The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) has updated their 2017 clinical practice guideline on the surgical treatment of female stress urinary incontinence (SUI). This amendment is based on their review of 24 studies published through February 2022. No changes were made to the patient evaluation and cystoscopy and urodynamics testing sections and only a minor update was made to patient counseling.

In The Journal of Urology, Kathleen C. Kobashi, MD, chair of the Department of Urology at Houston Methodist Hospital in Houston, Texas, and fellow members of the guideline panel outlined the updates to treatment and special cases. Here’s a synopsis:

Defining Patients

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Distinguishing between index and non-index patients remains paramount. The index patient, according to the panel, is a healthy female with minimal or no prolapse who desires surgical therapy for treatment of pure SUI or stress-predominant mixed urinary incontinence. Non-index patients have factors affecting treatment choice, according to the panel, such as grade 3 or 4 prolapse, urgency-predominant mixed incontinence, neurogenic lower urinary tract dysfunction, incomplete bladder emptying, dysfunctional voiding, SUI following anti-incontinence treatment, mesh complications, high body mass index, or advanced age.


Conservative Measures

The guideline discusses the use of pelvic floor muscle exercises with or without biofeedback and a small randomized controlled trial (RCT) that supports the addition of dynamic lumbopelvic stabilization in short pelvic floor muscle and lumbar muscle resistance training.

Transobturator Midurethral Sling (TMUS) vs Retropubic Midurethral Sling (RMUS)

Patients should be counseled on the safety and efficacy of each surgical option, the panel emphasized. Some studies showed greater risks with TMUS, although a study looking at composite outcomes over 5 years found comparable rates of mesh exposure, urinary retention, repeat anti-incontinence surgery, and moderate to severe pelvic pain between the TMUS and RMUS procedures.

The panel cited one systematic review that specifically examined a non-index patient that reported favorable subjective and objective outcomes for transvaginal tape over transobturator tape in patients with obesity, intrinsic sphincter deficiency, persistent SUI after MUS, and prolapse.

Single-Incision Slings

Long-term data are now emerging on single-incision slings (SIS), according to the panel, demonstrating noninferiority to the TMUS in cure rates and adverse events. An updated systematic review and meta-analysis comparing SIS with RMUS indicated a lower objective cure rate with SIS over 60 months.

Bulking Agents

With urethral bulking, repeat injection is often needed. There are limited long-term data on bulking agents, except for calcium hydroxyapatite, polydimethylsiloxane, and polyacrylamide hydrogel, which show benefit for 5 years or more.

Stem Cell Therapy

Stem cell therapy may be a future option for women with SUI, but comparative data and outcome data are lacking.

Laser and magnetic/electrical stimulation therapy is being explored, but the efficacy and safety data are immature.

Special Cases

Fixed Immobile Urethra: Autologous pubovaginal sling is preferred over RMUS and bulking agents.

Refractory or recurrent SUI: the adjustable RMUS, which allows clinicians to adjust sling tension over time, is being explored.

Concomitant Sling at the Time of Prolapse Repair: Combination surgery continues to show favorable results compared with prolapse surgery alone, but with higher rates of complications and adverse events.

Severe Outlet Dysfunction, Recurrent or Persistent Postoperative SUI After Anti-incontinence Surgery: In a new guideline statement,patients with a severely compromised bladder outlet may have an obstructing pubovaginal sling or bladder neck closure with urinary drainage. In challenging cases with functional or anatomic problems, urologists should consider a traditional autologous pubovaginal sling, an obstructing autologous sling, or formal bladder neck closure with a catheterizable stoma, an artificial urinary sphincter, or total urinary diversion via ileal conduit or continent diversion.

Outcomes assessment: The Panel continues to recommend early follow-up whether in-person, by phone, or via telemedicine.


To advance the field, it is essential to standardize outcomes evaluation, assessment tools, and what defines success in SUI treatment, according to the panel.

“While technology continues to evolve and new innovative techniques emerge, accurate assessment of outcomes following medical intervention is paramount to optimizing one’s ability to offer the best treatments for our patients.”


Kobashi KC, Vasavada S, Bloschichak A, et al. Updates to surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline (2023). J Urol. 2023 Jun;209(6):1091-1098. doi: 10.1097/JU.0000000000003435