Guidelines for the surgical management of female SUI

This study outlined guidelines for the surgical management of stress urinary incontinence (SUI).

Stress urinary incontinence (SUI) is the involuntary urine leakage during exertion, sneezing, coughing, lifting or any other physical activity. It has been estimated that the prevalence of SUI could be as high as 49%.

Vaginal sling procedures are currently the most common type of surgery used to help control SUI. They typically involve a minimally invasive procedure placing a mesh tape to create a ‘sling’ of support around the urethra. Mesh tape slings can be placed via incision through the abdomen (retropubic), the thighs (transobturator), or via a single incision through the vagina (mini-slings).

Autologous fascial slings use the patient’s own tissue as a sling to support the urethra. In the past, colposuspension was the most commonly performed surgery for SUI. This involves an open surgery where the bladder neck is lifted and stitched to a more optimal position. A less invasive surgical treatment option involves injections of bulking agents (such as collagen) to provide the urethra with support.

The American Urological Association and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction provided recommendations for the surgical management of SUI.

A medical examination for SUI should involve a medical history assessment, a pelvic exam, a demonstration of SUI, and a urine analysis. Cystoscopy (insertion of lens for internal mapping of the urethra and bladder) or urodynamic testing (functional test of storage and transport of urine) are not necessary in most cases.

Some patients may need additional evaluations before being considered for surgical intervention. This includes cases of incomplete diagnosis or demonstration of SUI, suspected neurological cause for SUI, abnormal urine analysis, strong urge urinary incontinence, incomplete bladder emptying, or pelvic organ prolapse. Patients with overactive bladder symptoms and those with previous surgery for incontinence or pelvic organ prolapse will also need to undergo additional evaluations.

Patients who seek treatment for SUI should be counselled regarding surgical and non-surgical treatment options. Non-surgical options include observation, pelvic floor muscle training, vaginal inserts and pessaries (a removable device). Patients should be made aware of the possible benefits and complications of each treatment option.

The risks and benefits of different types of vaginal slings should also be discussed with patients. Retropubic slings tapes are the most widely studied. Long-term success rates vary between 51 and 88%. Transobturator slings are often associated with fewer side effects. Success rates between 43 and 92% have been reported. However, retropubic slings appear show an advantage over transobturator slings in the long-term.

Mini-slings are similar to transobturator slings with regard to effectiveness and sexual function, but more studies are needed. Autologous fascial slings have between 85 and 92% success with 3 to 15-year follow up. The need for retreatment is lower when compared to colposuspension. Colposuspension is often considered as an add-on for patients already undergoing pelvic surgery (such as hysterectomy). Bulking agents are a possible treatment option for SUI, but little long-term data exists.

There are special cases that can determine the which type of surgical intervention is suitable. SUI patients with an immobile urethra (often called intrinsic sphincter deficiency) should be offered either an autologous fascial sling, a retropubic mesh sling, or a bulking agent. Any incontinence procedure is suitable for patients undergoing pelvic organ prolapse surgery. Mesh slings should not be used for patients at risk of poor wound healing. Vaginal slings may be offered to patients planning to bear children, those with diabetes, obese patients, and elderly patients after appropriate evaluation.

Patients should be followed-up within 6 months of any surgical procedure. Additional follow-up may be needed in the case of unfavorable outcomes. 

This paper outlined guidelines for currently available surgical treatments for SUI.