Stress urinary incontinence (SUI) is one of the most common forms of urinary incontinence in women. It occurs when urine leaks because pressure inside the abdomen rises faster than the urethra and pelvic floor can close.

Coughing, sneezing, laughing, lifting, running, jumping and exercise can all trigger leakage. For some women the leakage is only a few drops; for others it can be substantial enough to interfere with exercise, work, intimacy and everyday life.

The good news is that SUI is treatable, and treatment can be tailored to the severity of symptoms, the woman’s lifestyle and preferences, previous surgery, pelvic floor function and other bladder symptoms.

What are the symptoms and signs of stress urinary incontinence?

The classic symptom is involunta

ry urine leakage with physical exertion.

Common triggers include:

• Coughing or sneezing
• Laughing
• Getting up from a chair
• Lifting children or heavy objects
• Running or jumping
• Exercise, particularly high-impact exercise
• Sexual intercourse
• Changes in position
• Sports such as tennis, running or aerobics

Some women notice only occasional leakage, while others need pads every day.

Stress incontinence versus urgency incontinence

It is important to distinguish SUI from urgency urinary incontinence, where urine leakage follows a sudden, difficult-to-defer urge to urinate.

Many women have mixed urinary incontinence, with both stress and urgency leakage.

This distinction matters because the treatment strategy can be quite different. Treating the wrong component first can produce disappointing results.

How is stress urinary incontinence diagnosed?

For many women, the diagnosis can be made from the history and examination without an extensive battery of tests.

A specialist assessment usually includes:

1. Medical history

Your doctor will ask about:

• The nature and severity of leakage
• What activities trigger leakage
• Urinary urgency and frequency
• Night-time urination
• Recurrent urinary tract infections
• Previous pregnancies and childbirth
• Menopause and hormonal symptoms
• Previous pelvic or continence surgery
• Pelvic-organ prolapse
• Neurological conditions
• Medications
• Impact on exercise, work, social activities and sexual function

2. Bladder or voiding diary

A bladder diary records fluid intake, urinary frequency, urine volumes, urgency episodes and leakage over several days.

It can be surprisingly revealing. It helps determine whether the problem is predominantly stress leakage, urgency, excessive fluid intake, frequent small-volume voiding or a combination of these.

3. Physical examination

A pelvic examination can assess:

• Pelvic organ prolapse
• Pelvic floor muscle strength
• Urethral mobility
• Vaginal and vulval health
• Atrophic changes associated with menopause
• Evidence of previous surgery

A cough stress test may be performed with a comfortably full bladder. Leakage of urine through the urethra during coughing supports the diagnosis of stress urinary incontinence.

4. Urine testing

A urine test is often appropriate, particularly when there are symptoms suggesting infection, blood in the urine or other urinary abnormalities.

5. Measurement of residual urine

A bladder ultrasound can measure the amount of urine left after voiding. This is particularly useful if there are symptoms suggesting incomplete bladder emptying or voiding dysfunction.

Do I need urodynamic studies?

This is one of the most common questions asked by women considering treatment.

Not every woman with straightforward stress urinary incontinence requires urodynamics.

Urodynamic testing measures how the bladder, urethra and pelvic floor behave while the bladder fills and empties. It can determine whether leakage is associated with increased abdominal pressure, whether involuntary bladder contractions occur and whether there is evidence of obstruction or impaired bladder emptying.

Contemporary guidelines generally do not recommend routine urodynamics before surgery in women with uncomplicated, clinically demonstrable SUI because it has not been shown to improve surgical outcomes.

Urodynamics becomes particularly useful when:

• The diagnosis is uncertain
• There are significant urgency or other storage symptoms
• Mixed urinary incontinence is present
• Voiding dysfunction is suspected
• There is significant pelvic organ prolapse
• Previous continence surgery has failed
• The symptoms and examination findings do not match
• There is suspected intrinsic sphincter deficiency
• The results may change the choice of treatment

In these situations, urodynamics can turn a clinical puzzle into a much clearer picture.

Treatment of stress urinary incontinence

Treatment is usually progressive, beginning with conservative measures and moving towards minimally invasive or surgical treatment when necessary.

The appropriate treatment depends on the severity of the leakage and, importantly, how much it bothers you.

1. Pelvic floor muscle training

Pelvic floor muscle training (PFMT) is generally the first-line treatment for SUI.

The pelvic floor muscles provide support to the bladder neck and urethra. Strengthening and correctly coordinating these muscles can significantly reduce leakage.

A structured program with a pelvic floor physiotherapist is preferable to simply being told to “do your Kegels”.

A good program may include:

• Identification of the correct muscles
• Strength training
• Endurance training
• Rapid contractions for coughs and sneezes
• Coordination of the pelvic floor with movement
• Techniques for managing leakage during exercise

Guidelines recommend supervised pelvic floor muscle training for at least three months as initial therapy for SUI.

The advantage is obvious: there is no incision, no anaesthetic and essentially no procedural risk.

The disadvantage is that it requires commitment, correct technique and time.

2. Lifestyle measures

Lifestyle modifications can make a meaningful difference, particularly when combined with pelvic floor rehabilitation.

These may include:

• Weight reduction where appropriate
• Optimizing fluid intake
• Reducing excessive caffeine intake
• Treating constipation
• Addressing chronic coughing
• Smoking cessation
• Modifying high-impact exercise temporarily while rehabilitation is undertaken

These measures rarely “cure” significant anatomical SUI on their own, but they can reduce symptoms and improve the results of other treatments.

3. Continence pessary

A vaginal continence pessary can provide mechanical support to the urethra and bladder neck.

It may be particularly useful for women who:

• Want to avoid surgery
• Have leakage predominantly during exercise
• Are awaiting surgery
• Have coexisting pelvic organ prolapse
• Want an additional treatment alongside pelvic floor rehabilitation

A pessary is fitted inside the vagina and can sometimes be removed and inserted by the patient.

Possible problems include vaginal irritation, discharge, discomfort and difficulty with insertion or removal. Regular review is important.

4. Vaginal oestrogen

For postmenopausal women with vaginal or genitourinary symptoms, local vaginal oestrogen may improve vaginal tissue health and urinary symptoms.

It is not a replacement for continence surgery when significant anatomical SUI is present, but it can be a useful component of treatment in appropriately selected women.

5. Urethral bulking injections

Urethral bulking involves injecting a material around the urethra to improve its ability to remain closed.

One example used clinically is polyacrylamide hydrogel.

The procedure is minimally invasive and can be attractive to women who:

• Prefer to avoid sling surgery
• Are poor surgical candidates
• Have recurrent SUI after previous surgery
• Want a relatively quick procedure

The trade-off is durability.

Bulking agents are generally less effective than sling procedures and repeat injections may be necessary. Their effectiveness can diminish with time.

Potential side effects include:

• Temporary urinary urgency
• Urinary tract infection
• Difficulty emptying the bladder
• Blood in the urine
• Discomfort
• Recurrent leakage
• Need for repeat treatment

6. Mid-urethral sling

For women with bothersome SUI who have not obtained sufficient improvement from conservative treatment, a mid-urethral sling (MUS) is one of the most established surgical treatments.

The sling sits beneath the middle portion of the urethra and provides support when abdominal pressure rises.

Two principal approaches have been used:

Retropubic mid-urethral sling

The tape passes behind the pubic bone.

Mid-urethral slings have substantially reduced the morbidity and complexity of traditional continence surgery, with high rates of improvement and continence. Contemporary evidence suggests broadly similar effectiveness between retropubic and transobturator approaches, although their complication profiles differ.

Importantly, mid-urethral sling surgery is not the same as the transvaginal mesh products that were used for pelvic organ prolapse. The Australian regulatory position is different. Mid-urethral slings for SUI remain approved products in Australia, with approved devices subject to Class III medical-device requirements.

What are the risks of a mid-urethral sling?

Although most women do well, sling surgery is not risk-free.

Potential complications include:

• Bleeding or haematoma
• Infection
• Bladder or urethral injury during insertion
• Temporary or persistent difficulty passing urine
• Urinary retention
• New or worsening urgency
• Recurrent stress incontinence
• Pelvic, groin or suprapubic pain
• Pain during sexual intercourse
• Mesh exposure or erosion
• Rarely, chronic pain or other mesh-related complications
• Need for further surgery

The TGA specifically identifies complications including bladder or urethral injury, mesh exposure or erosion, voiding dysfunction, urinary retention, urgency and acute or chronic pain among the potential adverse outcomes associated with urogynaecological mesh.

The decision to use a sling should therefore involve an individual discussion about benefits, alternatives and risks rather than treating the operation as a one-size-fits-all solution.

7. Autologous fascial sling

For women who wish to avoid synthetic mesh, another established surgical option is an autologous fascial sling.

A strip of the woman’s own tissue, usually rectus fascia from the lower abdominal wall, is fashioned into a sling and placed beneath the bladder neck/urethra.

This avoids a synthetic implant.

It can be particularly useful in selected women with:

• Severe stress incontinence
• Intrinsic sphincter deficiency
• Previous failed sling surgery
• Previous mesh complications
• A strong preference to avoid synthetic mesh

The disadvantages are that it is generally a more extensive operation, requires harvesting tissue and can have a higher risk of postoperative voiding dysfunction. Fascial harvest can also cause abdominal wound pain, infection, seroma or, rarely, hernia.

What about an allograft mid-urethral sling?

This is an important distinction.

An allograft is tissue obtained from another human donor, rather than tissue harvested from the woman herself. Historically, cadaveric fascia lata has been used to construct pubovaginal slings.

The attraction is obvious: it avoids harvesting the woman’s own rectus fascia and therefore avoids the additional abdominal wound associated with an autologous sling.

However, there is an important catch.

The evidence for allograft slings is considerably weaker than for modern mid-urethral synthetic slings or autologous fascial slings. This based on older studies and different mechanisms to prepare the graft.

Older studies of cadaveric fascia lata reported encouraging short-term outcomes, including reduced postoperative pain compared with harvesting autologous fascia. However, other studies reported substantial recurrence of stress incontinence, raising concerns about long-term durability.

Systematic evidence reviews have also concluded that the evidence supporting biological/allograft slings is limited and of low or very low certainty. In comparisons with synthetic slings, there has not been convincing evidence that cadaveric fascia lata provides a superior outcome.

For this reason, an allograft sling should not simply be regarded as a “mesh sling without mesh.”

Its role is much more selective.

Where available, it may be considered in carefully selected women who want to avoid synthetic mesh and would otherwise be candidates for a fascial sling, but the surgeon should explain the limitations of the evidence and uncertainty around long-term durability.

In Australia, the availability and regulatory status of any particular allograft product or technique should be confirmed with the treating surgeon and relevant institution. The TGA’s current approved urogynaecological mesh list specifically identifies approved devices for SUI, while not all historical mesh or biological products remain available.

8. Burch colposuspension

Burch colposuspension is a traditional operation in which sutures are placed to support the tissues around the bladder neck and urethra.

It can be performed through an abdominal approach, including laparoscopically or robotically in appropriately experienced centres.

It remains an important non-mesh surgical option, although it is more invasive than a mid-urethral sling.

Potential complications include:

• Bleeding
• Infection
• Bladder injury
• Postoperative urinary retention or voiding dysfunction
• New urgency
• Recurrent SUI
• Pelvic or abdominal pain
• Development or worsening of pelvic organ prolapse

Choosing the right operation

There is no single “best” operation for every woman.

The decision should take into account:

Consideration	Why it matters
Severity of SUI	Determines how much treatment is justified
Previous surgery	May alter the choice of procedure
Intrinsic sphincter deficiency	May favour a different surgical approach
Pelvic organ prolapse	May require combined treatment
Urgency/mixed incontinence	May affect expected outcome
Desire to avoid synthetic mesh	Makes fascial procedures more relevant
Previous mesh complications	May favour non-mesh options
General health	Influences operative risk
Future pregnancies	May influence timing and choice of surgery
Patient preference	An essential part of shared decision-making

The aim is not simply to make the pad dry. The aim is to find the treatment that gives the woman the best balance between continence, bladder function, quality of life and procedural risk.

What happens after treatment?

Following continence surgery, women are generally reviewed to assess:

• Continence
• Urgency and frequency
• Bladder emptying
• Residual urine
• Pelvic pain
• Sexual function
• Vaginal healing
• Mesh exposure where a mesh sling has been used

If symptoms persist or recur, further investigation may be necessary. In women with failed previous SUI surgery, repeat urodynamics and specialist assessment can be particularly valuable.

Australia also has the Australasian Pelvic Floor Procedures Registry, which collects information about stress incontinence and pelvic floor procedures with the goal of improving quality and long-term safety.

The bottom line

Stress urinary incontinence is common, but it is not something women simply have to put up with.

Treatment ranges from pelvic floor physiotherapy and lifestyle modification through to pessaries, urethral bulking injections and surgery.

For women requiring surgery, options in Australia include mid-urethral sling procedures, autologous fascial sling surgery and colposuspension, with the appropriate choice depending on individual circumstances.

An allograft fascial sling is a more specialised option. Although it avoids harvesting the patient’s own fascia, the evidence base is considerably less robust than that for established mid-urethral sling and autologous fascial sling procedures. It should therefore be discussed as a selective option rather than assumed to be a routine alternative to synthetic mesh.

Most importantly, treatment should be individualised. A woman should understand not only the likelihood of becoming dry, but also the possibility of urgency, voiding problems, pain, recurrent incontinence and other procedure-specific complications before making a decision.

If urinary leakage is interfering with exercise, work, relationships or everyday life, an assessment by a GP, urogynaecologist, urologist or pelvic-floor physiotherapist is a good place to start.

This information is intended for education and does not replace an individual medical assessment. Treatment availability, device approvals and clinical recommendations can change, so patients should discuss the current options with their treating clinician.

 

Don’t suffer in silence. Come see what your Brisbane Urologist Uro-Jo can do for you.