Urinary Incontinence — Assessment & Treatment
Urinary incontinence is common, treatable, and — crucially — not something women simply have to accept. Mr. Jesuraj provides specialist assessment, conservative treatment, surgical options, and careful referral to a urogynaecologist where needed. Treatment is always matched to the individual.
Stress Incontinence
Leakage on coughing, sneezing, laughing or exercise — when abdominal pressure exceeds urethral resistance
Urgency Incontinence
Sudden, compelling urge to void followed by leakage — caused by overactive bladder (OAB)
Mixed Incontinence
Both stress and urgency components — requires careful assessment to identify the predominant type
INTRODUCTION
Understanding Urinary Incontinence
Urinary incontinence — the involuntary leakage of urine — affects approximately one in three women at some point in their lives. Despite being so common, many women do not seek help, assuming it is an inevitable consequence of childbirth or ageing. This is not the case. Effective treatments exist at every level of severity — from simple lifestyle measures to surgery.
Accurate diagnosis of the type of incontinence is the essential first step. Stress incontinence, urgency incontinence and mixed incontinence have different underlying mechanisms and require different treatments. Treating urgency incontinence surgically — when it actually requires bladder-directed therapy — will not help, and vice versa. Mr. Jesuraj takes a structured, investigation-led approach before any treatment is recommended.
Treatment always begins with conservative measures. Surgery is considered only when conservative management has been given a fair trial and has not provided adequate relief — and only after the nature of the incontinence has been thoroughly assessed.
NICE Guideline NG123
Our practice follows NICE Guideline NG123 — Urinary Incontinence and Pelvic Organ Prolapse in Women: Management (2019, updated 2025). This is the authoritative evidence-based guideline governing assessment and treatment of urinary incontinence in England and Wales.
NICE Patient Decision Aid
NICE has produced a dedicated Patient Decision Aid for surgery for stress urinary incontinence — a practical tool to help women understand the surgical options, their benefits and risks, and make an informed, personal decision.
ASSESSMENT
How We Assess Urinary Incontinence
Accurate assessment is the cornerstone of good incontinence management — the treatment depends entirely on the correct diagnosis.
Detailed History & Bladder Diary
Symptom type, severity, timing, fluid intake, impact on quality of life. A 3-day bladder diary is invaluable — recording voiding frequency, volumes, leakage episodes and triggers.
Clinical Examination
Pelvic examination to assess pelvic organ prolapse, pelvic floor tone and any demonstrable stress leakage on coughing.
Urine Tests
Dipstick urinalysis and MSU to exclude urinary tract infection — which can cause or worsen urgency incontinence and must be treated before any further assessment.
Bladder Scan
Post-void residual urine measurement — to identify incomplete bladder emptying, which affects treatment choices and contraindicates some procedures.
Urodynamic Studies
Pressure-flow urodynamics where the diagnosis is unclear, in mixed incontinence, before surgery, or where previous surgery has failed. Confirms stress or urgency mechanism and identifies detrusor overactivity or voiding dysfunction.
Cystoscopy
Where bladder pathology (tumour, interstitial cystitis, bladder stone) may be contributing to urgency symptoms. Performed under local anaesthetic in clinic.
Conservative Treatment
First-Line — Conservative Management
Conservative treatment is always the starting point. Surgery is only considered after conservative measures have been given a proper trial — typically 3–6 months of supervised treatment.
Lifestyle Modifications — For All Types of Incontinence
Bladder Retraining — For Urgency & Mixed Incontinence
Bladder retraining is the primary behavioural intervention for urgency incontinence and overactive bladder. The bladder has a degree of neurological plasticity — it can be retrained to hold larger volumes before triggering the urge to void, breaking the cycle of urgency and frequent urination.
Timed Voiding
Voiding at set intervals regardless of urge — starting at a manageable interval (e.g. 1 hour) and gradually extending by 15–30 minutes each week until a 2.5–3.5 hour voiding interval is achieved.
Urge Suppression Techniques
When urgency occurs, distraction techniques (mental arithmetic, wiggling toes, sitting on a firm surface) and pelvic floor contraction can suppress the urge and “hold on” until the scheduled voiding time.
Bladder Diary Monitoring
Regular 3-day bladder diaries track progress and motivate continued engagement with the programme. Visible improvement in voiding intervals is a powerful reinforcer.
Medication for Overactive Bladder & Urgency Incontinence
For women with urgency or mixed incontinence where bladder retraining alone is insufficient, medication targeting detrusor overactivity is an important part of the treatment pathway.
SURGICAL TREATMENT
Surgical Options for Stress Urinary Incontinence
Surgery is considered when conservative management has failed to provide adequate relief after 3–6 months. The right procedure depends on the type of incontinence, the presence of prolapse, previous surgery, and patient preference.
NICE Patient Decision Aid — Surgery for Stress Urinary Incontinence
Before any decision about surgery, Mr. Jesuraj uses the NICE Patient Decision Aid with every patient. This tool explains all three surgical options recommended by NICE — autologous fascial sling, colposuspension, and mid-urethral mesh sling (where available) — including their benefits, risks and what to expect. It is designed to support shared decision-making rather than replace it.
Urethral Bulking Agents
Periurethral injections to bulk the urethral lining and improve coaptation
MINIMALLY INVASIVE
Bulking agents are injectable substances introduced around the urethra to bulk the urethral wall and improve urethral closure — reducing stress leakage. They are the least invasive surgical option and can be performed under local anaesthetic as a day case. Agents include polyacrylamide hydrogel (Bulkamid) and calcium hydroxylapatite (Coaptite).
Bulking agents are less effective than surgery — NICE notes the evidence suggests lower success rates than slings or colposuspension — but they are an appropriate option for women who are medically unfit for general anaesthetic, who wish to avoid or defer surgery, or in whom previous surgery has failed. Effects may wear off over time and repeat injections may be needed.
SUITABLE FOR
ANAESTHETIC
Local anaesthetic
DURATION
15–30 minutes
RECOVERY
48 hours rest
EFFECTIVENESS
>99.9% — confirmed by semen test
Mid-Urethral Slings — Autologous (Fascial) Sling
A sling of tissue placed under the mid-urethra to restore urethral support
★ Offered — Autologous
A mid-urethral sling is the most effective surgical treatment for stress urinary incontinence. A sling of material is placed under the mid-urethra to provide a supportive platform — correcting the loss of urethral support that underlies stress incontinence. There are two distinct types of sling material: autologous (using the patient’s own tissue) and synthetic (mesh). These are not interchangeable and must be considered separately.
Autologous Rectus Fascial Sling – We offer this
The autologous fascial sling uses a strip of the patient’s own rectus abdominis fascia (the tough fibrous sheath of the abdominal muscle) harvested from a small incision in the lower abdomen. This strip is then placed as a sling under the mid-urethra and attached to the abdominal wall. Because it uses the patient’s own tissue, there are no mesh-related complications — no risk of erosion, no foreign body.
ANAESTHETIC
General anaesthetic
DURATION
60–90 minutes
Voiding
1–2 weeks
SETTING
Day case or overnight stay
RECOVERY
4–6 weeks
Durability
Excellent — own tissue, no foreign body risks
Synthetic Mid-Urethral Tape (TVT/TOT) – Suspended from Practice
Synthetic mid-urethral slings — the retropubic TVT (tension-free vaginal tape) and the transobturator TOT — use a narrow strip of polypropylene mesh placed under the mid-urethra. These procedures became widely used from the late 1990s because of their simplicity, short recovery, and good short-term success rates.
However, serious, life-altering complications affecting a significant number of women — including mesh erosion through the vaginal wall or urethra, chronic pelvic pain, dyspareunia (painful intercourse), and nerve injury — led to a major patient safety review.
Following the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege, and on the recommendation of NHS England, synthetic mid-urethral mesh sling procedures were placed under a “High Vigilance Restriction” in England in July 2018. This restriction has been maintained and these procedures are not routinely available on the NHS in England and Wales outside of specialist centres meeting specific governance requirements.
We do not offer synthetic mesh sling procedures — in line with current NHS England guidance. Women who wish to explore this option within the regulated framework can be referred to an appropriate specialist centre after thorough discussion of the risks.
Colposuspension (Burch Colposuspension)
Elevation and suturing of the bladder neck to the iliopectineal ligament — restoring the urethrovesical junction
VIA REFERRAL
Colposuspension is an open or laparoscopic operation in which the tissues on either side of the bladder neck and proximal urethra are elevated and sutured to the iliopectineal (Cooper’s) ligament — restoring the urethrovesical junction to its correct anatomical position. It was the gold standard surgical treatment for stress incontinence for decades before the introduction of mesh tapes.
Colposuspension has excellent long-term cure rates — comparable to the autologous fascial sling — and has the advantage of simultaneously correcting anterior wall prolapse. The laparoscopic approach (keyhole) offers similar efficacy to open surgery with faster recovery.
This procedure is recommended by NICE as a primary surgical option alongside the autologous fascial sling. Mr. Jesuraj provides assessment, investigation and counselling for colposuspension and will arrange referral to a urogynaecologist with specialist expertise in this procedure where it is the most appropriate choice.
Best For
APPROACH
Open or laparoscopic
ANAESTHETIC
General anaesthetic
SETTING
1–2 nights inpatient
RECOVERY
4–6 weeks
EFFICACY
Excellent — comparable to fascial sling
AVAILABLE
Via urogynaecology referral
COMBINED CONDITIONS
Stress Incontinence with Pelvic Organ Prolapse
When stress incontinence coexists with significant pelvic organ prolapse, both conditions need to be considered together — the surgical strategy for one affects the other.
Pelvic organ prolapse — descent of the bladder (cystocele), uterus, or vaginal vault — commonly accompanies stress incontinence, as both conditions share the same underlying weakness in pelvic floor support. When prolapse is present, treatment must address both — treating the incontinence without addressing the prolapse, or vice versa, may produce incomplete or unsatisfactory results.
Importantly, prolapse can also mask underlying stress incontinence — the prolapse kinks the urethra preventing leakage (occult or latent stress incontinence). When the prolapse is corrected surgically, the incontinence may then become apparent. This possibility is discussed at assessment and planned for in advance.
The management of combined stress incontinence and pelvic organ prolapse is within the specialist domain of urogynaecology. Mr. Jesuraj provides initial assessment, investigation including urodynamics, and a clear clinical summary — and then arranges referral to a consultant urogynaecologist with expertise in complex pelvic floor reconstruction.
Managing Mixed Urinary Incontinence
Mixed incontinence — both stress and urgency components — requires careful patient selection, treatment sequencing and realistic expectations.
Women with mixed urinary incontinence present a particular challenge — they have both a structural problem (urethral support failure causing stress leakage) and a functional problem (detrusor overactivity causing urgency and urge leakage). Treating one without the other will not fully resolve symptoms, and treating surgically without first addressing the urgency component risks significant post-operative dissatisfaction.
1
Identify the Dominant Component
Through detailed symptom history, bladder diary and urodynamic testing — determine whether stress or urgency is the predominant complaint and is causing the most bother. This determines the primary treatment target.
2
Treat the Urgency Component First
Bladder retraining, OAB medication (anticholinergics or mirabegron) and lifestyle modification should be established and optimised before any surgical decision. Urgency symptoms may persist or worsen after stress incontinence surgery if OAB is not first addressed — and conversely, some urgency symptoms in women with stress incontinence resolve after surgical correction of the leakage.
3
Reassess After Bladder Retraining
After 3–6 months of combined bladder retraining and pelvic floor muscle training, the symptom picture may change — urgency symptoms may improve significantly, leaving primarily stress incontinence (or vice versa). Reassessment determines whether and what type of surgery is then indicated.
4
Surgical Treatment if Appropriate
Where stress incontinence remains the dominant, functionally impairing problem after conservative measures, surgery can be offered. The patient must be counselled that urgency symptoms may not fully resolve after surgery for stress incontinence, and may require continued medical management.
5
Continued OAB Management Post-Surgery
Bladder Botox injection, continuation of OAB medication, or neuromodulation (sacral nerve stimulation) may be needed post-operatively for women with persistent urgency incontinence. These are planned for in advance — not presented as a surprise complication.
PATIENT SELECTION
Who Is Suitable for Surgery?
Surgery Is Appropriate When:
Stress incontinence is confirmed — clinically and/or urodynamically
Conservative management (3–6 months supervised PFMT) has been completed and failed to provide adequate relief
The symptom burden is sufficient to make surgery worthwhile — impact on quality of life, activity, relationships
The patient fully understands and accepts the risks, including voiding difficulty and the possibility of symptoms persisting
Prolapse has been assessed and a plan exists for managing it
Urgency component has been treated and reassessed
Family is complete — or the patient understands implications if considering future pregnancy
Surgery Is Not Appropriate When:
Conservative management has not been properly completed
Urgency incontinence is the dominant component — and has not been treated
The diagnosis is uncertain and urodynamics have not been performed
The patient is planning further pregnancies — risk of recurrence is high
Medical co-morbidities make surgical risk unacceptable
Significant post-void residual suggests voiding dysfunction — risk of urinary retention post-surgery
Active urinary tract infection
Interested?
Book a consultation with Mr. Jesuraj to find out if you are a suitable candidate. Appointments available within days.
Treatments — Female Urology
Urinary Incontinence — Assessment & Treatment
Urinary incontinence is common, treatable, and — crucially — not something women simply have to accept. Mr. Jesuraj provides specialist assessment, conservative treatment, surgical options, and careful referral to a urogynaecologist where needed. Treatment is always matched to the individual.
Types of Urinary Incontinence
Leakage on coughing, sneezing, laughing or exercise — when abdominal pressure exceeds urethral resistance
Sudden, compelling urge to void followed by leakage — caused by overactive bladder (OAB)
Both stress and urgency components — requires careful assessment to identify the predominant type
Introduction
Understanding Urinary Incontinence
Urinary incontinence — the involuntary leakage of urine — affects approximately one in three women at some point in their lives. Despite being so common, many women do not seek help, assuming it is an inevitable consequence of childbirth or ageing. This is not the case. Effective treatments exist at every level of severity — from simple lifestyle measures to surgery.
Accurate diagnosis of the type of incontinence is the essential first step. Stress incontinence, urgency incontinence and mixed incontinence have different underlying mechanisms and require different treatments. Treating urgency incontinence surgically — when it actually requires bladder-directed therapy — will not help, and vice versa. Mr. Jesuraj takes a structured, investigation-led approach before any treatment is recommended.
Treatment always begins with conservative measures. Surgery is considered only when conservative management has been given a fair trial and has not provided adequate relief — and only after the nature of the incontinence has been thoroughly assessed.
NICE Guideline NG123
Our practice follows NICE Guideline NG123 — Urinary Incontinence and Pelvic Organ Prolapse in Women: Management (2019, updated 2025). This is the authoritative evidence-based guideline governing assessment and treatment of urinary incontinence in England and Wales.
Read NICE Guideline NG123 →NICE Patient Decision Aid
NICE has produced a dedicated Patient Decision Aid for surgery for stress urinary incontinence — a practical tool to help women understand the surgical options, their benefits and risks, and make an informed, personal decision.
Download NICE Decision Aid (PDF) →Mr. Jesuraj uses this decision aid as part of the consent and decision-making process for all women considering surgery for stress incontinence.
Assessment
How We Assess Urinary Incontinence
Accurate assessment is the cornerstone of good incontinence management — the treatment depends entirely on the correct diagnosis.
Symptom type, severity, timing, fluid intake, impact on quality of life. A 3-day bladder diary is invaluable — recording voiding frequency, volumes, leakage episodes and triggers.
Pelvic examination to assess pelvic organ prolapse, pelvic floor tone and any demonstrable stress leakage on coughing.
Dipstick urinalysis and MSU to exclude urinary tract infection — which can cause or worsen urgency incontinence and must be treated before any further assessment.
Post-void residual urine measurement — to identify incomplete bladder emptying, which affects treatment choices and contraindicates some procedures.
Pressure-flow urodynamics where the diagnosis is unclear, in mixed incontinence, before surgery, or where previous surgery has failed. Confirms stress or urgency mechanism and identifies detrusor overactivity or voiding dysfunction.
Where bladder pathology (tumour, interstitial cystitis, bladder stone) may be contributing to urgency symptoms. Performed under local anaesthetic in clinic.
Conservative Treatment
First-Line — Conservative Management
Conservative treatment is always the starting point. Surgery is only considered after conservative measures have been given a proper trial — typically 3–6 months of supervised treatment.
Lifestyle Modifications — For All Types of Incontinence
A 5–10% reduction in body weight produces clinically meaningful improvement in stress and urgency incontinence. Obesity increases intra-abdominal pressure — weight loss directly reduces this. One of the most effective interventions in overweight women.
Appropriate fluid intake — neither excessive nor restricted. Aim for 1.5–2 litres of water per day. Restricting fluids concentrates the urine, irritates the bladder and worsens urgency. Avoiding fluids near bedtime reduces nocturia.
Caffeine is a bladder irritant and diuretic. Reducing or eliminating tea, coffee, energy drinks and cola significantly reduces urgency symptoms in many women — often within days. NICE recommends a trial of caffeine reduction as first-line for OAB.
Smoking causes chronic cough — which repeatedly stresses the pelvic floor and worsens stress incontinence. Nicotine also irritates the bladder directly. Stopping smoking improves both types of incontinence.
Oestrogen deficiency after the menopause causes thinning of urogenital tissue and worsens both stress and urgency incontinence. Topical vaginal oestrogen (cream, pessary or ring) restores tissue health, reduces urgency and improves the urethral sphincter mechanism. Safe for long-term use.
Constipation and straining at stool increase intra-abdominal pressure and worsen stress incontinence while also contributing to an overactive bladder. A high-fibre diet, adequate hydration and regular bowel habit are important adjuncts to incontinence management.
Pelvic Floor Muscle Training (PFMT)
Pelvic floor muscle training is the most important and effective conservative intervention for stress incontinence and has a role in mixed incontinence. It involves structured, supervised exercises to strengthen the levator ani and pubococcygeus muscles — improving urethral support and closure pressure during sudden rises in intra-abdominal pressure.
To be effective, PFMT must be performed correctly, consistently and for a sustained period. Many women do not know how to contract the correct muscles, and benefit greatly from supervised instruction — either by a specialist nurse or a pelvic health physiotherapist. Biofeedback and electrical stimulation may be used adjunctively.
NICE recommends that a supervised pelvic floor muscle training programme of at least 3 months is offered as first-line treatment to all women with stress or mixed urinary incontinence. Surgery should not be offered without first completing this.
Supervised PFMT Programme
Assessment of pelvic floor muscle function by specialist nurse or physiotherapist
Instruction in correct technique — pelvic floor biofeedback where needed
Individualised home exercise programme — minimum 8 contractions, 3 times daily
Regular review and progression — at least monthly for the first 3 months
Continued long-term maintenance — pelvic floor exercises should continue indefinitely
Bladder Retraining — For Urgency & Mixed Incontinence
Bladder retraining is the primary behavioural intervention for urgency incontinence and overactive bladder. The bladder has a degree of neurological plasticity — it can be retrained to hold larger volumes before triggering the urge to void, breaking the cycle of urgency and frequent urination.
Voiding at set intervals regardless of urge — starting at a manageable interval (e.g. 1 hour) and gradually extending by 15–30 minutes each week until a 2.5–3.5 hour voiding interval is achieved.
When urgency occurs, distraction techniques (mental arithmetic, wiggling toes, sitting on a firm surface) and pelvic floor contraction can suppress the urge and “hold on” until the scheduled voiding time.
Regular 3-day bladder diaries track progress and motivate continued engagement with the programme. Visible improvement in voiding intervals is a powerful reinforcer.
Medication for Overactive Bladder & Urgency Incontinence
For women with urgency or mixed incontinence where bladder retraining alone is insufficient, medication targeting detrusor overactivity is an important part of the treatment pathway.
Anticholinergic (Antimuscarinic) Drugs
The most widely used class — block the muscarinic receptors that drive detrusor contractions. Commonly prescribed agents include oxybutynin, solifenacin (Vesicare), tolterodine (Detrusitol), darifenacin and fesoterodine. Dry mouth and constipation are the most common side effects. Extended-release formulations and transdermal patches reduce side effects.
Caution in older women: Anticholinergic medications carry a long-term risk of cognitive impairment in elderly patients. Mirabegron or bladder Botox are preferred alternatives in older women where this is a concern.
Mirabegron (Beta-3 Agonist)
Mirabegron (Betmiga) relaxes the detrusor muscle during bladder filling by a different mechanism to anticholinergics — activating beta-3 adrenergic receptors. It has comparable efficacy to anticholinergic drugs with a different side effect profile — no dry mouth, no cognitive impairment risk. Particularly useful where anticholinergics are not tolerated or contraindicated. NICE-approved for OAB.
Bladder Botox Injection
Where medication does not provide adequate relief, intravesical injection of botulinum toxin directly into the bladder muscle (detrusor) under cystoscopy is highly effective for refractory OAB — reducing urgency and leakage episodes significantly. Effects last 6–9 months and repeat injection is needed. See our Cystoscopy & Botox page for full details.
Surgical Treatment
Surgical Options for Stress Urinary Incontinence
Surgery is considered when conservative management has failed to provide adequate relief after 3–6 months. The right procedure depends on the type of incontinence, the presence of prolapse, previous surgery, and patient preference.
Before any decision about surgery, Mr. Jesuraj uses the NICE Patient Decision Aid with every patient. This tool explains all three surgical options recommended by NICE — autologous fascial sling, colposuspension, and mid-urethral mesh sling (where available) — including their benefits, risks and what to expect. It is designed to support shared decision-making rather than replace it.
Urethral Bulking Agents
Periurethral injections to bulk the urethral lining and improve coaptation
Bulking agents are injectable substances introduced around the urethra to bulk the urethral wall and improve urethral closure — reducing stress leakage. They are the least invasive surgical option and can be performed under local anaesthetic as a day case. Agents include polyacrylamide hydrogel (Bulkamid) and calcium hydroxylapatite (Coaptite).
Bulking agents are less effective than surgery — NICE notes the evidence suggests lower success rates than slings or colposuspension — but they are an appropriate option for women who are medically unfit for general anaesthetic, who wish to avoid or defer surgery, or in whom previous surgery has failed. Effects may wear off over time and repeat injections may be needed.
Suitable For
- Women medically unfit for general or spinal anaesthetic
- Women who decline or wish to defer surgery
- Previous failed surgery where repeat major surgery carries higher risk
- Intrinsic sphincter deficiency with poor urethral function
Mid-Urethral Slings — Autologous (Fascial) Sling
A sling of tissue placed under the mid-urethra to restore urethral support
A mid-urethral sling is the most effective surgical treatment for stress urinary incontinence. A sling of material is placed under the mid-urethra to provide a supportive platform — correcting the loss of urethral support that underlies stress incontinence. There are two distinct types of sling material: autologous (using the patient’s own tissue) and synthetic (mesh). These are not interchangeable and must be considered separately.
Autologous Rectus Fascial Sling ✓ We Offer This
The autologous fascial sling uses a strip of the patient’s own rectus abdominis fascia (the tough fibrous sheath of the abdominal muscle) harvested from a small incision in the lower abdomen. This strip is then placed as a sling under the mid-urethra and attached to the abdominal wall. Because it uses the patient’s own tissue, there are no mesh-related complications — no risk of erosion, no foreign body.
The autologous fascial sling has excellent long-term durability — it is the oldest established sling procedure with the longest follow-up data. It is recommended by NICE as one of the primary surgical options for stress incontinence alongside colposuspension. It requires slightly longer recovery than the synthetic tape procedures it has largely replaced, but carries none of the serious complications associated with synthetic mesh.
Synthetic Mid-Urethral Tape (TVT/TOT) Suspended from Practice
Synthetic mid-urethral slings — the retropubic TVT (tension-free vaginal tape) and the transobturator TOT — use a narrow strip of polypropylene mesh placed under the mid-urethra. These procedures became widely used from the late 1990s because of their simplicity, short recovery, and good short-term success rates.
However, serious, life-altering complications affecting a significant number of women — including mesh erosion through the vaginal wall or urethra, chronic pelvic pain, dyspareunia (painful intercourse), and nerve injury — led to a major patient safety review.
⛔ Suspended from Practice in England and Wales
Following the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege, and on the recommendation of NHS England, synthetic mid-urethral mesh sling procedures were placed under a “High Vigilance Restriction” in England in July 2018. This restriction has been maintained and these procedures are not routinely available on the NHS in England and Wales outside of specialist centres meeting specific governance requirements.
We do not offer synthetic mesh sling procedures — in line with current NHS England guidance. Women who wish to explore this option within the regulated framework can be referred to an appropriate specialist centre after thorough discussion of the risks.
NICE Recommendation (NG123)
NICE recommends women choosing surgery for stress incontinence be offered the choice of:
- Autologous rectus fascial sling
- Colposuspension
- Retropubic mid-urethral mesh sling — with additional governance requirements
The NICE Patient Decision Aid helps women compare these options in detail.
NICE NG123 →Colposuspension (Burch Colposuspension)
Elevation and suturing of the bladder neck to the iliopectineal ligament — restoring the urethrovesical junction
Colposuspension is an open or laparoscopic operation in which the tissues on either side of the bladder neck and proximal urethra are elevated and sutured to the iliopectineal (Cooper’s) ligament — restoring the urethrovesical junction to its correct anatomical position. It was the gold standard surgical treatment for stress incontinence for decades before the introduction of mesh tapes.
Colposuspension has excellent long-term cure rates — comparable to the autologous fascial sling — and has the advantage of simultaneously correcting anterior wall prolapse. The laparoscopic approach (keyhole) offers similar efficacy to open surgery with faster recovery.
This procedure is recommended by NICE as a primary surgical option alongside the autologous fascial sling. Mr. Jesuraj provides assessment, investigation and counselling for colposuspension and will arrange referral to a urogynaecologist with specialist expertise in this procedure where it is the most appropriate choice.
Best For
- Primary stress incontinence with good urethral function
- Coexisting anterior prolapse (corrected at same time)
- Women who prefer to avoid any foreign material
- Previous failed sling — as revision procedure
Combined Conditions
Stress Incontinence with Pelvic Organ Prolapse
When stress incontinence coexists with significant pelvic organ prolapse, both conditions need to be considered together — the surgical strategy for one affects the other.
Pelvic organ prolapse — descent of the bladder (cystocele), uterus, or vaginal vault — commonly accompanies stress incontinence, as both conditions share the same underlying weakness in pelvic floor support. When prolapse is present, treatment must address both — treating the incontinence without addressing the prolapse, or vice versa, may produce incomplete or unsatisfactory results.
Importantly, prolapse can also mask underlying stress incontinence — the prolapse kinks the urethra preventing leakage (occult or latent stress incontinence). When the prolapse is corrected surgically, the incontinence may then become apparent. This possibility is discussed at assessment and planned for in advance.
The management of combined stress incontinence and pelvic organ prolapse is within the specialist domain of urogynaecology. Mr. Jesuraj provides initial assessment, investigation including urodynamics, and a clear clinical summary — and then arranges referral to a consultant urogynaecologist with expertise in complex pelvic floor reconstruction.
Bladder descending into the vagina. Causes voiding difficulty, pressure symptoms and may mask or worsen stress incontinence. Repaired by anterior repair or colposuspension simultaneously.
Descent of the uterus into the vagina. Managed by sacrohysteropexy (preserving the uterus) or vaginal hysterectomy with vault support, depending on the patient’s wishes and anatomy.
After previous hysterectomy — the vaginal vault descends. Treated by sacrocolpopexy (mesh-assisted vault suspension, laparoscopic or open) or other vault support procedures.
Urogynaecology Referral
Mr. Jesuraj works within a network of specialist urogynaecologists and will arrange referral for:
- Stress incontinence with significant pelvic organ prolapse
- Colposuspension as the preferred surgical option
- Complex or recurrent incontinence after previous surgery
- Mesh complications requiring specialist management
- Voiding dysfunction complicating the clinical picture
Referral is always accompanied by a detailed clinical summary, investigation results and a clear recommendation — ensuring continuity and the best possible outcome.
Mixed Incontinence
Managing Mixed Urinary Incontinence
Mixed incontinence — both stress and urgency components — requires careful patient selection, treatment sequencing and realistic expectations.
Women with mixed urinary incontinence present a particular challenge — they have both a structural problem (urethral support failure causing stress leakage) and a functional problem (detrusor overactivity causing urgency and urge leakage). Treating one without the other will not fully resolve symptoms, and treating surgically without first addressing the urgency component risks significant post-operative dissatisfaction.
Identify the Dominant Component
Through detailed symptom history, bladder diary and urodynamic testing — determine whether stress or urgency is the predominant complaint and is causing the most bother. This determines the primary treatment target.
Treat the Urgency Component First
Bladder retraining, OAB medication (anticholinergics or mirabegron) and lifestyle modification should be established and optimised before any surgical decision. Urgency symptoms may persist or worsen after stress incontinence surgery if OAB is not first addressed — and conversely, some urgency symptoms in women with stress incontinence resolve after surgical correction of the leakage.
Reassess After Bladder Retraining
After 3–6 months of combined bladder retraining and pelvic floor muscle training, the symptom picture may change — urgency symptoms may improve significantly, leaving primarily stress incontinence (or vice versa). Reassessment determines whether and what type of surgery is then indicated.
Surgical Treatment if Appropriate
Where stress incontinence remains the dominant, functionally impairing problem after conservative measures, surgery can be offered. The patient must be counselled that urgency symptoms may not fully resolve after surgery for stress incontinence, and may require continued medical management.
Continued OAB Management Post-Surgery
Bladder Botox injection, continuation of OAB medication, or neuromodulation (sacral nerve stimulation) may be needed post-operatively for women with persistent urgency incontinence. These are planned for in advance — not presented as a surprise complication.
Patient Selection
Who Is Suitable for Surgery?
✓ Surgery Is Appropriate When:
- Stress incontinence is confirmed — clinically and/or urodynamically
- Conservative management (3–6 months supervised PFMT) has been completed and failed to provide adequate relief
- The symptom burden is sufficient to make surgery worthwhile — impact on quality of life, activity, relationships
- The patient fully understands and accepts the risks, including voiding difficulty and the possibility of symptoms persisting
- Prolapse has been assessed and a plan exists for managing it
- Urgency component has been treated and reassessed
- Family is complete — or the patient understands implications if considering future pregnancy
✗ Surgery Is Not Appropriate When:
- Conservative management has not been properly completed
- Urgency incontinence is the dominant component — and has not been treated
- The diagnosis is uncertain and urodynamics have not been performed
- The patient is planning further pregnancies — risk of recurrence is high
- Medical co-morbidities make surgical risk unacceptable
- Significant post-void residual suggests voiding dysfunction — risk of urinary retention post-surgery
- Active urinary tract infection
NICE Resources for Patients
You Don’t Have to Live With This
Appointments at Best Life Clinic, Stockton-on-Tees — Monday, Thursday and Friday. Most patients seen within 7 days. No GP referral required.