Physician Dilemma and Attitude Towards Surgical Treatment and Subsequent Mode of Delivery for Women with Stress Urinary Incontinence – An International Survey

Stress urinary incontinence (SUI) is a common bothersome condition that negatively affects women's quality of life worldwide. One of the major contributing risk factors for SUI is pregnancy and childbirth. A systematic review and meta-analysis have found that the adjusted odds ratio (aOR) to develop SUI after vaginal delivery compared to cesarean section is 1.85 (1). Furthermore, a cohort study has found that compared with spontaneous vaginal delivery, cesarean delivery was associated with a significantly lower hazard for stress urinary incontinence, overactive bladder, and pelvic organ prolapse (2). Although the prevalence of SUI increases with age, a substantial number of women suffer from SUI at a younger age and seek treatment. Women who decline or have insufficient improvement following conservative therapies will eventually become candidates for surgical treatment. Currently, there is limited data regarding the mode of delivery following anti-incontinence surgical repair. The American Urogynecological Society (AUGS) presently states that existing data are insufficient to establish whether recurrent SUI rates differ between vaginal versus cesarean delivery (3). The unique group of women who have not completed their family (i.e.childbearing) and seek surgical treatment for SUI impose a great dilemma on their physicians, which might ask the following questions: 1. Should we consider surgery for those who have not completed their family? 2. If so, what will be the appropriate surgical management? 3. What would be the recommended mode of delivery post-surgical treatment?
The current study aims to determine physicians' attitudes towards surgical treatment and its consequences for women of reproductive age who desire childbearing capacity.

Bibliography:
1. Tähtinen RM, Cartwright R, Tsui JF, Aaltonen RL, Aoki Y, Cárdenas JL, et al. Long- term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis. Eur Urol. 2016 Jul;70(1):148–158.
2. Blomquist JL, Muñoz A, Carroll M, Handa VL. Association of delivery mode with pelvic floor disorders after childbirth. JAMA. 2018 Dec 18;320(23):2438–2447.
3. Wieslander CK, Weinstein MM, Handa VL, Collins SA. Pregnancy in women with prior treatments for pelvic floor disorders. Female Pelvic Med Reconstr Surg. 2020 Apr 22;

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The following questions (1-7) are aimed at the index patient who presents with symptomatic SUI and has not completed her family (childbearing) 

1. Will you perform or recommend surgical treatment for stress urinary incontinence for a patient who has not completed her family (childbearing)?

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2. Would you advise your patient to postpone the surgery until she has completed her family (childbearing)?

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Required

4. Which of the following negatively affects your opinion on performing the surgery? (You can choose more than one answer)

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Required

5. For a patient who plans a subsequent pregnancy and presents with SUI, and you have decided to perform surgery: what would be the procedure of choice (assuming you are allowed to practice all) – please rank from 1-6

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Retropubic Mid-urethral sling
Transobturator Mid-urethral sling
Single-incision sling
Colposuspension
Bulking agents
Autologous sling
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6.  After performing continence surgery on women of reproductive age, would you routinely offer to perform a permanent contraception procedure? 

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7. After explaining the risks and benefits of surgical treatment when childbearing is not complete, what is the importance that the professional places on ‘shared decision-making’ on a scale from 0 to 10? (0 is none, and 10 is the most important)

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The following questions (8-13) are aimed at the index patient who presented with symptomatic SUI and plans a subsequent pregnancy 

8. For how long would you recommend postponing subsequent pregnancy following surgery for SUI?

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9.  In your opinion, what contributes to worsening incontinence for a patient who has undergone a surgical procedure for SUI? (Please rank from 1-6) *
Pregnancy by itself
Mode of delivery
Patient's age
Patient's BMI
Surgical procedure
Surgeon experience
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10. Following continence surgical intervention, and assuming your patient becomes pregnant, what would be the recommended mode of delivery? *
11. Following continence surgical intervention, and assuming your patient becomes pregnant and she is incontinent, what would be the recommended mode of delivery? *

12. Following continence surgical intervention, and assuming your patient becomes pregnant and she is continent, what would be the recommended mode of delivery?

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13. How long after delivery will you delay your continence procedure? 

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The following questions (14- 20)  are demographic questions

14. In the last five years, how many cases have you encountered? (Cases of a patient who has not completed her family and you performed a TVT for her SUI?) 

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15. Your gender *
16. Your age *
17. Your position\title *

18. Years of training/experience 

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19. Workplace: *
20. Which region of the world do you practice at? *
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