Portal de Periódicos da CAPES

Treatment Options for Women With Stress Urinary Incontinence

1999; Elsevier BV; Volume: 74; Issue: 11 Linguagem: Inglês

10.4065/74.11.1149

1942-5546

Deborah J. Lightner, NANCY M. B. ITANO,

Urinary Bladder and Prostate Research

About one-quarter million surgical procedures are performed each year in the United States for stress urinary incontinence. After outlining the presentation and diagnostic evaluation of stress urinary incontinence, this review concentrates specifically on the numerous conservative management strategies and minimally invasive surgical options for women with this common complaint. In the evaluation of nursing home residents with incontinence, the Minimum Data Set and Resident Assessment Protocol facilitate nonspecialist evaluation and management. In healthy adults, the therapeutic implications of the physical examination of the pelvic floor, assessing for the presence and strength of the voluntary contraction of the pelvic floor muscles, are detailed as the basis for all conservative management strategies. Reports on the effectiveness of pelvic floor muscle reeducation and pelvic floor electrical stimulation vary substantially, as do long-term results of surgical interventions. Surgical management is highly effective in the appropriate candidate. The current theory and practice of surgical treatment of stress urinary incontinence are outlined, with certain caveats regarding the lack of long-term follow-up for newer less invasive techniques. About one-quarter million surgical procedures are performed each year in the United States for stress urinary incontinence. After outlining the presentation and diagnostic evaluation of stress urinary incontinence, this review concentrates specifically on the numerous conservative management strategies and minimally invasive surgical options for women with this common complaint. In the evaluation of nursing home residents with incontinence, the Minimum Data Set and Resident Assessment Protocol facilitate nonspecialist evaluation and management. In healthy adults, the therapeutic implications of the physical examination of the pelvic floor, assessing for the presence and strength of the voluntary contraction of the pelvic floor muscles, are detailed as the basis for all conservative management strategies. Reports on the effectiveness of pelvic floor muscle reeducation and pelvic floor electrical stimulation vary substantially, as do long-term results of surgical interventions. Surgical management is highly effective in the appropriate candidate. The current theory and practice of surgical treatment of stress urinary incontinence are outlined, with certain caveats regarding the lack of long-term follow-up for newer less invasive techniques. An estimated one-quarter million surgical procedures are performed annually in the treatment of stress urinary incontinence (SUI). Physicians must understand that urinary incontinence is not the inevitable result of aging, childbirth, or weight gain. Stress urinary incontinence occurs commonly with athletic activity, even in young, healthy nulliparous women, but becomes life altering in a large proportion of older American women. In an era in which emphasis is increasingly placed on more cost-effective treatments, a frank look at what is currently available to patients and what might be available in the future is prudent. Diagnosis and management of urge urinary incontinence are beyond the scope of this article. By definition, SUI is a symptom. A patient may say, "When I cough, I leak urine." Stress urinary incontinence is also a sign, urine leakage from the urethral meatus with cough or Valsalva maneuver. Of most importance, SUI is a diagnosis: meatal urinary leakage that occurs with transient increases in abdominal pressure in the absence of detrusor muscle activity. In contrast, urge urinary incontinence occurs involuntarily in association with a strong urge. It is not a symptom of outlet weakness, like SUI, but results from bladder overactivity, either motor (detrusor instability) or sensory (sensory urge incontinence) in origin. Urge incontinence occurs in 60% of women with SUI. Of note, however, if a patient coughs and that triggers a bladder contraction, this is not SUI, but cough-induced detrusor instability. This rare condition does not improve with surgical procedures directed at stabilizing the position and integrity of the urinary sphincter. Thus, a physical examination alone would lead to a misdiagnosis and possibly an unnecessary surgery. Two important issues are, Which patients require an invasive urodynamic study? and Should these evaluations be reserved for women who present with mixed incontinence symptoms (urge and stress) or failed prior treatment? The most cost-effective strategy for evaluating SUI has yet to be refined. Although multiple studies have confirmed that, while the risk of incontinence increases with age, this increase generally occurs with patients complaining of urge incontinence. Urge incontinence is more likely to affect quality of life adversely; urinary leakage that can be predicted, as resulting from a cough, sneeze, or sudden movement, can often be better accommodated than spontaneous leakage of large volumes of urine with only momentary urge and little warning.1Kelleher CJ Cordoza CD Sexual dysfunction and urinary incontinence.J Sex Health. 1994; 3: 186-191Google Scholar2Wyman JF Harkins SW Choi SC Taylor JR Fantl JA Psychosocial impact of urinary incontinence in women.Obstet Gynecol. 1987; 70: 378-381PubMed Google Scholar In contrast, the incidence of SUI does not seem to increase substantially with age; most researchers have found that any decline in continence usually begins with the first parturition. However, the severity of SUI generally increases with age, multiple births,3Peschers U Schacr G Anthuber C Delancey JO Schuessler B Changes in vesical neck mobility following vaginal delivery.Obstet Gynecol. 1996; 88: 1001-1006Crossref PubMed Scopus (173) Google Scholar hysterectomy, and weight gain. Effective treatment strategies must be developed early in the presentation of these symptoms to halt progression of SUI. A recent study of women older than 65 years detected a baseline SUI prevalence of 40.3% when SUI was defined as an affirmative response to the question, "Do you ever leak urine when you cough, sneeze, or laugh?" The transition from continent to incontinent over a 3-year follow-up period was 20.4%. However, a remission rate (incontinent to continent) was 28.6%, with only 3 of 710 patients undergoing surgical intervention during that same period.4Nygaard IE Lemke JH Urinary incontinence in rural older women: prevalence, incidence and remission.J Am Gerialr Soc. 1996; 44: 1049-1054Google Scholar The study did not address whether the patient thought the leakage was pronounced, nor did it determine the percentage of women who would require intervention. Another study demonstrated a 2-year spontaneous remission rate for all types of incontinence in older adults—11% for for women and 27% for men.5Herzog AR Diokno AC Brown MB Normolle DP Brock BM Two-year incidence, remission, and change patterns of urinary incontinence in non institutionalized older adults.J Gerontol. 1990; 45: M67-M74Crossref PubMed Scopus (241) Google Scholar Urge incontinence is more likely to resolve spontaneously than stress incontinence; thus, men have a higher remission rate. Therapeutic trials without a control arm are difficult to interpret because rates of success include an underlying component of spontaneous resolution. Stress urinary incontinence is diagnosed with visualization of urethral meatus–based leakage concurrent with an increase in abdominal pressure, with or without pelvic floor prolapse or urethral hypermobility and in the absence of bladder detrusor activity. As the severity of the incontinence worsens, less provocation is needed to cause leakage. For example, a patient may have leakage with strenuous activities that progresses to leakage with bending or reaching for objects. The general theory is that SUI results from pelvic floor damage because of fascial defects, muscular weakness, or denervation. Pelvic floor muscle exercises (PFMEs), a mainstay of treatment, are often prescribed without diagnosis of the type or degree of pelvic floor damage. Pelvic floor muscle exercises are of little utility for the patient with denervation injury or anatomical muscle detachments.6DeLancey JO Stress urinary incontinence; where arc we now, where should wc go?.Am J Obstet Gynecol. 1996; 175: 311-319Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Although recent guidelines from the Agency for Health Care Policy and Research suggest that initial treatment of urinary incontinence should be conservative and used before any operative intervention, the literature on the efficacy of conservative treatment is confusing. Inconsistent patient populations, protocols, devices, and outcome measurements used in these mostly nonrandomized, nonplacebo-controlled trials make comparisons almost impossible. Although most investigators agree that the least invasive and safest treatment should be the first choice, many disagree whether conservative methods alone are sufficiently effective. Others suggest that, if physicians do not embrace conservative therapies, other market-driven health care resources will supply this need, resulting in medical professionals not being involved in the evaluation of patients with incontinence. There are 2 types of conservative treatments: behavioral intervention and physiotherapy. Behavioral methods used primarily for urge incontinence include timed toileting, prompted voiding,7Burgio LD McCormick KA Scheve AS Engel BT Hawkins A Leahy E The effects of changing prompted voiding schedules in the treatment of incontinence in nursing home residents.J Am Geriatr Soc. 1994; 42: 315-320Google Scholar fluid schedules, avoidance of dietary irritants, and bowel programs. Physiotherapy, however, is useful for both urge and stress incontinence. Training in the use of the pelvic floor muscle may consist of simple selfdirected exercises or assisted exercises using weighted vaginal cones, pelvic floor biofeedback, or electrical stimulation. Conservative treatments entail minimal risk and should be considered first-line therapy for the patient without severe degrees of prolapse, and they will complement a surgical repair if needed at a later date. Obesity is a major risk factor for the development of SUI and in surgical failure; weight reduction is an overlooked but critical component in the conservative management of incontinence. The initial evaluation of the patient for conservative management strategies is brief. It requires an understanding of the patient's voiding habits, including the number of leaks per day, the severity of leaks, and the provocative situations or activities that lead to incontinence. An initial objective assessment of the independently living adult is best obtained by a voiding diary, which includes both measured intake and output and is often completed before the first consultation. The history should include bowel function, with particular attention to continence of flatus and stool. Many patients will not volunteer a history of coexistent bowel dysfunction; it should be elicited directly. The medical history should note all prescription and over-the-counter medications as well as bladder stimulants (such as alcohol and xanthine-containing compounds). The physical examination should include a brief cognitive assessment and an anatomical examination of the pelvic floor relative to prolapse, rectal tone, and ability of a cough or Valsalva maneuver to produce urinary leakage. Whether the patient can correctly contract the pelvic floor muscles must be documented. Patients with hematuria, recurrent symptomatic infections, recent pelvic floor surgery, radiation therapy, pronounced pelvic floor prolapse, or other severe abnormality on physical examination require subspecialty referral, not conservative management of incontinence. Most nursing home residents can be managed without urologic consultation. In light of the impossibility of diagnosing and treating the estimated 1 million incontinent American nursing home residents, the Minimum Data Set (MDS) and the Resident Assessment Protocol (RAP) questionnaires were developed as mandated by Congress. These questionnaires were tested and found to be valid instruments8Resnick NM Brandeis GH Baumann MM Morris JN Evaluating a national assessment strategy for urinary incontinence in nursing home residents: reliability of the minimum data set and validity of the resident assessment protocol.Neurourol Urodyn. 1996; 15: 583-598Crossref PubMed Scopus (50) Google Scholar for providers; they identify patients with severe incontinence (MDS), focus on probable causes (RAP), assist in the development of treatment plans, and eliminate the need for invasive urodynamic evaluation in most patients. Although the accuracy of the MDS and RAP is excellent, SUI may be overdiagnosed in the female patient in whom urodynamic studies later demonstrate that she has a common geriatric voiding abnormality, detrusor hyperactivity with impaired contractility.9Resnick NM Yalla SV Laurino E The pathophysiology of urinary incontinence among institutionalized elderly persons.N Engt J Med. 1989; 320: 1-7Crossref Scopus (339) Google Scholar In 1 study, a misdiagnosis occurred in 9 of 37 women with detrusor hyperactivity with impaired contractility; each misdiagnosis resulted from failure to recognize low-level detrusor contractions responsible for the leakage.10Resnick NM Bratidcis GH Baumann MM DuBeau CE Yalla SV Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution.Neurourol Urodyn. 1996; IS: 599-613Crossref Scopus (46) Google Scholar Simple cystometry with a "clinical stress test" can minimize the misclassification of such women and further enhance the success of a conservative treatment protocol—the bladder is filled to 200 μL and SUI can be confirmed by visualizing the leakage provoked by coughing. The efficacy of conservative therapy for SUI is difficult to estimate based on the available literature. Few articles have standardized diagnostic or outcome criteria. Subjective improvement may be a valid endpoint in the management of incontinence—that is, the patient is minimally bothered by her symptoms and does not wish to undergo additional therapy (ie, surgery). However, third-party payers may question treatment validity because the risk of the patient's requiring future surgical intervention remains unknown. In published reviews of pure SUI treated with assisted PFME, improvement occurs in 70% to 80% of patients, with 40% to 50% satisfied with the degree of improvement. Additionally, 20% of patients will be cured of leakage.11Jeter KF Pelvic muscle exercises with and without biofeedback for the treatment of urinary incontinence.Probl Ural. 1991; 5: 72-84Google Scholar, 12Payne CK Biotcedback for community-dwelling individuals with urinary incontinence.Urology. 1998; 5l: 35-39Abstract Full Text PDF Scopus (10) Google Scholar Many of these studies, however, do not account for either placebo effect or natural remission rates. The success of conservative treatment programs requires cooperative, well-motivated patients interested in their own continence. Attrition rates are as high as one third, even in well-established centers.13Wells TJ Brink CA Diokno AC Wolfe R Gillis GL Pelvic muscle exercise for stress urinary incontinence in elderly women.J Am Geriatr Soc. 1991; 39: 785-791PubMed Google Scholar The patient who is not bothered by her symptoms because of either cognitive disinterest or lack of perceived severity will not be compliant. In addition, patients with severe neurologic disease, poor detrusor function, or cognitive impairment are not appropriate candidates. Patient compliance is the strongest factor relating to the eventual success of conservative incontinence treatment programs and is more critical than the type or severity of incontinence treated.14Bo K Kvaretein B Hagen RR Larsen S Pelvic floor muscle exercise for the treatment of female stress urinary incontinence, II: validity of vaginal pressure measurements of pelvic floor muscle strength and the necessity of supplementary methods for control of correct contraction.Neurourol Urodyn. 1990; 9: 479-487Crossref Scopus (203) Google Scholar Pharmacotherapy for SUI has progressed little in the past 2 decades. Although α-adrenergic agents, such as ephedrine, can increase outlet resistance and may decrease incontinent events, the sympathomimetic adverse effects make these medications of little clinical utility. In a meta-analysis, hormone replacement therapy for postmenopausal women was shown to be ineffective in both the prevention and the treatment of SUI.15Fantl JA Cardozo L McClish DK Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis: first report of the Hormones and Urogenital Therapy Committee.Obstet Gynecol. 1994; 83: 12-18PubMed Google Scholar Tolteridine and other anticholinergic medications may be helpful for urge incontinence but are not indicated in the treatment of SUI. About half of all patients with SUI are unable to localize and contract the pelvic floor muscles on request. A recent study showed that verbal instruction alone on Kegel exercises ("contract the muscles you would use if you were trying to stop your stream") resulted in appropriate contraction of the pelvic floor in only 60% of patients, with 25% of women substituting a counterproductive Valsalva maneuver.16Bump RC Hurt WG Fantl JA Wyman JF Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction.Am J Obstet Gynecol. 1991; 165: 322-327Abstract Full Text PDF PubMed Scopus (337) Google Scholar The ability of a patient to perform a voluntary PFME is unrelated to parity, prolapse, age, menopausal status, or a history of previous repairs. Therefore, the physician cannot assume that patients can identify the appropriate muscles unless they are directly tested during a digital vaginal examination or through various vaginally or rectally placed sensing devices, ie, biofeedback. Pelvic floor biofeedback monitors pelvic floor muscle activity and signals this information to the patient. Gaining awareness and identification of the pelvic floor facilitate repetitive muscle training exercises designed to build strength and endurance. A simple vaginal examination can document the patient's ability to identify and contract these muscles. Biofeedback can be added in the form of specialized devices to assist patients who cannot otherwise isolate their pelvic floor. A recent study of patients with low-grade genuine SUI tested intensive self-directed PFME against PFME coupled with biofeedback. Although equal improvement was demonstrated in both groups, a significant reduction in leakage was achieved more rapidly in the biofeedback group.17Berghmans LCM Frederiks CMA De Bie RA et al.Efficacy of biofeedback, when included with pelvic floor muscle exercise treatment, for genuine stress incontinence.Neurourol Urodyn. 1996; 15: 37-52Crossref PubMed Scopus (107) Google Scholar Consensus is lacking on how many exercises are sufficient to effect an optimal response. PFMEs should be performed daily with many repetitions; although other skeletal muscular strength training usually entails a 5- to 6-month training period, PFMEs seem effective in a shorter period. Patient education may include a technique termed the Knack, a voluntary contraction of the pelvic floor muscles during increases in abdominal pressure, such as coughing or sneezing.18Miller J Ashlon-Millcr JA DcLanccy JOL The Knack: use of precisely-timed pelvic muscle contraction can reduce leakage in SUI [abstract].Neurourol Urodyn. 1996; 15: 392-393Google Scholar Other adjunctive measures in the treatment of SUI include weighted vaginal cones to reinforce PFME. The cost of such cones has decreased dramatically to less than $30; their efficacy seems limited to the self-motivated individual who needs only to strengthen the pelvic floor muscles. Other commercial devices, such as thigh adductor machines, act only by secondary recruitment of the pelvic floor muscles, not by direct pelvic floor strengthening. A strong pelvic floor musculature has long been thought to prevent the development of anatomical SUI (genuine SUI) in multiparous women. The ability of the pelvic floor to respond to PFME has not been correlated with the degree of pelvic floor injury. One prospective controlled study on postpartum PFME for the prevention and treatment of urinary incontinence found that, in 198 new mothers, the training group had significantly improved pelvic floor muscle strength and less urinary leakage compared with the control group.19Morkved S Bo K The effect of postparlum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence.Int Urogynecol J Pelvic Floor Dysfunct. 1997; 8: 217-222Crossref Scopus (76) Google Scholar Whether this early improvement translates to a lower long-term incidence or severity of urinary incontinence remains unknown. Avoidance of incontinent risk factors (obesity, smoking, chronic obstructive pulmonary disease, and prolonged second stage of labor20Brandeis GH Baumann MM Hossain M Morris JN Resnick NM The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set.J Am Gerialr Soc. 1997; 45: 179-184Google Scholar) is more likely to prevent SUI than is self-directed PFME. Furthermore, a familial tendency toward the development of SUI has been identified, with a 20% prevalence rate in first-degree relatives compared with an 8% prevalence rate in a control group.21Mushkat Y Bukovsky I Langer R Female urinary stress incontinence—does it have familial prevalence?.Am J Obstet Gynecol. 1996; 174: 617-619Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Norton et a122Norton PA Baker JE Sharp HC Warenski JC Genitourinary prolapse and joint hypermobility in women.Obstet Gynecol. 1995; 85: 225-228Crossref PubMed Scopus (202) Google Scholar identified hypermobility as a risk factor for the development of prolapse symptoms. No studies have directly addressed the issue of cost-effectiveness of conservative management of SUI. However, surgery is not an option for many patients. Infirmity or nonanatomical causes of incontinence (primarily urge) limit treatment options for most women. The treatment of incontinence is purely conservative; therefore, a cost comparison with surgical intervention is inappropriate. Most incontinent patients will experience improvement with conservative treatment, and it complements surgical repair. Moreover, a significant reduction in the number and severity of incontinent events, while not achieving cure, affects the secondary costs of urinary incontinence, including urinary tract infections, falls, skin irritation, hospital admissions, expensive pads, and a higher risk of institutionalization. Furthermore, in the patient with a durable improvement, a delay in operative intervention might result in a future decrease in hospital costs as new and less invasive technologies become available. In contrast, a Markov-cohort statistical analysis estimated that the 10-year cost for conservative therapy would be greater than that for surgical intervention.23Ramsey SD Wagner TH Bavendam TG Estimating costs of treating stress urinary incontinence in elderly women according to the AHCPR clinical practice guidelines.Am J Manag Care. 1996; 2: 147-154Google Scholar Three studies of women with SUI suggest that a successful response to assisted PFME is durable. Cammu and Van Nylen24Cammu H Van Nylen M Pelvic floor muscle exercises; 5 years later.Urology. 1995; 45: 113-117Abstract Full Text PDF PubMed Scopus (54) Google Scholar received follow-up questionnaires from 48 of 52 patients at 5 years after assisted PFME; cured or much improved at the end of training was 54%, and at 5 years remained at 58%. In that study, continuation of PFME did not correlate with continued success; perhaps pelvic floor education is more important than long-term muscle strengthening. Bo and Talseth25Bo K Talseth T Long-term effect of pelvic floor muscle exercise 5 years after cessation of organized training.Obsle) Gvnecol. 1996; 87: 261-265Google Scholar reassessed 23 women with urodynamically proven genuine SUI 5 years after cessation of an intensive course of assisted PFME; they demonstrated significant and stable improvement in urine loss, as measured by pad testing and urodynamic studies. Furthermore, 75% of these women did not experience leak during provocative stress testing, and 70% still perform routine PFMEs. Three patients (13%) underwent operative repair, in 2 because the initial PFMEs failed to correct their incontinence. Klarskov et al26Klarskov P Nielson KK Kromann-Andersen B Macgaard E Long-term results of pelvic floor training and surgery for female genuine stress incontinence.Int Urogynecol J. 1991; 2: 132-135Crossref Scopus (51) Google Scholar reevaluated 48 patients 4 to 8 years after assisted PFME, surgery, or a combination; those responding to PFME remained successfully treated at long-term follow-up, as measured by pad-weighing tests. Although surgery resulted in a higher overall cure rate, it incurred a complication rate not seen with assisted PFME. In their original series, 3 of 42 patients developed persistent postoperative pelvic pain or dyspareunia. Other adjunctive measures in the treatment of SUI include weighted vaginal cones to reinforce PFME. The cost of such cones has decreased dramatically to less than $30; their efficacy seems limited to the self-motivated individual who needs only to strengthen the pelvic floor muscles. Other commercial devices, such as thigh adductor machines, act only by secondary recruitment of the pelvic floor muscles, not by direct pelvic floor strengthening. Assisted PFME seems to improve surgical results. In their study, Klarskov et al27Klarskov P Belving D Bischoff N et al.Pelvic floor exercise versus surgery for female urinary stress incontinence.Urol Int. 1986; 41: 129-132Crossref PubMed Scopus (79) Google Scholar randomized 50 patients with genuine SUI to undergo operative repair or biofeedback-assisted PFME. Although the results demonstrated that anatomical repair was clearly superior in reestablishing continence, 42% of those randomized to PFME were satisfied with the results and did not desire surgical intervention at 12-month follow-up. Of the 26 patients who underwent surgical repair, 16 were cured, and 7 had significant improvement. Of interest, 7 postoperative patients requested adjunctive therapy with assisted PFME, resulting in 2 more who experienced improvement and 5 who experienced cure. Brubaker et al28Brubaker L Benson JT Bent A Clark A Sho S Transvaginal electrical stimulation for female urinary incontinence.Am J Obstet Gynecol. 1997; 177: 536-540Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar reported a prospective, double-blind, randomized trial using transvaginal electrical stimulation alone. Patients treated with electrical stimulation for pure SUI experienced no improvement. Of the 16 women who used a sham device, 13 had resolution of leakage on repeated urodynamic testing, suggesting a pronounced placebo effect. Sand et al29Sand PK Richardson DA Staskin DR et al.Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo-controlled trial.Am J Obstet Gynecol. 1995; 173: 72-79Abstract Full Text PDF PubMed Scopus (225) Google Scholar described a transvaginal electrical stimulation trial over 15 weeks in 52 patients with SUI. Significant improvement occurred in 62% of the women who received treatment but in only 19% of those who used the sham device. Bø and Talseth30Bø K Talseth T Single blinded randomized controlled trial on the effect of pelvic floor muscle strength iraining, electrical stimulation, cones or control on severe genuine stress incontinence [abstract).Neurourol Urodyn. 1998; 17: 421-422Google Scholar studied 118 women with SUI who were randomized to no treatment, assisted biofeedback, weighted vaginal cones, or transvaginal electrical stimulation. After treatment, the assisted PFME group demonstrated the most improvement in both urodynamic and subjective parameters, with 56% reporting their incontinence as "unproblematic." Based on urodynamic criteria, electrical stimulation fared as well as weighted vaginal cones; only 12% in the electrical stimulation group, 7.4% in the cone group, and 3.3% in the continence guard group reported leakage as "unproblematic" at completion of the 6-month program. Although pelvic floor electrical stimulation has been hypothesized to provide actual, albeit passive, exercise, a recent study31Bo K Maanum M Does vaginal electrical stimulation cause pelvic floor muscle contraction? a pilot study.Scand J Urol Nephroi Suppl. 1996; 179: 39-45Google Scholar suggests that this is not true. In 9 women treated with electrical stimulation at 10 to 50 Hz, the typical frequencies used for SUI and for detrusor hyperactivity, only 1 could correctly contract the pelvic floor. New devices using electromagnetic resonance that do not require vaginal or rectal instrumentation are being investigated. Single-use devices for obstructing the urinary outlet have been recently marketed, and newer devices are undergoing trials. Urethral inserts occlude the bladder neck by their intraurethral position, conceptually like a shortened Foley catheter that has been plugged. None of these devices treat the underlying cause. The disposable insert is usually removed for voiding and then replaced. Surprisingly, tissue stretching with these devices has been minimal, and concerns that this accommodation would result in worsening leakage have not been proved in short-term trials. Of note, these devices are designed only for SUI. Increased intravesical pressures occurring with detrusor instability or poor compliance would place the patient at high risk for infectious complications and deterioration of the upper urinary tract. Self-adherent patches placed over the urethral meatus have been introduced within the past 3 years. Effective for small-volume leakage, the device is removed for voiding and replaced. Although the reported patient acceptance of these devices has been positive, manufacture of several of these devices was recently suspended. Pessaries used to support the pelvic floor can serve as an aid for pelvic floor prolapse symptoms or urinary incontinence. If the urinary incontinence is due to bladder neck hypermobility, support in this region may reduce leakage in a manner similar to a bladder neck suspensory operation. These devices must be prescribed cautiously because the pelvic floor will continue to stretch, an outcome that can render the devices ineffective and make a future surgical repair more extensive. Parenthetically, patients often self-report reduced leakage with the use of a vaginal tampon. Patient expectations of any surgical procedure should be explored to obtain informed consent. Physicians must accept that the patient may choose a lower estimated longterm success rate to minimize complications. Incomplete understanding of the mechanisms maintaining urinary continence notwithstanding, certain basic concepts form the basis of surgical treatments. The oldest theory, and arguably the most widely held, is that SUI results from failed bladder neck support and urethrovesical junction hypermobility. Another hypothesis, which is gaining in importance, proposes that the urethral sphincter is weakened, a condition termed intrinsic sphincter deficiency or low-pressure urethra. Stress urinary incontinence is most likely the result of both derangements. Evolving surgical repairs are increasingly based on providing a backboard32DcLancey JO Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis.Am J Obstet Gynecol. 1994; 170: 1713-1720Google Scholar to support the bladder neck or providing urinary sphincter augmentation as necessary. Critical in achieving a long-term, symptom-free, and continent pelvic floor is the correction of other anatomical defects of the bladder (cystocele repair), the vagina (including hysterectomy, vault repair, sacrospinous fixation), and the posterior pelvic floor (enterocele and rectocele repair); referral to a trained subspecialist is appropriate in these settings. Contrary to a long-held dictum, there is no urodynamic reason for a hysterectomy to be performed in a patient with pure SUI; pelvic floor prolapse or medical conditions including abnormal uterine bleeding and potential cancer risk reduction should dictate the necessity for concurrent hysterectomy. As economics and a desire for outpatient repairs have increased, minimally invasive anti-incontinence procedures have been widely advocated, many of which have little or no long-term published success rates. For example, percutaneous needle suspension procedures were used extensively in the 1980s and early 1990s but were largely abandoned when long-term success rates at experienced centers plummeted. A lack of evidence-based outcomes also plagues the literature on surgical treatment results. Currently, almost 100 anti-incontinence procedures are in use, with advocates supporting each technique or modification. To clarify the situation, the American Urological Association recently established clinical guidelines.33Leach GE Dmochowski RR Appell RA et al.American Urological Association. Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence.J Urol. 1997; 158: 875-880Abstract Full Text Full Text PDF PubMed Scopus (593) Google Scholar This panel of urologists and gynecologists reviewed 5322 articles and citations that yielded only 282 peer-reviewed articles inclusive of original data and with appropriate follow-up of at least 12 months. The most common reason for article rejection was insufficient outcome data. Each of the 4 major categories of anti-incontinence operations, including retropubic suspensions, transvaginal suspensions, anterior repairs, and sling procedure repairs, were examined. The panel concluded that long-term data supported the efficacy of surgical treatment of women with SUI. Retropubic bladder neck suspensions (including the Burch and the Marshall-Marchetti-Krantz procedures) had an 84% median probability of cure at 48 months. Transvaginal endoscopic procedures (including the Pereyra, Stanley, and Gittes procedures and modifications) were far less effective at 67%. Anterior repairs were least effective, with only a 61% median probability of cure lasting 48 months. More than one half of women presenting for surgical management of incontinence also have bladder instability, which will not improve reliably with surgery. A category of dry/cure/improved was included by the panel to account for this confounding factor. Each procedure category then demonstrated a higher success rate, ranging from 78% to 91%. There was no statistically significant difference in intraoperative or postoperative treatment complications, although in the opinion of the authors, retropubic and sling procedures have longer convalescence and may result in a higher incidence of postoperative voiding dysfunction. Intrinsic sphincter deficiency may coexist with urethral hypermobility and prolapse, which will result in poorer success rates if only anatomical-based repairs are performed. The use of a sling procedure or an injectable periurethral bulking agent is clearly advantageous when augmentation of the sphincteric mechanism itself is needed. Other forms of sphincter augmentation include injectable periurethral bulking agents and artificial genitourinary sphincters. Many substances have been used as injectable bulking agents, but glutaraldehyde cross-linked bovine collagen has emerged as the current standard. Although a recent study demonstrated cure rates in patients with intrinsic sphincter deficiency of only 24% at 2 years, 40% of patients experienced improvement34Swami S Batista JE Abrams P Collagen for female genuine stress incontinence after a minimum 2-year follow-up.Br J Urol. 1997; 80: 757-761Crossref PubMed Google Scholar; additionally, injection of periurethral bulking agents has the advantage of being a well-tolerated, safe procedure performed in an outpatient setting with a local anesthetic. It is an excellent choice for patients who cannot tolerate a major surgical intervention. Repeated injections are possible if leakage recurs. Difficulty with erosion of the cuff component of artificial genitourinary sphincters has been encountered; therefore, its application in women is limited. Because of cost containment, decreasing convalescence, and commercial interests, faster, less invasive outpatient procedures are appealing. However, long-term follow-up is insufficient, and complication rates have not been established for most of these approaches. The transvaginal endoscopic bladder neck suspension, a minimally invasive technique, had poor success at 2-year follow-up and has been largely abandoned. Laparoscopic Burch procedures were recently reported to have only a 50% cure rate at 2-year follow-up. A well-respected urologic device manufacturer recently suspended sale of synthetic sling materials because of erosion rates of almost 30%. Various bone anchors, synthetic tape, and cadaveric sling materials now available in vendor areas at scientific meetings may not "stand the test of time." Patients should be informed about the deficiencies of the newer procedures.