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Who has Stress Incontinence?

• Reported as 49% prevalence
• 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

Workup

History

• Inciting factors: cough, sneeze, lifting, walk/run (PPV 73-74%, NPV 66-86%)
• Degree of bother
• Assess characteristics: chronicity, frequency/severity, treatment expectations
• Pad usage
• UTI/LUTS: urgency, frequency, nocturia, dysuria, hematuria, slow flow, hesitancy, incomplete emptying
• Pelvic symptoms: pain, pressure, bulging, dyspareunia
• GI symptoms: constipation, diarrhea, splinting to defecate
• OB Hx: gravity, parity, delivery method, menopause status
• Prior SUI (non)surgical therapy
• PMHx, meds
• Fluid intake (water, alcohol, caffeine)
• Questionnaires: haven't been shown to be overall helpful

Physical

• Abdominal exam
• Pelvic exam w/ moderately full bladder: pelvic prolapse, vaginal atrophy, pelvic floor dysfunction
• Q-tip test: demonstrates urethral mobility, not predictive of SUI
• Focused neuro exam

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: single elevated PVR is not reliable
• Urinalysis: check for infection/hematuria

Definitely needs further workup if...

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

May need further workup if...

OAB symptoms, prior failed surgery, prior prolapse surgery

Obtional Adjuncts:

• Cystoscopy: not required except for specific diagnoses, recommended if prior SUI surgery (especially if mesh used)
• UDS not required if SUI is obvious, but optional in non-index patients

Nonsurgical options

• Observation: not bothered, not interested, or too sick for surgery
• PFPT
• Inserts: urethral inserts, pessaries

Surgical Options

Midurethral Sling

• Uses synthetic mesh - FDA approved
• Retropubic: placed via suprapubic incision
• Transobturator: placed via lateral incision
• Goal is urethral support (loose sling), not urethral kinking (tight sling)

Pubovaginal sling

• Placed at bladder neck, not at midurethra
• Harvest autologous rectus or fascia lata
• Non-autologous sources are not recommended (worse outcomes)

Burch Colposuspension

• Useful if undergoing A/P surgery at the same time (hysterectomy etc)
• Avoids mesh and fascial harvest complications

Intraurethral bulking agents

• Inject material into submucosal space to coapt urethra
• Less invasive with shorter operative and recovery time

Non-Index Patients

• 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
• 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
• 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

Risks/Complications

General Risks

• Pain: abdominal, pelvic, vaginal, groin, thigh, dyspareunia
• Bleeding
• Infection: UTI rates highest within first 3mo
• Intraop injury: do not place mesh sling if urethral injury
• Mesh: exposure, erosion, perforation
• LUTS: unmask or worsen OAB symptoms

Retropubic sling

• Vascular/visceral injuries
• Bladder/urethral perforation
• Voiding dysfunction
• Suprapubic pain

Transobturator sling

• Groin pain
• Repeat surgery

Pubovaginal Sling

• Factor in morbidity of fascial harvest

Burch Colposuspension

• 20% have wound complications

Bulking Agents

• Need for repeat injections

Important Stress Incontinence Studies

CARE (Brubaker 2008): colposuspension at time of sacrocolpopexy leads to less postoperative SUI (without preoperative SUI)

OPUS (Wei 2009): anterior vaginal wall prolapse repair, postoperative SUI rates 27% if retropubic MUS performed (vs 43% for sham procedure), NNT 6.3 to see benefit of adding MUS

TOMUS (Kobashi 2017): at 5yrs, minimal difference in success between retropubic and transobturator midurethral slings

SISTEr (Albo 2007): PVS vs Burch, effectiveness (no SUI, no need for retreatment, negative stress test was 66% vs 49%, retreatment rates was 4% vs 13%

Sources

• Albo, Michael E., et al. "Burch colposuspension versus fascial sling to reduce urinary stress incontinence." New England Journal of Medicine 356.21 (2007): 2143-2155.
• Brubaker, Linda, et al. "Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence." Obstetrics and gynecology 112.1 (2008): 49.
• 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.
• Richter, Holly E., et al. "Retropubic versus transobturator midurethral slings for stress incontinence." New England Journal of Medicine 362.22 (2010): 2066-2076.
• Wei, John, et al. "Outcomes following vaginal prolapse repair and mid urethral sling (OPUS) trial—design and methods." Clinical Trials 6.2 (2009): 162-171.