Editing AUA: Female SUI (2023)



'''See [https://pubmed.ncbi.nlm.nih.gov/28625508/ 2017 Original Guideline]'''

'''See [https://pubmed.ncbi.nlm.nih.gov/37096580/ 2023 Updated Original Guideline]'''

'''See [https://www.auanet.org/documents/Guidelines/PDF/SUI/GUI-23-8333%20SUI%20Ammendment.pdf Algorithm] from [https://www.auanet.org/guidelines-and-quality/guidelines/stress-urinary-incontinence-(sui)-guideline Original Guideline]'''

See [https://www.youtube.com/watch?v=MwuvvsoMP0o Video Review of 2017 AUA Guidelines for the Treatment of Stress Urinary Incontinence]

== Definitions ==

* '''<span style="color:#ff0000">Stress Urinary Incontinence (SUI): symptom of urinary leakage due to increased abdominal pressure, which can be caused by activities such as sneezing, coughing, exercise, lifting, and position change.</span>'''
* '''<span style="color:#ff0000">Intrinsic sphincter deficiency (ISD): often defined as an abdominal leak point pressure <60 cm H20</span>''' '''or a maximal urethral closure pressure <20 cm H20,''' often in the face of minimal urethral mobility
** The utility of urethral function assessment remains controversial
* <span style="color:#ff0000">'''Urgency urinary incontinence (UUI): symptom of urinary leakage that occurs in conjunction with the feeling of urgency and a sudden desire to urinate that cannot be deferred.'''</span>
* <span style="color:#ff0000">'''Mixed urinary incontinence refers to a combination of SUI and UUI'''</span>

== Background ==

* Prevalence of female SUI: up to 49%
* '''The index patient for this guideline is an otherwise healthy female who is considering surgical therapy for the correction of pure stress and/or stress-predominant mixed urinary incontinence (MUI) who has not undergone previous SUI surgery.''' 
* Non-index patients include (9):
*# Prior surgical interventions for SUI
*#Neurogenic lower urinary tract dysfunction
*#Females with SUI and high-grade pelvic organ prolapse (stage 3 or 4)
*#*Patients with low-grade pelvic organ prolapse were also considered to be index patients.
*#Advanced age (geriatric)
*#High BMI
*# MUI (non-stress-predominant)
*# Incomplete emptying/elevated post-void residual (PVR) and/or other voiding dysfunction
*# Recurrent or persistent SUI
*# Mesh complications

== Differential Diagnosis of SUI ==

* '''<span style="color:#ff0000">Options (7)</span>'''
*# '''<span style="color:#ff0000">Overflow incontinence</span>'''
*# '''<span style="color:#ff0000">Detrusor overactivity incontinence</span>'''
*# '''<span style="color:#ff0000">Low bladder compliance</span>'''
*# '''<span style="color:#ff0000">Stress-induced detrusor overactivity</span>'''
*# '''<span style="color:#ff0000">Diverticulum</span>'''
*# '''<span style="color:#ff0000">Urinary fistula</span>'''
*# '''<span style="color:#ff0000">Ectopic ureter</span>'''

== Diagnosis and Evaluation of Patients Wanting Surgery for SUI ==

=== Recommended Investigations ===

==== Mandatory (4): ====
# '''<span style="color:#ff0000">History (including assessment of bother) and Physical Exam</span>'''
# '''<span style="color:#ff0000">Objective demonstration of stress urinary incontinence</span>'''
# '''<span style="color:#ff0000">Urinalysis</span>'''
# '''<span style="color:#ff0000">PVR</span>'''

=== History and Physical Exam ===

==== History ====
* '''<span style="color:#ff0000">Characterize incontinence</span>''' (stress, urgency, mixed, continuous, without sensory awareness).
** Presence of coughing, sneezing, lifting, walking, or running as initiators of incontinence increases the likelihood of SUI as the cause of urinary leakage
** '''<span style="color:#ff0000">Chronicity of symptoms</span>'''
** '''<span style="color:#ff0000">Frequency, bother, and severity</span>''' of incontinence episodes. Pad or protection use.
*** '''<span style="color:#ff0000">An assessment of bother is paramount to the decision to operate in the index patient.</span>'''
* '''<span style="color:#ff0000">Associated</span>''' 
**'''<span style="color:#ff0000">Urinary tract symptoms</span>''' (e.g., urgency, frequency, nocturia, dysuria, hematuria, slow flow, hesitancy, incomplete emptying)
** '''<span style="color:#ff0000">Pelvic symptoms</span>''' (e.g., pelvic pain, pressure, bulging, dyspareunia)
**'''<span style="color:#ff0000">GI symptoms</span>''' (e.g., constipation, diarrhea, splinting to defecate)
* '''<span style="color:#ff0000">Menopausal status</span>'''
* '''<span style="color:#ff0000">Obstetric history</span>''' (e.g., gravity, parity, method of delivery)
* '''<span style="color:#ff0000">Previous pelvic surgeries</span>'''
* '''<span style="color:#ff0000">Past medical history</span>''' (e.g., hypertension, diabetes, history of pelvic radiation)
* '''<span style="color:#ff0000">Current and past medications</span>'''
* '''<span style="color:#ff0000">Fluid, alcohol, and caffeine intake</span>'''
* '''<span style="color:#ff0000">Previous treatments for incontinence</span>''' (e.g., behavioral therapy, Kegel exercises/pelvic floor muscle training, pharmacotherapy, surgery)
* '''<span style="color:#ff0000">Patient’s expectations of treatment</span>''' (patient-centered goals)
* '''<span style="color:#ff0000">History alone, while helpful, does not definitively diagnose SUI in women</span>'''

==== Physical exam (6): ====
# '''<span style="color:#ff0000">Stress test (supine and/or standing) with comfortably full bladder</span>'''
# '''<span style="color:#ff0000">Focused abdominal examination</span>'''
# '''<span style="color:#ff0000">Urethral mobility</span>''' (Q-tip test or other method)
# '''<span style="color:#ff0000">Pelvic prolapse</span>''' (any method)
# '''<span style="color:#ff0000">Vaginal atrophy/estrogenization status</span>'''
# '''<span style="color:#ff0000">Focused neurologic examination</span>'''

==== Objective demonstration of SUI ====
* '''<span style="color:#ff0000">Stress test (supine and/or standing) with comfortably full bladder</span>'''
** Considered positive if involuntary urine loss from the urethral meatus is witnessed coincident with increased abdominal pressure
*** A positive stress test had a high sensitivity and specificity for detecting SUI
** '''If leakage is not witnessed in the supine position, the test may be repeated in the standing position to facilitate the diagnosis'''

==== Urinalysis ====
* Screen for abnormalities (microscopic hematuria, pyuria, etc.), which may prompt further investigations and reveal underlying cause (bladder tumour, for example) of incontinence

==== Post-void Residual (PVR) ====
* May prompt further investigations and reveal underlying cause (overflow, for example) of incontinence

=== Other Tests ===

===== Questionnaires =====
* Overall, low strength of evidence due to limited number of studies for each questionnaire

===== Q-tip test =====
* '''Positive test is unlikely to aid in the diagnosis of SUI; SUI may exist without urethral hypermobility and vice versa.'''
* Can provide potentially useful information regarding the degree of urethral mobility

===== Pad test =====
* May confirm the presence of incontinence but does not distinguish the specific type

=== Additional Evaluations ===
* '''<span style="color:#ff0000">Should be considered for patients with the following conditions (8)</span>''':
*# '''<span style="color:#ff0000">Neurogenic lower urinary tract dysfunction</span>''' (known or suspected)
*# '''<span style="color:#ff0000">Inability to demonstrate stress urinary incontinence</span>'''
*# '''<span style="color:#ff0000">Inability to make definitive diagnosis based on symptoms and initial evaluation</span>'''
*# '''<span style="color:#ff0000">Elevated post-void residual</span>''' per clinician judgment
*# '''<span style="color:#ff0000">Evidence of significant voiding dysfunction</span>'''
*# '''<span style="color:#ff0000">Urgency-predominant mixed urinary incontinence</span>'''
*# '''<span style="color:#ff0000">Abnormal urinalysis,</span>''' such as unexplained hematuria or pyuria
*# '''<span style="color:#ff0000">High grade pelvic organ prolapse</span>''' (POP-Q stage 3 or higher) '''if SUI not demonstrated by pelvic organ prolapse reduction'''
* '''May be performed in patients with:'''
** Concomitant overactive bladder symptoms
** Failure of prior anti-incontinence surgery
** Prior pelvic prolapse surgery

==== Cystoscopy ====
* '''<span style="color:#ff0000">Should not be performed in index patients for the evaluation of SUI</span>''' 
*'''<span style="color:#ff0000">Indications (3):</span>'''
*#'''<span style="color:#ff0000">Suspected bladder pathology</span>''' based on history or concerning findings on physical exam or urinalysis (e.g. microhematuria)
*#'''<span style="color:#ff0000">Structural lower urinary tract abnormality</span>'''
*#'''<span style="color:#ff0000">Patients undergoing certain surgical procedures (e.g., midurethral (MUS) or pubovaginal fascial (PVS) slings)</span> to confirm the integrity of the lower urinary tract and the absence of foreign body'''
*#'''<span style="color:#ff0000">History of prior anti-incontinence surgery or pelvic floor reconstruction, particularly if mesh or suture perforation is suspected</span>'''
*#*'''Perforation should be suspected with new onset of lower urinary tract symptoms, hematuria, or recurrent UTI'''

==== UDS ====
* '''<span style="color:#ff0000">May be omitted for the index patient desiring treatment when SUI is clearly demonstrated'''
**'''<span style="color:#ff00ff">VALUE (NEJM 2012)</span>'''
***Population: 630 females with uncomplicated SUI
***Randomized to preoperative office evaluation and urodynamic tests vs. evaluation only
***Primary outcome: Treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of “much better” or “very much better” on the Patient Global Impression of Improvement
***Results: preoperative office evaluation alone was not inferior to evaluation with urodynamic testing
***[https://pubmed.ncbi.nlm.nih.gov/22551104/ Nager, Charles W., et al. "A randomized trial of urodynamic testing before stress-incontinence surgery." ''New England Journal of Medicine'' 366.21 (2012): 1987-1997.]
* '''<span style="color:#ff0000">May be performed at the urologist’s discretion in certain non-index patients, including but not limited to (8):'''
*# '''<span style="color:#ff0000">Neurogenic lower urinary tract dysfunction</span>'''
*# '''<span style="color:#ff0000">Unconfirmed SUI</span>'''
*# '''<span style="color:#ff0000">Mismatch between subjective and objective measures</span>'''
*# '''<span style="color:#ff0000">Elevated PVR per clinician judgment</span>'''
*# '''<span style="color:#ff0000">Significant voiding dysfunction</span>'''
*# '''<span style="color:#ff0000">Significant urgency, UUI, overactive bladder (OAB)</span>'''
*# '''<span style="color:#ff0000">History of prior pelvic organ prolapse surgery</span>'''
*# '''<span style="color:#ff0000">History of prior anti-incontinence surgery</span>'''

== Management ==

=== Options ===
*'''<span style="color:#ff0000">Observation</span>'''
*'''<span style="color:#ff0000">Non-surgical interventions (3):</span>'''
*# '''<span style="color:#ff0000">Urethral plugs</span>'''
*#'''<span style="color:#ff0000">Continence pessary</span>'''
*# '''<span style="color:#ff0000">Vaginal inserts</span>'''
*# '''<span style="color:#ff0000">Pelvic floor muscle training (± biofeedback)</span>'''
* '''<span style="color:#ff0000">Surgical intervention</span>'''
** '''<span style="color:#ff0000">Options (4):</span>'''
**# '''<span style="color:#ff0000">Bulking agents</span>'''
**# '''<span style="color:#ff0000">Midurethral sling (MUS)</span>'''
**#'''<span style="color:#ff0000">Autologous pubovaginal sling (PVS)</span>'''
**#'''<span style="color:#ff0000">Burch culposuspension</span>'''
*Physicians should not offer stem cell therapy for SUI outside of investigative protocols

==== Observation ====

===== Indications (2) =====

#'''<span style="color:#ff0000">Patient expresses minimal subjective bother due to the SUI</span>'''
#*The degree of bother should be considered when considering treatment
#'''Not candidate for other forms of therapy'''

==== Non-surgical interventions (3): ====

===== Options (3): =====
# '''<span style="color:#ff0000">Urethral plugs</span>'''
#'''<span style="color:#ff0000">Continence pessary</span>'''
# '''<span style="color:#ff0000">Vaginal inserts</span>'''
# '''<span style="color:#ff0000">Pelvic floor muscle training (± biofeedback)</span>'''

====== Pelvic floor physical therapy ======

* Patient must be willing and able to commit to regularly and consistently performing pelvic floor training for this to be successful.

==== Surgical intervention ====

===== Options (4): =====
#'''<span style="color:#ff0000">Bulking agents</span>'''
#'''<span style="color:#ff0000">Synthetic midurethral slings (MUS)</span>'''
#'''<span style="color:#ff0000">Autologous pubovaginal sling (PVS)</span>'''
#'''<span style="color:#ff0000">Burch culposuspension</span>'''

====== Bulking agents ======
* Trade name: Bulkamid
**FDA approved in 2020[https://www.accessdata.fda.gov/cdrh_docs/pdf17/P170023B.pdf §]
*'''Little long-term data'''
* '''<span style="color:#ff0000">Indications (2):</span>'''
*#'''<span style="color:#ff0000">Patients who wish to avoid more invasive surgical management or are concerned with the lengthier recovery time after surgery</span>''' 
*#'''<span style="color:#ff0000">Patients who experience insufficient improvement following a previous anti-incontinence procedure.</span>'''
*'''<span style="color:#ff0000">Disadvantage (1)</span>'''
*#'''<span style="color:#ff0000">Patients should be counseled on the expected need for repeat injections</span>'''
*Adverse events[https://www.accessdata.fda.gov/cdrh_docs/pdf17/P170023C.pdf §]
**Pain at implantation (13%)
**Acute urinary retention (6%)
**Urinary tract infection (4%)
**Blood in urine (2%)

====== Synthetic Midurethral Sling (MUS) ======
* Most studied surgical treatment for female SUI
*Other than bulking agents, MUS is also the least invasive surgical options to treat SUI
*'''<span style="color:#ff0000">Classification (3):</span>'''
*#'''<span style="color:#ff0000">Retropubic MUS (RMUS, e.g. TVT-R);</span>''' top-down or bottom-up
*#'''<span style="color:#ff0000">Transobturator MUS (TMUS e.g. TVT-O);</span>''' inside-out or outside-in 
*#*TVT without specification refers to TVT-R
*#'''<span style="color:#ff0000">Single incision sling (SIS)/adjustable sling types</span>'''
* '''<span style="color:#ff0000">Retropubic vs. Trans-obturator synthetic midurethral sling</span>'''
** '''<span style="color:#ff0000">Efficacy</span>'''
***'''Short-term analyses found them to be equivalent'''
***'''Long-term comparisons are relatively lacking, however, data from increasing follow up appear to be demonstrating a <span style="color:#ff0000">lack of durability of Transobturator MUS, compared to Retropubic MUS</span>'''
** '''<span style="color:#ff0000">Adverse events:</span>'''
***'''<span style="color:#ff0000">Significant differences:</span>'''
**** '''<span style="color:#ff0000">Retropubic MUS more likely to have (4):</span>'''
****# '''<span style="color:#ff0000">Major vascular or visceral injuries</span>'''
****# '''<span style="color:#ff0000">Bladder or urethral perforations</span>'''
****# '''<span style="color:#ff0000">Voiding dysfunction</span>'''
****# '''<span style="color:#ff0000">Suprapubic pain</span>'''
**** '''<span style="color:#ff0000">Transobturator MUS more likely to have (3):</span>'''
****# '''<span style="color:#ff0000">Groin pain</span>'''
****# '''<span style="color:#ff0000">Repeat incontinence surgery between 1-5 years</span>'''
****# '''<span style="color:#ff0000">Repeat incontinence surgery after >5 years</span>'''
**** '''Briefly, Retropubic MUS riskier but lasts longer</span>'''
***** '''<span style="color:#ff00ff">TOMUS (Trial of Mid-Urethral Slings) (NEJM 2010)</span>'''
****** Population: 597 women with SUI
****** Randomized to retropubic vs. transobturator midurethral sling
****** Primary outcome: treatment success at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment)
******Results:
******* At 12 months, retropubic slings equivalent efficacy and greater risk of post-operative voiding dysfunction compared to transobturator slings
******[https://pubmed.ncbi.nlm.nih.gov/20479459/ Richter, Holly E., et al. "Retropubic versus transobturator midurethral slings for stress incontinence." ''New England Journal of Medicine'' 362.22 (2010): 2066-2076.]
* Single incision sling
**Introduced as a less invasive, lower morbidity surgery with the potential to maintain the efficacy of the existing MUS techniques
*Single incision sling vs. Retropubic MUS vs. Trans-obturator MUS MUS
** SIS demonstrates similar efficacy to TMUS; however, there is limited comparative data to RMUS.
* '''<span style="color:#ff0000">Guideline Recommendations on choice of MUS</span>'''
**<span style="color:#ff0000">'''Both Retropubic MUS (either the bottom-up or the top-down) and Transobturator MUS (either the in-to-out) or out-to-in can be offered for MUS.'''</span> 
**'''<span style="color:#ff0000">SIS can be offered with patient understanding that long-term data on safety and efficacy is lacking</span>'''
* '''<span style="color:#ff0000">Patient counselling</span>'''
** '''<span style="color:#ff0000">Must discuss the specific risks and benefits of mesh as well as the alternatives to a mesh sling.</span>'''
**'''<span style="color:#ff0000">Patients considering MUS should be made aware of the prior FDA public health notifications regarding the use of transvaginal mesh to treat SUI or pelvic organ prolapse and be advised of possible mesh-related risks, such as vaginal exposure (which can also be associated with dyspareunia) and perforation into the lower urinary tract or other neurovascular or visceral symptoms</span>''' '''<span style="color:#ff0000">either of which could require additional procedures for surgical removal of the involved mesh</span> and, if necessary, repair of the lower urinary tract.'''
***'''Risk factors for mesh erosion (5):'''
***#'''Diabetes'''
***#'''History of smoking'''
***#'''Older age'''
***#'''>2 cm vaginal incision length'''
***#'''Previous vaginal surgery'''
** '''<span style="color:#ff0000">Abdominal, pelvic, vaginal, groin, and thigh pain can be seen after sling placement</span>'''
** '''The literature does not definitively suggest that MUS is more or less effective to alternative interventions, such as PVS or colposuspension'''
* '''<span style="color:#ff0000">Technique</span>'''
** '''<span style="color:#ff0000">Do not place a mesh sling if the urethra is inadvertently injured at the time of planned MUS procedure</span>'''
***If the surgeon feels it is appropriate to proceed with sling placement in the face of an inadvertent entry into the urethra, then a non-synthetic sling should be utilized
* '''<span style="color:#ff0000">Contraindications</span>'''
**'''<span style="color:#ff0000">Should not utilize a synthetic MUS in patients undergoing concomitant (3):</span>'''
**# '''<span style="color:#ff0000">Urethral diverticulectomy</span>'''
**# '''<span style="color:#ff0000">Repair of urethrovaginal fistula</span>'''
**# '''<span style="color:#ff0000">Urethral mesh excision</span>'''
*** Mesh placed in close proximity to a concurrent urethral incision can theoretically affect wound healing, potentially resulting in mesh perforation.
***Instead, an anti-incontinence procedure that does not involve placement of synthetic material suburethrally, or use of a biologic material, preferably autologous fascia, should be considered.
** '''<span style="color:#ff0000">Consider avoiding the use of mesh in patients undergoing SUI surgery who are at risk for poor wound healing, including</span>'''
**#'''<span style="color:#ff0000">Following radiation therapy</span>'''
**#'''<span style="color:#ff0000">Presence of significant scarring</span>'''
**#'''<span style="color:#ff0000">Poor tissue quality</span>'''
**#'''<span style="color:#ff0000">Long-term steroid use</span>'''
**#'''<span style="color:#ff0000">Impaired collagen associated with systemic autoimmune disorders, such as visceral Sjogren’s disease or systemic lupus erythematosus</span>'''
**#'''<span style="color:#ff0000">Immune suppression</span>'''

====== Autologous Fascia Pubovaginal Sling ======
* '''<span style="color:#ff0000">Involves the placement of autologous fascia lata or rectus fascia beneath the urethra to provide support</span>'''
**'''<span style="color:#ff0000">Procedure more morbid than MUS</span>'''
**Efforts to use other materials, such as porcine dermis and cadaveric fascia, as substitution for the autologous fascia have shown inferior results.
* '''<span style="color:#ff0000">Adverse events:</span>'''
*#'''<span style="color:#ff0000">Wound infection</span>'''
*#'''<span style="color:#ff0000">Seroma formation</span>'''
*#'''<span style="color:#ff0000">Ventral incisional or leg hernia depending on the fascial harvest site</span>'''
*'''<span style="color:#ff00ff">SISTEr (NEJM 2007)</span>'''
**Population: 655 women with SUI
**Randomized to autologous rectus fascia PVS vs. Burch colposuspension
** Results
***Success rates higher for PVS
*** Voiding dysfunction (63% vs. 47%, ''P'' < .001), UTI, difficulty voiding, and postoperative urgency incontinence higher for PVS
**[https://pubmed.ncbi.nlm.nih.gov/17517855/ 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.]

====== Burch colposuspension ======
*Largely replaced by MUS
**Several RCTs showed essentially equivalent outcomes with the Burch colposuspension vs. TVT
*Likely inferior to pubovaginal fascial sling
*'''<span style="color:#ff0000">Indications (2):</span>'''
*#'''<span style="color:#ff0000">Patient preference to avoid mesh and avoid the morbidity of fascial harvest</span>'''
*# '''<span style="color:#ff0000">Undergoing a simultaneous abdominal procedure, such as open or minimally invasive hysterectomy</span>'''

===== Risks of surgical intervention =====
* '''<span style="color:#ff0000">Intra-operative risks: risks of anesthesia, bleeding, UTI, bladder injury, and urethral injury, and procedure-specific risks (see below)</span>'''
* '''<span style="color:#ff0000">Post-operative (4):</span>'''
*# '''<span style="color:#ff0000">Voiding dysfunction</span>'''
*#* '''May involve both storage and emptying symptoms'''
*#* '''Risk of de novo or worsening of baseline storage symptoms for patients with MUI or SUI with urinary urgency.'''
*#* '''Management'''
*#** '''Appropriate and effective to initially treat persistent voiding dysfunction conservatively.''' This includes temporary catheter drainage, CIC, timed voiding, double voiding, biofeedback, pelvic floor muscle training, and anticholinergic therapy.
*# '''<span style="color:#ff0000">Obstruction resulting in urinary retention</span>'''
*#* '''Management'''
*#** '''Would require intermittent catheterization, indwelling Foley catheter drainage, and possible sling incision, sling loosening, or urethrolysis if this does not resolve spontaneously'''
*#** '''Midurethral slings'''
*#*** '''Urinary obstruction after MUS surgery is usually transient and can be managed with short-term intermittent catheterization''', although occasionally symptoms mandate sling release.
*#*** '''If persistently elevated residual urine and bothersome symptoms refractory to conservative management, transvaginal sling release can be attempted'''
*#****'''Transvaginal sling release procedures consistently provide resolution of symptoms with maintenance of continence in the majority of patients.''' 
*#****'''A waiting period of at least 2 to 4 weeks is recommended before sling release.'''
*#**'''Pubovaginal slings'''
*#*** '''Transient urinary retention is common, usually improves or resolves with time'''
*#****'''Most patients return to spontaneous voiding within the first 10 days'''
*#*** '''If persistently elevated residual urine and bothersome symptoms refractory to conservative management and within first 6 weeks after autologous PVS surgery, sling loosening in the operating room''' '''can be attempted.''' 
*#****This is done by first inserting a cystoscope into the bladder (using spinal or general anesthesia) and then gently applying caudal pressure to the urethra. 
*#****'''This procedure is not advised with synthetic slings'''
*#*** '''After 6 weeks or when conservative measures fail, a formal urethrolysis or sling incision is indicated.'''
*# '''<span style="color:#ff0000">Pain with sexual activity</span>'''
*# '''<span style="color:#ff0000">Persistent SUI</span>''' immediately after the procedure or recurrent SUI at a later time that may require further intervention

== Special cases ==

* '''<span style="color:#ff0000">Fixed, immobile urethra (often referred to as ‘intrinsic sphincter deficiency’)</span>'''
**'''<span style="color:#ff0000">Autologous PVS is the preferred surgical approach</span>'''
**RMUS or urethral bulking agents can be offered as alternatives
* '''<span style="color:#ff0000">Concomitant surgery for pelvic prolapse repair and SUI</span>'''
**SUI may coexist with pelvic organ prolapse in a significant number of patients.
**Women with preexisting SUI may have worsening of urinary incontinence, and some without any symptoms of SUI may develop de novo stress leakage following reduction of the prolapse.
**'''<span style="color:#ff0000">Any of the incontinence procedures (e.g., midurethral sling, PVS, Burch colposuspension) may be performed</span>'''
*** Must balance the benefits with the potential for an unnecessary surgery and possible additional morbidity
*** A nomogram has been developed that can help estimate the risk of developing SUI after vaginal prolapse surgery and can aid in the decision regarding whether or not to perform a concomitant anti-incontinence procedure.
* '''Concomitant neurologic disease affecting lower urinary tract function (neurogenic bladder)'''
**Patients with neurogenic lower urinary tract dysfunction do not fall into the category of the index patient, and a detailed evaluation should be performed.
***'''Issues, such as incomplete emptying, detrusor overactivity, and impaired compliance, should be identified and in many cases treated prior to surgical intervention for SUI.'''
**'''Surgical treatment of SUI may be offered''' after appropriate evaluation and counseling have been performed.
*** '''In a patient who requires intermittent catheterization, one must be cognizant of possible complications with the use of a bulking agent (bulking effect may be attenuated by frequent catheter passage) or a synthetic sling (potential catheter trauma in the area of the sling could place the patient at risk for mesh erosion into the urethra).'''
*** '''Patients with neurogenic lower urinary tract dysfunction who undergo sling procedures in particular should be followed long-term for changes in lower urinary tract function that could be either induced over time by the neurologic condition itself, or potentially by the sling procedure.'''
**** New onset hydroureteronephrosis found after sphincter/sling placement in patients with a neurogenic bladder may be caused by bladder decompensation (detrusor noncompliance) that was not identified on pre-operative urodynamic studies
* '''Synthetic MUS, in addition to other sling types, may be offered to the following patient populations after appropriate evaluation and counseling have been performed''':
*# '''Patients planning to bear children'''
*#* '''Placement of a sling should be postponed until child bearing is complete; among women with prior MUS, there is a high rate of SUI recurrence following delivery''', independent of mode of delivery
*# '''Diabetes'''
*#* '''Higher risk for mesh erosion and reduced effectiveness''' compared with their non-diabetic counterparts.
*# '''Obesity'''
*#* '''Worse clinical effectiveness of slings in obese patients compared with those with lower BMI.'''
*# '''Geriatric (age >65)'''
*#* '''Lower likelihood of successful clinical outcomes compared with younger patients'''
*'''Severe outlet dysfunction or recurrent or persistent SUI after surgical intervention (e.g., surgical failure)'''
**Patients who have an exceedingly compromised bladder outlet due to functional or anatomic issues such as neurogenic bladder, failed surgery for treatment of stress incontinence, or severe ISD may require more drastic measures to achieve relief from their SUI.
**'''Obstructing pubovaginal sling or bladder neck closure with urinary drainage (catheterizable stoma, an AUS, or total urinary diversion via ileal conduit or continent diversion) may be offered after counseling regarding the risks, benefits, and alternatives.''' 

== Outcomes assessment ==

* '''<span style="color:#ff0000">Patients should be evaluated within the early postoperative period to assess any significant voiding problems, pain, or other unanticipated events</span>'''. If patients are experiencing any of these outcomes, they should be seen and examined.
** '''If there is evidence a patient has symptoms of obstruction, early intervention may be necessary to reduce patient bother and to prevent development of bladder dysfunction in the long-term.'''
* '''<span style="color:#ff0000">Patients should be seen and examined within 6 months post-operatively.</span>''' 
** '''<span style="color:#ff0000">Recommended evaluations</span>'''
**#'''<span style="color:#ff0000">Subjective outcome of surgery as perceived by the patient should be assessed and documented</span>'''. 
**#*Patients should be asked about residual incontinence, ease of voiding/force of stream, recent UTI, pain, sexual function and new onset or worsened overactive bladder symptoms.
**# '''<span style="color:#ff0000">Physical exam, including an examination of all surgical incision sites''', '''should be performed</span>''' 
**#*To evaluate healing, tenderness, mesh extrusion (in the case of synthetic slings), and any other potential abnormalities.
**# '''<span style="color:#ff0000">Post-void residual should be obtained</span>'''
** '''Optional'''
***'''Standardized questionnaire (e.g. PGI-I) may be considered'''
*'''Patients with unfavorable outcomes may require additional follow-up.'''

== Questions ==

# What is the differential diagnosis of a patient presenting with incontinence?
# What is the recommended workup of a patient presenting with SUI?
# Take a history of a patient presenting with SUI
# Describe your physical exam.
# When should UDS be considered in a patient presenting with SUI?
# What are non-surgical/surgical treatment options for SUI?
# What are the potential risks associated with surgical intervention for SUI?
# What are the 3 surgical approaches to a MUS? Which approach to the MUS is more likely to be associated with bladder perforation?
# In which patients should a synthetic MUS be avoided?
# What is the preferred surgical treatment in a patient with SUI due to intrinsic sphincter deficiency?

== Answers ==

# What is the differential diagnosis of a patient presenting with incontinence?
## Overflow incontinence
## Detrusor overactivity incontinence
## Low bladder compliance
## Stress-induced detrusor overactivity
## Diverticulum
## Urinary fistula
## Ectopic ureter
# What is the recommended workup of a patient presenting with SUI?
## History + physical exam
## Objective demonstration of SUI
## Urinalysis
## PVR
# Take a history of a patient presenting with SUI
## Characterize LUTS
## Degree of bother
## Associated pelvic or GI symptoms
## Gyne/obstetric history, menopausal status
## Fluid intake
## PMHx, PSHx, Meds, allergies
## Previous treatments, treatment expectations
# Describe your physical exam.
## Focused abdominal examination
## Evaluation of urethral mobility (any method)
## Supine and/or standing stress test with comfortably full bladder
## Assessment of pelvic prolapse (any method)
## Assessment of vaginal atrophy/estrogenization status
## Focused neurologic examination
# When should UDS be considered in a patient presenting with SUI?
## History of prior anti-incontinence surgery
## History of prior pelvic organ prolapse surgery
## Mismatch between subjective and objective measures
## Significant voiding dysfunction
## Significant urgency, UUI, overactive bladder (OAB)
## Elevated PVR per clinician judgment
## Unconfirmed SUI
## Neurogenic lower urinary tract dysfunction
# What are non-surgical/surgical treatment options for SUI?
#* Non-surgical:
#*# PFMT
#*# Biofeedback
#*# Pessary
#*# Vaginal inserts
#* Surgical:
#*# Bulking agents
#*# MUS
#*# PVS
#*# Burch-coloposuspension
# What are the potential risks associated with surgical intervention for SUI?
## Voiding dysfunction (de novo or worsening of LUTS)
## Urinary retention
## Dyspareunia
## Persistent/recurrent SUI
# What are the 3 surgical approaches to a MUS? Which approach to the MUS is more likely to be associated with bladder perforation?
## Retropubic, most likely to be associated with bladder perforation
## Transobturator
## Single-incision
# In which patients should a synthetic MUS be avoided?
#* Patients undergoing concomitant
#*# Urethral diverticulectomy
#*# Repair urethrovaginal fistula
#*# Excision urethral mesh
# What is the preferred surgical treatment in a patient with SUI due to intrinsic sphincter deficiency?
#* Autologous PVS

== References ==

* [https://pubmed.ncbi.nlm.nih.gov/28625508/ Kobashi, Kathleen C., et al. "Surgical treatment of female stress urinary incontinence: AUA/SUFU guideline." ''The Journal of urology'' 198.4 (2017): 875-883.]