Surgical treatment of anatomical stress incontinence

Abstract The condition Stress Incontinence may be classified as (a) anatomical (AI) and (b) due to intrinsic sphincter damage (ID). While anatomical incontinence is due to anatomical malposition of a normal sphincteric unit in intrinsic damage, the sphincteric unit is abnormal (damaged from multiple surgery, radiation, neurologic disease, etc). The goal of surgery for AI is to reposition the bladder neck and urethra in a high, fixed retropubic position without obstruction. With improvements in the surgical techniques and a better understanding of the anatomical landmarks a clear trend has evolved in recent years toward vaginal approach. Important principles of the vaginal approach include mobilization or the urethra and bladder neck, precise placement of the suspension sutures in sturdy tissue (endopelvic fascia), fingertip guidance of a ligature carrier through the retropubic space, cystoscopy control and tying the sutures without tension. The advantages are simplicity, less morbidity and providing equal or better results than the abdominal approach. AI is only a symptom of pelvic prolapse and concomitant pathology like rectocele, enterocele and uterine prolapse should be addressed at the time of surgical repair. The pathophysiology, classification and different modalities of treatment for anatomical incontinence are discussed.