Management of mixed urinary incontinence (MUI) is controversial. There are limited number of studies that report on simultaneous treatment approaches. Our primary aim was to determine the outcome of combined trans-obturator tape sling (TOT) and low dose intra- detrusor injection of Abobotulinumtoxin-A (Abobot-A, Dysport®) in women with MUI.

This was a prospective before-after clinical trial conducted on 50 women who had the symptoms of MUI and were referred to female urology clinic in a teaching hospital. All subjects in the study underwent history taking as well as physical and vaginal examinations, and stress test. The inclusion criteria was women with MUI previously treated with anticholinergic drugs who did not tolerate or responded to oral pharmacotherapy or conservative therapy. All females with severe prolapse, neurogenic disease (multiple sclerosis, spinal cord injury, cerebrovascular accident, etc.), history of intravesical botulinum toxin injection, sacral neuromodulation, and patients with a history of vaginal surgery or any  surgery for urinary incontinence were excluded from the study. For the enrolled MUI patients, after filling the questionnaires, urodynamics study was performed. The patients in the study had positive Valsalva leak point pressures (VLPP) + detrusor overactivity (DO), cough induced DO and normal or average capacity . We requested urine culture for all patients before the interventions and for  symptomatic patients in follow-up.
Under general or local anesthesia we performed cystoscopy using a 19-Fr rigid cystoscope in the lithotomy position. The bladder was filled with 150ml of irrigation fluid and injected 300 U of Abobotulinumtoxin-A in 20 to 30 injection sites intra-detrusor in each patient after reconstituting with 10cc normal saline using a 27 Gauge disposable needle in all the bladder wall, away from the trigone. After that they underwent the TOT procedure procedure.
TOT is a surgical procedure for the treatment of SUI. This method was first described by Delorme (20). The surgical procedure involves using a monofilament polypropelene mesh that passes under the middle of the urethra and through the two holes of the obturator (Boston or KIM).

Before the operation, women with MUI reported worse baseline overall incontinence and OAB symptoms. The mean (SD) age of patients was 52.26 (10.32). The mean score was 17.42 (2.76) for ICIQ-UI-SF and 9.38 (2.77) for ICIQ-OAB prior to the treatment. We followed the patients 12 weeks after intervention. Their mean ICIQ-OAB symptoms decreased  [1.19 (1.02); P<0.001]. The mean score of ICIQ-UI-SF decreased post-intervention, too [1.50 (1.42); P<0.001]. Considering improvement using the PGI-I scale, 46 (92.3%) stated that they had significant subjective improvement of their symptoms. Four patients (7.7%) mentioned a slight degree of improvement of their symptoms.

Combination therapy of TOT and 300 U Dysport® was accompanied with a promising effect in the patients with MUI according to the results of standardized questionnaires. However, further studies with controlled arms are recommended.

Combination therapy of TOT and 300 U Dysport® was accompanied with a promising effect in the patients with MUI according to the results of standardized questionnaires. However, further studies with controlled arms are recommended.