Care Pathway for the Management of Stress Urinary Incontinence (SUI) | Australian Commission on Safety and Quality in Health Care

SPECIALIST MANAGEMENT

This may include care by gynaecologists, urogynaecologists, urologists and geriatricians with an interest in pelvic floor disorders

No treatment

Non-surgical treatments

Patient assessed as requiring operative management

SUI Surgery Pathway – routine cases

Bothersome SUI not responding to conservative treatment

Mid-urethral sling
(synthetic mesh)

Bulking Agent

Colposuspension
(native tissue)

Pubovaginal sling
(native tissue)

Retropubic
tape

Obturator
tape

Mini-sling

Patients should be offered the opportunity for a minimum period of six months follow-up after surgery.

Preferred options for treatment – use of mesh for these procedures is supported by evidence.

Possible pathway – use of native tissue and mesh for these procedures is supported by evidence.

Not recommended.

Bothersome SUI not responding to conservative treatment

Mid-Urethral Sling (synthetic mesh)

Retropubic tape

Obturator tape

Mini-sling

Bulking Agent

Colposuspension (native tissue)

Pubovaginal sling (native tissue)

Patients should be offered the opportunity for a minimum period of six months follow-up after surgery.

Preferred options for treatment – use of mesh for these procedures is supported by evidence.

Possible pathway – use of native tissue and mesh for these procedures is supported by evidence.

Not recommended.

Colposuspension (native tissue)

	GoR*
Inferior outcomes to pubovaginal slings for primary repair, possibly with less voiding dysfunction	B
Outcomes similar or slightly less than synthetic MUS however longer operating time and recovery, slower return to activities of daily living and more prolapse in medium term	B
Laparoscopic approach when performed same technique as open has similar success rate with less morbidity than open approach	B
Lower rates of success, with higher retreatment rates, when compared to pubovaginal slings for primary repair	B

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Obturator tape

Retropubic versus transobturator mid-urethral sling	GoR*
In the short-term there are similar success rates for retropublic and transobturator	A
Obturator tapes slightly quicker, with less blood loss, bladder perforation and voiding dysfunction difficulties. Most of these differences were small and the complications are readily able to be managed.	A
However in the medium term (>5 years) the reoperation for recurrent SUI greater in obturator group and a small number developed groin pain (3-4%) that is difficult to treat.	B
Retropubic considered as the preferred procedure with transobturator reserved for those patients with a hostile abdomen	C

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Retropubic tape

Retropubic versus transobturator mid-urethral sling	GoR*
In the short‐term there are similar success rates for retropubic and transobturator mid urethral slings	A
Obturator tapes are slightly quicker, with less blood loss, bladder perforation and voiding dysfunction difficulties. Most of these differences were small and the complications are readily able to be managed.	A
However in the medium term (>5 years) the reoperation for recurrent SUI greater in obturator group and a small number developed groin pain (3-4%) that is difficult to treat.	B
Retropubic considered as the preferred procedure with transobturator reserved for those patients with a hostile abdomen	C

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Pubovaginal sling (native tissue)

Pubovaginal (fascial) sling	GoR*
Similar success rates compared to MUS with longer operating time and possibly higher voiding dysfunction; fascial sling has lower rates of chronic pelvic pain, no risk of erosion or extrusion, and higher rates of post‐operative morbidity	B
Lower rate of bladder perforation during surgery compared to MUS.	B
Fascial sling has higher patient satisfaction and treatment success compared to colposuspension	B
Involves a longer operation, post‐operative hospital stay (2–3 days) and recovery period than MUS	B
Consider in women wishing to avoid mesh‐related complications	–

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

Bulking Agent

	GoR*
May be a useful option for recurrent SUI with a well supported urethra	B
Greater symptomatic improvement was observed with surgical treatments, although the advantage needs to be balanced against risk of intervention	C
Consider in women wishing to avoid mesh‐related complications	–

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

The Grade of Recommendation has been derived from the 5th International Consultation on Incontinence (see Int Urogynecol J. 2013 Nov;24(11):1781 https://link.springer.com/article/10.1007/s00192-013-2168-x and expert opinion during the Commission’s development of the guidance

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