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Workup

History

• Inciting factors: cough, sneeze, lifting, walk/run (PPV 73-74%, NPV 66-86%)
• Assess characteristics: chronicity, frequency/severity, treatment expectations, degree of bother, maximal pad usage
• Pad usage
• UTI/LUTS: urgency, frequency, nocturia, dysuria, hematuria, slow flow, hesitancy, incomplete emptying
• Pelvic symptoms: pain, pressure, bulging, dyspareunia
• GI symptoms: constipation, diarrhea, incontinence, splinting to defecate
• OB Hx: gravity, parity, delivery method, menopause status
• Prior SUI (non)surgical therapy
• PMHx: neurologic conditions, DM, dementia, prior radiation
• PSHx: prior pelvic surgery, SUI treatments
• Medications: stimulants, a-blockers, anticholinergics, diuretics
• Transient causes in elderly (DIAPPERS): delirium, infection, atrophic vaginitis, psychologic, pharmacologic, excess urine production, restricted mobility, stool impactino
• Fluid intake: water, alcohol, caffeine
• Questionnaires: currently no proven benefit
• Frequency/volume chart: can help differentiate SUI from OAB or other presentations

Physical

• Abdominal exam
• External genital/vaginal exam: lesions, tissue health, obvious bulges
• Urethra: check for masses, tendernes, and scarring, Q-tip test not predictive of SUI
• Cough stress test: 200mL in bladder has 84% sensitivity and 90% specificity, if no leak while recumbent can repeat while standing
• Vaginal vault: assess prolapse at rest and with valsalva, assess wall tenderness (pelvic floor dysfunction)
• Focused neuro exam: gait, congnitive status, lower extremity sensation/strength
• Rectal exam: assess for laxity, can assist with checking rectocele
• Bulbocavernosus reflex: assesses S2-4 function, present in 70% women and 100% men, squeezing glans causes anal and pelvic floor contractinos

Adjuncts

• Objective demonstration of SUI: positive stress test, involuntary urine loss while supine and/or standing
• 48hr pad test: PPV 81%, NPV 87%
• 1hr pad test: 94% sensitivity, 44% specificity, PPV 69%, 85% NPV
• Assess post-void residual: required, but single elevated PVR is not reliable
• Urinalysis: required, check for infection/hematuria
• Cystoscopy: optional, recommended if prior SUI surgery (especially if mesh used)
• UDS: not required if obvious SUI, optional for non-index patients
• Indications for further workup: unclear diagnosis, unable to demonstrate SUI, concern for neurogenic LUTS, abnormal UA (hematuria/pyuria), urge predominant MUI, elevated PVR, high grade PVR (3-4), significant voiding dysfunction
• Potential indications for further workup: OAB symptoms, prior failed surgery, prior prolapse surgery

Index vs Non-Index

• Index patient: otherwise healthy woman, interested in surgical therapy, SUI or stress-predominant MUI, no prior SUI surgery, low grade POP
• Non-Index Patient: POP stage 3-4, non-stress predominant SUI, incomplete emptying with elevated PVR, prior SUI surgery, mesh complications, high BMI, neurogenic LUTS, advanced age

Treatment options

Non-Index Patient recommendations

• Intrinsic sphincteric deficiency (ISD): retropubic MUS, autologous PVS, and bulking agents - transobturator MUS does not provide adequate support with an immobile urethra
• Diverticulectomy, urethrovaginal fistula repair, or mesh excision: avoid mesh placement at same time (high risk for erosion), but staged procedure is okay, can use PVS
• History XRT, scarring, or poor tissue quality: avoid mesh placement (high risk for erosion)
• Pelvic prolapse repair: all options available, see nomogram for probability of needing concurrent SUI procedure
• NGB: factor in patient-specific risks/benefits, do not use mesh if requiring catheter
• Prepregnancy: high rate of SUI recurrence, consider waiting until completing childbirth, can use any option
• Diabetes: increased risk of mesh erosion, but can use any option
• Obesity: increased BMI decreases overall effectiveness, but can use any option
• Age > 65yrs: overall lower success rates

Sling facts

• Anatomy: creates a suburethral hammock to prevent urethral hypermobility, requires pubourethral ligaments, suburethral vaginal hammock, and pubococcygeus muscles for support
• Types: "midurethral" refers to FDA-approved synthetic slings (retropubic or transobturator), whereas "pubovaginal" refers to autologous fascial slings

Midurethral Sling

• Retropubic: placed via suprapubic incision
• Transobturator: placed via lateral incision
• Technique: goal is urethral support (loose sling), not urethral kinking (tight sling)
• Retropubic risks: vascular/visceral injuries, bladder/urethral perforation, voiding dysfunction, suprapubic pain
• Transobturator risks: groin pain, need for repeat surgery
• Do not place if: fistula, prior mesh erosion, intraoperative urethral injury, or diverticulum

Pubovaginal sling

• Location: placed at bladder neck, not at midurethra
• Fascial harvest: autologous rectus or fascia lata, worse outcomes with non-autologous fascia, but increases perioperative morbidity (26% wound complications) and postoperative pain, erosino risk nonexistent with autologous tissue
• Success: 24-97% continence, 3-7% reoperation/revision, new urgency 2-22% (not predictable preop)
• Postoperative voiding dysfunction: initially manage conservatively, manage complete retention with sling loosening via inferior pressure from rigid cystoscope, perform complete urethrolysis (success 65-93%), incision (success 84-100%)

Colposuspension

• Indications: useful if undergoing A/P surgery at the same time (hysterectomy etc), avoids mesh and fascial harvest complications, but 20% have wound complications
• Burch technique: permanent sutures placed through anterior vaginal wall next to urethra/bladder neck and suspended to ileopectineal (Cooper) ligament
• Marshall-Marchetti-Krantz (MMK): permanent sutures placed through periurethral tissue and sutured to periostoeum or cartilage of symphysis pubic
• Side effects: urge incontinence (9-13%), UTI (32%), voiding dysfunction (3-9%), bladder injury (1-4%), osteitis pubic (2.5%, MMK only)

Intraurethral bulking agents

• Inject material into submucosal space to coapt urethra
• Less invasive with shorter operative and recovery time
• Current options: bovine collagen, zirconium beads (durasphere), silicone (macroplastique), calcium hydroxylapatite (Coaptite), polyacrylamide (Bulkamid)
• Visible on X-ray: Durasphere, Coaptite, Teflon
• Can be performed via periurethral or transurethral approach
• May require repeat injections
• Success: 30-40% completely dry at 1yr, 50-60% dry or improved
• Side effects (transient): retention (0-12%), elevated PVR (55-75%), storage symptoms (17-46%), hematuria (8-40%), dysuria (9-46%), UTI (0-23%)
• Retention management: short course catheterization, concern for bulking agent molding around catheter
• Rare complications: periurethral abscess, urethral necrosis, urethral erosion, bulking agent extrusion, particle migration
• Contraindications: UTI, inflammation, friable urethra, stricture, pregnancy, hx pelvic XRT

Nonsurgical options

• Behavioral: timed voiding, voiding before exercise, pelvic floor PT
• can be inserted intraurethral or intravaginal, help to obstruct urethra, may cause bladder spasms
• Pessary: has knob to compress urethra, also treats prolapse
• Medication: currently no recommended options for treatment of stress incontinence

Sling complications

General surgical risks

• Pain: abdominal, pelvic, vaginal, groin, thigh, dyspareunia
• Bleeding: need for transfusion is rare
• Infection: UTI rates highest within first 3mo
• Intraop injury: do not place mesh sling if urethral injury
• Mesh: exposure, erosion, perforation
• LUTS: may unmask or worsen OAB symptoms, although 50% see improvement in urge symptoms after sling placement

Vaginal mesh exposure

• Prevalence: 0.5-8.1%
• Symptoms: vaginal discharge, rough vaginal surface, dyspareunia, pelvic pain, UTI symptoms
• Management: observation, estrogen +/- antibiotic cream, limited excision and trimming with reapproximation, or liberal mesh excision

Urethral perforation

• Prevalence: 0-0.6%
• Intraoperative management: repair and do not place mesh sling at that time
• Postoperative presentation: presents with voiding/storage symptoms, retention, rUTI, and incontinence
• Diagnosis: visualize mesh in urethra on cystoscopy
• Management: consider endoscopic excision (may require multiple procedures) vs transvaginal urethrotomy and excision

Bladder perforation

• Prevalence: 0.5-0.6%, usually caused by unrecognized intravesical mesh placement, more common with retropubic (4.8%) than transobturator (0.6%)
• Intraoperative diagnosis: assess full bladder intraoperatively with 30 and 70 degree lenses, can remove trocar and replace if identified
• Presentation: abdominal pain, hematuria, rUTI, LUTS, dysuria, incontinence
• Diagnosis: use cystoscopy, imaging not adequate
• Management: endoscopic incision vs transvaginal or retropubic mesh excision

Pain/Infection

• Risks: younger age, preexisting pelvic pain, and prior chronic pain diagnosis
• Prevalence: 16% after transobturator vs 1.5% after retropubic, 0-2% vaginal wound infections
• Management: NSAIDs, rest, and PT, rarely requires excision with orthopedic assistance, can consider immediate removal of mesh prior to tissue ingrowth

Voiding dysfunction

• Prevalence: 2% after retropubic vs 0% after transobturator (retention seen 3.7% vs 0%), 8% require temporary catheterization after surgery
• Diagnosis: VCUG, translabial US, MR pelvis
• Sling readjustment: give 3mo after PVS or 1mo after MUS before performing incision, irreversible bladder remodeling can occur within 6mo

References

• AUA Core Curriculum
• Boone, T., J. Stewart, and L. Martinez. "Additional Therapies for Storage and Emptying Failure." Campbell-Walsh Urology 12 (2020).
• Cameron, A. "Complications Related to the Use of Mesh and Their Repair." Campbell-Walsh Urology 12 (2020).
• Gomelsky, A. and R. Dmochowski. "Slings: Autologous, Biologic, Synthetic, and Mid-urethral." Campbell-Walsh Urology 12 (2020).
• Jelovsek, J. Eric, et al. "A model for predicting the risk of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery." Obstetrics and gynecology 123.2 0 1 (2014): 279.
• Kobashi, Kathleen C., et al. "Surgical treatment of female stress urinary incontinence: AUA/SUFU guideline." The Journal of urology 198.4 (2017): 875-883.
• Lucioni, A. and K. Kobashi. "Evaluation and Management of Women with Urinary Incontinence and Pelvic Prolapse." Campbell-Walsh Urology 12 (2020).
• Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.