Examqo › Examqo library › Urology › Voiding dysfunction and urodynamics · IMLE
Female stress urinary incontinence and sling surgery
Stress incontinence is leakage of urine on coughing, laughing or effort because of urethral hypermobility or intrinsic sphincter deficiency; start with pelvic floor muscle training for at least 3 months, and if there is no improvement — a midurethral sling is the standard operation.
Why it matters in the exam
The exam shows a woman with leakage on effort, often after childbirth, and asks about the first treatment, the evaluation before surgery or a complication of a sling. The basic evaluation includes history, examination with a cough stress test with a full bladder, urinalysis, post-void residual and a bladder diary; urodynamics is not needed in simple stress incontinence, but is recommended when there are significant urgency symptoms, previous surgery, a high residual or advanced prolapse. In mixed incontinence the dominant component is treated first.
There are two types of sling: retropubic (TVT) and transobturator (TOT). Success rates are similar. The retropubic route has more bladder perforation — so cystoscopy is mandatory during the operation — and more voiding dysfunction; TOT has more groin and thigh pain. Alternatives: Burch colposuspension, an autologous fascial pubovaginal sling (preferred in intrinsic sphincter deficiency, after failure, or when mesh is to be avoided), and periurethral bulking agents, which are less effective and suit a patient who is unfit for surgery.
Sling complications: vaginal mesh exposure, mesh erosion into the urethra or bladder, retention or a weak stream after surgery, new urgency and pain. Retention that does not improve in the first days is treated by releasing the sling. Mesh in the bladder or urethra must be removed. Duloxetine has been studied as drug treatment, but its efficacy is limited and side effects are common. Weight loss improves leakage in overweight women.
Key points
- First line — pelvic floor training for at least 3 months.
- The midurethral sling is the standard operation.
- TVT — bladder perforation; TOT — groin pain.
- Sphincter deficiency or failure — fascial sling or Burch.
- Urodynamics is not needed in a simple case.
Summary table
| Option | Suits | Advantage | Disadvantage |
|---|---|---|---|
| Pelvic floor training | First line for every woman | No risk | Needs 3 months of persistence |
| Retropubic sling (TVT) | Simple SUI or sphincter deficiency | High efficacy | Bladder perforation, cystoscopy needed |
| Transobturator sling (TOT) | Simple SUI | Less bladder perforation | Groin pain |
| Autologous fascial sling | Sphincter deficiency, previous failure, mesh avoidance | No mesh | More retention and morbidity |
| Bulking agents | Patient unfit for surgery | Minor procedure | Lower and repeated efficacy |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Urology, Medical licensing exam (IMLE), Obstetrics and gynecology, Geriatrics.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- AUA/SUFU Guideline: Surgical Treatment of Female Stress Urinary Incontinence, 2023 amendment — Evaluation and surgical options
- EAU Guidelines on Non-neurogenic Female LUTS, 2025 edition — Stress urinary incontinence
- Campbell-Walsh-Wein Urology, 12th edition (2020) — Slings: Autologous, Biologic, Synthetic, and Midurethral
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.