A thorough and detailed patient history should elicit whether the patient has stress incontinence, urge incontinence, or mixed incontinence. It is important to ascertain a history of previous incontinence or pelvic surgeries, as this may affect surgical decision making. Prolapse symptoms should also be queried, as almost two-thirds of women with SUI have coexisting POP (7), and additional procedures may be necessary at the time of the incontinence surgery. Finally, it is prudent for physicians performing pelvic surgery to inquire about whether the patient’s Pap screening is up to date.

The physical examination should include a bimanual and speculum examination to assess the vaginal tissue and vaginal support and to rule out any pelvic masses. A positive empty supine cough stress test is highly predictive of urodynamic stress incontinence (8). Urethral hypermobility is typically confirmed before considering a Burch urethropexy. Traditional teaching has used the cotton-tipped swab test to measure urethral hypermobility. A cotton-tipped swab is inserted transurethrally to the proximal urethra, and the patient is asked to maximally Valsalva. A deflection of >30 degrees from the resting angle during Valsalva is considered to reflect urethral hypermobility. The surgeon should inspect the lower abdominal wall for scars indicative of previous pelvic surgery and correlate with the patient’s surgical history.

If the patient relates SUI symptoms and desires surgical treatment, many surgeons choose to perform urodynamics (UDS) to confirm the diagnosis. It is believed that the Burch is not as effective in women with “intrinsic sphincter deficiency,” typically defined by indirect measures of urethral function, including leak point pressure <60 mm Hg or urethral closure pressure of 20 mm Hg or less. However, a randomized trial comparing Burch to sling in women with low urethral closure pressures (20 cm H2O or less) did not show a difference in subjective success between the two procedures at a mean 5 years of follow-up (84% versus 93%, respectively, P = .47) (9). Although the study was not powered to detect small differences between the treatment groups, the findings still demonstrate that the Burch procedure can be effective in women with low urethral closure pressures. Valsalva leak point pressure (VLPP) has not been shown to be a significant predictor of success after the Burch procedure (10). In addition, a retrospective review of women who underwent a Burch urethropexy with preoperative VLPPs of <60 cm H2O showed an objective success rate of 91.7%, indicating that a low VLPP is not necessarily predictive of Burch failure (11). Direct measurement of striated urethral sphincter physiology using electromyography suggested that women with better innervation of their urethral sphincters were more likely to be cured by the Burch urethropexy (12). In summary, there are no UDS parameters clearly predictive of Burch success or failure. Therefore, traditional urodynamic testing does not seem to aid in the surgeon’s decision of which incontinence procedure to perform. However, the study can provide helpful information about the coexistence of detrusor overactivity, clarify confusing symptomatology, and confirm diagnoses in patients who have undergone previous incontinence surgeries.