Urgency after a sling: review of the management

Urinary urgency after synthetic sling surgery may be persistent urgency that preceded the surgery or de novo urgency that developed after surgery. Recent studies estimate a 40 % rate of persistent urgency after synthetic sling surgery in women with mixed urinary incontinence. Causes of de novo urgency after synthetic sling surgery include postoperative urinary tract infection (7.4-17.4 %), bladder outlet obstruction (1.9-19.7 %), perforation of the urinary tract (0.5-5 %), and idiopathic urgency (0-28 %). Given the temporal relationship of de novo urgency developing after surgery, until proven otherwise, one should assume that the etiology is obstruction. Evaluation includes a history and physical exam, urinalysis, and post-void residual. Cystoscopy and urodynamics may help rule out surgical complications. Management is based on the etiology of the urgency. Urinary tract perforation and bladder outlet obstruction are treated with surgical intervention. Idiopathic de novo or persistent urgency after synthetic sling surgery are treated similarly to idiopathic overactive bladder, with behavioral therapy as first-line treatment, antimuscarinics or beta-agonists as second-line therapy, and intravesical onabotulinumtoxinA or sacral neuromodulation as third-line therapy.