Reconstruction

Stress urinary incontinence (SUI) is leakage with increased abdominal pressure (coughing, sneezing, exercise, lifting). The workup distinguishes it from urgency and mixed incontinence, confirms it objectively, and — when surgery is planned — screens for the few situations needing urodynamics. Management climbs a ladder from pelvic-floor therapy through midurethral slings to autologous slings and colposuspension.

Definitions

• Stress urinary incontinence (SUI): leakage from increased abdominal pressure.
• Urgency urinary incontinence (UUI): leakage with a sudden, undeferrable desire to void. Mixed (MUI): both SUI and UUI.
• Intrinsic sphincter deficiency (ISD): often defined as ALPP <60 cm H₂O or MUCP <20 cm H₂O, frequently with minimal urethral mobility (the utility of urethral-function testing remains controversial).
• Mesh terms: perforation — mesh in the lower urinary tract; exposure — mesh extruded through skin or vagina.

Pathogenesis

Prevalence of female SUI is up to 49%. By the integral theory, three components support the proximal/mid-urethra: the pubourethral ligaments, the suburethral vaginal hammock, and the pubococcygeus muscle. Injury from surgery, childbirth, aging, or hormonal loss impairs mid-urethral function.

• ISD is the primary underlying cause of SUI; hypermobility is secondary. All women with SUI have some ISD; not all have hypermobility. Hypermobility is a sign of damaged support, not itself a cause.
• MUCP <20 or ALPP <60 cm H₂O indicates ISD; ALPP >90 cm H₂O signifies little or no ISD. In continent women, maximal urethral closure pressure occurs at the mid-urethra.

Differential Diagnosis (7)

Overflow incontinence, detrusor-overactivity incontinence, low bladder compliance, stress-induced detrusor overactivity, diverticulum, urinary fistula, and ectopic ureter.

Diagnosis and Evaluation

Mandatory work-up (4): history with bother assessment + physical exam; objective demonstration of SUI; urinalysis; and post-void residual (PVR).

• History — characterize the incontinence (stress/urgency/mixed/continuous), chronicity, frequency, severity and pad use, associated urinary/pelvic/GI symptoms, menopausal and obstetric history, prior pelvic surgery/treatments, and patient goals. Assessment of bother is paramount to the decision to operate; history alone does not definitively diagnose SUI.
• Physical exam (6): stress test (supine and/or standing) with a comfortably full bladder; focused abdominal exam; urethral mobility (Q-tip); pelvic prolapse; vaginal atrophy/estrogen status; focused neurologic exam.
• Objective demonstration — a positive stress test (involuntary leak coincident with raised abdominal pressure) is highly sensitive and specific; if not seen supine, repeat standing.
• Urinalysis screens for hematuria/pyuria; PVR screens for overflow.
• Adjuncts of limited value: questionnaires (low-quality evidence), the Q-tip test (shows mobility but doesn't diagnose SUI), and the pad test (confirms presence, not type).

Additional evaluation should be considered with (8): known/suspected neurogenic LUT dysfunction; inability to demonstrate SUI; inability to make a definitive diagnosis; elevated PVR; significant voiding dysfunction; urgency-predominant MUI; abnormal urinalysis; or high-grade POP (≥stage 3) where SUI is not shown on prolapse reduction.

• Cystoscopy should not be done in the index SUI patient; indications are suspected bladder pathology (e.g. microhematuria), structural LUT abnormality, or at the time of sling surgery (to confirm integrity/absence of foreign body). Suspect mesh/suture perforation with new LUTS, hematuria, or recurrent UTI.
• Urodynamics may be omitted when SUI is clearly demonstrated in an index patient. VALUE (NEJM 2012; n=630 uncomplicated SUI): preoperative office evaluation alone was non-inferior to evaluation plus UDS for 12-month success. UDS is reserved for non-index patients (neurogenic disease, unconfirmed SUI, subjective/objective mismatch, elevated PVR, significant voiding dysfunction, significant urgency/OAB, or prior POP/anti-incontinence surgery); with significant prolapse, do UDS with and without a pessary.

Management

Options: observation; non-surgical (urethral plugs, vaginal inserts, continence pessary, pelvic-floor muscle training ± biofeedback); and surgical (periurethral bulking, midurethral sling, autologous pubovaginal sling, Burch colposuspension). Stem-cell therapy should not be offered outside trials.

Bulking Agents

Polyacrylamide hydrogel (Bulkamid; FDA-approved 2020) has little long-term data. Indications: patients wishing to avoid more invasive surgery, or insufficient improvement after a prior anti-incontinence procedure; counsel on the expected need for repeat injections. Adverse events: implantation-site pain 13%, acute retention 6%, UTI 4%, hematuria 2%.

Midurethral Slings (MUS)

The most studied surgical treatment for female SUI and, after bulking agents, the least invasive.

• Types: retropubic (RMUS, e.g. TVT-R; top-down or bottom-up), transobturator (TMUS, e.g. TVT-O; inside-out or outside-in), and single-incision/adjustable slings.
• Mechanism: restricts posterior-urethral-wall movement and compresses the lumen during stress; patients without urethral mobility respond less well.
• Anatomy: retropubic — the dorsal nerves of the clitoris cross under the pubic bone ~1.4 cm from midline, and the obturator vessels are the closest major vessels; transobturator — avoids the true pelvis and levators, traversing obturator internus/membrane/externus and (laterally) the adductors, with the dorsal clitoral nerve ≥1–2 cm away.
• Material: soft, loosely woven, macroporous polypropylene monofilament mesh, pore size >75 μm (allows tissue ingrowth, reduces infection).
• Contraindicated with concomitant urethral diverticulectomy, urethrovaginal fistula repair, or urethral mesh excision (impaired healing → perforation). Avoid mesh with poor healing risk (radiation, scarring, poor tissue, chronic steroids, impaired collagen [Sjögren's, SLE], immunosuppression) — use a biologic (preferably autologous fascia) instead.
• Technique: placed loosely at the mid-urethra; single-incision slings need slightly tighter tension. Cystoscopy excludes trocar penetration; if the bladder is perforated, withdraw and re-pass the trocar.

Outcomes: retropubic and transobturator give similar results overall, but transobturator shows less durability with longer follow-up; single-incision slings lose efficacy over time. In ISD/fixed urethra, MUS success is lower and retropubic > transobturator (MUS still benefits ISD if some urethral mobility remains). Cure rates in the elderly with hypermobility match younger women (but more de novo urgency and slightly higher persistent SUI). For recurrent SUI, salvage MUS efficacy is similar to primary (higher bladder-perforation risk after prior retropubic suspensions).

Adverse events (overall low): bladder trocar injury 2.7–3.8% (higher with retropubic, 2.7–23.8% vs 0–1.3% transobturator; manage intraoperatively by repassing more laterally + Foley 3–7 days); voiding dysfunction 7.6%; vaginal mesh exposure 0.5–8.1%; urethral mesh perforation 0–0.6%; bladder mesh perforation 0.5–0.6%; groin pain (higher transobturator); bleeding/vascular injury (higher retropubic); and rarely infection, bowel perforation, death.

• Vaginal mesh exposure — usually within weeks–months; risk factors: diabetes, smoking, older age, >2 cm incision, prior vaginal surgery. Small (<1 cm) asymptomatic exposures may be managed conservatively (conjugated estrogen ± antibiotic cream); otherwise excise (continence maintained in most even with partial excision).
• Urethral or bladder mesh perforation — observation is never appropriate. Small areas: endoscopic management (excise/holmium laser); larger or failed: transvaginal/retropubic excision and reconstruction with non-overlapping suture lines ± labial fat-pad/omental interposition. An inverted-U incision is best for urethral perforation; an autologous fascial sling can augment the repair.
• Voiding dysfunction — de novo urgency in up to 12%, usually transient and much less than with pubovaginal slings; from a sling too tight or too proximal, or associated POP. A RCT showed higher voiding dysfunction needing surgery after retropubic vs transobturator (3% vs 0%). Manage with short-term intermittent catheterization; if persistent within the first 3 months, transvaginal sling release (midline incision through a single vertical vaginal incision) resolves symptoms while maintaining continence in most; incise within 4 weeks. After 3 months, formal sling excision/urethrolysis is needed.
• Sexual dysfunction — de novo dyspareunia 3–14%; sling removal can improve it.
• Regulatory note: the 2008 (updated 2011) FDA communications concerned transvaginal mesh for POP, not slings; an FDA panel deemed MUS products "safe and effective."

Pubovaginal Slings (PVS)

Positioned at the bladder neck (vs mid-urethra for MUS) under mild tension to compress the urethra during raised pressure. Indicated for ISD, hypermobility, MUI, concomitant cystocele/urethral diverticula, and neurologic conditions.

Feature	MUS	PVS
Position	Mid-urethra	Bladder neck
Material	Predominantly synthetic	Predominantly autologous
Donor morbidity	None	Yes
Corrects	Hypermobility	ISD + hypermobility
With urethral diverticulum repair	Cannot	Can
Postop voiding dysfunction	Lower	Higher

• Materials: autologous, allograft, xenograft, or synthetic. Autologous fascia is the gold standard for all forms of SUI (minimal inflammation, negligible erosion) — most commonly rectus abdominis fascia, or fascia lata (preferred after prior ventral hernia repair). Allograft (HIV risk ~1 in 1.67 million; CJD ~1 in 3.5 million) has questionable durability; xenograft (porcine dermis/SIS, bovine pericardium) has inferior long-term cure vs autologous in RCTs; synthetic PVS is no longer used (perforates the urethra 15× and is exposed in the vagina 14× more often than non-synthetic materials).
• Technique: drain the bladder before passing Stamey needles; cystoscopy after trocar passage and at tensioning; never tension the sling before the weighted speculum is removed and the vaginal incision closed.
• Outcomes: autologous PVS continence 61–97%; particularly helpful for ISD and recurrent SUI; effective for MUI (cure similar to pure SUI). The most common reason for dissatisfaction is urgency/urgency incontinence.
• Voiding dysfunction (obstruction) — higher than Burch. SISTEr (NEJM 2007; n=655): autologous rectus-fascia PVS vs Burch — PVS had higher success but more voiding dysfunction (63% vs 47%), UTI, and postop urgency incontinence. Permanent retention ≤5% (mostly preexisting neurogenic bladder). Transient retention usually resolves within ~10 days; if symptoms persist within 6 weeks, loosen the sling in the OR (not for synthetic); after 6 weeks or conservative failure, sling incision or formal urethrolysis (incision has comparable success with less morbidity; success 65–93%). Refractory storage symptoms after urethrolysis: consider anticholinergics and sacral neuromodulation.

Burch Colposuspension

Largely replaced by MUS (equivalent to TVT in RCTs; likely inferior to autologous fascial sling). Indications: patient preference to avoid mesh and fascial harvest, or a simultaneous abdominal procedure (e.g. hysterectomy).

Self-Test

1. In the integral theory, what supports the proximal/mid-urethra? The pubourethral ligaments, suburethral vaginal hammock, and pubococcygeus muscle.

2. What urodynamic values suggest ISD? ALPP <60 cm H₂O or MUCP <20 cm H₂O (ALPP >90 indicates little/no ISD).

3. Give five differences between MUS and PVS. MUS: mid-urethra, mostly synthetic, no donor morbidity, corrects hypermobility, cannot be combined with urethral diverticulectomy, lower postop voiding dysfunction. PVS: bladder neck, mostly autologous, donor-graft morbidity, corrects ISD + hypermobility, can be combined with urethral diverticulectomy, higher postop voiding dysfunction.

4. What are the most commonly used autologous PVS materials? Rectus abdominis fascia (most common) and fascia lata.

5. Advantages vs disadvantages of synthetic PVS? Advantages: unlimited supply, consistency, no harvest morbidity, durability. Disadvantages: inflammatory/foreign-body reaction, higher graft infection, urinary-tract perforation, and vaginal exposure — so synthetic PVS is no longer used.

6. Main findings of the SISTEr trial? Autologous rectus-fascia PVS vs Burch — PVS had higher success but more voiding dysfunction (63% vs 47%), UTI, and postop urgency incontinence.

7. Typical presenting symptoms of obstruction after PVS? More often persistent/increasing urgency and urgency incontinence (8–25%) than frank retention; permanent retention is ≤5%.

8. Surgical management of voiding dysfunction after PVS? If persistent within 6 weeks, loosen the sling in the OR (not synthetic); after 6 weeks or conservative failure, sling incision or formal urethrolysis.

9. Management of PVS perforation? Autologous/allograft urethral perforation: incise/excise the perforated portion and close the urethra primarily.

10. Closest vascular structure to the retropubic MUS approach? The obturator vessels (dorsal nerves of the clitoris cross ~1.4 cm from midline).

11. How do MUS outcomes in the elderly differ from the young? Cure rates with hypermobility are comparable, but de novo urgency/urgency incontinence and persistent SUI are somewhat higher; no increase in intraoperative complications.

12. List MUS complications. Bladder trocar injury, voiding dysfunction, vaginal mesh exposure, urethral/bladder mesh perforation, groin pain, sexual dysfunction, bleeding/vascular injury, infection, rarely bowel perforation/death.

13. Management of urinary retention after MUS? Usually transient → short-term intermittent catheterization; persistent within 3 months → transvaginal midline sling release (incise within 4 weeks).