Editing AUA: Female SUI (2023) (section)

== 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.'''