Discussion:
A single modality may be inadequate for treatment of MUI and multiple treatment modalities are required. There is a controversy about the results of pharmaceutical treatment for MUI and surgical treatment is associated with significant failure rates. It is mentioned that applying of anti-incontinence procedures may be effective in treating both the stress and urge components of MUI. (4)
American urology association (AUA) mentioned “the success rate of TVT surgery is between 51% and 87 %” (5). Labire et al (6) expressed that the pharmacological therapy is less effective in comparison to surgery after 12 months. Surgery is done for those patients who deny conservative managements or symptoms have not been improved inadequately. (1) Kulseng-hanssen et,al (7) mentioned “the TVT objective care was 87.3% after 7 months and 82.7 after 38 months. The subjective care was 60 % and 53.8% after 7 and 38 months”.
Botulinum toxin is a neurotoxin which has been used for various clinical applications for many years, and inhibits the release of the neurotransmitter acetylcholine at the presynaptic nerve terminals. Urologists use it for patients with lower urinary tract symptoms secondary to idiopathic overactive bladder (OAB) and also after initial therapeutic modalities have failed to improve symptoms. Intradetrusor botulinum toxin injection has shown to improve urinary urgency, frequency, nocturia, and urgency urinary incontinence. In the other hand, not all patients can achieve excellent therapeutic outcomes which is leakage associated with a rise in abdominal pressure e.g., due to cough, sneeze and exercise (8). Phelan et al reported that after injection, 67% of patients were able to void smoothly with the PVR decreased by 71% and voiding pressure decreased by 38% (9).
For tissue regeneration of muscles; stem cells, PRP and fibrin glue strongly collaborate together to create new blood vessels and capillaries, extracellular matrix through cell proliferation, chemotaxis, cell differentiation, and angiogenesis. PRP provides the best concentration of growth factors (transforming growth factor–β, platelet-derived growth factor, insulin-like growth factor, fibroblast growth factor, epidermal growth factor, vascular endothelial growth factor, and endothelial cell growth) and bioactive factors (serotonin, histamine, dopamine, calcium, and adenosine). These factors lead to wound healing events by modulating the recruitment, duplication, activation, and differentiation. FG creates a temporary matrix and stimulating the local proliferation of fibroblasts, collagen synthesis, new blood vessels formation and connective tissue (3). The malfunction old cells will be replenished by stem cells which these young workers actively collaborate in vascularization and muscle tissue repairmen. In our previous report, peripheral stem cells and PRP are used for treatment of SUI. (10)
In this case report, PRP-Fibrin Glue- Stem Cell injection, Botox injection, and TVT has been used for treatment of MUI. Further research is need to validate the efficacy of these mixed treatments for recalcitrant MUI.
Conclusion: Mix treatment of PRP-Fibrin Glue- Stem Cell injection, Botox injection, and TVT may be a very good approach for treatment of patients with MUI who have a very open sphincter. Further research is need to validate the efficacy of these mixed treatments for recalcitrant MUI.
Acknowledgments : None