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
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
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
Retropubic sling location, from Campbell's
Transobturator sling placement, from Campbell's
Predicting SUI after POP surgery, from Jelovsek 2014
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 mechanism of action
Creates a suburethral hammock to prevent urethral hypermobility
Requires pubourethral ligaments, suburethral vaginal hammock, and pubococcygeus muscles for support
Sling readjustment: give 3mo after PVS or 1mo after MUS before performing incision
Do not wait, irreversible bladder remodeling can occur within 6mo
Sources
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).