Beyond the Abstract - The role of anti-incontinence surgery in management of occult urinary stress incontinence, by Miriam Malak, MD and Mark Malak, MD

BERKELEY, CA ( - Occult urinary stress incontinence [OUSI] is incontinence only observed after the reduction of co-existent prolapse.

The decision to combine anti-incontinence and pelvic organ prolapse surgery for patients with prolapse and OUSI is both controversial and complex. The two main reasons are:

  1. The variable rate of OUSI: The preoperative detection rate of OUSI varies from 6% to 83% due to many factors. The most commonly reported factors are the methods used to reduce the prolapse. It was found that OUSI detection rate was 6% using vaginal pessary and 30% using a speculum. It is difficult to decide if a method is under- or over-estimating the OUSI rate, as the true incidence of OUSI cannot be currently established.
  2. The variable outcome of continence after prolapse surgery: Following prolapse surgery, without adding anti-incontinence surgery, between 13% and 67.4% (average is 33%) of patients with OUSI develop postoperative urinary stress incontinence. Therefore if anti-incontinence surgery was recommended for all patients with OUSI, it would have constituted an unnecessary invasive surgery in about third of the cases.

In this clinical opinion paper, using the already published data, the author,

  1. Highlighted a group of patients in which the detected OUSI is unlikely to be overestimated, thus reducing the chance of over treatment if anti-incontinence surgery is combined with prolapse surgery:

    1. Patients who have a clear and documented history of urinary stress incontinence that improved or stopped with worsening of the prolapse.
    2. Patients with OUSI detected with a vaginal pessary in situ: It has been found that vaginal pessary is the least likely to result in OUSI when compared to four other reduction methods due to possible associated urethral compression.
    3. Patients requiring posterior vaginal surgery if occult urinary stress incontinence is detected on reducing the posterior vaginal wall.
  2. Highlighted another possible reason, rather than overestimating OUSI rate, for the dramatic difference between the preoperative detection of OUSI and the much lower rate of postoperative incontinence following vaginal prolapse surgery. This is the potential curative effect of vaginal prolapse surgery on urinary stress incontinence that has not been considered as one of the factors that influence the rate of postoperative stress incontinence. A Cochrane review showed that anterior vaginal repair has up to a 62% success rate in controlling urinary stress incontinence, irrespective of the co-existence of pelvic organ prolapse. Therefore, we are effectively treating these patients with OUSI with anterior vaginal repair rather than offering them the more advanced surgical methods, e.g. mid-urethral tension free vaginal slings which are known to be more successful (both short and long term) in comparison to vaginal repair. We may be, therefore, denying patients with OUSI the surgical advances in the last 30 years by treating their incontinence with anterior vaginal repair that was commonly used few decades ago. The anti-incontinence surgery should be, therefore, re-evaluated as a therapeutic rather than preventative procedure for OUSI patients. Subsequently calculating the benefit: risk profile of anti-incontinence surgery for patients with occult stress incontinence should be based on the same principles as those for evident urinary stress incontinence.

Therefore, should we combine anti-incontinence surgery with vaginal prolapse surgery for all patients with occult urinary stress incontinence? Until we find a means to detect the true incidence of occult stress incontinence, which should be the priority of our research, we will not be able to counsel our patients properly about the risk of over- or under-estimating OUSI and hence - if anti-incontinence surgery is added it could be an over-treatment in some cases, or if denied, it could be under-treatment in other cases.

What should we do until we are able to diagnose true occult urinary stress incontinence? The above mentioned group of patients can be offered anti-incontinence surgery in combination with vaginal prolapse surgery as there is only a very small risk of false positive OUSI detection. For other patients, the decision should be taken on an individual basis after explaining to the patients all the above facts.

The author concluded that we might currently be denying some patients with true occult urinary stress incontinence the last 30 years advances in surgical management of urinary stress incontinence if they are not tested for the possibility of OUSI. We may continue denying our patients these surgical advances until we are able to accurately detect the true incidence of OUSI. Once this is established, all patients with occult urinary stress incontinence should be offered therapeutic anti-incontinence surgery combined with vaginal surgery, as it is the case with evident urinary stress incontinence.


Written by:
Miriam Malaka and Mark Malakb as part of Beyond the Abstract on This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

aFoundation doctor, Southampton University Hospital NHS Trust
bConsultant Urogynaecologist, East Sussex Healthcare NHS Trust


The role of anti-incontinence surgery in management of occult urinary stress incontinence - Abstract

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