Vaginal delivery after surgical treatment for stress incontinence using transobturator tape: A case report.

A 36-year-old woman presented at the one-stop urodynamic clinic with a 12-month history of urinary stress incontinence. She had no other urinary symptoms or history of urinary tract infection. She had a 17-month-old daughter delivered by spontaneous vaginal delivery. Stress incontinence occurred soon after her first delivery. She was single and had no plans for a second child. On clinical examination, the woman was found to have a normal abdomen and pelvis. Urodynamic assessment showed moderate urodynamic stress incontinence, with a stable normal capacity bladder and no voiding dysfunction. This woman was offered a transobturator tape (TOT) (Advantage Mid-Urethral Sling; Boston Scientific, St Albans, UK) as a surgical option for treatment, with preoperative physiotherapy. The operative details, together with risks and complications, were described, and a handout leaflet was given describing the operation. The woman decided to opt for conservative treatment initially while she thought matters were over. She was referred to the continence care clinic where she was examined and assessed for bladder re-education and pelvic floor muscle strength and tone. She was given a pelvic floor educator and instruction on pelvic floor exercises and fluid intake. Four months later, she requested surgery, and a TOT procedure was performed. Her last menstrual period was noted to be 2 weeks before. The urinary pregnancy test performed on admission was negative. A TOT (Boston Scientific) was inserted under general anaesthesia using a 1–2 cm midurethral incision in the anterior vaginal wall and an incision on each upper thigh over the obturator fossa, on a line levelling the clitoris. The polypropylene tape was placed loosely to form a suburethral hammock. The woman was returned from theatre without a urethral catheter. She voided normally, with residual volumes of less than 100 ml, noted on bladder scanning. She was discharged home on the second postoperative day. Two weeks later, the woman telephoned the hospital seeking advice after having a positive home pregnancy test and was given an appointment for the one-stop urodynamic clinic. An ultrasound scan showed a gestational sac of 5 weeks. Comprehensive counselling was provided by the urogynaecologist and the consultant anaesthetist involved with her case. She decided to continue with the unplanned pregnancy. Repeat ultrasound scan 4 weeks later confirmed a viable intrauterine pregnancy of 9 weeks of gestation. The woman’s GP was contacted and she was referred for antenatal booking at her local hospital, with written information to the obstetrician concerning her recent surgery. The woman’s antenatal progress was entirely uneventful. Serial urinalysis was negative for protein and bacterial culture. There was no stress incontinence antenatally. There was good communication between the obstetric unit and the one-stop urodynamic clinic during the antenatal period. There was a detailed discussion about the mode of delivery, and the woman decided that she would prefer vaginal delivery if possible. Spontaneous vaginal delivery occurred at 39 weeks of gestation. She was in labour in hospital for 75 minutes, with 10 minutes in the second stage. The baby weighed 3018 g and was normal. The woman required two sutures to the perineum for a first-degree tear. She was seen at 4 weeks postnatal in the one-stop urodynamic clinic. She had resumed normal voiding immediately after delivery and reported no stress incontinence on any occasion. Vaginal examination revealed that the tape was well placed, as previously, with no tightening or erosion.