A: strong, usually RCTs
C: conditional when there is no clear cut benefit
In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. It is intended to guide clinical practice. The guidelines are focused on an index patient, which is defined as a healthy female with no prior pelvic or incontinence surgery, and no other pelvic floor disorders.
Non-index: All female patients with co-morbid factors, neurogenic bladder, pelvic organ prolapse, previous surgery, advanced age, obesity, etc.
ISD Leak PP <60 cmH2O
Confirm SUI, characterize incontinence
History, assessment of bother and expectations, physical examination including pelvic exam, demonstration of SUI, post-void residual urine volume (PVR) and uranalysis.
There should be assessment of urethral mobility and POP by any method.
No cystoscopy (only intraoperative) or urodynamics recommended for index patient with clear demonstration of SUI.
Additional evaluation or expert opinion may be needed in these situations when unable to demonstrate SUI, High PVR, Voiding dysfuction, POP, Concomitant overactive bladder (OAB), hematuria or pyuria.
Degree of bother can guide physician to discuss different options for SUI management. Ranging from observation, physiotherapy and biofeedback, pessaries and surgery. Prior to selecting midurethral synthetic sling procedures for the surgical treatment of stress urinary incontinence in women, physicians must discuss the specific risks and benefits of mesh as well as the alternatives to a mesh sling. Intra-operative and post-operative risks and outcome should be discussed.
In index patients considering surgery for stress urinary incontinence, physicians may offer the following options: (Strong Recommendation; Evidence Level: Grade A)
- MUS (synthetic midurethral sling)
- Pubovaginal sling (PVS) - autologous
- Bulking agents
Single incision sling may be used, but patients should be counseled to less mature data, similar to TOT in short term (12 months).
No Mesh use if there is urethral injury
Stem-cell therapy is considered investigational
In cases of immobile urethra and intrinsic sphincter deficiency pubovaginal sling (PVS) , retropubic MUS, or bulking agent can be offered.
For mobile urethra MUS can be offered.
Synthetic MUS should not performed with diverticulectomy.
MUS should be used carefully when there is poor risk of wound healing as in following radiation or excessive scar tissue.
Physicians should communicate early with patients to assess any complications or voiding dysfunction. Physicians should see patients within 6 months, or sooner if unfavorable outcome or residual incontinence. At the visit a physical examination including the site of surgery and residual urine should be carried out.
Use of Telemedicine to monitor outcomes, innovative techniques to educate patients, stem cell therapy are the main focus of SUI focus.
Presenter by: Stephen Kraus, MD, Professor of Urology UT San Antonio, TX
Written by: Gamal Ghoniem, MD, FACS, FPMRS, Professor and Vice Chair of Urology, University of California, Irvine, California at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting (SUFU 2018), February 27-March 3, 2018, Austin, Texas