Should a patient with stress urinary incontinence undergo peri-urethral suspension or repair of cystocele (bladder prolapse) and rectocele (rectal prolapse)?

From the Guidelines

For a patient with stress urinary incontinence (SUI), a peri-urethral suspension procedure is the most appropriate choice, as it directly addresses the underlying mechanism of SUI, with success rates of 80-90% and minimal invasiveness, as supported by the most recent guideline updates 1.

Key Considerations

• Peri-urethral suspension procedures, such as midurethral slings (TVT or TOT), provide support to the urethra during increases in intra-abdominal pressure, directly addressing the underlying mechanism of SUI.
• These procedures have high success rates and can be performed with relatively quick recovery times, making them a preferred option for patients with SUI.
• In contrast, repair of cystocele and rectocele primarily addresses anatomical defects of the vaginal wall and may not adequately resolve urinary incontinence symptoms.

Decision-Making Factors

• The decision between peri-urethral suspension and repair of cystocele and rectocele should be based on thorough urodynamic testing, physical examination, and assessment of the patient's symptoms.
• If a patient has both SUI and significant pelvic organ prolapse, combination procedures might be warranted, as noted in the collaborative review on SUI management 1.
• Post-operative care typically includes temporary urinary catheterization, pelvic floor physical therapy, and avoiding heavy lifting for 6-8 weeks to ensure optimal surgical outcomes.

Evidence-Based Recommendation

• The most recent guideline updates and collaborative reviews support the use of peri-urethral suspension procedures as a first-line surgical treatment for SUI, due to their high success rates and minimal invasiveness 1.
• Pelvic floor muscle training emerges as a first-line management strategy, showing efficacy in symptom improvement when good educational instructions and supervision are provided, as noted in the European Urology review 1.

From the Research

Treatment Options for Stress Urinary Incontinence

• The patient with stress urinary incontinence has several treatment options, including peri-urethral suspension and repair of cystocele & rectocele 2.
• However, the midurethral sling remains the gold standard for surgical treatment of stress urinary incontinence, although patients and clinicians should acknowledge the potentially serious complications of transvaginal mesh (TVM) 2, 3.
• Burch urethropexy and pubovaginal sling offer good SUI cure and may be preferred in women wishing to avoid mesh implants; however, their operative morbidities and more challenging surgical approach may limit their use 2, 4.
• Site-specific cystocele or rectocele repairs may be indicated for isolated anterior or posterior vaginal compartment prolapse; however, in women with more severe POP, evidence supports using a vaginal native-tissue repair involving apical suspension as the primary surgical technique 2.

Factors to Consider in Treatment Decision

• The choice of operation depends on a variety of factors including severity of stress incontinence, anatomy, medical and surgical comorbidities, and patient preferences 5.
• Urethral closure pressure is the factor most strongly associated with stress incontinence, implying that improving urethral function may have therapeutic promise 6.
• Shared decision-making between the patient and the physician is used to decide the management strategy, facilitating alignment of the chosen intervention with the patient's unique circumstances and preferences 5.

Non-Surgical Management Options

• Nonsurgical management options include pelvic floor physical therapy, vaginal inserts, or continence pessaries 5.
• Observation and conservative measures (eg, pads) can be used if the patient is not bothered by their symptoms 5.