Surgical Treatment of Female Stress Urinary Incontinence

1. In the initial evaluation of patients with stress urinary incontinence (SUI) desiring to undergo surgical intervention, clinicians should include the following components:

• History, including assessment of bother
• Physical examination, including a pelvic examination
• Objective demonstration of SUI with a comfortably full bladder (any method)
• Assessment of post-void residual urine (any method)
• Urinalysis

2. Clinicians should perform additional evaluations in patients being considered for surgical intervention who have the following conditions

• Inability to make definitive diagnosis based on symptoms and initial evaluation
• Inability to demonstrate SUI
• Known or suspected neurogenic lower urinary tract dysfunction
• Abnormal urinalysis, such as unexplained hematuria or pyuria
• Urgency-predominant mixed urinary incontinence (MUI)
• Elevated post-void residual per clinician judgment
• High grade pelvic organ prolapse (POP-Q stage 3 or higher) if SUI is not demonstrated with pelvic organ prolapse reduction
• Evidence of significant voiding dysfunction

3. Clinicians may perform additional evaluations in patients with the following conditions: (Expert Opinion)

• Concomitant overactive bladder symptoms
• Failure of prior anti-incontinence surgery
• Prior pelvic prolapse surgery

4. Clinicians should not perform cystoscopy in index patients for the evaluation of SUI unless there is a concern for urinary tract abnormalities.

5. Clinicians may omit urodynamic testing for the index patient desiring treatment when SUI is clearly demonstrated.

6. Clinicians may perform urodynamic testing in non-index patients.

7. In patients wishing to undergo treatment for SUI, the degree of bother that their symptoms are causing them should be considered in their decision for therapy.

8. In patients with SUI or stress-predominant MUI who wish to undergo treatment, clinicians should counsel regarding the availability of the following treatment options:

• Observation
• Pelvic floor muscle training (± biofeedback)
• Other non-surgical options (e.g., continence pessary)
• Surgical intervention

9. Clinicians should counsel patients on potential complications specific to the treatment options.

10. Prior to selecting midurethral synthetic sling procedures for the surgical treatment of SUI in women, clinicians must discuss the specific risks and benefits of mesh as well as the alternatives to a mesh sling.

• Continence pessary
• Vaginal inserts
• Pelvic floor muscle exercises (PFME) ± biofeedback

• Midurethral sling (retropubic, transobturator, or single-incision sling)
• Autologous fascia pubovaginal sling
• Burch colposuspension
• Bulking agents

• Patients planning to bear children
• Diabetes
• Obesity
• Geriatric

• The subjective outcome of surgery as perceived by the patient should be assessed and documented.
• Patients should be asked about residual incontinence, ease of voiding/force of stream, recent urinary tract infection (UTI), pain, sexual function and new onset or worsened overactive bladder symptoms.
• A physical exam, including an examination of all surgical incision sites, should be performed to evaluate healing, tenderness, mesh extrusion (in the case of synthetic slings), and any other potential abnormalities.
• A post-void residual should be obtained.