56 Vik Khullar Queen Charlotte’s and Chelsea Hospital, Imperial College London, London, UK Urinary incontinence has a major impact on the quality of life of women and urgency incontinence has been found to be associated with increased mortality [1]. Through ignorance, embarrassment and a belief that loss of bladder control is a ‘normal’ result of childbirth and ageing, many women suffer for years before seeking help [2]. An accurate diagnosis can be made and many women can be cured or improved by the use of various management strategies. Urinary incontinence is defined as the complaint of any involuntary loss of urine [3], whereas continence is the ability to retain urine at all times except during micturition. Both continence and micturition depend on a structurally and functionally normal lower urinary tract. Urinary incontinence is best classified according to aetiology, as shown in Table 56.1. There are a number of additional causes of urinary incontinence in elderly woman (Table 56.2), many of which can be reversed by appropriate intervention. Table 56.1 Causes of urinary incontinence in women. Table 56.2 Causes of incontinence in the elderly, many of which may be transient. Symptoms of lower urinary tract dysfunction fall into three main groups: (i) incontinence; (ii) overactive bladder (OAB) symptoms; and (iii) voiding difficulties. Stress urinary incontinence (SUI) is the most common complaint. It may be a symptom or a sign but it is not a diagnosis. Apart from stress incontinence, women may complain of urge incontinence, dribble or giggle incontinence, or incontinence during sexual intercourse. Nocturnal enuresis (bed wetting) may occur on its own or in conjunction with other complaints. Symptoms of voiding difficulty include hesitancy, a poor stream, straining to void and incomplete bladder emptying. Apart from the symptoms of lower urinary tract dysfunction, it is important to take a full history from all women who present with urinary incontinence. Other gynaecological symptoms such as prolapse or menstrual disturbances may be relevant. A fibroid uterus may compress the bladder and can cause urinary frequency and urgency. There is an increased incidence of stress incontinence amongst women who have had large babies, particularly following instrumental vaginal delivery, so an obstetric history may be helpful. Information regarding other urological problems, such as recurrent urinary tract infections, episodes of acute urinary retention or childhood enuresis, should be sought. Urinary incontinence is sometimes the first manifestation of a neurological problem (such as multiple sclerosis) so it is important to enquire about neurological symptoms. Endocrine disorders such as diabetes may be responsible for symptoms of lower urinary tract dysfunction and should therefore be recorded. Some drugs affect urinary tract function, especially diuretics, which increase urine output. In older people they may cause urinary incontinence where only urgency existed previously. Other drugs that affect detrusor function include tricyclic antidepressants, major tranquillizers and α‐adrenergic blockers. Unfortunately, clinical examination is usually unhelpful in cases of female urinary incontinence. General examination should include the subject’s mental state and mobility as well as the appearance of local tissues. Excoriation of the vulva will indicate the severity of the problem and atrophic changes may reveal long‐standing hormone deficiency. A gynaecological/urological examination should be carried out and although stress incontinence may be demonstrated, this will only confirm the patient’s story; it will not actually indicate the cause. If a neurological lesion is suspected, then the cranial nerves and sacral nerve roots S2–S4 should be examined. The bladder has been described as an ‘unreliable witness’. The correlation between clinical diagnosis and urodynamic diagnosis is poor, and therefore it is unusual to be able to make an accurate diagnosis based on history and examination alone. Urodynamic stress incontinence is the commonest cause of urinary incontinence in women and detrusor overactivity is the second most common cause. These two diagnoses account for over 90% of cases of female urinary incontinence. As their treatment differs it is important to make an accurate initial diagnosis. Investigations range from the very simple to the highly sophisticated and complex and are outlined in Table 56.3. Table 56.3 Investigations of female urinary incontinence. A midstream urine (MSU) specimen should always be sent for culture and sensitivity prior to further investigation. Although the patient’s symptoms are unlikely to be caused by a urinary tract infection, they can be altered by one. It is often helpful to ask women to complete a frequency–volume chart or urinary diary (Fig. 56.1). This is informative for the doctor as well as the patient and may indicate excessive drinking or bad habits as the cause of lower urinary tract symptoms. The frequency–volume chart (urinary or bladder diary) provides an objective assessment of a patient’s fluid input and urine output. Fig. 56.1 A frequency–volume chart showing frequent small voided volumes. As well as the number of voids and incontinence episodes, the mean volume voided over a 24‐hour period can also be calculated, as well as the diurnal and nocturnal volumes. Frequency–volume charts have the advantage of assessing symptom severity in the everyday situation. Incontinence can be confirmed (without diagnosing the cause) by performing a pad weighing test. Many different types of pad test have been described based on the method for filling the bladder or length of the test. Urodynamic studies comprise several investigations that are employed to determine bladder function. Uroflowmetry, the measurement of urine flow rate, is a simple test that can exclude the presence of outflow obstruction or a hypotonic detrusor, but on its own will not differentiate between the two. In order to obtain a flow rate, the patient is asked to void onto the flowmeter, in private, when her bladder is comfortably full. The maximum flow rate and volume voided are recorded. In women, the normal recording is a bell‐shaped curve with a peak flow rate of at least 15 mL/s for a volume of 150 mL of urine voided (Fig. 56.2a). A reduced flow rate in an asymptomatic woman may be important if she is to undergo incontinence surgery as she is more likely to develop voiding difficulties in the postoperative period (Fig. 56.2b). Fig. 56.2 (a) Normal uroflowmetry (maximum flow 45 mL/s, voided volume 330 mL); (b) reduced flow rate (maximum flow rate 12.5 mL/s, voided volume 225 mL). Cystometry, which measures the pressure–volume relationship within the bladder, can differentiate between urodynamic stress incontinence and detrusor overactivity in the majority of cases. The bladder is filled with physiological saline via a urethral catheter. During bladder filling the intravesical (total bladder) pressure and the intra‐abdominal pressure are measured. The rectal (or vaginal) pressure is recorded to represent intra‐abdominal pressure and this is subtracted from the bladder (intravesical) pressure to give the detrusor pressure. This is called subtracted cystometry (Fig. 56.3). Fig. 56.3 Subtracted cystometry. The information obtained from a subtracted cystometrogram includes sensation, capacity, contractility and compliance (Fig. 56.4). The urinary residual volume is normally less than 50 mL, the first sensation of desire to void is normally at 150–250 mL and the cystometric bladder capacity is normally 400–600 mL. Under normal circumstances, the detrusor pressure does not rise by more than 0.03 cmH2O for 1 mL of bladder volume and there are no detrusor contractions during bladder filling. Ideally, the bladder is filled with the woman sitting or standing and the filling catheter removed once capacity is reached. She is asked to cough several times and to heel bounce and any rise in detrusor pressure or leakage per urethram is recorded. She is then asked to pass urine and the detrusor pressure is measured and any urinary residual volume can be noted (Fig. 56.5). Fig. 56.4 Subtracted cystometrogram trace showing a picture of low compliance. Fig. 56.5 A normal cystometrogram trace (the bottom line represents the flow rate, which is normal). Videocystourethrography with pressure and flow studies, which combines cystometry, uroflowmetry and radiological screening of the bladder and urethra, can be a most informative investigation (Fig. 56.6). It is relatively expensive and time‐consuming and is only available in tertiary referral centres. Abnormal bladder morphology can be assessed as well as the presence of vesico‐ureteric reflux, trabeculation or diverticula. Occasionally, a urethral diverticulum or vesicovaginal fistula may be identified (Fig. 56.7). Fig. 56.6 Videocystourethrography demonstrating urodynamic stress incontinence. Subtracted filling cystometry showing no evidence of detrusor overactivity and synchronous screening demonstrating urethral sphincter incompetence on coughing. Fig. 56.7 Videocystourethrography images. (a) Extrinsic compression of the bladder by uterine fibroids; (b) large cystocele; (c) multiple bladder diverticula; (d) neurogenic bladder with uninhibited detrusor contraction and associated leakage; (e) bladder trabeculation, diverticula and right‐sided vesico‐ureteric reflux; and (f) multiple diverticula, bladder trabeculation and an unprovoked contraction with leakage. The resting urethral pressure profile (UPP) is a graphical record of pressure within the urethra at successive points along its length. Of particular interest are the maximum urethral closure pressure and functional urethral length (Fig. 56.8). In addition, stress pressure profiles can be performed if the patient coughs repeatedly during the procedure. This enables the pressure transmission ratio (the increment in urethral pressure, on stress, as a percentage of the simultaneously recorded increment in intravesical pressure) to be calculated. Urethral instability or relaxation can also be identified. Although urethral pressure profilometry is not useful in the diagnosis of urodynamic stress incontinence, it is helpful in women whose incontinence operations have failed and also in those with voiding difficulties [4]. Fig. 56.8 Urethral pressure profilometry: normal trace. Imaging of the urinary tract is mainly through ultrasound, X‐rays or MRI [5]. Intravenous urography has now largely been replaced by ultrasound of the upper urinary tract. However, a CT urogram is important in cases of haematuria (Fig. 56.9). Additional pathology may be diagnosed, such as the presence of a ureteric fistula, a transitional cell carcinoma or calculi. Fig. 56.9 Intravenous urogram showing a right duplex ureter. Ultrasound is now routinely used for assessing bladder volumes [6] and assessing the upper urinary tracts. Transvaginal ultrasound does allow clear visualization of the urethra and urethral diverticula. Bladder wall thickness of an empty bladder can be measured transvaginally giving a reproducible and sensitive method of screening for detrusor overactivity (a mean bladder wall thickness >5 mm gave a predictive value of 94% in the diagnosis of detrusor overactivity) [7]. Measurement of bladder wall thickness has also been shown to have a role as an adjunctive test in those women whose lower urinary tract symptoms are not explained by conventional urodynamic investigations [8]. MRI is useful in diagnosing urethral diverticula and imaging the pelvic floor muscles [9]. Electromyography can be employed to assess the integrity of the nerve supply to a muscle [10]. The electrical impulses to a muscle fibre are measured following nervous stimulation. Two main types of electromyography are employed in the assessment of lower urinary tract dysfunction. The pudendal nerve is stimulated and potentials measured via the electrode. This is inaccurate as the muscular activity of the levator ani is not necessarily representative of that of the rhabdosphincter urethrae [11]. Single‐fibre electromyography is more accurate as it assesses the nerve latency within individual muscle fibres of the rhabdosphincter. Electromyography may be useful in the assessment of women with neurological abnormalities or those with voiding difficulties and retention of urine [12]. All urodynamic tests are unphysiological and most are invasive. Various authors have suggested that long‐term ambulatory monitoring may be more physiological as the assessment takes place over a prolonged period of time and during normal daily activities. Ambulatory urodynamics is defined as a functional test of the lower urinary tract utilizing natural filling and reproducing the subject’s everyday activities [13]. Ambulatory urodynamics is useful in cases where the clinical and conventional urodynamic diagnoses differ, or when no abnormality is found on laboratory urodynamics [14] (Fig. 56.10). Ambulatory urodynamics has been shown to be more sensitive than laboratory urodynamics in the diagnosis of detrusor overactivity but less sensitive in the diagnosis of urodynamic stress incontinence [14], although its role in clinical practice remains controversial [15]. Fig. 56.10 Ambulatory urodynamic equipment demonstrating (a) the digital recording unit and Urilos pad and (b) microtip pressure transducer. Urethral incontinence will occur whenever the intravesical pressure involuntarily exceeds the intraurethral pressure. This may be due to an increase in intravesical (or detrusor) pressure or a reduction in urethral pressure or a combination of the two. Thus, the fault which leads to incontinence may lie in the urethra or the bladder or both. Urodynamic stress incontinence is defined as the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction [3]. There are various different underlying causes that result in weakness of one or more of the components of the urethral sphincter mechanism (Table 56.4). Table 56.4 Causes of urodynamic stress incontinence. Urodynamic stress incontinence is associated with vaginal delivery due to denervation of the urethral sphincter mechanism or damage to the urethral sphincter [16,17]. Snooks et al. [18] employed electromyography to reveal evidence of pelvic floor denervation in women who had delivered vaginally but not in those who had undergone caesarean section. A long active second stage of labour was the only factor associated with severe damage. If a woman complains of stress incontinence as her sole symptom and stress incontinence can be demonstrated on coughing, there is a 95% chance that the diagnosis is urodynamic stress incontinence. However, Haylen et al. [19] have shown that only 2% of women who present for urodynamic assessment fall into this category. Types of conservative treatment for urodynamic stress incontinence are listed in Table 56.5. Conservative treatment is indicated as first‐line therapy if the patient is medically unfit for surgery or does not wish to undergo an operation, or in women who have not yet completed their families. Table 56.5 Conservative treatment for urodynamic stress incontinence. Pelvic floor muscle training (PFMT) and pelvic floor physiotherapy remain the first‐line conservative measures since their introduction in 1948 [20]. PFMT appears to work in a number of different ways: Cure rates varying from 21 to 84% have been reported [22,23]. Success appears to depend on the type and severity of incontinence treated, the instruction and follow‐up given, the compliance of the patient and the outcome measures used. However, the evidence would suggest that PFMT is more effective if patients are given a structured programme to follow rather than simple verbal instructions [24] and it appears that pelvic floor exercises increase the size of the urethral sphincter on three‐dimensional ultrasound measurement [25]. The results are not superior to continence surgery [26]. These are currently available as sets of five or three [27], all of the same shape and size but of increasing weight (20–90 g). When inserted into the vagina, a cone stimulates the pelvic floor to contract to prevent it from falling out and this provides ‘vaginal weight training’. A 60–70% improvement rate has been reported using this technique [27] and two studies have shown that cones are as effective as more conventional forms of pelvic floor re‐education and require less supervision [28]. Maximal electrical stimulation can be carried out using a home device that utilizes a vaginal electrode through which a variable current is passed. The woman is able to adjust the strength of the stimulus herself and is instructed to use the device for 20 min daily initially for 1 month. Maximum electrical stimulation has been employed in both the management of urodynamic stress incontinence and detrusor overactivity, although it has not gained popularity [29]. There are many women who, for various reasons, are not suitable for, or who do not wish to undergo, active treatment of their incontinence. However, they do require some sort of ‘containment’ of their leakage and vaginal devices may be suitable for use during exercise on a short‐term basis [30]. Although various agents such as α1‐adrenoceptor agonists, oestrogens and tricyclic antidepressants have all been used anecdotally in the past for the treatment of stress incontinence, duloxetine is the first drug to be specifically developed and licensed for this indication. Duloxetine is a potent and balanced serotonin (5‐hydroxytryptamine) and noradrenaline reuptake inhibitor (SNRI) that enhances urethral striated sphincter activity via a centrally mediated pathway [31]. Duloxetine was associated with significant and dose‐dependent decreases in incontinence episode frequency. Reductions were 41% for placebo and 54, 59 and 64% for the 20, 40 and 80 mg groups, respectively. Discontinuation rates were also dose dependent: 5% for placebo and 9, 12 and 15% for the 20, 40 and 80 mg groups, respectively; the most frequently reported adverse event was nausea [32]. Surgery is usually the most effective way of curing urodynamic stress incontinence, and a 90% cure rate can be expected for an appropriate, properly performed primary procedure. Traditional surgery for urodynamic stress incontinence aims to support the bladder neck and proximal urethra and in some cases to increase the outflow resistance. Undoubtedly, the results of suprapubic operations such as Burch colposuspension or the Marshall–Marchetti–Krantz procedure are better than those for the traditional anterior colporrhaphy with bladder neck buttress [33–35]. Numerous operations have been described and many are still performed today. Common operations for urodynamic stress incontinence are listed in Table 56.6. Table 56.6 Operations for urodynamic stress incontinence. Anterior colporrhaphy is only rarely performed for urodynamic stress incontinence. Although it is usually the best operation for a cystourethrocele, the cure rates for urodynamic stress incontinence are poor compared with those from suprapubic procedures [36]. As prolapse is relatively easier to cure than stress incontinence, it is appropriate to perform the best operation for incontinence when the two conditions coexist. The Marshall–Marchetti–Krantz procedure is a suprapubic operation in which the paraurethral tissue at the level of the bladder neck is sutured to the periostium and/or perichondrium of the posterior aspect of the pubic symphysis. This procedure elevates the bladder neck but will not correct any concomitant cystocele. It has been largely superseded by Burch colposuspension because its complications include osteitis pubis in 2–7% of cases. The Burch colposuspension has been the operation of choice in primary urodynamic stress incontinence as it corrects both stress incontinence and a cystocele. The operation is performed via a low transverse suprapubic incision. The bladder, bladder neck and proximal urethra are dissected medially off the underlying paravaginal fascia and three or four pairs of non‐absorbable or long‐term absorbable sutures are inserted between the fascia and the ipsilateral iliopectineal ligament. Haemostasis is secured and the sutures are tied, thus elevating the bladder neck and bladder base (Fig. 56.11). Postoperatively, a suction drain is left in the retropubic space and a suprapubic catheter is inserted into the bladder. Colposuspension is now well recognized as an effective procedure for stress incontinence but complications include detrusor overactivity, voiding difficulties or exacerbated recto‐enterocele. There have been studies comparing open and laparoscopic colposuspension, with similar results if surgeons are trained adequately [33]. Fig. 56.11 Suture placement for the Burch colposupension between the paravaginal tissue and the ileopectineal ligament. Sling procedures are normally performed as secondary operations where there is scarring and narrowing of the vagina. The sling material can be either biological (autologous rectus fascia, porcine dermis, cadaveric fascia) or synthetic (Prolene® and Mersilene®, Ethicon, Somerville, NJ, USA). The sling may be inserted either abdominally or vaginally, or by a combination of both. Sling procedures are associated with a higher incidence of side effects and complications, especially after the insertion of inorganic material but mid‐ to long‐term continence outcomes are superior to open colposuspension [33] but there are increased rates of irritative symptoms [37]. The tension‐free vaginal tape (Gynecare®, Ethicon, Somerville, NJ, USA), first described by Ulmsten in 1996 [38], is now the most commonly performed procedure for SUI in the UK, and more than 2 million procedures have been performed worldwide. A knitted 11 mm × 40 cm polypropylene mesh tape is inserted transvaginally at the level of the mid‐urethra, using two 5‐mm trocars (Fig. 56.12). The procedure may be performed under local, spinal or general anaesthesia. Most women can go home the same day, although some do require catheterization for short‐term voiding difficulties (2.5–19.7%). Other complications include bladder perforation (2.7–5.8%), de novo urgency (0.2–15%) and bleeding (0.9–2.3%) [34]. It has comparable outcomes to Burch colposuspension [33]. Fig. 56.12 Tension‐free vaginal tape in situ under the mid‐urethra and exiting suprapubically. The transobturator route for the placement of synthetic mid‐urethral slings was first described in 2001 by Delorme [39] (Fig. 56.13). However, the transobturator route may be associated with damage to the obturator nerve and vessels; in an anatomical dissection model, the tape passes 3.4–4.8 cm from the anterior and posterior branches of the obturator nerve, respectively, and 1.1 cm from the most medial branch of the obturator vessels [40]. Consequently, nerve and vessel injury, in addition to bladder injury and vaginal erosion, remain a potential complication of the procedure. Also the success rate has been found to be lower than retropubic tape in randomized studies [41]. Fig. 56.13 Transobturator tape: ‘inside out’ procedure. Endoscopically guided bladder neck suspensions [42–44] are simple to perform but are less effective than open suprapubic procedures and are now seldom used. Urethral bulking agents are a minimally invasive surgical procedure for the treatment of urodynamic stress incontinence and may be useful in the elderly and those women who have undergone previous operations and have a fixed, scarred and fibrosed urethra. Although the actual substance injected may differ, the principle is the same. It is injected either periurethrally or transurethrally on either side of the bladder neck under cystoscopic control, and is intended to ‘bulk’ the bladder neck and mid‐urethra in order to stop premature bladder neck opening, without causing outflow obstruction. The procedure may be performed under local, regional or general anaesthesia. There are now several different products available (Table 56.7). The use of minimally invasive implantation systems (Fig. 56.14) has also allowed some of these procedures to be performed in the office setting without the need for cystoscopy. Long‐term follow‐up studies give a greater than 50% objective cure rate at 2 years but a subjective improvement rate of about 70% [45–47]. Table 56.7 Urethral bulking agents. * Bard, Covington, GA, USA. † Uroplasty, Minnetonka, MN, USA. ‡ Coloplast, Peterborough, UK. § Boston Scientific, Marlborough, MA, USA. ¶ Gynecare, Somerville, NJ, USA. Fig. 56.14 Macroplastique urethral bulking agent and implantation device. Although success rates with urethral bulking agents are generally lower than those with conventional continence surgery, they are minimally invasive and have lower complication rates, meaning that they remain a useful alternative in selected women. An artificial sphincter is a device that may be employed when conventional surgery fails [48]. It is implantable and consists of a fluid‐filled inflatable cuff that is surgically placed around the bladder neck. A reservoir containing fluid is sited in the peritoneal cavity and a small finger‐operated pump is situated in the left labium majus. The three major components are connected via a control valve. Under normal circumstances the cuff is inflated and thus obstructs the urethra. When voiding is desired the pump is utilized to empty the fluid in the cuff back into the balloon reservoir so that voiding may occur. The cuff then gradually refills over the next few minutes. Artificial sphincters are associated with many problems [49]: they are expensive, the surgery required to insert them is complicated and the tissues around the bladder neck following previous failed operations may be unsuitable for the implantation of the cuff. In addition, mechanical failure may occur, necessitating further surgery. However, there is a place for these devices and their technology is likely to improve in the future. In the UK, the management of SUI has recently been reviewed by the National Institute for Health and Care Excellence (NICE) [50]. A trial of supervised PFMT of at least 3 months’ duration should be offered as first‐line treatment to all women with stress or mixed urinary incontinence. Retropubic mid‐urethral tape procedures using a ‘bottom‐up’ approach with macroporous (type 1) polypropylene meshes are recommended as treatment options for SUI in cases where conservative management has failed. Open colposuspension and autologous rectus fascial sling procedures are recommended alternatives where clinically appropriate. Synthetic slings using materials other than polypropylene that are not of a macroporous (type 1) construction are not recommended for the treatment of SUI. Intramural bulking agents (glutaraldehyde cross‐linked collagen, silicone, carbon‐coated zirconium beads} should be considered for the management of SUI if conservative management has failed, although women should be made aware that repeat injections may be required and that efficacy diminishes with time and is inferior to that of a retropubic suspension or sling. Laparoscopic colposuspension is not recommended as a routine procedure for the treatment of SUI in women and should only be performed by an experienced laparoscopic surgeon. Anterior colporrhaphy, needle suspension procedures, paravaginal defect repair and the Marshall–Marchetti–Krantz procedure are not recommended. It is important to remember that the first operation for stress incontinence is the most likely to succeed. Most suprapubic operations in current use produce a cure rate in excess of 85–90% in patients undergoing their first operation for correctly diagnosed urodynamic stress incontinence. The colposuspension has long been recognized as the ‘best’ first operation, although mid‐urethral tape procedures would now appear to be as efficacious. Repeat continence surgery is often less efficacious than primary surgery and subsequent surgery may have to be performed on a vagina that is less mobile and in which there is fibrosis of the urethra. In such cases, insertion of a urethral bulking agent may be easier to perform and more effective. Ultimately, it is important that the operative procedure performed is tailored to the needs of the individual.
Urinary Incontinence
Urodynamic stress incontinence (urethral sphincter incompetence)
Detrusor overactivity (neurogenic detrusor overactivity)
Overactive bladder
Retention with overflow
Fistulae: vesicovaginal, ureterovaginal, urethrovaginal, complex
Congenital abnormalities, e.g. epispadias, ectopic ureter, spina bifida occulta
Urethral diverticulum
Temporary, e.g. urinary tract infection, faecal impaction
Functional, e.g. immobility
Infection (e.g. urinary tract infection)
Confusional states (e.g. dementia)
Faecal impaction
Oestrogen deficiency
Restricted mobility
Depression
Drug therapy (e.g. diuretics)
Endocrine disorder (e.g. diabetes)
Limited independence
Clinical presentation of urinary incontinence
Investigations
General practitioner/outpatient
Mid‐stream specimen of urine
Frequency–volume chart
Pad test
Basic urodynamics
Uroflowmetry
Cystometry
Videocystourethrography
Specialized
Urethral pressure profilometry
Cystourethroscopy
Ultrasound
Cystourethrography
Intravenous urography
Electromyography
Ambulatory urodynamics
GP/outpatient tests
Midstream urine sample
Frequency–volume charts
Pad test
Urodynamics
Uroflowmetry
Cystometry
Videocystourethrography
Special investigations
Urethral pressure profilometry
Imaging of the urinary tract
Electromyography
Ambulatory urodynamics
Causes of urinary incontinence
Urodynamic stress incontinence
Urethral hypermobility
Urogenital prolapse
Pelvic floor damage or denervation
Parturition
Pelvic surgery
Menopause
Urethral scarring
Vaginal (urethral) surgery
Incontinence surgery
Urethral dilatation or urethrotomy
Recurrent urinary tract infections
Radiotherapy
Raised intra‐abdominal pressure
Pregnancy
Chronic cough (bronchitis)
Abdominal/pelvic mass
Faecal impaction
Ascites
(Obesity)
Conservative treatment
Pelvic floor muscle training (PFMT)
Perineometry
Vaginal cones
Maximum electrical stimulation
Duloxetine
Pelvic floor muscle training
Weighted vaginal cones
Maximal electrical stimulation
Vaginal devices
Medical therapy
Surgery
Vaginal
Retropubic mid‐urethral tape procedures
Transobturator mid‐urethral tape procedures
Urethral bulking agents
Urethrocliesis
Anterior colporrhaphy ± Kelly/Pacey suture
Abdominal
Burch colposuspension
Marshall–Marchetti–Krantz procedure
Laparoscopic
Colposuspension
Combined
Sling
Endoscopic bladder neck suspension, e.g. Stamey, Raz
Complex
Neourethra
Artificial sphincter
Urinary diversion
Anterior colporrhaphy
Marshall–Marchetti–Krantz procedure
Colposuspension
Sling procedures
Retropubic mid‐urethral tape procedures: tension‐free vaginal tape
Transobturator mid‐urethral sling procedures
Bladder neck suspension procedures
Urethral bulking agents
Urethral bulking agent
Application technique
Glutaraldehyde cross‐linked bovine collagen (Contigen*)
Cystoscopic
Polydimethylsiloxane (Macroplastique†)
Cystoscopic
MIS implantation system
Pyrolytic carbon‐coated zirconium oxide beads in β‐glucan gel (Durasphere‡)
Cystoscopic
Ethylene vinyl copolymer in dimethyl sulfoxide (DMSO) gel
Cystoscopic
Calcium hydroxylapatite in carboxymethylcellulose gel (Coaptite§)
Cystoscopic
Copolymer of hyaluronic acid and dextranomer
Cystoscopic
Implacer system
Polyacrylamide hydrogel (Bulkamid¶)
Cystoscopic
Artificial urinary sphincter
National Institute for Health and Care Excellence guidelines
Conclusions: stress incontinence
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