2 Diagnosis
2.1 Anamnesis and clinical examination
Patients with urinary incontinence should undergo a systematic examination,
including a general anamnesis, urogynaecological anamnesis, physical examination
and expectations of examination and treatment (LOE 2, recommendation grade
B).
The following should be taken into account: storage of urine, bladder emptying,
complaints following bladder emptying, type and extent of incontinence, and
psychological strain (LOE 3, recommendation grade B).
2.2 Questionnaires
Questionnaires are used to record the patientʼs symptoms, the severity, and the
effects on the patient, as well as to document changes in the symptoms over
time, e.g. following treatment. Questionnaires validated in terms of content and
language should be used.
There is no scientific evidence that the use of questionnaires to assess urinary
incontinence influences the treatment outcome (LOE 4).
2.3 Micturition report/micturition diary
Micturition diaries, which are kept for 3–7 days, are a reliable method of
quantifying the average micturition volume and the micturition frequency during
the day and night. Micturition reports are used to determine and assess bladder
filling and bladder emptying disorders occurring concomitantly with urinary
incontinence (LOE 2b).
2.4 Urine examination
Urinary incontinence occurs more frequently in women with urinary tract
infections. In contrast to symptomatic urinary tract infection, asymptomatic
bacteriuria seems to have little influence on urinary incontinence.
2.5 Measuring of residual urine
Residual urine is the amount of urine remaining in the urinary bladder at the end
of micturition. There is no standard definition of a pathological quantity of
residual urine.
Sonography of the urinary bladder after micturition provides a precise estimate
of the quantity of residual urine. The quantity of residual urine should be
determined using sonography (LOE 1b, recommendation grade A).
The quantity of residual urine should be determined in female patients with
urinary incontinence or micturition problems (LOE 1b, recommendation grade
B).
The quantity of residual urine should be determined in female patients receiving
treatment that can potentially cause or exacerbate bladder emptying problems
(LOE 1b, recommendation grade B).
2.6 Pad test (sample weighing test)
The pad test serves to quantify the loss of urine and can be used as a follow-up
and to assess the success of treatment.
2.7 Urodynamics
Urodynamic examinations serve to objectify and quantify the symptoms, to
correctly classify symptoms and pathophysiology, as well as identify risk
factors that have a key influence on the success of treatment or possible
complications and unwanted sequelae.
Preliminary urodynamic testing does not influence the success of conservative
urinary incontinence treatment. A routine urodynamic examination is not
indicated prior to conservative treatment for urinary incontinence (LOE 1a,
recommendation grade O).
Prior to surgical interventions – in particular, recurrent interventions – a
urodynamic examination should be performed to advise the patient with the
greatest possible care and introduce the right treatment (LOE 3,
recommendation grade B).
An assessment of urethral function should be taken into account within the
urodynamic investigation into stress urinary incontinence (LOE 3,
recommendation grade B).
In patients with higher-grade genital prolapse without symptoms of stress urinary
incontinence, a stress test should be performed following prolapse
repositioning. To assess concomitant hidden stress urinary incontinence and/or
detrusor dysfunction, urodynamic testing should be carried out with prolapse
repositioning (LOE 3, recommendation grade B).
2.8 Imaging
When using imaging to depict the morphology and function of the lower urinary
tract, sonography and magnetic resonance imaging are increasingly superseding
X-ray investigations.
Cystography and micturating cystourethrography are not indicated for the primary
diagnosis of uncomplicated stress urinary incontinence (LOE 4, recommendation
grade O).
Introitus sonography and perineal sonography are used when performing a
topographical and functional assessment of the urinary bladder, urethra and
pelvic floor musculature. Sonography now has an established importance in
relation to the diagnosis and further treatment algorithm in women with stress
urinary incontinence (LOE 2). Its use in the event of unsuccessful
treatment, in particular, can be very helpful clinically.
Within the scope of conservative treatment, rehabilitative ultrasound imaging
(RUSI) has become established as a visual biofeedback tool in physiotherapy.
2.9 Endoscopy
Urethrocystoscopy is recommended for stress urinary incontinence if additional
urge symptoms, emptying disorders, relapsing urinary tract infections or
haematuria exist, in order to rule out morphological causes such as urinary
bladder tumours or stones, urethral stenosis or chronic changes to the mucous
membrane of the bladder (LOE III).
3 Treatment
3.1 Conservative treatment
3.1.1 Oestrogen
Patients should be informed prior to systemic oestrogen substitution that
this can lead to the occurrence or exacerbation of urinary incontinence
(LOE 1a, recommendation grade A).
Local oestrogen therapy should be recommended for all post-menopausal
patients with urinary incontinence. The duration of treatment and the best
mode of application are unclear (LOE 1a, recommendation grade A).
3.1.2 Body weight
Being overweight is a risk factor for stress urinary incontinence in women.
Weight loss of more than 5 % improves incontinence symptoms (LOE
1b).
Weight loss (> 5 %) should be recommended to overweight patients with
urinary incontinence (LOE 1b, recommendation grade A).
3.1.3 Duloxetine
Duloxetine does not cure incontinence, but instead reduces episodes of stress
and urge urinary incontinence (LOE 1b). Duloxetine causes significant
adverse effects affecting the gastrointestinal and central nervous systems
(nausea, vomiting, mouth dryness, constipation, dizziness, insomnia,
fatigue), which lead to high rates of treatment discontinuation (LOE
1b).
Duloxetine should be offered to women who aim for a temporary improvement in
incontinence symptoms (LOE 1b, recommendation grade A).
Due to the high number of adverse effects, duloxetine treatment should be
started gradually (LOE 1b, recommendation grade A).
3.1.4 Pessary treatment
Pessary treatment should be offered as a treatment option to female patients
with stress urinary incontinence (LOE 1b, recommendation grade
B).
3.1.5 Pelvic floor exercise
In the event of stress urinary incontinence, guided pelvic floor exercise
over more than 3 months, combined with bladder training, should be
implemented (LOE 1a, recommendation grade A).
Pelvic floor exercise should be used to prevent and treat incontinence during
pregnancy and after the birth (LOE 1a, recommendation A).
Pelvic floor exercise should be instructed individually and can be
implemented as an individual treatment, in a group or within independent
training (LOE 1b and 2b, recommendation grade B).
Pelvic floor exercise should also be carried out by older patients (LOE 1b
and 2b, recommendation grade B).
Active pelvic floor exercise should be preferred to electrostimulation on its
own (LOE 1b, recommendation grade B). A combination of both measures
can be more effective than pelvic floor exercise on its own (LOE
1b).
To assess pelvic floor activity, vaginal palpation or a perineometer should
be used (LOE 2b, recommendation grade B).
Vibration treatment using a base plate with a side-alternating vibration
leads to an improvement in continence when used in combination with
physiotherapy (LOE 2).
3.2 Surgical treatment
Surgical treatment for stress urinary incontinence should only be considered once
conservative treatment options have been exhausted.
Each surgery should be preceded by a detailed discussion with the patient, during
which she is informed about the reasons for and objectives of the surgical
intervention, the benefits and possible complications. It is equally important
to review the advantages and disadvantages of alternative treatment options,
where these are available.
When there are no incontinence operations in the anamnesis, no neurological
symptoms and no symptomatic genital prolapse or desire for children, the stress
urinary incontinence is known as uncomplicated. In contrast, if women are
affected by one or more of the aforementioned criteria, it is known as
complicated stress urinary incontinence.
3.2.1 Surgical treatment for uncomplicated stress urinary
incontinence
3.2.1.1 Open colposuspension
Systematic reviews have shown that open colposuspension (Burch) and the
autologous fascial sling procedure are equally effective in treating
stress urinary incontinence in women over the short term (after 5 years)
(LOE 1b).
The efficacy of colposuspension declines after 5 years. In the 1st
postoperative year, the continence rate was still 85–90 % following open
colposuspension. The failure rate (persistent incontinence/recurrent
incontinence) was 17 % within the first 5 years and then rose to 21 %. A
genital prolapse occurred more frequently following colposuspension than
following other incontinence operations. The autologous fascial sling
procedure involves higher perioperative complication risks than open
colposuspension, above all caused by bladder emptying disorders and
postoperative urinary tract infections (LOE 1b).
3.2.1.2 Laparoscopic colposuspension
Laparoscopic colposuspension demonstrates an equally high efficacy as
open colposuspension in curing stress urinary incontinence 2 years
postoperatively (LOE 1a).
Laparoscopic colposuspension is associated with less postoperative pain,
a shorter time taken to resume normal activities, a shorter stay in
hospital, and shorter catheterisation time than open colposuspension
(LOE 1a).
3.2.1.3 Suburethral tension-free tape
Suburethral tension-free tape was quickly adopted into the primary
treatment of stress urinary incontinence due to its efficacy, low
invasiveness, and the rapid postoperative recovery of the patient.
The NICE (National Institute for Health and Clinical Excellence) Clinical
Guideline 2006 recommends the use of synthetic, macroporous type-I tape
in the treatment of stress urinary incontinence in women.
A comparison of suburethral tension-free tape and
colposuspension
Retropubic tape operations demonstrate the same subjective and better
objective stress urinary incontinence cure rates in comparison with
colposuspension 12 months postoperatively (LOE 1a).
Transobturator tape operations show the same subjective and objective
cure rates in stress urinary incontinence in comparison with
colposuspension 12 months postoperatively (LOE 1a).
Following a suburethral tape operation, fewer de novo urge syndromes
and bladder emptying disorders occurred than following
colposuspension (LOE 1a).
In the meta-analysis by the European Association of Urology (EAU),
the subjective cure rate 12 months following suburethral tape
operations was 75 %. Long-term follow-ups up to 5 years later show
no efficacy differences compared with colposuspension. Bladder
emptying disorders occurred more rarely following suburethral tape
operations in comparison with colposuspension. Bladder perforations
occurred more frequently during the insertion of suburethral tape
than during laparoscopic colposuspension or open
colposuspension.
Transobturator versus retropubic approaches
The meta-analysis by the EUA showed equally high subjective and
objective stress urinary incontinence cure rates 12 months following
insertion of a transobturator suburethral tape compared with
retropubic suburethral tape operations (LOE 1a). The
transobturator tape technique is associated with a lower risk of
bladder perforation and a lower risk of bladder emptying disorders
than the retropubic tape technique (LOE 1a).
In contrast, there is more frequent pain around the inside of the
thighs and groin and more frequent vaginal injuries in the region of
the sulci following the transobturator implantation technique. With
regard to arrosion, no significant differences appear to exist.
Bladder injuries, retropubic haematomas, bladder emptying disorders,
and symptoms of the lower urinary tract occur more frequently
following retropubic tape insertion.
12 months after the insertion of a transobturator tape, patients have
a higher risk of urethral perforation and chronic perineal pain
(LOE 1a).
If a hypotonic urethra is the cause of stress urinary incontinence,
the continence rates following insertion of a retropubic tape are
better than following insertion of a transobturator tape (LOE
2).
Outside-in vs. inside-out techniques. A comparison of retropubic
and transobturator techniques
The outside-in technique for retropubic suburethral tape insertion is
less effective than the inside-out technique (LOE 1a).
The outside-in technique for retropubic tape is associated with a
higher risk of postoperative bladder emptying disorders (LOE
1b).
The outside-in approach for transobturator tape is equally as
effective as the inside-out approach. However, the outside-in path
is associated with a higher rate of bladder emptying disorders and
bladder injuries.
Single-incision slings (called mini slings)
Mini slings were developed to further reduce the invasiveness of
incontinence operations. Various macroporous polypropylene tapes are
use to stabilise the middle third of the urethra. The insertion
points for mini slings are the retropubic tissue or the obturator
membrane/musculature. The mini slings have the aim of preventing
complications resulting from the tape passage through the retropubic
space or through the adductors of the thigh as well as injuries to
the obturator nerve.
Single-incision slings show an equally high stress urinary
incontinence cure rate as retropubic and transobturator tape up to
12 months postoperatively (LOE 1b). It has not yet been
possible to demonstrate this equivalence in a longer follow-up.
The loss of blood is less and postoperative pain occurs less often
following single-incision slings than following suburethral tape
insertion (LOE 1b). There is no evidence that other
complications occur less often or more frequently following
single-incision slings than following suburethral tape insertion
(LOE 1b).
Adjustable slings
Adjustable slings enable the tension of the implanted slings to be
altered intra- and postoperatively, thus optimising the balance
between continence and bladder emptying.
There is a small amount of evidence that adjustable suburethral
slings are effective in treating stress urinary incontinence in
women (LOE 3). However, there is no evidence that adjustable
slings are superior to suburethral tape (LOE 4).
3.2.1.4 Bulking agents
Bulking agents are injected into the urethral submucosa of the proximal
urethra/the external sphincter and have the aim of improving continence
through coaptation of the urethral wall.
The periurethral injection of a bulking agent leads to a short- or
medium-term improvement in symptoms, depending on the materials used.
There are no long-term data available (LOE 2a).
Repeated injections are often required in order to achieve lasting, yet
sometimes only short-term, treatment success (LOE 2a).
There is no evidence that one type of bulking agent is superior to
another. However, the substances differ considerably in terms of adverse
effects (LOE 1b).
Bulking agents are less effective in curing stress urinary incontinence
than colposuspension or autologous fascial slings (LOE 2a).
The percutaneous approach to the urethral mucosa is associated with a
higher residual urine risk in comparison with the transurethral approach
(LOE 2b).
The use of bulking agents is particularly suitable for a patient
collective with limited operability (LOE 2b).
3.2.2 Surgical treatment for complicated stress urinary
incontinence
The failure rate following incontinence operations differs widely and is
linked to the definition of surgical failures. Failure can occur immediately
following surgery (persistent incontinence) or years after the operation
(recurrent incontinence). Persistent stress urinary incontinence or
recurrent stress urinary incontinence should be clearly differentiated from
urge urinary incontinence or incontinence with another cause (incontinence
as a result of a fistula, neurogenic incontinence, overflow incontinence,
etc.).
Open colposuspension or autologous fascial sling insertion are equally
effective in treating recurrent stress urinary incontinence following
anterior colporrhaphy (LOE 1b). No statistically significant
connection between previous surgical treatment and treatment success
following colposuspension or an autologous fascial sling (LOE 2) can
be found. A systematic literature review showed that the risk of treatment
failure for a stress urinary incontinence operation is higher in women who
had already undergone an incontinence or prolapse operation (LOE 2).
The implantation of a suburethral tape can be less effective in the
secondary treatment of stress urinary incontinence than in primary treatment
(LOE 2). Due to the present data, no recommendation can be made
to remove the primary suburethral tape prior to a further incontinence
operation.
Artificial sphincter
There is only insufficient evidence with regard to the use of an
artificial sphincter in women. In case series with a follow-up of 1
month to 25 years, most of the patients report an improvement in stress
urinary incontinence. The subjective cure rate is between 59–88 %.
Complications comprise mechanical failure with revision operations
within 10 years in up to 42 % of cases and explantation rates of
5.9–15 %. Risk factors for a failure were age, a previous
colposuspension or radiotherapy of the lesser pelvis. Injuries to the
urethra, bladder or rectum were risk factors for the explantation of the
artificial sphincter.
The implantation of an artificial sphincter can improve or cure
complicated stress urinary incontinence in women (LOE 3).
Mechanical failure and the necessity of sphincter explantation or
sphincter replacement are typical risks of an artificial sphincter
(LOE 3).
Suburethral tape, colposuspension and autologous fascial slings are
options for the surgical treatment of persistent or recurrent stress
urinary incontinence in women. The choice depends on the prior
interventions and the preference of the patient or the surgeon.
3.2.3 Surgical treatment of stress urinary incontinence in women with
mixed urinary incontinence
Following surgical treatment of stress urinary incontinence, pre-existing
urge symptoms (urgency) can improve, remain the same or become worse (LOE
3). Women with mixed urinary incontinence and urodynamically
verified detrusor hyperactivity have lower satisfaction rates following
suburethral tape insertion compared with women with stress urinary
incontinence alone. Women with mixed urinary incontinence with dominating
stress urinary incontinence components have a significantly better outcome
following surgical treatment for stress urinary incontinence than women with
dominating components of urge urinary incontinence.
3.2.4 Summary
Recommendations for surgical treatment of uncomplicated female stress
urinary incontinence
Suburethral tape insertion (retropubic and transobturator) should be
offered to women with uncomplicated stress urinary incontinence as a
primary surgical treatment option (recommendation grade A).
Open or laparoscopic colposuspension or autologous fascial slings should
be offered to women with stress urinary incontinence if suburethral tape
insertion (retropubic or transobturator) is not possible.
Colposuspension can also be useful for concomitant traction cystocele,
or if a laparoscopic/open approach was already chosen for other reasons
(recommendation grade A).
Patients with stress urinary incontinence who are offered a retropubic
sling should be informed about the higher perioperative complication
risk compared with transobturator sling insertion (recommendation
grade A).
Patients with stress urinary incontinence who are offered a
transobturator sling should be informed about the higher risk of
dyspareunia and pain over the long term (recommendation grade
A).
Patients with stress urinary incontinence who receive treatment with an
autologous fascial sling should be informed about the high risk of
bladder emptying disorders and the necessity for intermittent
self-catheterisation; it should be ensured that they are capable of this
and in agreement with this (recommendation grade A).
Intraoperative urethrocystoscopy should be performed for every retropubic
suburethral tape insertion and difficulties during transobturator
suburethral tape insertion (recommendation grade B).
Patients with stress urinary incontinence who are offered a mini sling
(single-incision sling) should be informed that this could be less
effective than a suburethral standard sling and the efficacy after one
year has so far not been definitively determined (recommendation
grade B).
Adjustable suburethral slings should only be offered in the primary
treatment of stress urinary incontinence as part of studies
(recommendation grade B).
Periurethral bulking agents should not be offered to women who aim for a
cure for stress urinary incontinence (recommendation grade
A).
Recommendations for surgical treatment of complicated stress urinary
incontinence in women
The selection of surgical treatment to treat recurrent stress urinary
incontinence should only take place following a careful evaluation of
each patient (recommendation grade B).
Patients should be informed that the surgical success of a recurrent
intervention is inferior to that of primary treatment, both in terms of
a reduced benefit and also of an increased intraoperative risk of injury
(recommendation grade B).
An artificial sphincter should only be offered as a treatment option for
complicated stress urinary incontinence if the long-term medical
supervision of the patient is ensured and the patient is able to operate
the sphincter herself. The higher risk of mechanical failure and the
necessity for explantation in the event of complications should be
discussed prior to the operation (recommendation grade B).
