Surgical Treatment of Female Stress Urinary Incontinence

Publication Date: April 25, 2023
Last Updated: April 26, 2023


Patient Evaluation

1. In the initial evaluation of patients with stress urinary incontinence (SUI) desiring to undergo surgical intervention, clinicians should include the following components:

  • History, including assessment of bother
  • Physical examination, including a pelvic examination
  • Objective demonstration of SUI with a comfortably full bladder (any method)
  • Assessment of post-void residual urine (any method)
  • Urinalysis
(Clinical Principle, )

2. Clinicians should perform additional evaluations in patients being considered for surgical intervention who have the following conditions

  • Inability to make definitive diagnosis based on symptoms and initial evaluation
  • Inability to demonstrate SUI
  • Known or suspected neurogenic lower urinary tract dysfunction
  • Abnormal urinalysis, such as unexplained hematuria or pyuria
  • Urgency-predominant mixed urinary incontinence (MUI)
  • Elevated post-void residual per clinician judgment
  • High grade pelvic organ prolapse (POP-Q stage 3 or higher) if SUI is not demonstrated with pelvic organ prolapse reduction
  • Evidence of significant voiding dysfunction
(Expert Opinion, )

3. Clinicians may perform additional evaluations in patients with the following conditions: (Expert Opinion)

  • Concomitant overactive bladder symptoms
  • Failure of prior anti-incontinence surgery
  • Prior pelvic prolapse surgery
(Expert Opinion, )

Cystoscopy and Urodynamics Testing

4. Clinicians should not perform cystoscopy in index patients for the evaluation of SUI unless there is a concern for urinary tract abnormalities.

(Clinical Principle, )

5. Clinicians may omit urodynamic testing for the index patient desiring treatment when SUI is clearly demonstrated.

(Conditional, B)

6. Clinicians may perform urodynamic testing in non-index patients.

(Expert Opinion, )

Patient Counseling

7. In patients wishing to undergo treatment for SUI, the degree of bother that their symptoms are causing them should be considered in their decision for therapy.

(Expert Opinion, )

8. In patients with SUI or stress-predominant MUI who wish to undergo treatment, clinicians should counsel regarding the availability of the following treatment options:

  • Observation
  • Pelvic floor muscle training (± biofeedback)
  • Other non-surgical options (e.g., continence pessary)
  • Surgical intervention
(Clinical Principle, )

9. Clinicians should counsel patients on potential complications specific to the treatment options.

(Clinical Principle, )

10. Prior to selecting midurethral synthetic sling procedures for the surgical treatment of SUI in women, clinicians must discuss the specific risks and benefits of mesh as well as the alternatives to a mesh sling.

(Clinical Principle, )


11. In patients with SUI or stress-predominant MUI, clinicians may offer the following non-surgical treatment options:
  • Continence pessary
  • Vaginal inserts
  • Pelvic floor muscle exercises (PFME) ± biofeedback
(Expert Opinion, )
12. Clinicians should counsel index patients considering surgery for SUI regarding the efficacy and safety of each of their options, which may include the following:
  • Midurethral sling (retropubic, transobturator, or single-incision sling)
  • Autologous fascia pubovaginal sling
  • Burch colposuspension
  • Bulking agents
(Strong, A)
13. In index patients who select midurethral sling surgery, clinicians may offer a
retropubic sling (Conditional, A)
transobturator sling (Conditional, A)
single-incision sling (Conditional, B)
14. Clinicians should not place a mesh sling if the urethra is inadvertently injured at the time of planned midurethral sling procedure. (Clinical Principle, )
15. Clinicians should not offer stem cell therapy (SCT) for stress incontinent patients outside of investigative protocols. (Expert Opinion, )

Special Cases

16. In patients with SUI and a fixed, immobile urethra who wish to undergo treatment, clinicians may offer pubovaginal slings, retropubic midurethral slings, urethral bulking agents, or adjustable retropubic midurethral slings. (Expert Opinion, )
17. Clinicians should not utilize a synthetic midurethral sling in patients undergoing concomitant urethral diverticulectomy, repair of urethrovaginal fistula, or urethral mesh excision and stress incontinence surgery. (Clinical Principle, )
18. Clinicians should strongly consider avoiding the use of mesh in patients undergoing stress incontinence surgery who are at risk for poor wound healing (e.g., following radiation therapy, presence of significant scarring, poor tissue quality). (Expert Opinion, )
19. In patients undergoing concomitant surgery for pelvic prolapse repair and SUI, clinicians may perform any of the incontinence procedures (e.g., midurethral sling, pubovaginal sling, Burch colposuspension). (Conditional, C)
20. Clinicians may offer patients with SUI and concomitant neurologic disease affecting lower urinary tract function (neurogenic bladder) surgical treatment of SUI after appropriate evaluation and counseling have been performed. (Expert Opinion, )
21. Clinicians may offer synthetic midurethral slings, in addition to other sling types, to the following patient populations after appropriate evaluation and counseling have been performed:
  • Patients planning to bear children
  • Diabetes
  • Obesity
  • Geriatric
(Expert Opinion, )

Outcomes Assessment

22. In women with severe outlet dysfunction or recurrent or persistent SUI after surgical intervention (e.g., surgical failure), clinicians may offer placement of an obstructing pubovaginal sling (PVS) or bladder neck closure with urinary drainage after counseling regarding the risks, benefits, and alternatives. (Expert Opinion, )
23. Clinicians or their designees should communicate with patients within the early postoperative period to assess if patients are having any significant voiding problems, pain, or other unanticipated events. If patients are experiencing any of these outcomes, they should be seen and examined. (Expert Opinion, )
24. Patients should be seen and examined by their clinicians or designees within six months post-operatively. Patients with unfavorable outcomes may require additional follow-up.
  • The subjective outcome of surgery as perceived by the patient should be assessed and documented.
  • Patients should be asked about residual incontinence, ease of voiding/force of stream, recent urinary tract infection (UTI), pain, sexual function and new onset or worsened overactive bladder symptoms.
  • A physical exam, including an examination of all surgical incision sites, should be performed to evaluate healing, tenderness, mesh extrusion (in the case of synthetic slings), and any other potential abnormalities.
  • A post-void residual should be obtained.
(Expert Opinion, )

Recommendation Grading



Surgical Treatment of Female Stress Urinary Incontinence

Authoring Organizations

Publication Month/Year

April 25, 2023

Last Updated Month/Year

December 20, 2023

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Treatment, Management

Diseases/Conditions (MeSH)

D014549 - Urinary Incontinence, D014550 - Urinary Incontinence, Stress


Urinary Incontinence, female stress

Source Citation

Kobashi KC, Vasavada S, Bloschichak A, Hermanson L, Kaczmarek J, Kim SK, Kirkby E, Varela N, Malik R. Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023). J Urol. 2023 Apr 25:101097JU0000000000003435. doi: 10.1097/JU.0000000000003435. Epub ahead of print. PMID: 37096580.

Supplemental Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
January 1, 2005
Literature Search End Date
February 28, 2022