Surgical management of stress urinary incontinence in women: Preoperative evaluation for a primary procedure
- J Eric Jelovsek, MD, MMEd, FACOG, FACS
J Eric Jelovsek, MD, MMEd, FACOG, FACS
- Director of Simulation and Advanced Skills Center and Residency Director
- Associate Professor of Surgery
- Obstetrics, Gynecology, and Women's Health Institute
- Glickman Urologic and Kidney Institute
- Cleveland Clinic
- Jhansi Reddy, MD
Jhansi Reddy, MD
- Clinical Assistant Professor
- Obstetrics and Gynecology
- New York University Langone Medical Center
Stress urinary incontinence (SUI), the involuntary leakage of urine on effort or exertion, or on sneezing or coughing, affects 4 to 35 percent of women [1,2]. Conservative approaches to treatment of SUI include pelvic floor muscle training and incontinence pessaries. However, for women who fail or decline conservative therapy, there are a variety of surgical treatments. Preoperative evaluation of women with SUI helps to exclude other diagnoses and guide the choice of a surgical procedure.
The preoperative evaluation of women with SUI will be reviewed here. General principles of evaluation of women with urinary incontinence and conservative and surgical treatment of SUI, as well as evaluation of women with recurrent SUI after surgery, are discussed separately. (See "Evaluation of women with urinary incontinence" and "Treatment of urinary incontinence in women" and "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure" and "Stress urinary incontinence in women: Persistent/recurrent symptoms after surgical treatment".)
Continence is achieved when the urethra maintains a pressure greater than bladder pressure (eg, during a detrusor muscle contraction or an increase in intraabdominal pressure). Loss of the urethra's ability to maintain the required pressure results from anatomic or neurologic defects.
●The anatomic contribution to continence involves the anterior vaginal wall and overlying connective tissue, which provide the urethra with a stable base upon which to rest (hammock theory ). Upon an increase in bladder or intraabdominal pressure, the urethra is compressed onto this base, thereby closing the lumen and maintaining urethral pressure. When the support structures are weakened, the urethra loses its underlying support and becomes hypermobile. Thus, the normal mechanism of continence through urethral compression is compromised.
Etiologies of loss of urethral support include pregnancy/childbirth, aging, and repetitive stress on the pelvic floor (eg, repetitive heavy lifting, chronic cough, or obesity). Genetic factors may also contribute to a loss of pelvic support through deficient collagen structure.
●The neurologic component of continence is mediated through both bladder and urethral innervation. The bladder storage and filling phase is controlled through a spinal sympathetic reflex that (1) stimulates beta adrenergic receptors within the bladder wall causing relaxation of the smooth muscle and (2) activates alpha adrenergic receptors in the urethra which contract the urethra and increase its pressure. The urethra is also innervated through efferent pathways from the pudendal nerve, which increases the tone of the pelvic diaphragm and striated urethral sphincter. Pregnancy, childbirth, and aging can result in pudendal neuropathy leading to urinary incontinence.
- Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 2003; 61:37.
- Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol 2004; 6 Suppl 3:S3.
- DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994; 170:1713.
- Jackson SL, Weber AM, Hull TL, et al. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 1997; 89:423.
- Meschia M, Buonaguidi A, Pifarotti P, et al. Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse. Obstet Gynecol 2002; 100:719.
- Markland AD, Kraus SR, Richter HE, et al. Prevalence and risk factors of fecal incontinence in women undergoing stress incontinence surgery. Am J Obstet Gynecol 2007; 197:662.e1.
- Swift S, Barnes D, Herron A, Goodnight W. Test-retest reliability of the cotton swab (Q-tip) test in the evaluation of the incontinent female. Int Urogynecol J 2010; 21:963.
- Thorp JM, Jones LH, Wells E, Ananth CV. Assessment of pelvic floor function: a series of simple tests in nulliparous women. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7:94.
- Salvatore S, Serati M, Uccella S, et al. Inter-observer reliability of three different methods of measuring urethrovesical mobility. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:1513.
- Noblett K, Lane FL, Driskill CS. Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and I prolapse? Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:268.
- Mattison ME, Simsiman AJ, Menefee SA. Can urethral mobility be assessed using the pelvic organ prolapse quantification system? An analysis of the correlation between point Aa and Q-tip angle in varying stages of prolapse. Urology 2006; 68:1005.
- Cogan SL, Weber AM, Hammel JP. Is urethral mobility really being assessed by the pelvic organ prolapse quantification (POP-Q) system? Obstet Gynecol 2002; 99:473.
- Larrieux JR, Balgobin S. Effect of anatomic urethral length on the correlation between the Q-tip test and descent at point Aa of the POP-Q system. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:273.
- Dalpiaz O, Curti P. Role of perineal ultrasound in the evaluation of urinary stress incontinence and pelvic organ prolapse: a systematic review. Neurourol Urodyn 2006; 25:301.
- American College of Obstetricians and Gynecologists. Urinary incontinence in women. Obstet Gynecol 2005; 105:1533.
- Kleeman S, Goldwasser S, Vassallo B, Karram M. Predicting postoperative voiding efficiency after operation for incontinence and prolapse. Am J Obstet Gynecol 2002; 187:49.
- Foster RT Sr, Borawski KM, South MM, et al. A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery. Am J Obstet Gynecol 2007; 197:627.e1.
- Jelovsek JE, Hill AJ, Chagin KM, et al. Predicting Risk of Urinary Incontinence and Adverse Events After Midurethral Sling Surgery in Women. Obstet Gynecol 2016; 127:330.
- Weber AM, Walters MD. Cost-effectiveness of urodynamic testing before surgery for women with pelvic organ prolapse and stress urinary incontinence. Am J Obstet Gynecol 2000; 183:1338.
- Weber AM, Taylor RJ, Wei JT, et al. The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women. BJU Int 2002; 89:356.
- Rachaneni S, Latthe P. Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis. BJOG 2015; 122:8.
- American Urogynecologic Society and American College of Obstetricians and Gynecologists. Committee opinion: evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. Female Pelvic Med Reconstr Surg 2014; 20:248.
- Rosier PF, Gajewski JB, Sand PK, et al. Executive summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for urinary incontinence and for fecal incontinence. Part 1: Innovations in urodynamic techniques and urodynamic testing for signs and symptoms of urinary incontinence in female patients. Neurourol Urodyn 2010; 29:140.
- Wall LL, Wiskind AK, Taylor PA. Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994; 171:1472.
- Abstracts of the American College of Obstetricians and Gynecologists 53rd Annual Clinical Meeting. May 7-11, 2005, San Francisco, California, USA. Obstet Gynecol 2005; 105:1S.
- Kjølhede P, Rydén G. Prognostic factors and long-term results of the Burch colposuspension. A retrospective study. Acta Obstet Gynecol Scand 1994; 73:642.
- Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012; 366:1987.
- Leone Roberti Maggiore U, Ferrero S, Salvatore S. Value of urodynamics before stress urinary incontinence surgery: a randomized controlled trial. Obstet Gynecol 2013; 122:904.
- Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010; 362:2066.
- Jelovsek JE, Chagin K, Brubaker L, et al. A model for predicting the risk of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery. Obstet Gynecol 2014; 123:279.
- Wei JT, Nygaard I, Richter HE, et al. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012; 366:2358.
- http://www.r-calc.com/ExistingFormulas.aspx?filter=CCQHS (Accessed on August 15, 2014).
- CLINICAL EVALUATION
- MEDICAL AND VOIDING HISTORY
- PELVIC EXAMINATION
- OFFICE TESTING
- Urinary stress test
- Assessing urethral mobility
- Postvoid residual volume
- Urine culture
- Other testing
- URODYNAMIC TESTING
- Women with uncomplicated SUI
- Women with complicated SUI
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS