Version May 2024
INTRODUCTION — Stress urinary incontinence (SUI), the involuntary leakage of urine on effort or exertion or on sneezing or coughing, affects 4 to 35 percent of women [1-3]. In 2006, 1 in 1000 women in the United States had surgical treatment of incontinence [4]. The majority of women are adequately treated with one procedure, but up to 15 percent of women require further treatment for persistent/recurrent SUI [5].
The evaluation and management of recurrent or persistent SUI after a primary surgical treatment are reviewed here. Choosing a primary treatment procedure and preoperative evaluation of women prior to a primary procedure are discussed in detail separately. (See "Female stress urinary incontinence: Choosing a primary surgical procedure" and "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.
TERMINOLOGY
●Persistent stress urinary incontinence (SUI) refers to SUI symptoms that persist after a surgical procedure intended to resolve these SUI symptoms.
●Recurrent SUI refers to recurrence of SUI symptoms after a period without SUI symptoms following surgery.
Additional terminology for SUI treatment procedures can be found separately. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Terminology'.)
INCIDENCE — The rate of persistent/recurrent SUI is difficult to ascertain. Studies of this issue have reported data regarding reoperation rates. These rates do not include women with persistent/recurrent symptoms who are not treated with a subsequent surgery.
The rate of reoperation for SUI was illustrated in a study of over 155,000 women who underwent SUI surgery (82 percent of procedures were slings) and found that the nine-year cumulative reoperation rate was 14.5 percent [5]. In another study of over 40,000 United States women who underwent surgical treatment of SUI, 8.6 percent underwent a second surgical treatment for stress incontinence within eight years [6]. Similarly, a study that followed women for five years after surgical treatment for SUI reported a 6 percent retreatment rate [7]. Of the women who were retreated, 14 percent had undergone a prior Burch colposuspension, 8 percent had a fascial sling, 7 percent had a transobturator midurethral sling, and 5 percent had a retropubic midurethral sling.
RISK FACTORS — Patient characteristics associated with persistent or recurrent SUI after primary surgical treatment were illustrated in several prospective and randomized controlled trials, including:
●Advancing age [8-11] – Women age 50 years or older are at an increased risk of recurrent symptom SUI after surgical treatment [12-14]. The risk increases gradually with advancing age, increasing slowly among women in the fifth, sixth, and seventh decades. Within these age groups, the overall risk remains less than 20 percent. For women in the eighth and ninth decades, the rates of recurrent SUI are 25 and 50 percent, respectively.
●Urgency urinary incontinence – Many women have mixed incontinence, a combination of SUI and urgency urinary incontinence. Severe preoperative urgency incontinence and use of anticholinergic medications, used to treat urgency incontinence, are associated with persistent/recurrent SUI [10,15-18].
●Increasing stage of pelvic organ prolapse (POP) and concurrent surgery for prolapse – Some studies have found these factors to be associated with persistent/recurrent SUI [17,19]; however, in the Trial of Mid-Urethral Slings (TOMUS) randomized trial that compared retropubic and transobturator slings, concomitant surgery was associated with higher rates of objective treatment success [10,20].
●Urethral incompetence, defined by a low Valsalva leak point pressure (VLPP) and maximum urethral closure pressure (MUCP) – The values for VLPP and MUCP that are associated with an elevated risk of persistent/recurrent SUI are variable and some prospective studies have not found these measures to be predictive of surgical outcome [10,21-24]. The traditional definitions of low values are a VLPP of <60 cm H2O and a MUCP of <20 cm H2O; however, there are no data to support these as threshold values for an increased risk for recurrent SUI. (See "Urodynamic evaluation of women with incontinence".)
●Obstructive voiding symptoms [25].
●Obesity – Body mass index (BMI) >35 kg/m2 is associated with persistent/recurrent SUI [8]. Milder elevations in BMI (<30 kg/m2) do not appear to impact SUI treatment success rates [26-29].
●Diabetes mellitus [19,22].
Success rates for any procedure vary markedly depend upon the definition of success and the population studied. As an example, the success rate of a retropubic midurethral sling as a primary surgery in women with a typical presentation of SUI (with urethral hypermobility and no intrinsic sphincter deficiency) can be as high as 95.3 percent [30]. However, older adult women and those with intrinsic sphincter deficiency have success rates as low as 55 to 74 percent [19].
Women with persistent/recurrent SUI after a first operation may have anatomic or physiologic characteristics that differ from those who have good outcomes. Studies have found that these women have urethral electromyography findings consistent with poorer neuromuscular function than other women [31].
The rate of persistent/recurrent SUI also depends in large part upon the initial surgical procedure performed. Midurethral sling placement is the most common procedure for SUI, but bladder neck (fascial) slings and Burch colposuspension have comparable success rates. Some procedures are no longer performed due to poor efficacy. Following intraurethral bulking therapy with a biodegradable agent, such as collagen, recurrent SUI is common and to be expected [32]. (See 'Periurethral injection therapy' below.)
The efficacy of primary continence procedures is discussed in detail separately.
EVALUATION — The clinical features, evaluation, and diagnosis of women with persistent/recurrent SUI following a primary continence procedure are the same as for other women with SUI, and are discussed in detail separately. Selected aspects of the evaluation are reviewed briefly in this section. (See "Female urinary incontinence: Evaluation" and "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure".)
The key goals of the evaluation are to: (1) exclude nonstress etiologies of urinary incontinence, since these are treated differently; (2) assess the severity of symptoms and impact on quality of life to see if treatment is warranted; and (3) review the surgical and medical history to determine which types of treatment are appropriate.
Assessing symptoms — The clinician should inquire about the characteristics of the urinary incontinence, including time of onset in relation to the primary continence surgery, frequency, duration, volume of urine leaked, and precipitating factors (eg, cough or sudden sensation of the need to void). A voiding diary is often helpful to determine the pattern and volume of incontinence (form 1). The patient should be asked how bothersome the symptoms are and how they impact her quality of life. This information helps to guide management.
SUI symptoms may present at any point following surgery. Persistent symptoms are noted at the routine postoperative follow-up visit, while recurrent symptoms occur following a period of time without symptoms.
The characteristics of the incontinence symptoms help to exclude nonstress etiologies. SUI and urgency incontinence are common types of incontinence. SUI is characterized by incontinence with increased intraabdominal pressure (eg, cough, sneeze, lifting a heavy object) and urgency incontinence is typically preceded by a sudden sensation of the urge to urinate. For women who have mixed (stress and urgency) incontinence, it is important to determine whether the persistent/recurrent symptoms are predominantly stress or urge. Women may develop nonstress incontinence following surgery. Urgency symptoms may occur in women following sling surgery. Outflow obstruction resulting in overflow incontinence may in turn result from urethral obstruction by a sling or scar tissue. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Urinary urgency' and "Female urinary incontinence: Evaluation", section on 'Classification'.)
As with primary SUI, when both urgency and stress incontinence are present, their relative severity will impact management. As an example, a patient may describe frequent and bothersome urgency urinary incontinence, but relatively rare and innocuous stress incontinence. Treatment should, in this case, be directed towards urgency associated symptoms (eg, behavioral modification, use of anti-cholinergics). However, following an initial SUI surgery, a patient may still be incontinent and feel her surgery failed. However, the reason for the incontinence is no longer SUI; it may be urgency UI. After SUI surgery, it is important to assess bladder emptying, which may present as frequency, urgency and urgency incontinence. Incomplete voiding might in general be better treated with clean intermittent catheterization than anticholinergic medications. For women with urethral obstruction, removal of the obstruction with sling release or treatment of adhesions is required. (See "Female urinary incontinence: Treatment" and "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Loosening'.)
The clinician should also ask the patient about symptoms associated with uncommon causes of incontinence. A previously unrecognized urethral diverticulum may result in postvoid dribbling. A urogenital fistula is a rare complication of continence surgery. Intermittent leakage, particularly when positional, may occur with a ureterovaginal fistula; continuous urine loss is more characteristic of a vesicovaginal fistula. (See "Urethral diverticulum in females", section on 'Symptoms' and "Urogenital tract fistulas in females", section on 'Clinical presentation'.)
Medical and surgical history — The history of previous evaluation and treatment of urinary incontinence should be reviewed. Since pelvic organ prolapse (POP) often coexists with SUI, the history of treatment of prolapse should also be included:
●Diagnosis prior to surgery – SUI alone or mixed incontinence; results of preoperative urodynamic testing, if available.
●Surgical history with details of prior continence and POP repair procedures, including the following information:
•Indication for the procedure.
•Date of surgery, to determine the time interval from surgery to the development of symptoms and the timeline between surgeries and if the patient has had multiple procedures.
•If the patient has had multiple procedures, whether they were performed separately or concomitantly.
•Use of surgical mesh or biografts.
•Revision surgery – Transection versus removal of the sling can impact risk of urinary incontinence recurrence [33].
•Other treatments for incontinence and their results (eg, medications, vaginal pessary, bulking agents).
The surgical history provides information about risk factors for incontinence and failed treatments. It also helps to guide management with information about anatomic changes and the presence of reconstructive materials or scar tissue.
In addition, the history should include the obstetric history, and any other pelvic surgeries or conditions.
The patient's overall medical history and status since her primary continence surgery should be assessed. Medications (eg, diuretics) (table 1) or conditions (eg, diabetes, back problems) should be identified that may contribute to the development or exacerbation of urinary incontinence. Medications and conditions associated with urinary incontinence are discussed separately. (See "Female urinary incontinence: Evaluation", section on 'Etiology'.)
Pelvic examination — The pelvic examination may reveal anatomic changes that account for the patient's symptoms.
Urethral mobility is usually decreased after continence surgery and should be assessed by evaluating the position of point Aa of the Pelvic Organ Prolapse Quantitation System (POP-Q). Urethral hypermobility is present when there is Stage 2 prolapse or higher at point Aa. The cotton swab test was initially introduced to assess urethral mobility after incontinence surgery. While it provides a quantitative assessment of urethral mobility, itis no longer recommended for clinical use due to its poor predictive value [34]. In one study, mean urethral excursion between resting and straining prior to a primary surgery was 43 degrees and prior to a second procedure was just 17 degrees [35]. This may impact the efficacy of further treatment. In a study of recurrent SUI following multiple different types of primary surgery, women with urethral mobility >30 degrees by cotton swab testing had a cure rate of 90 percent with a subsequent retropubic midurethral sling whereas those with urethral mobility of <30 degrees had a cumulative cure and improved rate of 50 percent [36]. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Using the POP-Q system' and "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Assessing urethral mobility'.)
Careful examination and palpation of the anterior vaginal wall should be performed. This allows the examiner to assess the relative position of the urethra and a previous suburethral sling. If a sling is too distal (nearer the urethral meatus), the sling may not have controlled urethral mobility and this may be one reason for failure of treatment. If the urethra is hypersuspended and there is easily demonstrable incontinence, it may suggest poor intrinsic urethral function. Hypersuspension of the urethra can also account for obstructive symptoms.
Women with continuous or insensate leakage of fluid may have a urethral diverticulum, urogenital fistula, or a periurethral infection or abscess. A urethral diverticulum is associated with a palpable, often tender, suburethral mass. In women with a urethrovaginal or vesicovaginal fistula, the anterior vaginal wall may have a small, red area of granulation tissue. In addition, placement of reconstructive materials or permanent sutures during previous surgery can also cause chronic vaginal discharge, which often presents as insensate incontinence. Epidemiologic studies are not available to provide an accurate incidence of these events in the setting of recurrent/persistent SUI, but it seems safe to consider them relatively rare. If the history is suggestive of one of these entities, a careful physical examination can detect many suburethral masses. If there is significant enough suspicion for such a condition, and examination is unrevealing or inconclusive, magnetic resonance imaging (MRI) may be helpful. (See "Urethral diverticulum in females", section on 'Physical examination' and "Urogenital tract fistulas in females", section on 'Evaluation of suspected urogenital fistula'.)
Additional testing — The diagnostic testing for women with persistent/recurrent SUI is generally the same as for women with an initial presentation of urinary incontinence. However, the persistence of urinary incontinence symptoms should prompt consideration of cystoscopy and urodynamics to assess the integrity and function of the lower urinary tract.
Office testing — Testing that can be performed in the office includes:
●Urinalysis – Urinalysis is performed to assess for infection and hematuria. The chronic presence of red blood cells and leukocytes in the urine may exacerbate incontinence and cause irritative symptoms. In our practice, we evaluate these patients with cystoscopy to assess for urinary tract obstruction, implant erosion into the urethra or bladder, or bladder stones [37,38].
●Postvoid residual urine (PVR) – If the PVR is >200 mL, incontinence symptoms may be related to incomplete bladder emptying and overflow incontinence. These conditions should be treated appropriately, typically with clean intermittent catheterization.
●Cough stress test – This test documents the presence of SUI.
●Urethral mobility – This can be assessed with pelvic examination to assess POPQ point Aa. The absence of urethral mobility has significant prognostic value with respect to the likelihood of success with another anti-continence procedure [39]. (See 'Pelvic examination' above.)
●Dye test – This test is performed as indicated (if there is suspicion of a urogenital fistula, this occurs mainly in women who have had a hysterectomy). (See "Urogenital tract fistulas in females", section on 'Dye test'.)
Urodynamics — In our practice, we perform urodynamic testing for women who are considering additional surgery for persistent/recurrent SUI and who have symptoms not explained by office testing or unexplained lower urinary tract symptoms. In these situation, we evaluate the following:
●Bladder compliance (change in volume/change in pressure) – The bladder is normally highly compliant, accommodating large amounts of volume with little change in pressure. If intravesical pressure rises >10 to 15 cm H20 during instillation of fluid, there may be compromise of bladder storage function. If the patient leaks urine in the absence of a detrusor contraction or increased intraabdominal pressure and the detrusor pressure is >40 cm H20, there should be concern about the development of ureteral reflux and renal compromise. These changes originally described among patients with myelodysplasia can reflect changes due to neurologic disease, radiation and/or changes related to pelvic surgery. Changes in bladder compliance are remarkably rare in the absence of these risk factors.
●Evidence of detrusor instability and low bladder capacity – These are findings traditionally consistent with overactive bladder symptoms. They can, however, result in a clinical presentation of mixed or stress and urgency urinary incontinence when there is poor urethral function.
●Urethral sphincter incompetence – Maximum urethral closure pressure, Valsalva leak point pressure, and cough leak point pressure are used to assess urethral function. When these measures consistently demonstrate the phenomenon of a low pressure urethra, the likelihood of severe urethral sphincter incompetence explaining SUI is increased. Although these measures have not consistently predicted surgical outcomes, some clinicians find them useful in guiding treatment decisions when there are complicating factors such as a history of previous surgery, neurologic disease, mixed incontinence, or poor emptying function [40].
If the evaluation does not adequately reveal the nature of a patient's recurrent or persistent SUI symptoms, some clinicians perform fluoroscopic urodynamic testing. However, this testing exposes the patient to radiation and has not been proven to be clinically useful.
Urodynamic testing is discussed in detail separately. (See "Urodynamic evaluation of women with incontinence".)
Ultrasonography — Translabial, endovaginal, and transrectal sonography are increasingly used as research tools in the evaluation of recurrent SUI. The position of the midurethral sling from the bladder neck and the depth of its placement are associated with patient outcomes. The sling position along the length of the urethra is analyzed in centiles with the bladder neck at position 0 and the urethral meatus at 100. The depth of the sling placement is quantified by the distance between the sling and the urethral lumen or is qualitatively assessed by sling shape or "encroachment" at rest and during forceful efforts (eg, Valsalva or coughing). Two cohort studies separated by almost ten years reported that the likelihood of cure without complications or recurrent stress incontinence is highest when the sling is between the 50th and 70th percentile and is 3 to 5 mm from the urethral lumen [41,42]. Other studies evaluating sling location and distance from the urethral lumen have reported similar, consistent findings [43,44].
Cystoscopy — Cystoscopy is not routinely used in the evaluation of persistent/recurrent SUI. Indications for its use following previous incontinence surgery are symptoms suggestive of an intravesical foreign body or bladder pathology, including: symptoms of unexplained pain or irritative voiding; recurrent urinary tract infections; and/or hematuria.
MANAGEMENT — Management of women with persistent/recurrent urinary incontinence (UI), including SUI and urgency incontinence, is guided primarily by the impact of the symptoms on the patient's quality of life and the potential risks or benefits of treatment.
The data regarding treatment of persistent/recurrent SUI are limited. Many studies of SUI treatment have included women with persistent/recurrent SUI, but few have reported a separate analysis for outcomes for these patients. In addition, the definition of success of a treatment is not uniform across studies. Some studies report cure rates, while others report improvement in symptoms or use symptom scales. Subjective (cure or improvement by patient report) or objective outcomes (by office or urodynamic testing), or both, may be reported. Many authors did not report symptoms of urgency incontinence as a treatment failure if symptoms of SUI were cured.
Clinical approach — Treatment of persistent/recurrent SUI is indicated when symptoms are bothersome. Women who do not find their symptoms bothersome may be managed expectantly. Evaluation of the patient is important to ascertain that SUI is the dominant component of the patient's symptoms rather than urge or overflow incontinence. (See 'Evaluation' above.)
Once SUI is confirmed as the source of symptoms, we assess the woman's desire for treatment, the degree of invasiveness that she is willing to accept, and the balance of benefit versus complication. As a next step, we favor noninvasive approaches such as a trial of physical therapy, pelvic floor strengthening, or a flexible incontinence ring pessary. Urethral bulking agents are also an option, although they can be more invasive and usually require repeat injections. For women who fail or decline noninvasive treatment, we have a detailed discussion with them about symptoms, surgical history, and the risks and benefits of potential treatments. Reviewing patient goals and expectations is helpful in formulating a management plan.
When considering which surgery to perform for recurrent or persistent urinary symptoms, the choice is individualized with respect to each of the following factors:
●Symptom severity and type – We assess the patient's symptom severity and type (eg, pain, stress incontinence, or obstructive symptoms) to determine whether a repeat surgical procedure is indicated and likely to be helpful. As an example, a woman who underwent a suburethral sling procedure and presents with very bothersome recurrent or persistent stress incontinence symptoms, desires definitive therapy, and easily demonstrates SUI on evaluation is a reasonable candidate for a repeat suburethral sling because the procedure is minimally invasive and likely to improve her symptoms. If she has had one previous midurethral sling with a synthetic graft, we will most often consider a repeat midurethral sling with the same or similar type of material. We are less inclined to recommend a second suburethral sling procedure if the volume of incontinence is described as drops, the incontinence is difficult to elicit on examination, or the incontinence is only related to vigorous, exercise-related activity (eg, trampoline, horseback riding, vigorous exercise classes, etc) because the difference between continence and voiding dysfunction may be small and the risk-benefit ratio unfavorable.
●Prior surgical complication – Women who had a sling revision or excision due to mesh exposure, obstruction, or pain involving the vagina or urethra are at risk for recurrent SUI. We evaluate the scarring in the affected area of the vagina, consider the amount of mesh removed during the revision and the operative description of the treatment for mesh revision (mesh exposed in the vagina is not as concerning as mesh exposure in the urethra or bladder). It is worthwhile to keep in mind that another complication (erosion, obstruction, or pain), whether it is or is not associated with the material used, is an extremely disappointing event for the patient. If the suburethral scarring is significant and SUI is the predominant symptom and easily elicited, we favor a pubovaginal sling with autologous fascia, harvested from either the abdominal rectus muscle (which we favor) or the fascia lata (if there is a history of abdominal wound healing problems). If the previous surgery with synthetic material led to mesh exposure into the urethra or bladder, we avoid use of a synthetic graft due to increased risk for poor perfusion and tissue healing which could result in fistula. The recovery from the operation utilizing autologous fascia is longer than that for midurethral sling with synthetic material, but the avoidance of mesh is an important factor to consider in some situations.
●Pelvic organ support – Women with recurrent prolapse and a previous incontinence repair are at risk for poor bladder emptying. Repeat anterior and apical vaginal prolapse surgery can accentuate the obstructive effects of the previous anti-incontinence operation. Alternately, surgical repair of the prolapse can relieve the obstruction and lead to urinary incontinence, as it does with primary prolapse surgery. For women in whom the urethra is not appropriately supported (eg, mesh obviously in the distal urethra or above the bladder neck), there is marked urethral mobility, and SUI is easily observed, we are more likely to perform another incontinence procedure as well as removal of foreign material if clinically indicated. However, if the urethra itself is well supported (mesh is appropriately placed in the midurethra) and incontinence is not easily elicited with a full bladder stress test, we favor repairing the prolapse and reassessing incontinence symptoms postoperatively. Although an elevated postvoid residual (>100 mL) is not an absolute contraindication to another incontinence operation when there is recurrent prolapse, it is important to consider all the information available clinically. We grow increasingly reluctant to proceed with another operation when there is an elevated postvoid residual and there is a history of recurrent bladder infections or painful voiding.
●Results of office testing or urodynamic studies – Office testing or urodynamic studies can help determine the need for an additional procedure in women with atypical symptoms. While women who present with classic symptoms of bladder outlet obstruction (eg, difficulty voiding, frequency, recurrent urinary tract infections) can be clinically diagnosed with obstruction and treated with a sling revision, management of women who have a normal postvoid residual or an unclear history of recurrent urinary tract infections is more challenging. Pressure-flow studies that demonstrate elevated detrusor pressure with voiding (ie, obstruction) can indicate the need for a sling revision.
●Limitations of prior procedure(s) – Women who experienced a known failure from a prior incontinence surgery are reasonable candidates for repeat surgery with a more efficacious procedure. As an example, women with persistent or recurrent incontinence symptoms following a xenograft or allograft suburethral sling procedure are likely to do well with a synthetic mesh suburethral sling. (See "Transvaginal synthetic mesh: Use in stress urinary incontinence (SUI)", section on 'Graft material for SUI treatment'.)
●Medical comorbidities – Factors that make us reluctant to perform repeat invasive surgery include advanced age, lack of urethral mobility, significant obesity, poor functional capacity, or loss of normal vulvar and vaginal anatomy. In our experience, patients older than age 80 years, especially those with a nonmobile urethra, are the least likely to benefit from repeat surgery. As noted above, age is a risk factor for treatment failure. Urethral mobility is typically decreased in women who have had a prior continence surgery. This loss of mobility has important implications because the rates of failure with midurethral slings are higher when there is less urethral mobility [39,45]. In addition, voiding dysfunction is a common complication of suburethral sling surgery. Although this usually resolves, intermittent bladder self-catheterization may be required for a period of time. This type of regimen may not be possible for women with obesity, have low functional capacity, or have vulvovaginal changes (eg, due to severe atrophy, lichen sclerosis, or lichen planus). (See 'Risk factors' above.)
Women who decline or are poor candidates for surgery — Pelvic floor muscle exercises or a vaginal pessary are approaches that may be offered to all women with persistent/recurrent UI. The benefit of the nonsurgical options is that they carry little risk of morbidity and do not preclude the use of more invasive options in the future. There are no studies about the efficacy of conservative management of SUI for women with persistent/recurrent symptoms after surgical therapy. In general, however, conservative measures are not as effective for treatment of SUI as surgery. (See "Female urinary incontinence: Treatment".)
Periurethral injection therapy is an option for women who cannot tolerate or do not wish to undergo a more invasive procedure, but desire a treatment that is more effective than nonsurgical options.
Pelvic floor muscle exercises — Pelvic floor muscle (Kegel) exercises are effective in some women with SUI. This approach is most effective with specific instruction and monitoring by health professionals and diligent performance by motivated patients. (See "Female urinary incontinence: Treatment", section on 'Pelvic floor muscle (Kegel) exercises'.)f
For women with persistent SUI at the first postoperative visit in particular, we advise pelvic floor exercises. We generally try to avoid a repeat incontinence procedure until at least a few months have passed.
Vaginal pessary — Pessaries benefit many women with recurrent SUI. An incontinence dish or ring pessary is typically used. (See "Vaginal pessaries: Indications, devices, and approach to selection".)
Periurethral injection therapy — Urethral bulking agent therapy (UBA) is rarely used as a primary treatment for SUI, but remains an option for women with persistent/recurrent SUI. UBA is usually reserved for women who wish to avoid or cannot tolerate an invasive procedure because it is less effective than suburethral sling surgery. In a systematic review of two trials, surgical treatment of SUI was nearly two to five times more likely to result in a cure compared with bulking therapy [46]. In a retrospective review of 165 women who had recurrent SUI after undergoing a synthetic midurethral sling procedure, the women who underwent a urethral bulking procedure were more than three times more likely to have continued incontinence compared with those who underwent a repeat midurethral sling [47]. Injections often need to be repeated to maintain continence.
●Procedure – Urethral bulking injections are performed in the office or operating room, a decision that often depends on logistics such as the location of the proper equipment and personnel. The technique for periurethral injection therapy varies; cystoscopic transurethral injection at the vesical neck and transvaginal periurethral injection are commonly used approaches. The optimal route and site of urethral injection have not been determined [48,49]. Periurethral compared with transurethral injection was associated with a higher rate of urinary retention (6 of 20 patients versus 1 of 20) in one randomized trial [48].
●Adverse events – The most common complications associated with UBA are pain at the injection site, urinary retention and urinary tract infection, and these are easily managed [50]. Rarer and more concerning adverse consequences with UBA injection are sterile abscess formation, tissue necrosis, erosion or migration of injected material, periurethral abscess formation, and urethral prolapse [51].
●Injection types – Particulate and nonparticulate agents are available for periurethral injection therapy. Both types of agents initiate a process leading to periurethral cushions that narrow the urethral lumen [52].
●Particulate – Particulate agents induce a foreign body reaction that leads to fibrosis and capsule formation, which in turn produces urethral coaptation. The currently available products consisting of particulates are:
-Carbon-coated zirconium oxide beads suspended in a water-based gel (Durasphere EXP)
-Crosslinked polydimethylsiloxane (Macroplastique) or polydimethylsiloxane (Urolastic)
-Calcium hydroxylapatite suspended in a water and glycerin gel (Coaptite)
●Nonparticulate – The single available nonparticulate agent is polyacrylamide hydrogel (Bulkamid), which consists of 97.5% hydrogel and 2.5% polyacrylamide. Host cells migrate into the hydrogel to form a network of fibers that anchor the gel, which in turn provides cushions for the urethral lumen.
●Efficacy – Durasphere EXP, Macroplastique, Coaptite, and Bulkamid (63) have all been found to have comparable efficacy to Contigen in randomized trials. These products have not been compared directly to each other. They are hypoallergenic, unlike Contigen. Each of these products has been associated with both common and rare complications, but Macroplastique and Durasphere EXP appear to have a more favorable adverse effect profile than Coaptite [53-57]. The physiology of the nonparticulate gel Bulkamid (entry of host cells into hydrogel and exchange of water, nutrients, and waste) has led to the hope that there will be fewer adverse effects. A single case of a periurethral abscess has also been reported following polyacrylamide injection for recurrent SUI after a midurethral sling [58].
The findings from randomized trials and a meta-analysis listed below give some sense of the efficacy of each product. The success rates cannot be directly compared, since the studies used different definitions of treatment success and duration of follow-up:
•Durasphere EXP – 80 percent at 12-month follow-up [59]. In a case control study of 56 women treated with Durasphere EXP, at 12, 24, and 36 months of follow-up, it remained effective in 35, 33 and 21 percent of patients [60]. Prior hysterectomy was identified as a risk factor for failure with Durasphere EXP, but prior incontinence surgery was not.
•Macroplastique – 37 percent cure and 65 percent improvement at 6- to 18-month follow-up [61].
•Coaptite – 63 percent at 12-month follow-up [54]. Some concerning complications have been reported [55,56].
•Polyacrylamide gel (commercial name Bulkamid) – Studies evaluating the use of polyacrylamide gel for patients with insufficient improvement or recurrent SUI after a midurethral sling include:
-Incontinence after suburethral sling insertion – Analysis of 57 patients who underwent polyacrylamide gel injection after tension-free vaginal tape incontinence surgery reported both subjective and objective cure (subjective cure 22.8 percent (13 of 57) and objective cure in 73 percent (35 of 48) [62]. Among the subset of patients with preprocedure mixed symptoms, urge urinary incontinence (UI) symptoms were cured in 39.5 percent, improved in 36.8 percent, and worsened in 14 percent.
-Recurrent SUI – A study evaluating polyacrylamide hydrogel transurethral injection in 60 patients with recurrent SUI reported cure rates of 57, 43, and 25 percent at one, six, and 12 months, respectively [63]. Cure was defined as a negative cough test (supine and standing), <2 g urine on a one-hour pad test, and a visual analog scale (VAS) score improvement ≥90 percent. The decrease in cure rates over time were accompanied by an increase in rates of patients reporting either improvement (38.3, 46.7, and 58.2 percent) or failure (5, 10, and 16.4 percent). Improvement was defined as either a loss of only a few drops of urine during the cough test and 2 to 10 g urine on one-hour pad test or a reduction >50 percent compared with preoperative urine loss and a VAS score improved by 75 percent.
-Adverse events – In a meta-analysis of eight studies including 767 patients, the most commonly reported adverse events were pain at the injection site (4 to 14 percent), urinary tract infections (3 to 7 percent), and need for reinjection in 24.3 percent of all patients [50].
●Products no longer in use – Glutaraldehyde crosslinked bovine collagen (Contigen) was the most commonly used material until 2011, when production was discontinued. This formulation of collagen was well tolerated and effective (up to 93 percent short-term success rate) and was the standard against which other injectables were compared since its introduction in 1993 [64]. The most significant shortcoming with this material was the need for repeat injections due to its biodegradability [32,65]. With Contigen no longer available, it is not clear what the next best alternative is with respect to tolerability and durability. A systematic review found insufficient evidence to make recommendations [46].
Adverse health consequences have led to the discontinuation of UBA with autologous fat (pulmonary embolism [51]), polytetrafluoroethylene (Teflon; urethral diverticulum, periurethral granulomas [66]), and ethylene vinyl alcohol (Tegress; excessive rates of erosion [67]). Non-animal stabilized hyaluronic acid dextranomer gel (NASHA/Dx) is a biodegradable product used in Europe, but not approved by the United States Food and Drug Administration (FDA). There are case series reporting granuloma/abscess formation in up to 14 to 28 percent of patients treated with NASHA/Dx [68].
Intermittent catheterization — Infrequently, SUI, urgency incontinence and overflow incontinence are present. We manage these patients with clean intermittent bladder self-catheterization several times per day. This usually adequately addresses both types of symptoms. If severe SUI symptoms persist despite frequent catheterization, surgical treatment is an option if the patient is a surgical candidate.
Women who desire surgical treatment — A second anti-incontinence procedure is effective in many women with persistent/recurrent SUI. Candidates for surgery are women who can tolerate an invasive procedure and are willing to accept the risk of failure of the procedure and of surgical morbidity. Evidence demonstrating clear approach to treatment is lacking [69,70].
Traditionally, a pubovaginal sling with autologous fascia has been the favored option by many specialists for persistent/recurrent SUI. However, there is a growing body of evidence that a second midurethral sling is a reasonable option for persistent stress incontinence. In a Danish cohort study of subsequent surgery after failure of a synthetic midurethral sling, 6 percent (352 of 5820) of women underwent reoperation for midurethral slings that had been placed between 1998 and 2007 [71]. In this cohort, the first choice reoperation was another synthetic midurethral sling (46 percent) followed by urethral injection therapy (37 percent). While the likelihood of a successful outcome is somewhat lower than that observed with a primary surgery, a repeat midurethral sling procedure has a much lower morbidity profile than a pubovaginal sling [72] (see 'Midurethral sling' below). In general, the use of retropubic urethropexy has declined and we do not consider it for recurrent stress incontinence [73]. In the above cohort study, pubovaginal slings were used in only 3 percent of women [71].
There are few data regarding the choice of surgical procedure for persistent/recurrent SUI.
●Trial data – Data derived from prospective trials are lacking. An attempted 2019 review evaluating management of patients with persistent incontinence after placement of a midurethral sling did not find any trials that met the inclusion criteria [70].
●Observational data – A comparative study of surgical treatments reported that suburethral slings appeared to be more effective than retropubic urethropexy (Burch colposuspension) for women who had had two or more prior continence procedures. This retrospective observational study included 118 women who were surgically treated for recurrent SUI with either a suburethral polypropylene sling procedure or retropubic urethropexy (Burch colposuspension) by a single surgeon from 1985 to 1995 [74]. An analysis of 71 patients found that those who had one prior continence procedure had comparable cure rates for either the sling or Burch (77 versus 81 percent). However, cure rates were higher with the sling for patients with more than one prior continence procedure: two procedures (73 versus 25 percent) and three procedures (38 versus 0 percent). Thus, the choice of procedure is made based upon surgeon experience (taking into consideration the patient's medical and surgical history and diagnostic findings) and patient preference.
In our practice, we make a decision between a bladder neck sling and midurethral sling by considering the perioperative risks associated with length of surgery (pubovaginal sling takes longer), length of postoperative recovery (harvesting fascia leads to great postoperative pain and longer recovery), the risk of erosion (polypropylene is synthetic and carries a higher risk than autologous fascia), and the risk of urinary retention and voiding dysfunction (which can occur with either procedure).
Urodynamic findings are a critical part of surgical planning. If there is little urethral mobility on examination and the urodynamic findings are consistent with intrinsic sphincter deficiency (low maximum urethral closure pressure and cough leak point pressure and Valsalva leak point pressure of <60 cmH20), we are more likely to consider a bladder neck sling as opposed to a midurethral sling. If there is some urethral mobility on examination and the urodynamic findings support SUI with adequate urethral function (relatively preserved maximum urethral closure pressure [MUCP] and higher cough leak point pressure [CLPP] and Valsalva leak point pressure [VLPP]), a midurethral sling is likely a very reasonable option with lower morbidity than a bladder neck sling. In making the decision, the potential for voiding dysfunction and potential need for prolonged intermittent self-catheterization with a pubovaginal sling must be considered.
Bladder neck sling — Bladder neck slings are suburethral slings placed at the level of the proximal urethra or bladder neck. These are also referred to as fascial slings, or as pubovaginal slings when the arms of the sling material are affixed to the anterior rectus fascia rather than the pubic bone or Cooper's ligament. Use of bladder neck slings has largely been replaced by midurethral slings as a primary procedure. Current use is mainly for women with recurrent SUI following surgical treatment.
Bladder neck slings were traditionally made of autologous fascia, though polypropylene grafts have been used. Autografts appear to perform better than cadaveric tissue (allografts) [75-79]. The durability of cadaveric tissue has been questioned, leading to a marked decrease in their use [80]. The data on use of xenografts for bladder neck slings are limited, but suggest that this material is less optimal than autografts [81-84].
Data regarding the outcomes of pubovaginal slings for recurrent stress incontinence using autologous fascia and polypropylene grafts have been published. A systematic review identified four studies evaluating 140 cases and reported a pooled success rate of 79 percent. The rate of successful outcomes was similar among women who had an autologous fascia or polypropylene graft, but there were higher rates of pelvic abscesses and longer hospital stays among women getting an autologous fascia graft [72]. Three of the four studies in this review were published before midurethral polypropylene slings became the standard for surgical treatment of stress incontinence. Today, women presenting with recurrent stress incontinence most frequently have had a midurethral polypropylene sling. A retrospective study of 66 women in this situation found that 69.7 percent of women were cured of stress incontinence and that 37.9 percent were cured of both stress and urge incontinence. Women who required mesh removal were not less likely to be cured of their symptoms compared with those who did not (56 versus 64 percent) [85].
The rates of beneficial outcomes for patients having surgery for recurrent incontinence are in general lower than the studies establishing the use of suburethral slings as a standard for stress incontinence. In a meta-analysis that included 381 women who had a fascial bladder neck sling procedure, the median SUI cure rate for bladder neck slings with at least 48 months of follow-up was 82 to 96 percent [80]. In a classic study of patients who underwent a pubovaginal sling procedure (80 percent of the patients had prior surgery for incontinence), the cure rate was 81 percent [86]. By contrast, the success rate reported during a randomized controlled clinical trial was 47 percent [87]. The difference in success rates is likely related to methodology and the use of a strict composite of subjective and objective criteria, such as no self-reported symptoms, minimal increase in 24 hour pad weight, negative full bladder stress test, and no retreatment of any kind. Only 15 percent of the women from the later study had previous incontinence surgery, and their success rate was not reported to be different [87].
Midurethral sling — Midurethral sling surgery appears to be an effective approach to treating recurrent SUI, with slightly lower efficacy if the primary surgery was also a midurethral sling. A meta-analysis of 12 prospective studies (including one randomized trial) with a total of 430 women found that the cure rate for a midurethral sling after any previous surgery was 79 percent and after a prior midurethral sling was 73 percent [88,89]. There is observational evidence that the type of midurethral sling is important. A meta-analysis of women with various conditions placing them at high risk for recurrent incontinence reported higher subjective and objective cure rates among patients who underwent retropubic slings versus transobturator midurethral slings after previous incontinence surgery [90].
The management of the prior sling does not appear to impact the cure rate of the repeat sling, although the available data are limited. In retrospective cohort studies, there were no differences in the Incontinence Severity Index scores among patients whose prior sling was transected or excised versus left in situ [91,92].
There are several novel approaches to management of recurrent SUI in women who have undergone previous midurethral sling surgery. Successful resolution of SUI after adjustment of an existing midurethral sling has been reported [93]. Adjustable midurethral slings (eg, Remeex, Ajust) are slings that allow postoperative adjustment of sling tension. As an example, in one study, SUI was cured in 21 of 25 women with recurrent SUI after previous continence surgery who underwent placement of the AMI adjustable sling [94,95]. Another novel approach is the use of spiral slings; these are transvaginal slings that encircle the urethra and are held in place by sutures that pass through the retropubic space [96]. The target population for spiral slings are women with neurologic disease or a fixed, open, nonfunctioning urethra (referred to as a "lead pipe" or "pipe stem" urethra [97]). In a prospective study, 20 of 28 women had successful treatment of persistent SUI after spiral sling placement [98]. Further study is needed of these techniques. These procedures are likely to be highly dependent upon a combination of surgical and device-specific technical expertise.
The use of mini-midurethral slings in the setting of recurrent stress incontinence has not been studied but seems ill advised with currently available techniques. Several studies have reported significantly lower cure rates when mini-slings are used as primary surgery for SUI [99,100].
Retropubic urethropexy (Burch colposuspension or Marshall Marchetti Krantz) — The data with respect to retropubic urethropexy for recurrent stress incontinence are limited. One case series reports that the efficacy of a Burch colposuspension decreased from 81 percent to 25 percent to 0 percent for women with a history of one, two and three previous surgeries for incontinence [101]. In a study regarding the Space of Retzius anatomy at the time of repeat Marshall Marchetti Krantz (MMK) dissection, Lee and Symmonds coined the term "alleged MMK" because the lack of adhesions between the pubis and bladder indicated that an appropriate dissection and repair had not been performed. They furthermore advocated opening the bladder to facilitate the surgical approach in which the surgeon attempts "to see and feel" the effect of the operation on the atonic, funneled bladder neck and urethra [73].
Women with refractory SUI — Women who have severely bothersome SUI despite more than one or more continence surgeries and who can tolerate an invasive procedure may be offered placement of an artificial urinary sphincter or urinary diversion. These are procedures of last resort. They are highly invasive and, in the case of an artificial urinary sphincter, there is a high risk of complications and need for repeat procedures.
Artificial urinary sphincter — The artificial urinary sphincter (American Medical Systems 800) is rarely used in women because complications from the device are common. However, women with severe incontinence who are refractory to other treatments may benefit from artificial sphincter devices, which can be placed abdominally or transvaginally. The following types and frequencies of complications have been reported: mechanical failure (3 to 33 percent), early infection/erosion (4.5 to 67 percent), late erosion (15 percent), and delayed recurrent incontinence (7 percent) [102]. Placement of an artificial sphincter does not preclude sexual activity or pregnancy.
In 68 female patients who underwent sphincter placement, only 37 percent continued to use it seven years later, largely because of the significant complications associated with it [103]. Infection or erosion accounted for removal in almost one-half of the women who discontinued use. Mechanical failure with the need for reoperation was common, even among those who continued to use the device.
Due to this extremely high complication rate and need for subsequent intervention, we feel use of the device should be restricted to patients who have severe, recurrent incontinence, and understand the complications associated with it and the likelihood that they will need another operation.
Urinary diversion — Urinary diversion is the most invasive intervention for treatment of recurrent stress incontinence, and is rarely performed for this indication. Urinary diversions can be incontinent or continent. Options for an incontinent diversion or conduit diversion include suprapubic catheter drainage, an ileovesicostomy where ileum is anastomosed to the bladder and drains via a stoma, and colonic conduit drainage, which requires ureteral reimplantation. Continent diversions became possible with development of clean intermittent catheterization techniques and development of surgical procedures in which a detubularized segment of bowel is used as catheterizable stoma. Many series have reported continence rates greater than 90 percent with strict adherence to a catheterization protocol.
However, each of these approaches has been associated with a significant risk of complications, including stomal stenosis, ureteral damage (with reimplantation procedures), nutritional deficiencies (when ileum is for the conduit), and the potential for metabolic changes (hyperchloremic acidosis when colon is used as the conduit) [104].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Incontinence surgery in women" and "Society guideline links: Urinary incontinence in adults" and "Society guideline links: Gynecologic surgery".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Urinary incontinence treatments for women (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Persistent SUI – Stress urinary incontinence (SUI) is a common condition in women and many women undergo surgical treatment. The majority are adequately treated with one procedure, but up to 15 percent of women require further treatment for persistent or recurrent SUI. The rate of persistent/recurrent stress incontinence also depends upon the initial surgical procedure performed. (See 'Introduction' above.)
●Risk factors – Preoperative patient characteristics associated with a higher risk of failure of primary surgery for SUI include advanced age, urgency urinary incontinence, pelvic organ prolapse (POP), urethral incompetence, obstructive voiding symptoms, obesity, and diabetes mellitus. (See 'Risk factors' above.)
●Evaluation – The key goals of the evaluation are to: (1) exclude nonstress etiologies of urinary incontinence, since these are treated differently; (2) assess the severity of symptoms and impact on quality of life to see if treatment is warranted; and (3) review the surgical and medical history to determine which types of treatment are appropriate. (See 'Evaluation' above.)
●Shared decision-making – Management decisions involve consideration of multiple factors, including the results of the clinical and diagnostic evaluation, patient tolerance of short- and long-term side effects and complications, tissue status in the region of potential repeat surgery, and expectations of additional intervention. To arrive at a treatment plan, we perform shared decision-making with the patient and discuss these factors, the risks and benefits of the treatment as well as treatment alternatives, and potential complications. (See 'Management' above.)
●Approach to treatment – Treatment of persistent/recurrent SUI is indicated when symptoms are bothersome. Women who do not find their symptoms bothersome may be managed expectantly.
•Initial treatment – Initial treatment includes pelvic floor muscle exercises and/or a continence pessary. (See 'Pelvic floor muscle exercises' above and 'Vaginal pessary' above.)
•Periurethral injection – Periurethral injection therapy is a reasonable option for women who cannot tolerate surgery and for whom conservative measures are not effective or acceptable. (See 'Periurethral injection therapy' above.)
•Surgical treatment – For women with recurrent/persistent SUI who desire surgical treatment and are surgical candidates, we suggest procedure midurethral or bladder neck sling rather than retropubic urethropexy (Burch colposuspension) (Grade 2C). (See 'Women who desire surgical treatment' above.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
