Definition: clinical symptoms of involuntary loss of urine during increased abdominal pressure (coughing, laughing, lifting, etc.)

Etiology:

• Urodynamic SUI (in absence of detrusor contraction) - diagnose with urodynamics
• Intrinsic sphincter deficiency (ISD) (leak point pressure < 50-60 cm H₂O)
• Urethral hypermobility (impaired urethral copatation during Valsalva; caused by pelvic floor weakness)
• Urinary retention, detrusor overactivity

Risk factors: obesity (increased intra-abdominal pressure), pregnancy, vaginal delivery, hysterectomy

Pelvic exam: check for cystocele/enterocele/uterine prolapse/rectocele (POP-Q test)

• Cotton swab test to assess hypermobility - swab axis Δ > 30° from rest to strain = hypermobility

Cough/stress test - check for urine leak

Urodynamics does not always reveal SUI

Behavioral therapy

Medication: (not FDA-approved)

• Estrogen not recommended
• α-agonist to increase sphincter tone - weak evidence, avoid in cardiac disease/HTN
• Duloxetine (SNRI) - reduces SUI by 50%

Continence devices: e.g. pessary, indwelling catheter, urethral occlusive devices

Minimally invasive treatment

• Bulking agent injection (e.g. collagen, Coaptite/Macroplastique) into proximal urethra/bladder neck.
• Requires maintenance injections. Contraindicated with weak/inflamed/damaged urethral tissue
• Does not work...
• Transurethral radiofrequency collagen microremodeling (TURCM) - use for urethral hypermobility. Catheter deploys needles that use radiofrequency heating to denature collagen and cause contraction. A/w dysuria

Surgical treatment

Sling provides support for urethra during increased intra-abdominal pressure to prevent leakage

• Material - synthetic or autologous fascia from rectus or fascia lata
• No difference in success rate; more adverse events with synthetic sling, but more morbidity with autologous fascia

Traditional procedures - consider if undergoing concomitant open abdominal procedure

• Burch colposuspension/urethropexy - attach peri-urethral fascia to Cooper's ligament. Does not treat ISD though.
• MMK - very similar to Burch, but attach to periosteum of pubic symphisis instead (risk of osteomyelitis)
• Pubovaginal sling - abdominal + vaginal incision; sling at proximal urethra, through retropubic space to rectus fascia

Mid-urethral sling (tension-free vaginal tape; TVT) - similar success rate to traditional procedures, with less morbidity. New gold standard

• Incise anterior vaginal wall; dissect periurethral space
• Inside-out approach (insert sling from vagina to skin) preferred: more effective for retropubic, less complications/voiding difficulties
• Retropubic - slings over pubic ramus.
• Exit just superior to pubic bone, passes through endopelvic fascia
• Favor for recurrent SUI
• Transobturator (TVT-O) - slings through obturator foramen.
• *Avoids retropubic space/safer (e.g. 0.3% vs 4% bladder perf), but achieves less lift/support compared to retropubic and slightly less effective
• Exit just superior to obturator foramen, passes through obturator membrane (avoid piercing adductor longus superiorly)
• Mini-sling (single vaginal incision) - fixed to obturator internus/membrane with barb-like device
• Limited data; currently less effective
• 

Operation (sling)

• Pre-op abx - cefoxitin (Elliott); cipro/ancef + flagyl (vaginal incision)
• Elliott - void trial in PACU, PVR on POD1, and f/u 1 month
• Comiter - home with Foley, remove at home POD2

Post-operative complications

• Urinary retention (retropubic > transobturator; sling too tight) - CIC q3-4 hrs until PVR < 60
• If persists > 4-8 weeks, can incise sling
• Persistent groin pain (transobturator > retropubic)
• Mixed urinary incontinence - urge incontinence may persist; increased risk of persistent SUI. 15% rate of de novo OAB after sling

Male SUI (eg after RRP):

Grade by pad weight - < 200g mild, 200-400g moderate, > 400g severe

• Artificial urinary sphincter (e.g. Boston/AMS 800)
• Reservoir filled with 22.5cc fluid
• If Foley required for any reason, need to deactivate cuff and minimize caliber and dwell time to avoid risk of urethral erosion
• For daily use (open the cuff to urinate): squeeze the bulb several times. The dimple will slowly re-inflate over a few minutes
• To DEACTIVATE (open the cuff and leak until reactivated): squeeze the bulb several (~3 times) until empty. Wait 5 seconds to allow a small amount of fluid back in (makes it easier to re-activate) and then press the button at the top to lock the valve. This should form a dimple. Check again in a few minutes to make sure the dimple is still there.
• To ACTIVATE (close the cuff and stay dry) - squeeze the sides of the 'box' part of the pump; the dimple will slowly re-inflate
• Comiter post-op: kefzol/gent pre-op, dc from PACU with 5d Keflex/Bactrim, f/u 6 wks for activation
• Harris post-op: 12 Fr Foley catheter remove POD1, f/u 4 weeks (make sure cuff is deactivated and dimple is present)
• Male sling
• AdVance - transobturator sling. Lower success rate with pad weight > 200g
• Virtue - 4 arm 'quadratic' sling - two transobturator arms and two prepubic arms