinence reported improvement in their symptoms. This compared with just 64% of the group offered pelvic-floor therapy with a physiotherapist.

NICE currently recommends offering pelvic floor muscle training of at least three months’ duration as first-line treatment to women with stress or mixed urinary incontinence.

But the researchers from University Medical Center Utrecht in the Netherlands said that that surgery should also be offered at this stage.

The study followed 460 study participants who were over 35, suffered from moderate-to-severe stress urinary incontinence and were randomly assigned to two groups: either pelvic-floor therapy by certified physiotherapists or mid-urethral-sling surgery.

Researchers found that after a year of treatment, 85% of the women who underwent surgery reported a subjective cure of stress urinary incontinence compared with 53% of the pelvic-floor therapy group. One in ten of the surgery group experienced non-permanent mild complications, such as bruising or urge incontinence, whilst no side effects were seen in the pelvic floor therapy group.

But when patients were asked if they wanted to cross over to the alternative therapy group if they were not satisfied with the results of the treatment they had been assigned, 49% of the physiotherapy group transferred across to the surgery group and just 11% of the surgery group transferred to physiotherapy.

The researchers explained: ‘Women randomly assigned to undergo initial surgery were significantly more likely to have improvement at 12 months than were those assigned to receive initial physiotherapy.’

Professor Huub van der Vaart, gynaecologist at the University Medical Center Utrecht and co-author of the study, said, ‘Based on the outcomes of this study, we propose to adapt national and international guidelines.

‘The current guidelines indicate that pelvic floor therapy is the mandatory standard initial treatment of stress incontinence in women. However, given that surgery has been found to be more effective, this option should be offered as primary therapy alongside pelvic floor therapy.’


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