** SUI : The involuntary leakage of urine on effort or exertion or on sneezing or coughing.

2. ** SUI: The involuntary leakage of urine on effort or exertion or on sneezing or coughing. * Affects4%-35% of women.

3. ** Continence: * is achieved when the urethra maintains a pressure greater than bladder pressure. (during a detrusor muscle contraction or an increase in intraabdominal pressure)

5. Etiology 1 -- Pregnancy, child birth 2 – Aging 3 -- Repetitive stress on the pelvic floor 4 --Genetic factor (deficient collagen structure)

6. Clinical Evaluation

8. *** Bladder Diary: * Particularly in patients in whom the etiology of urinary incontinence is UNCERTAIN.

11. Detailed neurologic examination ???

15. Post void Residual Volume ???

17. Laboratory tests FBS U/A , U/C

20. Level A • Preoperative UDS is not necessary before planning primary anti – incontinence surgery in women with uncomplicated SUI : • 1 - defined as PVR less than 150 ml • 2 – negative UA • 3 – a positive cough stress test • 4 – no pelvic organ prolapse beyond the hymen • ACOG 2015

22. * UDSdoesnot improve treatment outcomes in women with uncomplicated SUI prior to midurethralsling surgery. ** women with uncomplicated SUI in whom conservative treatment has failed and who desire midurethral sling surgery, UDS does not affect treatment outcomes .

23. ** Mixed urinary incontinence does not impact the choice of surgical procedure. these women should undergo a trial of pharmacologic therapyprior to surgery. ** Occult SUI, can usually be diagnosed by repeating the urinary stress test while the prolapse is reduced by the examiner. there is no evidence that UDS is required to detect occult SUI.

24. Treatment

25. درمان دارویی مورد توافق همگانی نیست.*

26. Level B • Incontinence pessaries may improve the symptoms of stress and mixed urinary incontinence but objective evidence regarding their effectiveness has not been reported. • When SUI is demonstrated during cough test :an increased rate of SUI after pelvic organ prolapse surgery is expected. ACOG 2015

27. Pelvic muscle exercises (PME) : • Kegle exercises strengthen the muscular urethral closure mechanism.( grade 2A )

30. Local topical Estrogen: • There is inconsistent evidence whether local topical estrogen ( cream , ring , dissolving tablets) improves incontinence symptoms.( grade 2C) * Randomized trials have demonstrated that OralEstrogenworsen urinary incontinence. Up to date 2017

31. Surgical trearment

32. 1 -- Women who decline or have persistent symptoms following conservative therapy • Surgical treatment have consistently been shown to have a higherefficacy rate than conservative therapy. *Surgery is associated with increased morbidity, postoperative voiding difficultly & development or worsening of urgency incontinence.

33. 2 -- Women with occult SUI : *Concomitant anti-incontinence surgery is warranted in some women who are undergoing repair of advanced pelvic organ prolapse

34. 3 -- Women finished with childbearing : * Since pelvic support may be disrupted during pregnancy and particularly a vaginal birth ,most physicians recommend delaying surgical management of SUI until childbearing has been completed.

35. Pre operative counseling • Patient & surgeon satisfaction with treatment can be optimized by having a discussion during the planning phase for the surgery about the individual patient goals & expectations for her treatment & awareness of potential adverse events.

36. Suburethral sling :A suburethral sling is a sling that is inserted through a small vaginal incision and placed either at the bladder neck, midurethra or proximalurethra. 1 - Bladder neck sling : A suburethral sling that is placed at the level of the proximal urethra and bladder neck 2 - Midurethralsling :A suburethral sling that is placed at the level of the midurethra in a tension free manner (eg, tension-free vaginal tape procedures). 3 - Retropubiccolposuspension:Procedures performed through laparotomy or laparoscopy in which the vaginal wall adjacent to the midurethra and bladder neck is suspended, using sutures, in a retropubicposition

38. Level A • Initial midurethral sling surgery results in higher 1 – year subjective and objective cure rates than pelvicfloor physical therapy in women with SUI. • MUS demonstrate efficacy that is similar to traditional suburethralfascial slings – open colposuspension and laparoscopic colposuspension. • Compared with suburethral fascial slings: feweradverse events have been reported with MUS. ACOG 2015

39. Level A • Voiding dysfunction is more common with open colposuspensionthan with MUS. • There are substantial safety and efficacy data that support the role of MUS as a primary surgical treatment option for SUI in women. ACOG 2015

42. Surgical Technique 1. antibiotic administration. 2. Sterile urine 3. Patient positioning and preparation.

43. 4. Anesthesia. 5. The exit site of the needle is marked. It should be 2 cm above the level of the urethra and 2 cm lateral to the labial fold.

49. 6. Vaginal incision. 7. Vaginal dissection

50. CHOOSING A TYPE OF TRANSOBTURATOR SLING ●Inside-out – The trocars are passed from a midurethral vaginal incision to exit through bilateral groin incisions (TVT Transobturator, often abbreviated as TVT-O). ●Outside-in – The trocars are passed from bilateral groin incisions to exit through a midurethral vaginal incision (Monarc, often abbreviated as TOT).