Stress urinary incontinence and midurethral sling — structured oral station (12 minutes)

Opening prompt — "Take a focused history and examination."

Model response — say it in this order:[1]

• "I would start with the classic features that confirm stress urinary incontinence: small-volume loss immediately on coughing, sneezing or exertion; dry at night lying flat; no urgency, frequency or nocturia; pads per day as a rough severity measure."[1]
• "I would then complete the urinary history: 3-day bladder diary, fluid intake, caffeine, prior continence surgery, menstrual and menopausal status, obstetric history (instrumental, macrosomia, perineal trauma), bowel function, prolapse symptoms, sexual function, and the impact on quality of life and exercise."
• "I would use a validated form — the ICIQ-UI-SF or UDI-6 — to anchor the assessment."
• "Examination: cough stress test with comfortably full bladder, POP-Q in lithotomy, pelvic-floor muscle assessment (Oxford grade 0–5), Q-tip test for urethral hypermobility, post-void residual by bladder scan, urinalysis to exclude infection and haematuria."
• "I would document the modifiable backdrop: BMI, smoking, chronic cough, constipation."

Examiner is listening for: a focused, structured history that differentiates SUI from urge and mixed incontinence; an examination that includes a demonstrable cough stress test; and the modifiable risk-factor review.[1]

Probe 1 — "She has completed 16 weeks of supervised PFMT. What does the evidence say?"

• "The Cochrane 2018 (Dumoulin) review is the bedrock. For SUI, supervised pelvic floor muscle training cured or improved symptoms in 56% of women versus 6% with no treatment — risk ratio 8.38, 95% CI 3.68 to 19.07, four trials, 165 women, high-quality evidence. We have already given her the 8 to 12 week trial recommended in C-Gyn 32."[2]
• "The next rung on the ladder is a pessary or surgery. The Pelvic Floor Disorders Network trial showed 92% successful pessary fitting in women with SUI and POP-Q stage 2 or less — worth a brief trial, especially given her preference to avoid surgery."
• "If she prefers surgery, midurethral sling is the operation of choice for female SUI in Australasia."

Probe 2 — "What is the local standard, and what does it say about retropubic versus transobturator?"

• "RANZCOG C-Gyn 32, the Position statement on midurethral slings, current July 2020 amended March 2022, review due July 2025. It has three recommendations."
• "Recommendation 1, Evidence-based Grade A: 'MUS surgery is a recommended surgical procedure for SUI in routine cases.'"
• "Recommendation 2, Consensus-based: 'It is recommended that the transobturator approach should only be offered in exceptional circumstances and following discussion in a multi-disciplinary or peer review forum.'"
• "Recommendation 3, Consensus-based: 'Single Incision Slings (SIS) have not yet demonstrated equivalence to MUS and are unavailable on the Australian Register of Therapeutic Goods (ARTG). They should be performed only within the context of a properly conducted clinical trial.'"
• "Good Practice Point: 'Local credentialling, provision of written information (particularly from the Australian Commission of Safety and Quality in Health Care); Clinical Audit (logging of cases and follow-up) and Patient Reported outcomes are essential for gynaecologists undertaking MUS procedures.'"[1]
• "The retropubic tape passes behind the pubic bone and acts as a backboard compressing the urethra against the pubic symphysis; the transobturator tape passes through the obturator membrane and supports the urethra from below. The Cochrane 2017 (Ford) review, 81 trials and 12,113 women, found the two approaches similar in short-term subjective cure — RR 0.98, 95% CI 0.96 to 1.00 — but with different complication profiles."[1]
• "RP is the routine ANZ option (C-Gyn 32, ACSQHC). TO is reserved for exceptional circumstances: extensive previous abdominal surgery where retropubic adhesions raise the bowel and vascular injury risk, inability to cease anticoagulation. RP is mandatory in intrinsic sphincter deficiency, where TO has a higher failure rate (Ford 2016 meta-analysis)."[6]

Probe 3 — "What complications does she have to consent on, and what are the numbers?"

• "C-Gyn 32 reproduces the consent list. I would cover the headline numbers from the statement's mesh-erosion paragraph."
• "Mesh exposure: approximately 2% for both RP and TO."[7]
• "Chronic pain: up to 5% — the Federal Court of Australia ruling in Gill v Ethicon (Katzmann 2019) found chronic pain in up to 5% of women having a synthetic mesh midurethral sling."[7]
• "Severe pain needing sling removal: approximately 1 in 150 (around 0.7%)."[7]
• "Voiding dysfunction needing sling release: approximately 0.6% (Laurikainen 2006 nationwide TVT cohort of 9,040 procedures) — and she needs to know that sling release can leave her with recurrent SUI."[5]
• "De novo urgency or worsening of overactive bladder symptoms: 5 to 15%."
• "Bleeding, bladder or urethral injury, bowel injury, major vessel perforation, dyspareunia, partner symptoms, failure of primary procedure, recurrence of SUI — all on the C-Gyn 32 list."
• "I would also tell her that her case will be logged on the UGSA database, the IUGA database, or the Australian Pelvic Floor Procedures Registry, and adverse events are reportable to the TGA in Australia or MEDSAFE in New Zealand."[1]

Probe 4 — "She asks 'what does the operation actually involve?' — explain."

• "A small incision is made under the urethra; the synthetic polypropylene tape is passed behind the pubic bone (retropubic) through two small suprapubic exit points; the tape sits as a backboard under the mid-urethra and is adjusted without tension; the vaginal incision is closed."
• "The operation takes about 20 to 30 minutes; it is usually a day-stay or overnight-stay procedure under general or spinal anaesthesia."[1]
• "Cystoscopy with a 70-degree lens is mandatory at every retropubic insertion — to exclude bladder perforation, which occurs in about 5% of cases in trial settings and is much lower with experience. A missed perforation recognised only when the woman presents with a fistula or stone is the worst avoidable error."[7]
• "She will have a catheter overnight and a trial of void the next morning; most women are dry immediately and back to normal activities within a week, with avoidance of heavy lifting and intercourse for 4 to 6 weeks."[1]

Probe 5 — "What if it doesn't work, or comes back?"

• "If the sling fails to cure her at 6 months, or if she is cured and then leaks again (recurrent SUI), the workup includes urodynamics, cystoscopy and translabial ultrasound to characterise the failure and exclude intravesical mesh."
• "Options include a repeat MUS (the opposite route to the original — RP if TO first), an autologous pubovaginal sling (rectus fascia), a Burch colposuspension, bulking agents, or in specialist centres an artificial urinary sphincter."
• "Burch colposuspension and pubovaginal sling are the alternatives when MUS is unsuitable or has failed; the SISTEr trial (Albo NEJM 2007) showed the sling was more effective than Burch at 2 years (47% vs 38%) but had more adverse events; both decline in efficacy by 5 to 7 years."[4]

Probe 6 — "She is BMI 31. Does that change anything?"

• "Yes. C-Gyn 32 says success rates for obese women who undergo MUS are significantly lower compared to women of normal BMI, and weight-loss strategies should be discussed pre and postoperatively."[1]
• "I would explore her motivation to lose weight, refer to a dietitian, and offer MUS after shared decision-making with explicit consent on the lower success. I would not deny her surgery on BMI alone."[1]

Probe 7 — "She is worried about mesh because of what she has read in the newspapers. What do you say?"

This is a scored domain — rapport, respect and communication. Demonstrate it out loud.[7]

• Move to her eye level, use her name, acknowledge her fear without dismissing it: "I understand your concern. The mesh used for stress incontinence is different from the mesh used for prolapse that has been in the news."[7]
• Distinguish: the FDA 2011 and 2019 safety communications and the TGA actions on transvaginal mesh were specifically about prolapse, not midurethral slings. C-Gyn 32 makes that distinction explicitly.[7]
• Quote the AUGS-SUFU 2018 position statement, which states that MUS remains a safe and effective standard of care, supported by over 2,000 publications.[7]
• Acknowledge the small but real risks: 2% mesh exposure, up to 5% chronic pain, approximately 1 in 150 needing removal. Offer written information from the ACSQHC.[7]
• Commit to the C-Gyn 32 audit and follow-up at 6 weeks and 6 months; tell her you would log her case on the registry.[7]