A 58-year-old presents with urinary incontinence on coughing and sneezing. Urodynamic testing shows a leak point pressure of 45 cmH₂O and no detrusor overactivity. Maximum urethral closure pressure is 12 cmH₂O. Which condition is present and which surgical procedure addresses the specific defect?
- A Urge incontinence; anticholinergic therapy
- B Genuine stress urinary incontinence with urethral hypermobility; Burch colposuspension
- C Intrinsic sphincter deficiency (ISD); urethral bulking agent injection or pubovaginal sling ✓
- D Mixed incontinence; combination pharmacotherapy and pelvic floor exercises
Explanation
Intrinsic sphincter deficiency (ISD) is defined by a Valsalva/abdominal leak point pressure (ALPP) < 60 cmH₂O and maximum urethral closure pressure (MUCP) < 20 cmH₂O on urodynamics, indicating a poorly functioning urethral sphincter mechanism rather than pure urethral hypermobility. ISD presents as stress incontinence with a fixed, non-mobile urethra. Procedures targeting urethral coaptation — urethral bulking agents (e.g., polyacrylamide hydrogel) or pubovaginal fascial sling — are appropriate. Burch colposuspension addresses hypermobility (anatomical stress incontinence) but is less effective for ISD. Mid-urethral slings (TOT/TVT) are also used in ISD but pubovaginal sling has the highest efficacy in severe ISD.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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