CLIMACTERIC 2014;17(Suppl 2):26–33

Managing urinary incontinence: what works? I. Giarenis and L. Cardozo Department of Urogynaecology, King’s College Hospital NHS Foundation Trust, London, UK Key words: ANTIMUSCARINICS, BOTULINUM TOXIN, COLPOSUSPENSION, MID-URETHRAL SLINGS, MIRABEGRON, NEUROMODULATION, PELVIC FLOOR MUSCLE TRAINING, REFRACTORY, REOPERATION, URGENCY, URINARY INCONTINENCE, STRESS URINARY INCONTINENCE

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ABSTRACT Urinary incontinence is a common condition, which, although not life-threatening, impairs the health-related quality of life of affected individuals. All women complaining of incontinence require a basic assessment and those with complex or refractory symptoms may benefit from urodynamic studies. Initial treatment includes lifestyle advice, behavioral modifications, bladder retraining and pelvic floor muscle training. For those women with persistent stress urinary incontinence following conservative therapy, surgical management might be considered. The development of the minimally invasive, retropubic, synthetic, mid-urethral sling procedures has revolutionized stress incontinence surgery and reduced the popularity of ‘traditional’ procedures, such as colposuspension and autologous fascial sling. In an attempt to reduce further the morbidity, transobturator and single-incision slings have been introduced. While antimuscarinic agents are the mainstay of the current medical management of urgency urinary incontinence, a recently developed selective b3-adrenergic receptor agonist (mirabegron) offers an alternative pharmacological option. Modalities such as intravesical botulinum toxin and neuromodulation (peripheral or sacral) are available to women with refractory urgency incontinence. Finally, when all other options have been explored and proven unsuccessful, inappropriate or not feasible, reconstructive surgery or catheter insertion might be considered as a last resort. The aim of this paper is to review conservative, medical and surgical management for urinary incontinence by using the best available evidence in the literature.

INTRODUCTION Urinary incontinence (UI) is defined as the complaint of involuntary loss of urine1. It is a common condition in the female population with most epidemiological studies reporting prevalence in the range of 25–45%2. Although not life-threatening, UI affects the physical, psychosocial and economic well-being of affected individuals and their families3. UI is categorized as stress UI (SUI, complaint of involuntary loss of urine on effort or physical exertion or on sneezing or coughing), urgency UI (UUI, complaint of involuntary loss of urine associated with urgency), and mixed UI (MUI, complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing). SUI is the predominant subtype in young and middleaged women, while MUI and UUI become more prevalent in the elderly population4. International professional bodies recommend initial symptom classification and management based on this classification (Figure 1).

CLINICAL ASSESSMENT AND INVESTIGATIONS While many women with UI may be managed initially with conservative measures, all patients should have a basic assessment in order to confirm the diagnosis, as well as excluding any other underlying causes for lower urinary tract dysfunction. Detailed history of lower urinary tract symptoms (LUTS) and medical co-morbidities including neurological symptoms and current medication should be taken. Physical examination should include a basic neurological examination, provocative stress (cough) test, pelvic organ prolapse assessment, inspection for vulval excoriation and urogenital atrophy. The completion of a 3-day bladder diary incorporating an urgency scale, such as the Patient’s Perception of Intensity of Urgency Scale5 and a disease-specific quality of life questionnaire such as the Kings Health Questionnaire6, is of paramount importance for overall assessment.

Correspondence: Professor L. Cardozo, Department of Urogynaecology, King’s College Hospital, Denmark Hill, London, SE5 9RS, UK; E-mail: linda@ lindacardozo.co.uk REVIEW © 2014 International Menopause Society DOI: 10.3109/13697137.2014.947256

Received 29-06-2014 Revised 15-07-2014 Accepted 18-07-2014

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Managing urinary incontinence: what works?

Giarenis and Cardozo

Figure 1 Initial management of urinary incontinence in women. OAB, overactive bladder; SUI, stress urinary incontinence; MUI, mixed urinary incontinence

Urinalysis, urine culture, measurement of postvoid residuals and uroflowmetry are the basic non-invasive tests. Whilst a number of women complaining of UI may be managed on the basis of simple investigations, those women with refractory symptoms or those undergoing continence surgery may benefit from urodynamic investigations (filling cystometry, pressure-flow study, video cystourethrography or ambulatory urodynamics)7.

GENERAL MEASURES – LIFESTYLE INTERVENTIONS Many women drink too much and those with LUTS should be told to reduce their fluid intake to between 1 and 1.5 l/day8 and to avoid tea, coffee, other caffeine-containing drinks and alcohol if these exacerbate their problem9. There is also increasing evidence to suggest that weight loss may improve symptoms of UI10. Low physical activity appears to be an important modifiable causal factor, operating directly as well as indirectly via pathways involving obesity or diabetes11. The use of drugs that affect bladder and urethral function such as diuretics or α-adrenergic receptor blockers (doxazosin) should be reviewed and, if possible, stopped. In cases where UI begins or worsens after starting systemic hormone

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replacement therapy (HRT)12, the risks and benefits of continuation of HRT should be individually discussed.

STRESS URINARY INCONTINENCE Conservative management Pelvic floor muscle training (PFMT) remains fundamental in the management of women with SUI, as the pelvic floor muscle plays an important role in the continence mechanism. A systematic review of 21 trials involving 1281 women (665 PFMT, 616 controls) showed that women in the PFMT groups were eight times more likely than the controls to report that they were cured (relative risk (RR) 8.38, 95% confidence interval (CI) 3.68–19.07) and 17 times more likely to report cure or improvement (RR 17.33, 95% CI 4.31–69.64)13. Consequently, the 5th International Consultation on Incontinence (ICI) recommends that PFMT should be considered as first-line treatment in all women with SUI (Grade A recommendation)14. Women receiving regular (e.g. weekly) supervision are more likely to report improvement than women doing pelvic floor muscle training with little or no supervision15. Therefore, clinicians should provide the most intensive health professional-led PFMT pro-

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Managing urinary incontinence: what works?

Figure 2

Specialized management of urinary incontinence in women. UT, urinary tract

gram possible within service constraints14. In the UK, the National Institute for Health and Care Excellence (NICE) recommends a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first-line treatment to women with SUI16. Outcomes of these programs depend on a number of factors such as self-motivation to perform PFMT17. Although studies are inconsistent, there does not appear to be a clear benefit of adding electrical stimulation or biofeedback to a PFMT program14,18. Weighted vaginal cones are better than no active treatment in women with SUI and may be of similar effectiveness to PFMT and electrostimulation19. However, their utility in clinical practice could be limited by difficulty in inserting the cones, discomfort and side-effects.

Pharmacological therapy Duloxetine, a combined norepinephrine and serotonin reuptake inhibitor, is the only medication licensed in Europe, but not in the United States, for women with SUI and works by improving urethral-striated sphincter activity via a centrally mediated pathway. It has been shown to reduce incontinence episode frequency by approximately 50% during treatment and significantly improve the quality of life of patients with SUI20. However, it is unclear whether or not the

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benefits are sustainable and side-effects such as nausea are common. In a non-trial cohort of women with SUI, the persistence with duloxetine was very low due to side-effects and lack of efficacy, with only 31% continuing beyond 4 weeks of treatment and 12% at 4 months21.

Surgical management Retropubic urethropexies and ‘traditional’ slings Many women with SUI who do not experience significant improvement with conservative management will require continence surgery (Figure 2). Although surgery is generally recommended when physiotherapy is unsuccessful, initial surgery, as compared with initial PFMT, results in higher rates of subjective improvement and subjective and objective cure at 1 year but with a higher rate of adverse events22. While urodynamic studies have traditionally played a central role in the preoperative assessment of SUI sufferers, there is an ongoing debate about their value prior to surgery23. More than 200 procedures have been described in the literature for the treatment of SUI24. Retropubic urethropexies (colposuspension) and ‘traditional’ pubovaginal slings used to be the ‘gold standards’ for SUI surgery. A recent systematic review comparing autologous fascial sling (AFS) with

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Managing urinary incontinence: what works? colposuspension has shown that patient-reported incontinence and development of pelvic organ prolapse was lower after AFS25. Colposuspension, however, was associated with fewer perioperative complications, and less long-term voiding dysfunction. According to the 5th ICI, open colposuspension and AFS can be recommended as effective treatments for SUI that have longevity (Grade A recommendation)26.

Retropubic mid-urethral slings

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More recently, the description of the integral theory27 has led to the development of the minimally invasive, synthetic, midurethral sling procedures (MUS)28, which have revolutionized surgery for SUI. Retropubic MUS is equally effective as open colposuspension and AFS29, but with shorter operative time, hospital stay and less postoperative complications.

Transobturator mid-urethral slings Since the introduction of the retropubic MUS, several modifications have been proposed in an attempt to avoid complications related to the passage through the space of Retzius. Placement through the obturator foramen and out of the vagina (outside–in) or through the vagina and out of the obturator foramen (inside–out) has gained popularity over the last few years30. There is no evidence of significant differences in the efficacy and impact on women’s quality of life between ‘inside–out’ and ‘outside–in’ transobturator MUS31. The obturator route is borderline less favorable than the retropubic route in efficacy and more likely to cause neurological symptoms (groin/thigh pain), but is associated with less voiding dysfunction, blood loss, bladder perforation and shorter operating time29,32. Especially in the challenging group of women with intrinsic sphincter deficiency, the cure rates for retropubic MUS are significantly greater than for transobturator MUS33.

Giarenis and Cardozo carried out only in the context of research studies or through submission of data to a national register.

Urethral bulking agents Another minimally invasive option that can be performed under local anesthesia in an outpatient clinic is the injection of urethral bulking agents. Traditionally, their use has been reserved for women with SUI and associated intrinsic sphincter deficiency, but more recently views towards utilizing urethral bulking agents in a broader range of patients have been published36. Currently available agents include calcium hydroxylapatite (Coaptite®), carbon-coated zirconium beads (Durasphere®), polyacrylamide hydrogel (Bulkamid®) and polydimethylsiloxane elastomer (Macroplastique®). However, their reported cure rates are much lower (10–59%) compared to MUS, AFS and colposuspensions and very often there is the need for repeat injections37. The available evidence base remains insufficient to guide practice regarding injection route, location for injection, superior urethral bulking agents, volume of material and re-injection intervals.

Persistent or recurrent stress urinary incontinence The management of persistent or recurrent SUI after failed MUS presents a new challenge as currently there are no robust data to recommend or refute any of the different management strategies38. The available surgical options are shortening of the existing MUS, urethral bulking agents, repeat MUS, autologous fascial slings, open or laparoscopic colposuspension, adjustable or spiral slings and placement of an artificial urinary sphincter39. A small retrospective comparative study has shown that the cure rate after repeat MUS is higher than tightening of the existing MUS (72% vs. 46%, p ⫽ 0.034)40. A repeat MUS has a lower cure rate than a primary procedure and, in the repeat group, the retropubic route is superior to the transobturator approach (71% vs. 48%, p ⫽ 0.04)41.

Single-incision mini-slings In an attempt to reduce further the morbidity associated with continence surgery, the single-incision mini-slings (SIMS) have been developed. The insertion of shorter synthetic slings requires less dissection and can be used in a true outpatient setting without sedation. The majority of the initial randomized, controlled trials showed that SIMS were associated with inferior patient-reported and objective cure rates when compared with standard MUS34. However, a more recent meta-analysis demonstrated that, excluding trials with a SIMS withdrawn from the market (TVT-Secur), there was no evidence of significant differences in efficacy, while SIMS were associated with a more favorable recovery time35. Nevertheless, results should be interpreted with caution due to the heterogeneity of the trials included. In view of this, the 5th ICI26 and the NICE16 recommend that SIMS should be

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URGENCY URINARY INCONTINENCE Conservative management Initial treatment of UUI includes lifestyle advice, behavioral modifications, bladder retraining and pelvic floor muscle training. Bladder retraining (BRT) was first described in the 1960s and has been shown to be effective as inpatient or outpatient therapy42. A number of different BRT protocols have been described, but there are no comparative studies to show the most effective program43. A systematic review has also concluded that PFMT is more effective than no treatment or inactive control treatment for women with UUI or MUI. Therefore, the ICI recommends BRT and supervised PFMT as first-line treatment for these women14.

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Pharmacological therapy

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Antimuscarinic agents Antimuscarinic therapy represents the most common pharmacological treatment and may be a useful addition to conservative therapy. During initial treatment, there is more symptomatic improvement when antimuscarinics are compared with BRT alone and when antimuscarinics combined with BRT are compared with bladder training alone44. Traditionally, side-effects such as dry mouth, constipation and detrimental central nervous system effects, including cognitive impairment and sleep disturbances, have limited the usefulness of antimuscarinic agents. All antimuscarinics appear to target both the muscarinic receptors of the detrusor muscle and the afferent (sensory) part of the micturition reflex45, but they vary both in structure and in their functional profile. There are now seven different licensed antimuscarinic drugs available on the market (darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine and trospium), while novel medications are emerging with the aim of improving tolerability and efficacy of treatment46. They are more effective than placebo, safe and well-tolerated treatments that improve health-related quality of life47. Whilst these data confirm the efficacy of antimuscarinic drugs clinically, the evidence comparing one drug with another is less robust. A recent Cochrane review summarized the available data48. Where the prescribing choice is between oral immediate-release oxybutynin or tolterodine, tolterodine might be preferred for reduced risk of dry mouth. Extended-release preparations of oxybutynin or tolterodine are associated with lower risk of dry mouth compared to the immediate-release preparations. Comparisons of solifenacin with immediate-release tolterodine have demonstrated better efficacy and less side-effects for solifenacin. Between fesoterodine and extended-release tolterodine, fesoterodine might be preferred for superior efficacy but has higher risk of withdrawal due to adverse events and higher risk of dry mouth. Should efficacy be the main reason for stopping previous therapy, then it would seem appropriate to try an alternative drug, whilst, if adverse effects are the main reason for discontinuation, then ER preparations, more selective agents or an alternative route of administration (transdermal) may be useful.

Mirabegron Novel agents such as the selective β3-adrenoreceptor agonist mirabegron might offer an alternative option for women not responding or experiencing serious side-effects to antimuscarinics. Large, multi-center, phase III, randomized, controlled trials have shown that mirabegron is more effective in reduction of incontinence episodes per day and improvement of health-related quality of life compared to placebo49,50. The safety and tolerability of mirabegron were established over 12 months, with sustained efficacy observed over this

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Giarenis and Cardozo treatment period51. A recent study has explored the potential synergistic effect of mirabegron with solifenacin in the treatment of overactive bladder52. Combination therapy with solifenacin/mirabegron was well tolerated and significantly improved symptoms of overactive bladder compared with solifenacin 5 mg monotherapy.

Estrogens Estrogens have been used in the treatment of UUI for many years and current evidence supports the use of local estrogens in postmenopausal women12. It remains unclear whether this is due to a true effect on the bladder or by simply reversing local atrophic changes. A recent study has shown that local estrogen therapy may be as beneficial as oral oxybutynin53. There is also some evidence to suggest that administration of local estrogens in conjunction with antimuscarinics could have a synergistic effect in the management of postmenopausal women with overactive bladder 54.

Desmopressin Desmopressin, a synthetic vasopressin analog, has been used primarily in the treatment of nocturia, nocturnal polyuria and nocturnal enuresis in children and adults55. It could also be an option for women who require short-lived situational relief from episodes of daytime UI56. Treatment in elderly patients (ⱖ 65 years of age) should only be undertaken together with careful monitoring of the serum sodium concentration, as it can result in hyponatremia and exacerbate congestive cardiac failure57.

Botulinum toxin Intravesical botulinum toxin, a neurotoxin derived from the anaerobic bacterium Clostridium botulinum, offers an alternative for those with intractable symptoms. Botulinum toxin is injected into multiple sites in the detrusor muscle via cystoscopy, whilst the trigone is generally spared because of the theoretical risk of vesicoureteric reflux. Botulinum toxin type A (BoNTA) is the most common subtype used and a number of proprietary preparations are commercially available. Although all BoNTA products have the same serotype, their dose, efficacy, duration of effect and safety profile are sufficiently different for them to be considered totally different compounds and not generically equivalent58. As there is a significant dose-related risk of voiding difficulties59, 100 units of onabotulinumtoxinA is the recommended dose that appropriately balances symptom benefits with adverse events for patients with idiopathic detrusor overactivity60. The effect of botulinum toxin may last for between 3 and 12 months, but we lack robust evidence on long-term outcome61. Whilst there are few studies regarding the efficacy and complications associated with repeat injections, current data would suggest that repeat procedures are safe and remain effective62.

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Managing urinary incontinence: what works?

Neuromodulation (electrical stimulation)

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Percutaneous posterior tibial nerve stimulation In refractory cases of UUI, percutaneous posterior tibial nerve stimulation (PTNS) can be offered. The postulated mechanism of action for PTNS is through stimulation of the S3 sacral nerve plexus, using a retrograde pathway through direct stimulation of the posterior tibial nerve, accessed just above the ankle. PTNS involves insertion of a 34-gauge stainless needle 3–4 cm cephalad to the medial malleolus of the left or right ankle. A surface electrode is applied near the arch of the foot and the needle and electrode are connected to a low-voltage electrical stimulator. It is usually offered as a course of 12 weekly, 30-min outpatient sessions. PTNS has been shown to be a safe and effective treatment option63, with objective outcome comparable to that of pharmacotherapy64. A significant drawback of PTNS in treating a chronic condition such as UUI is the need for repeated stimulations, as symptoms deteriorate by 6–12 weeks65.

Sacral nerve stimulation For those with refractory UUI, sacral nerve stimulation (SNS) has emerged as a potential therapeutic option. SNS uses a surgically implanted lead and generator to stimulate the S3 sacral nerve root. SNS is thought to activate or ‘reset’ the somatic afferent inputs that play a central role in the modulation of sensory processing and micturition reflex pathways in the spinal cord66. Whilst the reported success rates for subjects who actually received the implantation varied between 60% and 100%, an intention-to-treat analysis in a recent systematic review revealed success rates between 21% and 48% for one-stage implantation with percutaneous nerve evaluation and 75–80% for twostage implantation67. However, a longitudinal study with longterm follow-up reported a gradual decrease of the success rate from 87% at 1 month to 62% at 5 years68. Other limitations of the SNS are the high cost and high reoperation rate with a reported explantation rate of 21% and surgical revision rate of 39%69. Reasons for reoperation are no response, infection, loss of stimulation, painful stimulation, and radiation of stimulation to the leg. The reoperation rate appears to be decreased with the introduction of the tined lead technique70.

Reconstructive surgery Ultimately, a small number of women who have failed to respond to alternative options may benefit from reconstructive surgery. Augmentation cystoplasty involves the use of a gastrointestinal segment (bowel or stomach) to physically enlarge

Giarenis and Cardozo the bladder71. An alternative option is autoaugmentation by making an incision in the detrusor muscle (detrusor myomyotomy), or resecting a portion of the detrusor (detrusor myomectomy). Despite the advantages of avoiding gastrointestinal surgery and shorter operative time, the efficacy and durability appear inferior to augmentation cystoplasty72. Supravesical urinary diversion with or without cystectomy could also be offered for the management of refractory cases73. The ureteroileal conduit is the most common incontinent diversion.

Catheter insertion and coping mechanisms Finally, when all other options have been explored and proven unsuccessful or not feasible, catheter insertion (suprapubic or transurethral) can be considered as a last resort especially in the elderly population. The decision for long-term catheterization should be tailored to patient needs and expectations, as there is limited evidence in the literature about their role in this challenging group of women74. Making toilets and toilet substitutes (commodes) accessible could significantly improve the quality of life of affected patients. Simple measures such as advice about use of fewer layers of loose-fitting clothes, light slippery and easy-to-launder fabrics that do not retain odor can help women with UUI.

CONCLUSIONS Urinary incontinence is common in women of all ages and, whilst not life-threatening, severely adversely affects their quality of life. Whilst it is not always possible to cure everyone, our aim is to improve symptoms and to make the situation more manageable. There have been many significant new management strategies which have been developed over the last three decades, which have increased our armamentarium to deal with both stress and urgency urinary incontinence. Of note, the advent of mid-urethral slings has enhanced the lifestyle of more than 3 million women with stress urinary incontinence. The introduction of new antimuscarinic agents, the selective β3adrenoreceptor agonist mirabegron, and the use of botulinum toxin have enabled us to provide less invasive therapy for those with refractory overactive bladder symptoms. It is important to offer a wide range of options to enable women to choose, considering the benefits and risks associated with each. Conflict of interest I. Giarenis has received travel expenses from Astellas, Ethicon, and Pfi zer. L. Cardozo has acted as a consultant for Allergan, AMS, Astellas; she has received honoraria as a speaker for Astellas and Allergan, and has participated in trials for Pfi zer. Source of funding

Nil.

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Giarenis and Cardozo 20. Mariappan P, Alhasso A, Ballantyne Z, Grant A, N’Dow J. Duloxetine, a serotonin and noradrenaline reuptake inhibitor (SNRI) for the treatment of stress urinary incontinence: a systematic review. Eur Urol 2007;51:67–74 21. Vella M, Duckett J, Basu M. Duloxetine 1 year on: the long-term outcome of a cohort of women prescribed duloxetine. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:961–4 22. Labrie J, Berghmans BL, Fischer K, et al. Surgery versus physiotherapy for stress urinary incontinence. N Engl J Med 2013; 369:1124–33 23. Giarenis I, Cardozo L. What is the value of urodynamic studies before stress incontinence surgery? BJOG 2013;120:130–2 24. Bent AE. Stress urinary incontinence. In Rock JA, Jones HW, eds. Te Linde’s Operative Gynaecology, 10th edn. Philadelphia: Lippincott Williams & Wilkins, 2008:942–59 25. Rehman H, Bezerra CC, Bruschini H, Cody JD. Traditional suburethral sling operations for urinary incontinence in women. Cochrane Database Syst Rev 2011;1:CD001754 26. Dmochowski R, Athanasiou S, Reid F, et al. Surgery for urinary incontinence in women. In Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence, 5th edn. Paris, France: Health Publication Ltd, 2013:1307–75 27. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl 1990;153:7–31 28. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:81–5 29. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009;4:CD006375 30. Frati A, Poncelet C, Madelenat P, Luton D, Ducarme G. Evolution of surgical operations for female for stress urinary incontinence in gynaecology departments of Parisian public hospitals between 2002 and 2006. Gynecol Obstet Fertil 2009;37:589–97 31. Madhuvrata P, Riad M, Ammembal MK, Agur W, Abdel-Fattah M. Systematic review and meta-analysis of “inside-out” versus “outside-in” transobturator tapes in management of stress urinary incontinence in women. Eur J Obstet Gynecol Reprod Biol 2012;162:1–10 32. Richter HE, Albo ME, Zyczynski HM, et al.; Urinary Incontinence Treatment Network. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010; 362:2066–76 33. Schierlitz L, Dwyer PL, Rosamilia A, et al. Three year follow-up of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency. Obstet Gynecol 2012;119:321–7 34. Abdel-Fattah M, Ford JA, Lim CP, Madhuvrata P. Single-incision mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: a meta-analysis of effectiveness and complications. Eur Urol 2011;60:468–80 35. Mostafa A, Lim CP, Hopper L, Madhuvrata P, Abdel-Fattah M. Single-incision mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: an updated systematic review and meta-analysis of effectiveness and complications. Eur Urol 2014;65:402–27 36. Chapple CR, Wein AJ, Brubaker L, et al. Stress incontinence injection therapy: what is best for our patients? Eur Urol 2005; 48:552–65 37. Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD, McClinton S. Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev 2012;2:CD003881

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Managing urinary incontinence: what works?

Urinary incontinence is a common condition, which, although not life-threatening, impairs the health-related quality of life of affected individuals. ...
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