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!

1. ApproachtotheEvaluationandTreatmentofStressUrinary
IncontinenceinWomen

2. Review Article
Approach to the evaluation and treatment of stress urinary
incontinence in women
Sanjay Sinha
Senior Consultant Urologist and Transplant Surgeon, Apollo Hospital, Hyderguda, Hyderabad, India
a r t i c l e i n f o
Article history:
Received 19 January 2013
Accepted 31 January 2013
Available online 6 February 2013
Keywords:
Epidemiology
Urodynamics
Retropubic colposuspension
a b s t r a c t
Urinary incontinence in women is a common problem with a significant impact on the
quality of life of individuals and the well-being of the community. While economic impact
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!1
This data is unlikely to be
applicable to India, since urinary incontinence is essentially a quality of life problem while
many other diseases with a more obvious health impact are likely to get priority spending
in an Indian household.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Epidemiology and risk factors
A study of the pooled mean prevalence of any urinary incon-
tinence in women showed 34% and 25% prevalence in elderly
and middle aged or younger women respectively.2
Clinically
‘significant’ incontinence has been more difficult to evaluate
and scoring systems such as the Sandvik Severity Scale3
have
often been used in epidemiological studies (See Table 1). In
most prevalence studies, stress incontinence accounts for
about half of all incontinence, followed by mixed inconti-
nence with the smallest group being urge incontinence.
Prevalence and severity of urinary incontinence increases
with age. However, as shown by the Epicont study from
Scandinavia, stress urinary incontinence seems to peak in
women in the fifth decade while urgency incontinence is
commoner in older women. A lower prevalence of all forms of
urinary incontinence is seen consistently in Asian women
across studies.4
Bump and Norton have classified the risk factors into four
categories. These include predisposing factors such as race or
genetic abnormalities; inciting factors such as childbirth,
neuromuscular injury, radiation or prior surgery; promoting
factors such as obesity, smoking, comorbidities or infection
and decompensating factors such as aging, dementia or
limited mobility.5
2. Evaluation
The evaluation of stress urinary incontinence is a methodical
confirmation of the presence of incontinence, the type of
incontinence, the exclusion of other conditions that could
mimic the symptoms, assessment of the severity of the
problem, and evaluation for other health problems that
might impact treatment. This is accomplished by means of
a detailed history and physical examination as well as
appropriate 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 leak
of urine on coughing, sneezing, laughing or during other
E-mail address: drsanjaysinha@hotmail.com.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 3
0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2013.01.015

3. forms of effort. The predictive value of history of stress leak is
56% for pure SUI and 77% for SUI with other conditions. Up to
two-thirds of women with urgency incontinence can present
with a history similar to SUI. In contrast the physical exami-
nation finding of leak on a cough stress test has a positive
predictive value of 91% for some form of SUI.6
Women with
SUI may present with urgency or frequency of micturition.
This might reflect a defensive behavior pattern or may occur
due to the initial trickle of urine into the urethra triggering
a sense of urgency. One must ascertain whether the woman
has 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 be
best served by initial treatment directed at overactive bladder.
Table 2 e Evaluation of women with stress urinary incontinence6,21
.
Assessment Role and method Comment
Voiding diary Bladder diary including episodes of urgency or
incontinence, pad usage and physical activity
preferably recorded over 3 days (IUGA Terminology
document, 2009)
Objective quantification of severity by incontinence episode
frequency (IEF). Useful additional information for decision-
making in mixed urinary incontinence. Multiple episodes of
urgency without leak and small volume voids would suggest
the need for a trial of OAB medication. Counsel women with
large 24 h urine volumes
Stress test Observation of leakage of urine through the urethral
meatus at the time of a cough. Ideal: standing
position, full bladder, direct inspection
A positive stress test is marked by leakage of urine precisely
at the time of the cough with the leak stopping when the
cough is completed. Leak that is delayed or prolonged
beyond the cough may represent cough-induced detrusor
overactivity. Supine Empty Bladder Stress Test (SEST) in
supine position after voiding predicts ISD
Pelvic floor muscle
evaluation
Techniques (1) Visual inspection (2) Digital
evaluation (3) EMG (4) Perineometry (manometric)
(5) Perineal ultrasonography, 2-D and 3-D (6) Ultra-
rapid sequence MRI
Modified Oxford Grading System for digital evaluation
Grade 0 ¼ no contraction, 1 ¼ flicker, 2 ¼ weak, 3 ¼ moderate
with lift, 4 ¼ good with lift, 5 ¼ strong with lift. 3
contractions of 5 sec each are observed. Contraction can be
felt in three directions medioelateral, anteroeposterior and
cranial lift
Assessment of bladder
neck mobility
Techniques (1) Visual inspection (2) Q-tip test,
(3) POP-Q score (4) USG (5) Bead chain
cystourethrogram (historical) (6) Urethroscopy
(7) Video-cystourethrography
Deflection of meatus toward ceiling at straining is
abnormal. On Q-tip test, maximum strain deflection >30
from horizontal is positive. The Aa point score correlates
with Q-tip results. Q-tip positive in 95% with Grade II and
100% higher POP at point Aa. On urethroscopy, an open
bladder neck on full bladder correlates with positive Q-tip
Pad test To confirm and quantify leakage by weighing an
absorbable perineal pad before and after a fixed
duration of use
Short term (20 min, 1 h, 2 h): adv: easy, standardized (ICS 1 h
test, 1 g gain positive). Disadv: may miss OAB wet or mild
incontinence, impact of bladder fullness
Long 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 where
diagnosis is unclear and the source of urine leak is
uncertain
One-dye test (methylene blue in bladder) and two-dye test
(additional oral phenazopyridine). Rather than the
traditional swab tests, combine with careful direct vaginal
examination and endoscopic evaluation
Urodynamics UDS is useful for (1) obtaining a diagnosis
(2) predicting success (3) predicting complications
(4) understanding failure
Reference values (95th ) e MFR 24 ml/s (11.4 ml/s), PVR
25 ml (90 ml), PdetQmax18 cm H2O (39 cm H20). Detrusor
overactivity found in about 10% (depending on entry
criteria) 0.70% leak with valsalva, 15% with cough only and
15% may not leak with catheter in situ. Abdominal leak
point pressure (60 cm H20) and maximal urethral closure
pressure (20 cm H20) are common methods of diagnosing
ISD. Low voiding pressure with poor flow and large residuals
may predict postop voiding difficulty
Table 1 e Sandvik Severity Scale for epidemiological
studies.3
Frequency score (four levels) multiplied by amount score
(two levels)
Frequency score
1 ¼ Less than once/month
2 ¼ One or more times/month
3 ¼ One or more times/week
4 ¼ Every day or night
Amount score
1 ¼ Few drops or little
2 ¼ More
Scale
1e2 Mild; 3e4 moderate; 6e8 severe
a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 6 7 e7 368

4. An effort must be made to exclude other forms of lower tract
symptoms such as voiding difficulty, dysuria or hematuria
that might suggest an alternative diagnosis. Bowel function
must be evaluated.
Physical examination must include vaginal examination,
pelvic floor assessment, a focused neuro-urological evaluation
including anal tone and the stress test in all patients. The
stress test is done on a comfortably full bladder and should be
repeated in the standing position in case the woman fails to
leak in the supine position. Direct demonstration of urinary
leak 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 an
especially important finding.
Use of validated questionnaires is recommended both for
assessing the type of symptoms as well as the impact of the
problem on quality of life.7
The ICIQ, IIQ-7 or UDI-6 are various
detailed and short form questionnaires for this purpose.
Quantification of the severity of incontinence can be achieved
more objectively by a pad test or estimation of the number of
incontinence episodes over a fixed time frame by means of
a voiding diary. For SUI, both short term as well as longer-term
pad tests may be used. When the source of incontinence is
unclear, a dye test with careful clinical examination can be
very useful.
Standard investigative evaluation of all patients must
include a complete urine examination to exclude urinary
infection and microscopic hematuria, blood glucose estima-
tion and measurement of post-void residual by ultrasonog-
raphy. Additional investigations are guided by the patient’s
clinical presentation. In conjunction with the residual urine,
uroflow is a useful screening test for voiding dysfunction.
Urodynamics remains an important, though imperfect
tool, for the evaluation and diagnosis of stress urinary in-
continence. Urodynamics has been recommended prior to
surgical therapy by several guidelines including the IUGA
guidelines and NICE guidelines of UK. However, it’s quite clear
that some women with classical findings may not necessarily
need urodynamics. The recent VALUE study (Value of
Urodynamic Evaluation) from the UITN group in the USA
has questioned the role of routine urodynamics.8
However
in community practice, one needs to be careful in blindly
applying the results of this study performed on a specific
subset of patients. Clearly, urodynamics must be performed
prior to surgery in women with recurrent incontinence,
associated voiding difficulty or elevated residuals, suspicion of
neurogenic dysfunction or those with upper tract changes. In
women with a strong urgency component, one might be better
off performing urodynamics as there is a clear link between
high-pressure detrusor overactivity and a poor postoperative
outcome. Such women are unlikely to have been recruited
into the VALUE study since the women had predominant or
pure SUI symptoms on questionnaires.
Urodynamics can confirm urodynamic stress inconti-
nence, diagnose detrusor overactivity, establish normal
voiding function and diagnose intrinsic sphincter deficiency.
These factors may be important in clinical decisions for some
patients and are discussed in later sections.
3. Management of stress urinary
incontinence
3.1. Conservative therapies
These can be categorized into lifestyle modifications and
pelvic floor therapies.
3.1.1. Lifestyle modification
Timed voiding by the clock every 2e3 h can reduce the volume
of leak in women with SUI by ensuring that the bladder is kept
at a lower level of distension. This may especially help those
women who leak at capacity. Smoking is associated with
a higher risk of all forms of incontinence (RR 1.4) but the
benefits of cessation in terms of resolution of SUI remain
unclear.9
There is a clear link between obesity and inconti-
nence. Dallosso et al showed that the relative risk of urinary
incontinence was 0.82, 1.24 and 1.46 in underweight, over-
weight and obese women.9
Weight loss has been shown to
improve continence with one study showing 60% reduction in
incontinence episodes in women who lost 16 kg10
3.1.2. Pelvic floor rehabilitation
All treatments that are designed to increase the strength,
bulk or responsiveness of pelvic floor muscles are grouped
under this heading. This includes pelvic floor muscle training,
which is a regime of repeated contractions of the pelvic floor
that 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 the
right set of muscles. The International Consultation on
Incontinence makes a Grade A recommendation for pelvic
floor muscle training for all women with urinary inconti-
nence. Sets of 10e12 near-maximal contractions held for
6e8 s each with an equal period of rest is recommended 3e5
times every alternate day. The “Knack maneuver” is specifi-
cally recommended for patients with SUI. This consists of
timing the contractions with cough. However, evidence
suggests that women are unlikely to continue pelvic floor
therapies in the long term.11
The addition of biofeedback has the potential to improve
the outcome of pelvic floor muscle training. This can be ach-
ieved by palpation by a health professional, by means of
weighted vaginal cones, EMG activity feedback or squeeze
pressure feedback. Weighted vaginal cones need to be held
above the level of the levator for 15 min. Although apparently
simple, many women cannot hold the lightest cone, some
hold the cones using the thigh adductors (the wrong set of
muscles!) while some simply refuse. As yet, there is no clear
evidence that biofeedback adds to the efficacy of regular pelvic
floor training.
In contrast to pelvic floor training, peripheral stimulation
of the pelvic floor needs compliance but no effort on the part
of the patient. Stimulation can be achieved by home or of-
fice electrical stimulation. The classical recommendation for
SUI has been high-frequency 50e200 Hz stimulation using
vaginal or anal electrodes. Mixed low and high-frequency
stimulation has been recommended for mixed urinary
incontinence.
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. Table 3 e Important surgical procedures for stress urinary incontinence13,15,18
.
Surgical
procedure
Brief description Outcome Usual complications Indication
Synthetic mid-
urethral slings
Synthetic monofilament polypropylene
tape placed under mid-urethra either by
the retropubic route (TVT, Gynecare) or
transobturator route (Monarc, AMS; TVT-
O Gynecare)
80% success at 12 mo (rigorous criteria,
TOMUS trial), equivalent outcomes of both
routes. Patient satisfaction rate 85e90%.
Uncontrolled 11 year data shows durable
outcome of TVT
Bladder perforation 5%, neurological
symptoms 4%, vaginal exposure 3% and
voiding dysfunction 2.5% with TVT.
Neurological symptoms in 9.4% with TOT.
Overall serious adverse events 13.8% with
TVT versus 6.4% with TOTs (TOMUS trial)
Usual woman with SUI. In women
with previous failed procedures
TVT might be better choice
(uncontrolled data) while in
previous multiple pelvic surgeries,
TOT better
Autologous rectus
fascia sling
Autologous sling usually harvested from
rectus. Placed under the proximal or mid-
urethra and brought up over the rectus
fascia where it is fixed using non-
absorbable sutures
47% overall success versus 38% for Burch
(rigorous criteria, SISTEr trial). Patient
satisfaction rate 86%
Serious adverse events 13% (similar to
Burch). Voiding difficulty most important
problem leads to 6% revision rate.
Bothersome urgency incontinence due to
persistent preop urgency incontinence
rather than new onset
Valuable salvage option in patients
with recurrent SUI, severe ISD,
fixed urethra or scarred vaginal
tissues
Burch
colposuspension
Retropubic colposuspension of the
anterior vaginal wall and periurethral
tissues to the ileopectineal ligament by
open surgery or laparoscopy
51% success at 24 months equivalent to
tapes (rigorous criteria, Ward and Hilton).
Inferior to autologous slings for stress
incontinence success (SISTEr trial)
More morbid than tapes but less than the
autologous sling. Posterior compartment
prolapse 10% due to altered axis of vagina
Used chiefly in patients undergoing
concomitant pelvic surgery or
lacking vaginal access. Presence of
hypermobility is prerequisite
Periurethral
injection
Several substances used. Currently
available or recommended are e silicone
particles (Macroplastique), carbon beads
(Durasphere), calcium hydroxylapatite
(Coaptite). Injection at different locations
to achieve coaptation
Widely variable success rates upwards of
20% dry rate at one year. Need for multiple
injections. Lack of durability of results
Dysuria, hematuria, non-infectious
abscess and urethral prolapse. Migration
is less concern with current agents.
Hypersensitivity reaction rare
Indicated for patients who are poor
surgical candidates, on
anticoagulants, elderly women
with fixed urethra, desire non-
surgical treatment, young but not
completed family
apollomedicine10(2013)67e7370

6. 4. Surgery for stress urinary incontinence
Over the years several different approaches have been used
for the surgical management of SUI. Currently, on the basis of
evidence, one would consider the following as valid treatment
choices e retropubic colposuspension, mid-urethral slings
including synthetic and autologous but not xenograft or
allograft materials. In select situations periurethral injections
may be an acceptable choice. Artificial sphincter is rarely used
for SUI in women. Needle suspensions and anterior repairs in
all forms are not reliable forms of treatment for SUI. The
various 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 Ogah
et al compared Burch colposuspension with synthetic tapes
and showed that there was no difference in short term or
medium term outcome in efficacy.12
However, hospital stay
and operating time was understandably longer with Burch.
Urinary tract injury was more common with tapes while
postoperative pelvic organ prolapse, chiefly posterior com-
partment due to alteration in the vaginal axis, was more likely
with the Burch colposuspension.12
The rigorous SISTEr trial
compared Burch with the autologous sling and found that
slings were more effective in terms of stress incontinence-
specific success, overall success and patient satisfaction but
at the cost of a higher incidence of voiding dysfunction (14%
versus 2%).13
All the take-downs of the original procedure
happened in the sling group. Another Cochrane review com-
pared tapes with the autologous sling and found that they
were equivalent in efficacy.14
However, complications, oper-
ating time and de novo detrusor overactivity favored the
tapes. The TOMUS trial compared retropubic TVT with the
transobturator tapes and found them to be equivalent in ef-
ficacy at 12 months (Table 3).15
There does not appear to be
any major difference in efficacy between the inside-out and
outside-in approaches. Based on the above evidence, for the
usual patient with SUI, a synthetic tape surgery seems the
most logical. The type of tape is probably more a matter of
surgeon preference. One must recognize that long term data is
not yet available for the TOTs.
More recently, there has been interest in single incision
mini-slings that are placed in the general direction typically
taken by the classical retropubic or transobturator tapes. The
intention behind further making the tapes less invasive has
been a further reduction in complications, pain and anes-
thesia requirement. However, good quality medium and long
term data about their efficacy is currently lacking.
4.1. Recurrent urinary incontinence16e18
Mid-urethral slings will fail in 5e20% of patients in the long
term. Important risk factors associated with failure are sum-
marized in Table 4. Women with recurrent SUI are more likely
to be having ISD and some of these women will have a fixed
urethra. For the usual woman with recurrent SUI the options
are e repeat mid-urethral sling, autologous pubovaginal sling
and perhaps, periurethral bulking agents. In a retrospective
comparison of 77 patients undergoing redo surgery with over
1075 patients undergoing a primary procedure, Stav et al
noted that the conventional retropubic TVT had a better out-
come as compared with a transobturator tape irrespective of
whether the initial procedure was a TVT or a TOT.19
Overall
repeat procedures had a poorer outcome compared with pri-
mary procedures (62% versus 86%). Periurethral bulking
agents carry a low success of about 35%. The autologous
pubovaginal sling is an important salvage procedure for pa-
tients with recurrent SUI and is the treatment of choice in
most difficult situations. Repeat colposuspension surgery
carries a low success rate (81% for first, 25% for second and 0%
for third re-do surgery).20
All patients with recurrent SUI must
have urodynamics evaluation prior to surgical re-treatment.
4.2. Mixed urinary incontinence16e18
The literature on mixed urinary incontinence suffers from
lack of homogeneity with regards to what the term “mixed”
implies. In various publications, the term has been used to
include 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 Source
Age per 10 years X1.5 for both TOT and TVT TOMUS23
Post-menopausal women not on
hormone replacement therapy
X1.5 for both autologous sling and Burch colposuspension SISTEr24
Obesity X1.7 for TVT Meta-analysis, 7
pooled studies25
MESA questionnaire urge score,
per 10 points
X2 for both TOT and TVT
X1.8 for both autologous sling and Burch colposuspension
TOMUS23
SISTEr24
Prior SUI surgery X2 for both TOT and TVT TOMUS23
Stage III/IV POP X2.5 for both autologous sling and Burch colposuspension SISTEr24
Lack of hypermobility X2 for both TOT and TVT TOMUS26
Pad weight per 10 g increase X1.1 for both TOT and TVT TOMUS23
Pre-operative high-pressure
detrusor overactivity
Poorer outcomes for patients with high-pressure DO
(15 or 25 cm H20)
4th ICI18
Urodynamic evidence of poor
urethral function on valsalva
leak point pressure or maximal
urethral closure pressure
X2 for both TOT and TVT for women in the lowest quartile of
VLPP (86 cm H20) and MUCP (45 cm H20)
TOMUS26
a 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. urgency incontinence, detrusor overactivity or detrusor
overactivity incontinence. Clearly, each of these presentations
has a different implication. About 10% of women in the UITN
trials (TOMUS and SISTEr) had detrusor overactivity.15,21
While the outcome in these women was similar to the rest
of the group, high-pressure detrusor overactivity of pressure
25 cm H20 is clearly associated with a poorer outcome.
Women with significant urgency symptoms are more likely to
be unsatisfied with their surgery. In those with predominant
urgency symptoms, it makes sense to treat the urgency first.
However, in women with significant SUI, one could go ahead
with 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 itself
can present as urgency in some women and this is likely to
resolve with surgery. 24e90% of women will show resolution
of OAB symptoms following SUI surgery.
4.3. Intrinsic sphincter deficiency16e18
Traditional teaching segregated SUI into two compartments e
those with ISD and those with hypermobility. Contemporary
research shows quite clearly that most women with SUI will
have hypermobility as well as ISD and that SUI patients present
a spectrum from isolated ISD to significant hypermobility. ISD
has usually been defined by urodynamics as an abdominal leak
point pressure of 60 cm H20 or maximal urethral closure
pressure of 20 cm H20 or both. Historically, autologous slings
have been the most favored treatment for patients with ISD
and in this group they give cure rates of upwards of 80%. There
is a paucity of good quality data in this group. In a small series,
Rezapour et al found TVT to deliver success rates approaching
patients without ISD (74% cure and 12% improved).22
However,
five of the eigth patients with a fixed, immobile urethra failed.
The TOMUS trial showed equivalent outcomes for those with
ISD irrespective of whether a retropubic TVT or transobturator
tape surgery was performed. However, such patients were
twice as likely to fail surgery. There is uncontrolled data to
suggest 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 autologous
sling still remains the best salvage option. In select women, one
might consider periurethral injections provided the woman
understands the unpredictability of outcome and the possible
need for multiple sittings.
Conflicts of interest
The author has none to declare.
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sling surgery. Obstet Gynecol. 2011;117:913e921.
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8. 24. Richter HR, Diokno A, Kenton K, et al. Predictors of treatment
failure 24 months after surgery for stress urinary
incontinence. J Urol. 2008;179:1024e1030.
25. Greer WJ, Richter HE, Bartolucci AA, et al. Obesity and pelvic
floor disorders: a systematic review. Obstet Gynecol.
2008;112:341e349.
26. Nager C, Sirls L, Litman H, et alUrinary incontinence
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f u r t h e r r e a d i n g
27. Refer to the series of publications on the TOMUS, SISTEr and
ValUE trials from UITN. Complete list available on
http://www.uitn.net/rs.asp
28. Abrams P, Cardozo L, Khoury S, et al., eds. Incontinence. 4th
International Consultation on Incontinence. Plymouth: Health
Publication 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

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