- Conservative – lifestyle modification, weight loss, containment
- Pelvic floor exercises
- Devices and inserts
- Medical treatments
- Bulking agents
- Autologous pubovaginal slings
- Synthetic retropubic mid urethral slings
- Synthetic transobturator mid urethral slings
- Colposuspension
- AUS
Principles:
- SUI is a quality of life condition – management is primarily based on the patient’s degree of bother and individualised risk-benefit analysis (shared decision making)
- Each patient may have different goals or ideal outcomes
- Consider decision making aids
- Centres offering surgical management of SUI should perform significant volumes, and be able to deal with complications and provide follow up
- Conservative
Weight loss has been consistently shown to improve urinary incontinence.
This includes surgical weight loss / bariatric surgery.
Some patients elect for simple containment devices or pads if low level of bother and once counselled on options.
- Pelvic floor exercises
May be used as prevention as well as treatment.
56 % cure rate in Cochrane review (vs 6 % control) with significant improvements in QoL.
More effective with dedicated professional (i.e., physio) teaching and counselling.
Very safe with essentially no adverse effects.
Combining with biofeedback often performed but not supported by evidence.
EAU – Offer supervised intensive pelvic floor muscle training, for at least 3 months, as first line therapy for all women with SUI or MUI.
- Devices and inserts
Urethral plugs, continence pessaries and vaginal inserts are relatively low risk and may give benefit for some patients who wish to avoid other treatments.
Uncomfortable, preclude sexual intercourse and some need to be removed each time needing to void.
- Medical therapies
Duloxetine inhibits the presynaptic reuptake of serotonin and noradrenaline, with increased concentrations of these neurotransmitters increasing pudendal nerve stimulation and increasing resting urethral sphincter tone.
- High risk of adverse effects – nausea/vomiting, drowsiness and sedation, dry mouth, constipation, insomnia, mental health deterioration
- 80 mg daily.
- Approximately 50 % improvement, but cure is rare, and adverse effects common.
Oestrogen
- Topical oestrogen has some short term improvements in SUI, and should be offered to post-menopausal women
- Oral oestrogens give no improvement and may actually worsen UI.
- No proven evidence for ‘adjuvant’ oestrogen with other treatments.
- Topical oestrogens are not associated with increased risks of VTE, endometrial hypertrophy and breast cancer seen with systemic oestrogens.
Pseudoephedrine
- Alpha agonist which aims to increase sympathetic effect at bladder neck.
- Bulking agents
Good alternative to sling or other surgery in patients who want less invasive procedures or may be frailer.
Day-case. Can be done under local or GA.
Can be used after de novo or after previous surgery or radiation. Can be repeated.
Good option for ISD primarily.
Less efficacious in terms of cure or improvement cf. more invasive surgery, but less complications.
- 50 – 70 % success rate quoted
Most common complication is UTI.
- Occasionally migration or inflammatory reactions, and rarely abscesses or masses mimicking tumour and requiring resection.
- Urinary retention possible and more likely with periurethral injection cf. transurethral.
- 10 % reduced flow, 20 % recurrence of SUI
- Re-treatment rate around 30 %
Autologous fat has been used in past and may cause fatal embolism – not recommended.
EAU:
‘no evidence one type of bulking agent is better than another’.
‘offer bulking agents to women who request a low risk procedure with the understanding that efficacy is lower’ and ‘repeat injections are likely’
Bulkamid (polyacrylamide hydrogel)
- 66 % cure rate with negative cough stress test vs 95 % for sling in RCT
- “Non-particulate” – biocompatible (no host response), bulking is caused due to the volume of the gel injected
Macroplastique (silicon elastomer)
- Not reabsorbed – potential for migration or large inflammatory reaction, urethral mass
- “Particulate” – non biocompatible, induces inflammatory response, risk of mini particle migration – bulking is caused due to the inflammatory response and volume of mini particles
Other options – collagen (non particulate), Durasphere (carbon coated zirconium beads), Zuidex (cross-linked dextranomer), copatite.
- Autologous sling
Usually described as pubovaginal sling.
Provides a backboard to correct urethral hypermobility as the sling fibroses and is incorporated into endopelvic fascia, and can also provide passive urethral pressure with appropriate tensioning to correct ISD.
Options for graft/sling include rectus sheath or fascia lata – no significant difference in outcomes.
- Fascia lata harvest complications – paraesthesia, seroma, muscle hernia, pain.
Indications:
- Wanting to avoid synthetic material
- Previous failed mid urethral sling or colposuspension
- Concomitant urethral diverticulum (need to avoid synthetic material)
Pros:
- Good success rate – comparable to MUS – 80 – 90 % success.
- Lower rates of retreatment / higher success cf. Burch in RCT.
- Avoids synthetic mesh (and therefore useful in cases where mesh contraindicated).
- Good for all comers – ISD / hypermobility / previous surgery / neuropaths.
Sling can be tensioned under vision / intra-operatively for desired effect (eg. more tensioning if required in severe SUI).
Good for previous failed other surgeries including erosions (negligible risk of erosion itself).
Cons:
- Added morbidity of harvesting graft – second incision with added pain, risk of seroma, hernia and wound infection.
- Higher rates of voiding dysfunction post-operatively (urgency, obstruction) ~ 5 – 10 %.
- Longer hospital stay and recovery.
- Longer operative time and more technically difficult than MUS
- Difficult in those with previous abdominal surgeries.
Technique for autologous sling:
- Set-up:
- Prophylactic antibiotics, pre-operative urine.
- Lithotomy with access to abdomen and vagina.
- IDC
- Harvest rectus fascia graft:
- Pfannenstiel – expose and clear fat off rectus fascia
- Excise 9 x 1-2 cm piece of rectus sheath (widest in middle), completely clearing it off the muscle
- 0-vicryl stay sutures on back table at either end of graft, with long tails for later. Keep graft in wet packs or saline or antibiotic wash. Leave sheath open.
- Vaginal dissection:
- Weighted speculum
- Local and adrenaline infiltration anterior vaginal wall
- Midline or U shaped incision anterior vaginal wall – allowing access to bladder neck and proximal urethra
- Dissect off vaginal epithelium off pubocervical and pubourethral fasciae, leaving them intact. Dissect laterally either sharply or bluntly towards ischiopubic rami and endopelvic fascia – aiming to be able to get one finger inserted to flap
- Combined vaginal / retropubic part
- Identify dark yellow fat laterally in Retzius – pass Heiss clamp or Stamey needle skirting under the bone aiming for finger in lateral extent of vaginal dissection
- Pass tails of graft sutures back up through endopelvic fascia to abdominal wound
- Bleeding here can usually be managed conservatively – vaginal pack and patience. Ensure bladder is decompressed.
- Pass contralateral side through to abdomen also
- Place and secure graft
- Lay graft in ideal position mid/proximal urethra. Can do midline anchoring suture.
- Cystoscopy now to ensure bladder OK
- Bring tails of suture through new holes inferiorly in sheath, then close the rectus sheath defect
- Tie suture tails above the rectus sheath (after sheath is closed), with no tension – 4 cm proven optimal or two-fingers traditionally
- Close vaginal mucosa and skin, vaginal pack, TOV day 2
- Retropubic tension-free vaginal tape (TVT) mid urethral sling
Effective – comparable to autologous slings, 80 – 90 % success (better than colposuspension)
Less invasive – generally day case, quick recovery.
TOMUS study showed equivocal success between retropubic and transobturator slings but:
EAU guidelines – equivalent patient reported outcomes retropubic and transobturator at 1 year, perhaps better long term outcomes for retropubic after that.
- “long term outcomes from MUS inserted by retropubic route are superior to those inserted via transobturator route”
Bottom-to-top approach has less voiding dysfunction than top-to-bottom.
Single incision slings (“mini-slings”) were quicker and had less bleeding and post-operative pain – however have now largely been taken off the market and are recommended against by Australian Commission
Contraindications:
- Urethral or bladder injury during procedure – abandon.
- Previous radiation or any other potential healing issues (incr risk erosion).
- Concomitant repair of urethral diverticulum
Pros:
- Good outcomes and appears to be better long term efficacy cf. TOT
- Day case, minimally invasive, quick recovery.
- Preferred option by Australian Commission on Safety and Quality in Health Care
Cons:
- Mesh and potential complications of same – chronic pain, erosion (2 %), sexual dysfunction, infection
- Higher risk of bladder perforation and bleeding cf. TOT
- Voiding dysfunction may be higher cf. TOT (10 % de novo urgency, 5 % obstructive, worsening of OAB)
- May require ISC, division of sling
- More difficult in obese and hostile abdomens.
Technique for retropubic MUS:
- Set-up:
- Prophylactic ABx, lithotomy
- IDC – drain bladder
- Vaginal dissection
- Hydrodissection anterior vaginal wall with local and adrenaline
- Midline incision mid urethra (1.5 cm from meatus (urethra roughly 4 cm))
- Metz dissection of vaginal epithelial flaps directed laterally, care not to perforate pubocervical fascia
- Suprapubic stab incisions x 2
- 2 cm lateral to midline, just above pubic symphysis
- Passage of trocars
- Through vaginal incision, through endopelvic fascia out through stab incision, hugging the inferior pubic bone to avoid bladder injury
- Cystoscopy
- 70 degree lens
- Check trocars have not perforated bladder
- Passage and tensioning of sling
- Tape is passed through incisions loaded on trocars
- Tensioned appropriate (“tension free”) – should sit loosely at mid urethral position – function is not primarily due to compression of urethra
- Plastic sheath must be fully removed
- Redundant mesh excised at level of skin
- Closure
- No IDC
- Transobturator mid urethral sling
Main benefit over retropubic placement is avoidance of the retropubic space and less likelihood of bladder injury and bleeding.
Main downside is passage through obturator foramen – and risk of chronic groin pain, thigh pain and neuropraxia (5 %).
No apparent difference for outside-in or inside-out approaches – depends on brand/device instructions.
Short term outcomes similar to retropubic – but perhaps slightly less efficacious in long term, and slightly higher re-treatment rates.
Lower rates post-operative voiding dysfunction cf. retropubic.
Technique:
- Overall similar to retropubic sling
- Incision landmark is different – immediately below notch where adductor longus tendon meets inferior pubic ramus, at level of clitoris
- Needle passes through gracilis and adductor brevis muscles, then obturator externus, obturator internus and periurethral endopelvic fascia
- Try to avoid adductor longus tendon
- Remain close to bone on inner aspect obturator foramen – neurovascular bundle is cephalolateral
- Other parts similar to retropubic – 70 deg cystoscopy after passage of trocar.
Mini slings – no longer recommended by Australian Commission on Safety and Quality in Health Care. Many/most have been withdrawn from market.
- Benefit was no skin incisions – sling held in place by barbs.
- Potentially higher rates of erosion or extrusion.
Complications of mid-urethral slings
Bladder injury
- Should be identified with cystoscopy after trocar placement. Remove trocars and try again. Catheter for a few days post-operatively.
Urethral injury
- Close in two layers and abandon – do not place synthetic tape, higher risk of erosion.
Bleeding
- Usually can be managed with compression / packing and calm. Traction on catheter balloon may help. If bleeding significantly during vaginal dissection, consider if you are in the wrong plane.
- Injury to named obturator or pelvic vessels rare – may require exploration or IR.
Urinary retention / ‘hypercontinence’
- After sling – catheter for a 3 – 7 days then TOV. ISC if needed. Most settle.
- If still an issue after 2 – 4 weeks – consider UDS to see if obstructed – consider loosening, incision or division of sling transvaginally, or urethrolysis (may risk SUI recurrence – ongoing ISC an option).
- Consider other contributors to retention – narcotics, constipation, pain, immobility.
De novo OAB
- Check not obstructed / PVRs. Usual OAB management algorithms.
Vaginal erosion
- Excision of exposed segment followed by topical oestrogen. MDT approach, pain specialist. May have recurrent SUI – best treated with fascial sling.
Urethral or bladder erosion
- Excision of exposed segment with reconstruction (Martius flap etc). Reports of cystoscopic laser. MDT, specialist centre. Recurrent SUI.
Pain
- Full workup. EUA and cystoscopy to look for erosion. Physio, MDT. Partial or full removal – may not help – high volume centre.
- Colposuspension
Principle of re-suspending the bladder neck and proximal urethra to allow intra-abdominal pressure to be more effectively transmitted.
Most effective for primarily hypermobility, with poor results for ISD alone.
Widely studied as comparator for new techniques – equivalent outcomes 80 – 90 % success.
EAU guidelines suggest open colposuspension has better objective cure rates cf. lap.
Similar rates of voiding dysfunction / de novo OAB cf. slings.
Pros:
- Good efficacy.
- Can be performed with concurrent intra-abdominal procedures (hysterectomy, prolapse)
- No synthetic mesh and subsequent mesh complications.
Cons:
- More invasive with abdominal incision (or risks of laparoscopy/robotics).
- Higher rates of post-operative prolapse.
- Risk of bladder injury, especially if laparoscopic.
- Longer hospital stay, recovery etc
Technique:
- Lithotomy with access to vagina and abdomen
- IDC
- Pfannenstiel incision
- Creation of retropubic space and removal of fat to expose EPF and vaginal wall
- Swab on a stick in vagina to help mobilise
- Open endopelvic fascia
- Interrupted 0-PDS sutures from vaginal wall to Coopers ligament on inferior pubic ramus
- Place all sutures before tying
- Check swab in vagina not caught in suture
- Tie sutures – does not have to be tight
- Drain
- Leave IDC
MMK procedure – similar principle but involved suturing bladder neck to periosteum of pubic bone
- Artificial urinary sphincter
Rarely need in females for SUI – usually last resort after failed other procedures.
Complications including need for explant, mechanical failure and infection are not uncommon.