Kate Johnson

October 24, 2013

LAS VEGAS — A woman's lifetime risk of surgery for stress urinary incontinence or pelvic organ prolapse is 20% by the age of 80 — almost twice the risk commonly quoted for nearly 2 decades.

These results, from a large study of privately insured women, were presented here at the American Urogynecologic Society 34th Annual Scientific Meeting.

"It's a dramatically different statistic and it has huge public health implications," Jennifer Wu, MD, from the University of North Carolina, Chapel Hill, told Medscape Medical News. "What we've found is that there's about an 11% risk at the age of 60, but if you go on to age 80, it's up to 20%. That's 1 of 5 women — almost double what we were saying before."

That 11% lifetime risk figure comes from a 1995 study of about 150,000 women and nearly 400 surgeries (Obstet Gynecol. 1997;89:501-506). "That study was done almost 2 decades ago in a small cohort of patients and in a region of the United States that tends to have lower surgical rates," explained Dr. Wu.

In population-based MarketScan databases, Dr. Wu and her colleagues found claims for 51.8 million privately insured women and 311,070 surgeries from 2007 to 2011.

They used current procedural terminology codes to identify cases of inpatient and outpatient stress urinary incontinence and pelvic organ prolapse surgeries in women 18 years and older. Repeat procedures were discounted.

Dr. Wu should be recognized for producing a more modern and statistically accurate study.

The analysis showed that by the age of 80, a woman's cumulative lifetime risk is 14.5% for stress urinary incontinence surgery and 13.7% for pelvic organ prolapse surgery. A woman's combined risk for either surgery is 11.4% by the age of 60, rising to 15.9% at age 70, and then to 20.2% by age 80, said Dr. Wu, emphasizing that the study was confined to the insured population only.

"This highlights how common surgeries are for pelvic floor disorders, despite the fact that they're widely under recognized," she said. "Within the urogynecology field, that's what we're focused on, but people don't always screen for pelvic floor disorders. In general ob/gyn practices, internal medicine, family medicine — in any practice — it's important to screen for these disorders because women are often embarrassed to mention them and often aren't aware that there are treatments."

The finding of an increased incidence of pelvic floor repairs has a number of explanations, including the aging population.

"There's probably more recognition now than there used to be, so more people are being referred for treatment," Dr. Wu added. "There are also a lot of surgeries now that are minimally invasive, so maybe more women are willing to undergo treatment."

More Referrals, Minimally Invasive

Asked to comment on the findings, Chris Elliott, MD, from Santa Clara Valley Medical Center in San Jose and Stanford University in Palo Alto, California, said, "I would agree with Dr. Wu that the commonly quoted statistic of 11% lifetime risk of these surgeries was potentially flawed, as it was based on a smaller study sample and potential geographic bias. She should be recognized for producing a more modern and statistically accurate study."

Dr. Elliott said he agrees that minimally invasive techniques are likely largely responsible for the increase in stress urinary incontinence and pelvic organ prolapse surgeries. Work published by his team earlier this year emphasized the fact that modern, statistically accurate studies in this field should include both inpatient and outpatient procedures, as Dr. Wu's study did, to capture the full impact of the minimally invasive trend (Int Urogynecol J. 2013;24:1939-1946).

"Stress urinary incontinence surgery changed dramatically following the introduction of the midurethral sling in the late 1990s," Dr. Elliott told Medscape Medical News. "This turned the surgery into a relatively quick 20- to 30-minute procedure. Prior to this, most physicians were performing more invasive surgeries to treat stress incontinence, most of which required inpatient hospitalization. I think that the increased ease of the procedure for both the patient and the physician has led to an increased willingness to address this patient complaint."

Regarding pelvic organ prolapse surgery, Dr. Elliott added, "the introduction of vaginal mesh surgery and, more importantly, the introduction of robotic laparoscopic surgery to perform pelvic organ prolapse repair has decreased the amount of time a patient spends in the hospital postoperatively. This again likely leads to a patient's willingness to have their problems addressed."

Dr. Elliott said he hopes the updated figures provided in Dr. Wu's study will "prompt primary care physicians to screen patients more thoroughly. And this is still probably lower than the true number, as it only accounts for women who actually undergo surgery and does not include those who remain untreated."

Dr. Wu reports that she is a consultant for Proctor and Gamble. Dr. Elliott has disclosed no relevant financial relationships.

American Urogynecologic Society (AUGS) 34th Annual Scientific Meeting: Paper 32. Presented October 18, 2013.


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