Stress urinary incontinence & midurethral slings

It is 18 months after her second baby and a 38-year-old teacher describes leaking when she lifts a box of books, when she coughs during a cold, and when she goes for a run. She has reduced her fluid to almost nothing, she has stopped running, and she has bought a £14 pack of pads that she hides in her bag. She is dry at night, she makes it to the toilet in time when her bladder is full, and she is otherwise well. This is stress urinary incontinence — the cough wins against a poorly supported urethra, and the story is the diagnosis before you examine her.^[1][2]

This topic is the consultant's rehearsal: recognise the pattern, run the conservative ladder properly, offer surgery to the woman who has failed conservative therapy, defend the retropubic-versus-transobturator choice with the evidence, consent properly on the consent numbers, and manage the complications when the tape behaves badly.^[1]

Overview and definition

SUI is the involuntary loss of urine on effort, exertion, coughing or sneezing — the symptom. The urodynamic correlate is urodynamic stress incontinence (USI), which is urine loss without a detrusor contraction, in the presence of raised abdominal pressure. Two mechanisms drive it:^[1][15]

• Urethral hypermobility — loss of pelvic-floor support lets the urethra descend with cough; the pressure is transmitted to the bladder but not to the urethra, and the urethra opens.
• Intrinsic sphincter deficiency (ISD) — the urethral closure mechanism itself is weak; the urethra leaks at a low Valsalva leak point pressure (VLPP under 60 cm H₂O) or low maximum urethral closure pressure (MUCP under 20 cm H₂O).^[1][15]

The two often coexist. The clinical importance is that ISD predicts failure of the transobturator approach and argues for retropubic or pubovaginal sling.^[1][15]

^[1]

References15ShowHide

1. [1]Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA Mid-urethral sling operations for stress urinary incontinence in women Cochrane Database Syst Rev, 2017.PMID 28756647
2. [2]Dumoulin C, Cacciari LP, Hay-Smith EJC Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women Cochrane Database Syst Rev, 2018.PMID 30288727
3. [3]Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence N Engl J Med, 2010.PMID 20479459
4. [4]Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence N Engl J Med, 2007.PMID 17517855
5. [5]Labrie J, Berghmans BL, Fischer K, Milani AL, van der Wijk I, Smalbraak DJ, et al Surgery versus physiotherapy for stress urinary incontinence N Engl J Med, 2013.PMID 24047061
6. [6]Richter HE, Brubaker L, Stoddard AM, et al. Patient related factors associated with long-term urinary continence after Burch colposuspension and pubovaginal fascial sling surgeries J Urol, 2012.PMID 22704099
7. [7]Nager CW, Richter HE, Nygaard I, Paraiso MF, Wu JM, Kenton K, Atnip SD, Spino C; Pelvic Floor Disorders Network Incontinence pessaries: size, POPQ measures, and successful fitting Int Urogynecol J Pelvic Floor Dysfunct, 2009.PMID 19533009
8. [8]Laurikainen E, Kiilholma P A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure Int Urogynecol J Pelvic Floor Dysfunct, 2006.PMID 16132161
9. [9]Agur W, Riad M, Secco S, Litman H, Madhuvrata P, Novara G, Abdel-Fattah M Surgical treatment of recurrent stress urinary incontinence in women: a systematic review and meta-analysis of randomised controlled trials Eur Urol, 2013.PMID 23680414
10. [10][No authors listed] Restriction of Surgical Options for Pelvic Floor Disorders (AUGS Position Statement Update) Urogynecology (Phila), 2024.PMID 38683201
11. [11]Abdel-Fattah M, Chapple C, Guerrero K, Dixon S, Cotterill N, Ward K, et al Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms Trials, 2021.PMID 34702331
12. [12]Ow LL, Alexander JW, Leitch A, Murray C, Lee J, Dwyer PL, Rosamilia A Mini or Retropubic Sling in Women with Intrinsic Sphincter Deficiency at 12 Months-A Randomized Controlled Trial (Mini RISD) Int Urogynecol J, 2026.PMID 41317301
13. [13]Goldman HB Joint position statement on midurethral slings for stress urinary incontinence Neurourol Urodyn, 2022.PMID 34807991
14. [14]Coskun B, Lavelle RS, Alhalabi F, Lemack GE, Zimmern PE Mini-slings can cause complications Int Urogynecol J, 2015.PMID 25338728
15. [15]Ford AA, Ogah J Retropubic or transobturator mid-urethral slings for intrinsic sphincter deficiency-related stress urinary incontinence in women: a systematic review and meta-analysis Int Urogynecol J, 2016.PMID 26220506