A: Associated urgency or urgency incontinence, pad usage, degree of bother, and its effect on quality of life (QoL) which can be assessed using QoL questionnaires (see Table 4.2), pelvic floor exercises and duration, and weight control. Physical examination to palpate bladder, exclude neurological signs, vaginal examination to assess degree of estrogenization, and assess for pelvic organ prolapse.

A: Urine microscopy/culture, post-void residual urine, and body mass index (BMI) (Table 4.3). If these are within normal limits, then pelvic floor muscle training (PFMT) can be instituted for treatment of stress urinary incontinence, in conjunction with reduction in abdominal strain if indicated, e.g., weight loss and control of chronic airway disease such as asthma. (Tips 4.2)

Topical estrogen therapy may improve symptoms of overactive bladder and urge incontinence by its effect on atrophic vaginitis. However, estrogen treatment alone has limited effects on stress urinary incontinence. There may be a role as adjunctive treatment prior to surgery for stress incontinence or pelvic organ ­prolapse.

A: Pessaries and continence aids

There are two types of devices, intraurethral and intravaginal devices, available for women with mild to moderate stress incontinence who wish to consider this nonsurgical management option.

Both types of devices are suitable for women with good cognition and adequate manual dexterity to periodically remove and replace the device. Patients are usually referred to a nurse or physiotherapist specialized in intravaginal therapy for urinary incontinence and pelvic organ prolapse. Speculum examination of the vagina is necessary to confirm satisfactory degree of estrogenization before going for trial of a continence device. Patients should receive proper training and support to gain confidence in caring for the device. (McIntosh L, 2005).

This patient remains bothered by her stress incontinence despite 6 months of pelvic floor physiotherapy. She is keen to undergo surgical treatment.

A: This is an area of controversy. Many clinicians would perform UDS to assess detrusor function, confirm the presence of urodynamic SUI, and exclude voiding dysfunction before recommending a suitable type of sling or other options preoperatively. This is mainly because urinary symptoms may not be indicative of the underlying pathophysiological condition(s). This is especially true in the elderly when multiple medical comorbidities often exist (see Chap. 6) and contribute to urinary incontinence. While UDS may not change the decision to proceed to surgery, findings of OAB or voiding dysfunction may allow the surgeon to better consent the patient regarding potential complications and tailor the surgical procedure to optimize clinical outcome. Although some studies have shown that in clinical cases of “pure” symptomatic stress incontinence UDS may not affect clinical outcome, it should be noted with a caveat that “pure” stress incontinence cases are uncommon and some of these patients in fact have detrusor overactivity or other bladder dysfunction at UDS without SUI. Hence, in general, UDS are recommended before surgery especially in the presence of mixed stress and urgency incontinence.

A: Stress incontinence operations can be broadly classified into slings, suspension procedures, and injectable bulking agents. Slings provide support to the urethra/closure mechanism at times of exertion and can be synthetic or biological. Synthetic suburethral slings (Fig. 4.2) are commonly placed at the midurethra for patients with SUI associated with urethral hypermobility but may also be used in selected patients with more severe incontinence related to intrinsic sphincter deficiency (ISD) (Kleeman et al. 2011). The pubovaginal sling utilizes autologous fascia from the rectus sheath placed at the level of the proximal urethra and is commonly used for patients with severe incontinence related to ISD but can also be used in patients with urethral hypermobility or in patients who do not desire synthetic material (Athanasopoulos et al. 2011). Transurethral injection of bulking agents (Fig. 4.3) (e.g., Macroplastique® – silicone elastomer, Bulkamid® – polyacrylamide, Durasphere® – carbon beads) has a less important role nowadays and is often reserved for more frail patients with ISD (see Chap. 6). Suspension procedures such as Burch colposuspension and needle suspensions are now rarely performed and superseded by the less invasive midurethral slings in general. Other surgical treatments (rarely performed) include the artificial urinary sphincter (see Chap. 5) which may have a role in patients who have significant ISD and generally have failed at least one of the above treatments.