Introduction

Urinary stress incontinence is the involuntary loss of urine on effort or exertion. It occurs when bladder pressure is greater than urethral resistance (1). It is a common medical condition reported by up to 25 percent of premenopausal women; 40 percent of postmenopausal women report loss of urine (2). The prevalence of incontinence increases with each passing decade of life, with the lowest prevalence found in women younger than 30 years, and the highest among women older than 90 years. A peak also occurs between the ages of 50–54 years. Half of these women have pure stress incontinence (3).

A complete evaluation of stress urinary incontinence (SUI) should include a detailed history, physical examination, urinalysis (to rule out infection), a cough stress test, assessment of urethral hypermobility, and an evaluation of a postvoid residual (4). Technically a cough stress test is performed with a full bladder, and demonstration of leaking with an increase in abdominal pressure (cough or Valsalva) supports the diagnosis of SUI. See Chapter 22.

Nonsurgical management of SUI includes lifestyle modifications, pelvic floor muscle training, and use of an incontinence pessary (1,5). These may be selected by patients who prefer to avoid surgical management for medical or personal reasons.

Historical Procedures

Frank first described a procedure for urinary incontinence in 1882. He described a transvaginal approach for the excision of the urethral wall and plication of the vagina at the bladder neck. A similar procedure was later reported on by F. Winckel from Munich (1881–1882) and B. S. Schultze in 1888.

A different approach was attempted in 1883 by Karl Pawlik from Vienna. By flattening the outer urethra, he was able to oppose the urethral walls. Surgically he brought the external orifice of the uethra out to the clitoris, and sutured it bilaterally to fix the position. In 1888, R. Gersuny, also from Vienna, attempted to improve on this method. He described torsion of the urethra, dissecting the entire urethral from the external orifice to the bladder neck and then suturing it to a new position. Urethral dissection and transfixation toward the clitoris was also described by Alfred Pousson and Joaquin Albarran in 1892, and by E. C. Dudley in 1895 (6).