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Review ArticleApproach to the evaluation and treatment of stress urinaryincontinence in womenSanjay SinhaSenior Consultant...
forms of effort. The predictive value of history of stress leak is56% for pure SUI and 77% for SUI with other conditions. ...
An effort must be made to exclude other forms of lower tractsymptoms such as voiding difficulty, dysuria or hematuriathat m...
Table 3 e Important surgical procedures for stress urinary incontinence13,15,18.SurgicalprocedureBrief description Outcome...
4. Surgery for stress urinary incontinenceOver the years several different approaches have been usedfor the surgical manag...
urgency incontinence, detrusor overactivity or detrusoroveractivity incontinence. Clearly, each of these presentationshas ...
24. Richter HR, Diokno A, Kenton K, et al. Predictors of treatmentfailure 24 months after surgery for stress urinaryincont...
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Approach to the Evaluation and Treatment of Stress Urinary Incontinence in Women


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Urinary incontinence in women is a common problem with a significant impact on the
Received 19 January 2013 quality of life of individuals and the well-being of the community. While economic impact
Accepted 31 January 2013 data in India is lacking, the direct expenditure on management of urinary incontinence is about 20 billion dollars in the USA, which is more than the cost incurred in the treatment of cancers of the breast, uterus, cervix and ovary combined!

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Approach to the Evaluation and Treatment of Stress Urinary Incontinence in Women

  1. 1. ApproachtotheEvaluationandTreatmentofStressUrinaryIncontinenceinWomen
  2. 2. Review ArticleApproach to the evaluation and treatment of stress urinaryincontinence in womenSanjay SinhaSenior Consultant Urologist and Transplant Surgeon, Apollo Hospital, Hyderguda, Hyderabad, Indiaa r t i c l e i n f oArticle history:Received 19 January 2013Accepted 31 January 2013Available online 6 February 2013Keywords:EpidemiologyUrodynamicsRetropubic colposuspensiona b s t r a c tUrinary incontinence in women is a common problem with a significant impact on thequality of life of individuals and the well-being of the community. While economic impactdata in India is lacking, the direct expenditure on management of urinary incontinence isabout 20 billion dollars in the USA, which is more than the cost incurred in the treatment ofcancers of the breast, uterus, cervix and ovary combined!1This data is unlikely to beapplicable to India, since urinary incontinence is essentially a quality of life problem whilemany other diseases with a more obvious health impact are likely to get priority spendingin an Indian household.Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.1. Epidemiology and risk factorsA study of the pooled mean prevalence of any urinary incon-tinence in women showed 34% and 25% prevalence in elderlyand middle aged or younger women respectively.2Clinically‘significant’ incontinence has been more difficult to evaluateand scoring systems such as the Sandvik Severity Scale3haveoften been used in epidemiological studies (See Table 1). Inmost prevalence studies, stress incontinence accounts forabout half of all incontinence, followed by mixed inconti-nence with the smallest group being urge incontinence.Prevalence and severity of urinary incontinence increaseswith age. However, as shown by the Epicont study fromScandinavia, stress urinary incontinence seems to peak inwomen in the fifth decade while urgency incontinence iscommoner in older women. A lower prevalence of all forms ofurinary incontinence is seen consistently in Asian womenacross studies.4Bump and Norton have classified the risk factors into fourcategories. These include predisposing factors such as race orgenetic abnormalities; inciting factors such as childbirth,neuromuscular injury, radiation or prior surgery; promotingfactors such as obesity, smoking, comorbidities or infectionand decompensating factors such as aging, dementia orlimited mobility.52. EvaluationThe evaluation of stress urinary incontinence is a methodicalconfirmation of the presence of incontinence, the type ofincontinence, the exclusion of other conditions that couldmimic the symptoms, assessment of the severity of theproblem, and evaluation for other health problems thatmight impact treatment. This is accomplished by means ofa detailed history and physical examination as well asappropriate additional testing (Table 2).History is a key to making a working diagnosis and estab-lishing the degree of bother. Most women complain of a leakof urine on coughing, sneezing, laughing or during otherE-mail address: online at www.sciencedirect.comjournal homepage: p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 30976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. forms of effort. The predictive value of history of stress leak is56% for pure SUI and 77% for SUI with other conditions. Up totwo-thirds of women with urgency incontinence can presentwith a history similar to SUI. In contrast the physical exami-nation finding of leak on a cough stress test has a positivepredictive value of 91% for some form of SUI.6Women withSUI may present with urgency or frequency of micturition.This might reflect a defensive behavior pattern or may occurdue to the initial trickle of urine into the urethra triggeringa sense of urgency. One must ascertain whether the womanhas a significant component of urgency and urgency inconti-nence as this may have implications for treatment and prog-nosis. Women with predominant urgency symptoms may bebest served by initial treatment directed at overactive bladder.Table 2 e Evaluation of women with stress urinary incontinence6,21.Assessment Role and method CommentVoiding diary Bladder diary including episodes of urgency orincontinence, pad usage and physical activitypreferably recorded over 3 days (IUGA Terminologydocument, 2009)Objective quantification of severity by incontinence episodefrequency (IEF). Useful additional information for decision-making in mixed urinary incontinence. Multiple episodes ofurgency without leak and small volume voids would suggestthe need for a trial of OAB medication. Counsel women withlarge 24 h urine volumesStress test Observation of leakage of urine through the urethralmeatus at the time of a cough. Ideal: standingposition, full bladder, direct inspectionA positive stress test is marked by leakage of urine preciselyat the time of the cough with the leak stopping when thecough is completed. Leak that is delayed or prolongedbeyond the cough may represent cough-induced detrusoroveractivity. Supine Empty Bladder Stress Test (SEST) insupine position after voiding predicts ISDPelvic floor muscleevaluationTechniques (1) Visual inspection (2) Digitalevaluation (3) EMG (4) Perineometry (manometric)(5) Perineal ultrasonography, 2-D and 3-D (6) Ultra-rapid sequence MRIModified Oxford Grading System for digital evaluationGrade 0 ¼ no contraction, 1 ¼ flicker, 2 ¼ weak, 3 ¼ moderatewith lift, 4 ¼ good with lift, 5 ¼ strong with lift. 3contractions of 5 sec each are observed. Contraction can befelt in three directions medioelateral, anteroeposterior andcranial liftAssessment of bladderneck mobilityTechniques (1) Visual inspection (2) Q-tip test,(3) POP-Q score (4) USG (5) Bead chaincystourethrogram (historical) (6) Urethroscopy(7) Video-cystourethrographyDeflection of meatus toward ceiling at straining isabnormal. On Q-tip test, maximum strain deflection >30from horizontal is positive. The Aa point score correlateswith Q-tip results. Q-tip positive in 95% with Grade II and100% higher POP at point Aa. On urethroscopy, an openbladder neck on full bladder correlates with positive Q-tipPad test To confirm and quantify leakage by weighing anabsorbable perineal pad before and after a fixedduration of useShort term (20 min, 1 h, 2 h): adv: easy, standardized (ICS 1 htest, 1 g gain positive). Disadv: may miss OAB wet or mildincontinence, impact of bladder fullnessLong term (12 h, 1d, 2d): Adv: less likely to be false negative,home-based disadv: compliance problem, cumbersome.4 g gain on 1d-test positive (4th ICI)Dye test Use of dye testing recommended in situations wherediagnosis is unclear and the source of urine leak isuncertainOne-dye test (methylene blue in bladder) and two-dye test(additional oral phenazopyridine). Rather than thetraditional swab tests, combine with careful direct vaginalexamination and endoscopic evaluationUrodynamics UDS is useful for (1) obtaining a diagnosis(2) predicting success (3) predicting complications(4) understanding failureReference values (95th ) e MFR 24 ml/s (11.4 ml/s), PVR25 ml (90 ml), PdetQmax18 cm H2O (39 cm H20). Detrusoroveractivity found in about 10% (depending on entrycriteria) 0.70% leak with valsalva, 15% with cough only and15% may not leak with catheter in situ. Abdominal leakpoint pressure (60 cm H20) and maximal urethral closurepressure (20 cm H20) are common methods of diagnosingISD. Low voiding pressure with poor flow and large residualsmay predict postop voiding difficultyTable 1 e Sandvik Severity Scale for epidemiologicalstudies.3Frequency score (four levels) multiplied by amount score(two levels)Frequency score1 ¼ Less than once/month2 ¼ One or more times/month3 ¼ One or more times/week4 ¼ Every day or nightAmount score1 ¼ Few drops or little2 ¼ MoreScale1e2 Mild; 3e4 moderate; 6e8 severea p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 368
  4. 4. An effort must be made to exclude other forms of lower tractsymptoms such as voiding difficulty, dysuria or hematuriathat might suggest an alternative diagnosis. Bowel functionmust be evaluated.Physical examination must include vaginal examination,pelvic floor assessment, a focused neuro-urological evaluationincluding anal tone and the stress test in all patients. Thestress test is done on a comfortably full bladder and should berepeated in the standing position in case the woman fails toleak in the supine position. Direct demonstration of urinaryleak must be considered a prerequisite for any surgical ther-apy. One must actively search for an extra-urethral leak.Urethral hypermobility must be assessed by one of the stan-dard techniques (Table 2). Lack of hypermobility may be anespecially important finding.Use of validated questionnaires is recommended both forassessing the type of symptoms as well as the impact of theproblem on quality of life.7The ICIQ, IIQ-7 or UDI-6 are variousdetailed and short form questionnaires for this purpose.Quantification of the severity of incontinence can be achievedmore objectively by a pad test or estimation of the number ofincontinence episodes over a fixed time frame by means ofa voiding diary. For SUI, both short term as well as longer-termpad tests may be used. When the source of incontinence isunclear, a dye test with careful clinical examination can bevery useful.Standard investigative evaluation of all patients mustinclude a complete urine examination to exclude urinaryinfection and microscopic hematuria, blood glucose estima-tion and measurement of post-void residual by ultrasonog-raphy. Additional investigations are guided by the patient’sclinical presentation. In conjunction with the residual urine,uroflow is a useful screening test for voiding dysfunction.Urodynamics remains an important, though imperfecttool, for the evaluation and diagnosis of stress urinary in-continence. Urodynamics has been recommended prior tosurgical therapy by several guidelines including the IUGAguidelines and NICE guidelines of UK. However, it’s quite clearthat some women with classical findings may not necessarilyneed urodynamics. The recent VALUE study (Value ofUrodynamic Evaluation) from the UITN group in the USAhas questioned the role of routine urodynamics.8Howeverin community practice, one needs to be careful in blindlyapplying the results of this study performed on a specificsubset of patients. Clearly, urodynamics must be performedprior to surgery in women with recurrent incontinence,associated voiding difficulty or elevated residuals, suspicion ofneurogenic dysfunction or those with upper tract changes. Inwomen with a strong urgency component, one might be betteroff performing urodynamics as there is a clear link betweenhigh-pressure detrusor overactivity and a poor postoperativeoutcome. Such women are unlikely to have been recruitedinto the VALUE study since the women had predominant orpure SUI symptoms on questionnaires.Urodynamics can confirm urodynamic stress inconti-nence, diagnose detrusor overactivity, establish normalvoiding function and diagnose intrinsic sphincter deficiency.These factors may be important in clinical decisions for somepatients and are discussed in later sections.3. Management of stress urinaryincontinence3.1. Conservative therapiesThese can be categorized into lifestyle modifications andpelvic floor therapies.3.1.1. Lifestyle modificationTimed voiding by the clock every 2e3 h can reduce the volumeof leak in women with SUI by ensuring that the bladder is keptat a lower level of distension. This may especially help thosewomen who leak at capacity. Smoking is associated witha higher risk of all forms of incontinence (RR 1.4) but thebenefits of cessation in terms of resolution of SUI remainunclear.9There is a clear link between obesity and inconti-nence. Dallosso et al showed that the relative risk of urinaryincontinence was 0.82, 1.24 and 1.46 in underweight, over-weight and obese women.9Weight loss has been shown toimprove continence with one study showing 60% reduction inincontinence episodes in women who lost 16 kg103.1.2. Pelvic floor rehabilitationAll treatments that are designed to increase the strength,bulk or responsiveness of pelvic floor muscles are groupedunder this heading. This includes pelvic floor muscle training,which is a regime of repeated contractions of the pelvic floorthat has been taught to the patient by a health care profes-sional. The traditional Kegel’s exercises are not recom-mended since many women find it difficult to contract theright set of muscles. The International Consultation onIncontinence makes a Grade A recommendation for pelvicfloor muscle training for all women with urinary inconti-nence. Sets of 10e12 near-maximal contractions held for6e8 s each with an equal period of rest is recommended 3e5times every alternate day. The “Knack maneuver” is specifi-cally recommended for patients with SUI. This consists oftiming the contractions with cough. However, evidencesuggests that women are unlikely to continue pelvic floortherapies in the long term.11The addition of biofeedback has the potential to improvethe outcome of pelvic floor muscle training. This can be ach-ieved by palpation by a health professional, by means ofweighted vaginal cones, EMG activity feedback or squeezepressure feedback. Weighted vaginal cones need to be heldabove the level of the levator for 15 min. Although apparentlysimple, many women cannot hold the lightest cone, somehold the cones using the thigh adductors (the wrong set ofmuscles!) while some simply refuse. As yet, there is no clearevidence that biofeedback adds to the efficacy of regular pelvicfloor training.In contrast to pelvic floor training, peripheral stimulationof the pelvic floor needs compliance but no effort on the partof the patient. Stimulation can be achieved by home or of-fice electrical stimulation. The classical recommendation forSUI has been high-frequency 50e200 Hz stimulation usingvaginal or anal electrodes. Mixed low and high-frequencystimulation has been recommended for mixed urinaryincontinence.a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 3 69
  5. 5. Table 3 e Important surgical procedures for stress urinary incontinence13,15,18.SurgicalprocedureBrief description Outcome Usual complications IndicationSynthetic mid-urethral slingsSynthetic monofilament polypropylenetape placed under mid-urethra either bythe retropubic route (TVT, Gynecare) ortransobturator route (Monarc, AMS; TVT-O Gynecare)80% success at 12 mo (rigorous criteria,TOMUS trial), equivalent outcomes of bothroutes. Patient satisfaction rate 85e90%.Uncontrolled 11 year data shows durableoutcome of TVTBladder perforation 5%, neurologicalsymptoms 4%, vaginal exposure 3% andvoiding dysfunction 2.5% with TVT.Neurological symptoms in 9.4% with TOT.Overall serious adverse events 13.8% withTVT versus 6.4% with TOTs (TOMUS trial)Usual woman with SUI. In womenwith previous failed proceduresTVT might be better choice(uncontrolled data) while inprevious multiple pelvic surgeries,TOT betterAutologous rectusfascia slingAutologous sling usually harvested fromrectus. Placed under the proximal or mid-urethra and brought up over the rectusfascia where it is fixed using non-absorbable sutures47% overall success versus 38% for Burch(rigorous criteria, SISTEr trial). Patientsatisfaction rate 86%Serious adverse events 13% (similar toBurch). Voiding difficulty most importantproblem leads to 6% revision rate.Bothersome urgency incontinence due topersistent preop urgency incontinencerather than new onsetValuable salvage option in patientswith recurrent SUI, severe ISD,fixed urethra or scarred vaginaltissuesBurchcolposuspensionRetropubic colposuspension of theanterior vaginal wall and periurethraltissues to the ileopectineal ligament byopen surgery or laparoscopy51% success at 24 months equivalent totapes (rigorous criteria, Ward and Hilton).Inferior to autologous slings for stressincontinence success (SISTEr trial)More morbid than tapes but less than theautologous sling. Posterior compartmentprolapse 10% due to altered axis of vaginaUsed chiefly in patients undergoingconcomitant pelvic surgery orlacking vaginal access. Presence ofhypermobility is prerequisitePeriurethralinjectionSeveral substances used. Currentlyavailable or recommended are e siliconeparticles (Macroplastique), carbon beads(Durasphere), calcium hydroxylapatite(Coaptite). Injection at different locationsto achieve coaptationWidely variable success rates upwards of20% dry rate at one year. Need for multipleinjections. Lack of durability of resultsDysuria, hematuria, non-infectiousabscess and urethral prolapse. Migrationis less concern with current agents.Hypersensitivity reaction rareIndicated for patients who are poorsurgical candidates, onanticoagulants, elderly womenwith fixed urethra, desire non-surgical treatment, young but notcompleted familyapollomedicine10(2013)67e7370
  6. 6. 4. Surgery for stress urinary incontinenceOver the years several different approaches have been usedfor the surgical management of SUI. Currently, on the basis ofevidence, one would consider the following as valid treatmentchoices e retropubic colposuspension, mid-urethral slingsincluding synthetic and autologous but not xenograft orallograft materials. In select situations periurethral injectionsmay be an acceptable choice. Artificial sphincter is rarely usedfor SUI in women. Needle suspensions and anterior repairs inall forms are not reliable forms of treatment for SUI. Thevarious surgical treatments and some of the available evi-dence are summarized in Table 3.Several good publications have addressed the most com-monly performed procedures. A Cochrane review by Ogahet al compared Burch colposuspension with synthetic tapesand showed that there was no difference in short term ormedium term outcome in efficacy.12However, hospital stayand operating time was understandably longer with Burch.Urinary tract injury was more common with tapes whilepostoperative pelvic organ prolapse, chiefly posterior com-partment due to alteration in the vaginal axis, was more likelywith the Burch colposuspension.12The rigorous SISTEr trialcompared Burch with the autologous sling and found thatslings were more effective in terms of stress incontinence-specific success, overall success and patient satisfaction butat the cost of a higher incidence of voiding dysfunction (14%versus 2%).13All the take-downs of the original procedurehappened in the sling group. Another Cochrane review com-pared tapes with the autologous sling and found that theywere equivalent in efficacy.14However, complications, oper-ating time and de novo detrusor overactivity favored thetapes. The TOMUS trial compared retropubic TVT with thetransobturator tapes and found them to be equivalent in ef-ficacy at 12 months (Table 3).15There does not appear to beany major difference in efficacy between the inside-out andoutside-in approaches. Based on the above evidence, for theusual patient with SUI, a synthetic tape surgery seems themost logical. The type of tape is probably more a matter ofsurgeon preference. One must recognize that long term data isnot yet available for the TOTs.More recently, there has been interest in single incisionmini-slings that are placed in the general direction typicallytaken by the classical retropubic or transobturator tapes. Theintention behind further making the tapes less invasive hasbeen a further reduction in complications, pain and anes-thesia requirement. However, good quality medium and longterm data about their efficacy is currently lacking.4.1. Recurrent urinary incontinence16e18Mid-urethral slings will fail in 5e20% of patients in the longterm. Important risk factors associated with failure are sum-marized in Table 4. Women with recurrent SUI are more likelyto be having ISD and some of these women will have a fixedurethra. For the usual woman with recurrent SUI the optionsare e repeat mid-urethral sling, autologous pubovaginal slingand perhaps, periurethral bulking agents. In a retrospectivecomparison of 77 patients undergoing redo surgery with over1075 patients undergoing a primary procedure, Stav et alnoted that the conventional retropubic TVT had a better out-come as compared with a transobturator tape irrespective ofwhether the initial procedure was a TVT or a TOT.19Overallrepeat procedures had a poorer outcome compared with pri-mary procedures (62% versus 86%). Periurethral bulkingagents carry a low success of about 35%. The autologouspubovaginal sling is an important salvage procedure for pa-tients with recurrent SUI and is the treatment of choice inmost difficult situations. Repeat colposuspension surgerycarries a low success rate (81% for first, 25% for second and 0%for third re-do surgery).20All patients with recurrent SUI musthave urodynamics evaluation prior to surgical re-treatment.4.2. Mixed urinary incontinence16e18The literature on mixed urinary incontinence suffers fromlack of homogeneity with regards to what the term “mixed”implies. In various publications, the term has been used toinclude those women who have SUI along with urgency,Table 4 e Risk factors for failure of stress urinary incontinence surgery.Risk factor Odds ratio for failure SourceAge per 10 years X1.5 for both TOT and TVT TOMUS23Post-menopausal women not onhormone replacement therapyX1.5 for both autologous sling and Burch colposuspension SISTEr24Obesity X1.7 for TVT Meta-analysis, 7pooled studies25MESA questionnaire urge score,per 10 pointsX2 for both TOT and TVTX1.8 for both autologous sling and Burch colposuspensionTOMUS23SISTEr24Prior SUI surgery X2 for both TOT and TVT TOMUS23Stage III/IV POP X2.5 for both autologous sling and Burch colposuspension SISTEr24Lack of hypermobility X2 for both TOT and TVT TOMUS26Pad weight per 10 g increase X1.1 for both TOT and TVT TOMUS23Pre-operative high-pressuredetrusor overactivityPoorer outcomes for patients with high-pressure DO(15 or 25 cm H20)4th ICI18Urodynamic evidence of poorurethral function on valsalvaleak point pressure or maximalurethral closure pressureX2 for both TOT and TVT for women in the lowest quartile ofVLPP (86 cm H20) and MUCP (45 cm H20)TOMUS26a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 3 71
  7. 7. urgency incontinence, detrusor overactivity or detrusoroveractivity incontinence. Clearly, each of these presentationshas a different implication. About 10% of women in the UITNtrials (TOMUS and SISTEr) had detrusor overactivity.15,21While the outcome in these women was similar to the restof the group, high-pressure detrusor overactivity of pressure25 cm H20 is clearly associated with a poorer outcome.Women with significant urgency symptoms are more likely tobe unsatisfied with their surgery. In those with predominanturgency symptoms, it makes sense to treat the urgency first.However, in women with significant SUI, one could go aheadwith SUI surgery after a detailed counseling including a dis-cussion on the need for postoperative anticholinergic therapy.SUI resolution rates are no different in this group. SUI itselfcan present as urgency in some women and this is likely toresolve with surgery. 24e90% of women will show resolutionof OAB symptoms following SUI surgery.4.3. Intrinsic sphincter deficiency16e18Traditional teaching segregated SUI into two compartments ethose with ISD and those with hypermobility. Contemporaryresearch shows quite clearly that most women with SUI willhave hypermobility as well as ISD and that SUI patients presenta spectrum from isolated ISD to significant hypermobility. ISDhas usually been defined by urodynamics as an abdominal leakpoint pressure of 60 cm H20 or maximal urethral closurepressure of 20 cm H20 or both. Historically, autologous slingshave been the most favored treatment for patients with ISDand in this group they give cure rates of upwards of 80%. Thereis a paucity of good quality data in this group. In a small series,Rezapour et al found TVT to deliver success rates approachingpatients without ISD (74% cure and 12% improved).22However,five of the eigth patients with a fixed, immobile urethra failed.The TOMUS trial showed equivalent outcomes for those withISD irrespective of whether a retropubic TVT or transobturatortape surgery was performed. However, such patients weretwice as likely to fail surgery. There is uncontrolled data tosuggest that women with fixed immobile urethra behave dif-ferently from those with hypermobility along with a compo-nent of ISD. For the women with fixed urethrae, an autologoussling still remains the best salvage option. In select women, onemight consider periurethral injections provided the womanunderstands the unpredictability of outcome and the possibleneed for multiple sittings.Conflicts of interestThe author has none to declare.r e f e r e n c e s1. Wilson L, Brown JS, Shin GP, et al. Annual direct cost ofurinary incontinence. Obstet Gynecol. 2001;98:398.2. Thom D. Variation in estimates of urinary incontinenceprevalence in the community: effects of differences indefinition, population characteristics, and study type. J AmGeriatr Soc. 1998;46(4):473e480.3. Sandvik H, Hunskaar S, Seim A, et al. Validation of a severityindex in female urinary incontinence and its implementationin an epidemiological survey. J Epidemiol Community Health.1993;47:497.4. Sung VW, Hampton BS. Epidemiology of pelvic floordysfunction. Obstet Gynecol Clin North Am. 2009;36:421e443.5. Bump RC, Norton PA. Epidemiology and natural history ofpelvic floor dysfunction. Obstet Gynecol Clin North Am.1998;24(4):723e746.6. Staskin D, Kelleher C, Avery K, et al. Initial assessment ofurinary and faecal incontinence in adult male and femalepatients. In: Abrams P, ed. Incontinence. 4th ed. Plymouth, UK:Health Publications; 2009:311e362.7. Staskin D, Kelleher C, Avery K, et al. Committee 5B. Patientreported outcome assessment. In: Abrams P, ed. Incontinence.4th International Consultation on Incontinence. Plymouth: HealthPublication Ltd; 2009:363e412.8. Nager CW, Brubaker L, Litman HJ, et al. A randomized trial ofurodynamic testing before stress-incontinence surgery.Urinary Incontinence Treatment Network. N Engl J Med.2012;366:1987e1997.9. Dallosso HM, McGrother CW, Matthews RJ, et al. Theassociation of diet and other lifestyle factors with overactivebladder and stress incontinence: a longitudinal study inwomen. BJU Int. 2003;92:69e77.10. Subak LL, Whitcomb E, Shen H, et al. Weight loss: a novel andeffective treatment for urinary incontinence. J Urol.2005;174:190e195.11. Smith JH, Berghmans B, Burgio K, et al. Adult conservativemanagement. In: Abrams P, ed. Incontinence. 21st ed. Paris,France: Health Publications Ltd.; 2009:1025e1120.12. Ogah J, Cody JD, Rogerson L. Minimally invasive syntheticsuburethral sling operations for stress urinary incontinencein women. Cochrane Database Syst Rev. 2009 Oct;7(4):CD006375.13. Albo ME, Richter HE, Brubaker L, et al. Burch colposuspensionversus fascial sling to reduce urinary stress incontinence.N Engl J Med. 2007;356:2143e2155.14. Rehman H, Bezerra CC, Bruschini H, et al. Traditionalsuburethral sling operations for urinary incontinence inwomen. Cochrane Database Syst Rev. 2011 Jan;19(1):CD001754.15. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versustransobturator midurethral slings for stress incontinence.N Engl J Med. 2010;362:2066e2076.16. Midurethral slings for stress urinary incontinence:a urogynecology perspective. Urol Clin North Am.2012;39:289e297.17. Lee E, Nitti VW, Brucker BM. Midurethral slings for all stressincontinence: a urology perspective. Urol Clin North Am.2012;39:299e310.18. Smith ARB, Dmochowski R, Hilton P, et al. Surgery for urinaryincontinence in women. In: Abrams P, ed. Incontinence. 4th ed.Plymouth: Health Publications; 2009:1191e1272.19. Stav K, Dwyer PL, Rosamilia A, et al. Repeat synthetic midurethral sling procedure for women with recurrent stressurinary incontinence. J Urol. 2010;183:241e246.20. Amaye-Obu FA, Drutz HP. Surgical management of recurrentstress urinary incontinence: a 12-year experience. Am J ObstetGynecol. 1999;181:1296e1307.21. Nager C, Albo M, FitzGerald MP, et al. Reference urodynamicvalues for stress incontinent women. Neurourol Urodyn.2007;26:333e340.22. Rezapour M, Falconer C, Ulmsten U. Tension-free vaginal tape(TVT) in stress incontinent women with intrinsic sphincterdeficiency (ISD)da long-term follow-up. Int Urogynecol J PelvicFloor Dysfunct. 2001;12(suppl 2):S12eS14.23. Richter H, Litman H, Lukacz E, et al. Demographic and clinicalpredictors of treatment failure one year after midurethralsling surgery. Obstet Gynecol. 2011;117:913e921.a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 372
  8. 8. 24. Richter HR, Diokno A, Kenton K, et al. Predictors of treatmentfailure 24 months after surgery for stress urinaryincontinence. J Urol. 2008;179:1024e1030.25. Greer WJ, Richter HE, Bartolucci AA, et al. Obesity and pelvicfloor disorders: a systematic review. Obstet Gynecol.2008;112:341e349.26. Nager C, Sirls L, Litman H, et alUrinary incontinencetreatment network. Baseline urodynamic predictors oftreatment failure one year after midurethral sling surgery.J Urol. 2011;186:597e603.f u r t h e r r e a d i n g27. Refer to the series of publications on the TOMUS, SISTEr andValUE trials from UITN. Complete list available on Abrams P, Cardozo L, Khoury S, et al., eds. Incontinence. 4thInternational Consultation on Incontinence. Plymouth: HealthPublication Ltd; 2009.a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 3 73
  9. 9. Apollohospitals: