I Guideline Information
Guidelines program of the DGGG, OEGGG and SGGG
For information on the guidelines program, please refer to the end of the guideline.
Citation format
Diagnosis and Therapy of Female Urinary Incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/091, January 2022). Part 2 with Recommendations on
Interventional/Surgical Therapy of Overactive Bladder, Surgical Treatment of Stress Urinary Incontinence and Diagnosis and Therapy of Iatrogenic Urogenital Fistula. Geburtsh Frauenheilk
2023. doi:10.1055/a-1967-1888
Guideline documents
The complete long version in German and a slide version of this guideline as well as a list of the conflicts of interest of all the authors are available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-091.html
Guideline authors
See [Tables 1 ] and [2 ].
Table 1 Lead and/or coordinating guideline author.
Author
AWMF professional society
Prof. Dr. med. Christl Reisenauer
German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe [DGGG])
Priv. Doz. Dr. med. habil. Gert Naumann
Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG)
Table 2 Contributing guideline authors.
Author
Mandate holder
DGGG working group (AG)/AWMF/non-AWMF professional society/organization/association
PD Dr. med. Thomas Aigmüller
Austrian Urogynecology Working Group for Reconstructive Pelvic Floor Surgery (Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie
[AUB])
Prof. Dr. med. Werner Bader
German Society of Ultrasound in Medicine and Biology (Deutsche Gesellschaft für Ultraschall in der Medizin [DEGUM])
Prof. Dr. med. Ricarda Bauer
German Society of Urology (Deutsche Gesellschaft für Urologie [DGU])
Dr. med. Kathrin Beilecke
Working Group for Urogynecology and Plastic Pelvic Floor Reconstruction of the DGGG (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. [AGUB]
der DGGG)
PD Dr. med. Cornelia Betschart
Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG])
Swiss Working Group for Urogynecology and Pelvic Floor Pathology (Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie [AUG])
Dr. med. Gunther Bruer
Federal Association of Gynecologists (Bundesverband der Frauenärzte)
Prof. Dr. med. Dr. phil. Thomas Bschleipfer
German Society for Urology (Deutsche Gesellschaft für Urologie [DGU])
PD Dr. med. Miriam Deniz
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Dr. med. Thomas Fink
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Prof. Dr. med. Boris Gabriel
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Roswitha Gräble
Patient representative
Prof. Dr. med. Matthias Grothoff
Radiology expert
Prof. Dr. med. Axel Haferkamp
German Continence Society (Deutsche Kontinenz-Gesellschaft)
Prof. Dr. med. Christian Hampel
Deutsche Gesellschaft für Urologie (DGU)
Ulla Henscher
Gynecology, Obstetrics, Urology, Proctology Working Group of the German Association for Physiotherapy (Arbeitsgemeinschaft für Gynäkologie Geburtshilfe Urologie Proktologie
[AG-GGUP] im Deutschen Verband für Physiotherapie [ZVK])
Prof. Dr. med. Markus Hübner
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Dr. med. Hansjoerg Huemer
Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie (AUG)
PD Dr. med. Jacek Kociszewski
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Prof. Dr. med. Dr. h. c. Heinz Kölbl
Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)
Dr. med. Dieter Kölle
Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)
Dr. med. Stephan Kropshofer
Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)
Prof. Dr. med. Annette Kuhn
Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie (AUG)
PD Dr. med. Gert Naumann
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Prof. Dr. med. Dr. phil. Matthias Oelke
Deutsche Gesellschaft für Urologie (DGU)
Prof. Dr. med. Ursula Peschers
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Dr. med. Oliver Preyer
Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)
Prof. Dr. med. Christl Reisenauer
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Prof. Dr. med. Daniela Schultz-Lampel
Deutsche Gesellschaft für Urologie (DGU)
Prof. Dr. med. Karl Tamussino
Austrian Society for Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe [OEGGG])
Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)
Reina Tholen
Arbeitsgemeinschaft für Gynäkologie Geburtshilfe Urologie Proktologie (AG-GGUP) im Deutschen Verband für Physiotherapie (ZVK)
Prof. Dr. med. Ralf Tunn
Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG
Prof. Dr. med. Volker Viereck
Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie (AUG)
The following professional societies/working groups/organizations/associations stated that they wished to contribute to the guideline text and participate in the consensus conference and
nominated representatives to contribute and attend the conference ([Table 2 ]).
The guideline was moderated by Dr. Monika Nothacker (AWMF-certified guideline consultant/moderator).
II Guideline Application
Purpose and objectives
The guideline “Female Urinary Incontinence” represents a summary of the current state of knowledge as well as a formal consensus of experts on diagnostics and therapeutic options and should
serve as general orientation for physicians treating these patients.
Target areas of care
This guideline covers the whole range of diagnostics, treatment, and follow-up care of female patients with urinary incontinence and was developed for both outpatient and inpatient care.
The information on diagnostics and treatment of urinary incontinence should be of interest both for chief physicians and medical specialists.
Target user groups/target audience
This guideline covers the treatment given to adult women and is aimed at all physicians and professionals involved in outpatient and/or inpatient care or the rehabilitation of female
patients with urinary incontinence.
Adoption and period of validity
The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies/working groups/organizations/associations as well as
by the boards of the DGGG, SGGG and OEGGG as well as by the DGGG/OEGGG/SGGG Guidelines Commission in December 2021 and was thereby approved in its entirety. This guideline is valid from 1
January 2022 through to 31 January 2024. Because of the contents of this guideline, this period of validity is only an estimate. The guideline can be reviewed and updated earlier if
necessary. If the guideline still reflects the current state of knowledge, its period of validity can be extended.
III Methodology
Basic principles
The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and
requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a
set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a
structural consensus-based subclass (S2k). The highest S3 class combines both approaches.
This guideline was classified as: S2k
Grading of recommendations
The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k
guidelines. The various individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3 ]):
Table 3 Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010).
Description of binding character
Expression
Strong recommendation with highly binding character
must/must not
Regular recommendation with moderately binding character
should/should not
Open recommendation with limited binding character
may/may not
Statements
Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is
not possible to provide any information about the level of evidence for these statements.
Achieving consensus and level of consensus
At structured NIH-type consensus-based conferences (S2k/S3 level), authorized participants attending the session vote on draft statements and recommendations. The process is as follows. A
recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is
another round of discussions, followed by a repeat vote. Finally, the extent of consensus is determined, based on the number of participants ([Table 4 ]).
Table 4 Level of consensus based on extent of agreement.
Symbol
Level of consensus
Extent of agreement in percent
+++
Strong consensus
> 95% of participants agree
++
Consensus
> 75 – 95% of participants agree
+
Majority agreement
> 50 – 75% of participants agree
–
No consensus
< 51% of participants agree
Expert consensus
As the term already indicates, this refers to consensus decisions taken specifically relating to recommendations/statements issued without a prior systematic search of the literature (S2k)
or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical
consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only
expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).
IV Guideline
1 Interventional/surgical therapy of overactive bladder
Surgical treatment of OAB is indicated when conservative treatment and drug therapies have not resulted in the desired success even after adequate duration of conservative/drug therapy or
therapy must be discontinued due to intolerable side effects.
1.1 Injection of onabotulinum toxin A into the bladder
Injections of onabotulinum toxin A into the bladder wall are an effective, minimally invasive, surgical therapy for treatment-resistant overactive bladder. They significantly reduce the
number of episodes of incontinence and urge incontinence as well as the micturition frequency during the day and at night and lead to an overall improvement in the patientʼs quality of
life.
Only onabotulinum toxin A has been approved worldwide for the surgical therapy of overactive bladder. The approved dosage is 100 units (U) of onabotulinum toxin A, which is first diluted
in an NaCl solution before being injected endoscopically into the bladder wall (10 ml NaCl solution, 20 injections).
Consensus-based recommendation E6-01
Expert consensus
Level of consensus ++
Onabotulinum toxin A (100 U) injections should be offered to patients if conservative and oral drug therapy have not led to the desired success even after adequate
duration of therapy (recommendation) .
Consensus-based recommendation E6-02
Expert consensus
Level of consensus ++
Patients must be informed that the effect of onabotulinum toxin A will only persist for a limited time as well as about the post-intervention risk of urinary tract
infections and residual urine, possibly requiring intermittent (self) catheterization (strong recommendation) .
1.2 Electric neuromodulation
Sacral neuromodulation (SNM) or percutaneous tibial nerve stimulation (PTNS) are used to treat overactive bladder by amending the imbalance between the stimulating and inhibitory control
systems of the bladder through directly or indirectly influencing the function of the afferent bladder nerves. The advantages and disadvantages of botulinum toxin injections and of sacral
neuromodulation are listed in [Table 5 ].
Table 5 Advantages and disadvantages of botulinumtoxin A injections vs. sacral neuromodulation.
Botulinumtoxin A
Sacral neuromodulation
For
Against
limited duration of action (months), therefore requires regular re-injections
risk of residual urine, ISC, UTI
surgery (2 ×)
test phase
requires active cooperation on the part of the patient
implant
patient may have an aversion to the technology
revision surgery
requires long-term follow-up care
can only be carried out in centers with the required expertise
Sacral neuromodulation (SNM)
Consensus-based recommendation E6-03
Expert consensus
Level of consensus ++
Sacral neuromodulation should be offered to female patients with overactive bladder if conservative and oral drug therapies have not led to the desired success even
after adequate duration of therapy (recommendation) .
Consensus-based recommendation E6-04
Expert consensus
Level of consensus ++
The sacral neurostimulator should be switched off during pregnancy and birth (recommendation) .
Consensus-based recommendation E6-05
Expert consensus
Level of consensus +++
Sacral neuromodulation may be considered to treat female patients with overactive bladder and concurrent sexual dysfunction or fecal incontinence as it would
simultaneously treat the other functional disturbances (open recommendation) .
Posterior tibial nerve stimulation (PTNS)
Consensus-based recommendation E6-06
Expert consensus
Level of consensus ++
PTNS should be offered to female patients with overactive bladder as a treatment option if conservative and oral drug therapies have not led to the desired success even
after adequate duration of therapy (recommendation) .
Consensus-based recommendation E6-07
Expert consensus
Level of consensus +++
The option to offer PTNS also to patients with overactive bladder and concurrent sexual dysfunction or fecal incontinence may be considered (open
recommendation) .
1.3 Bladder augmentation/urinary diversion
The now widespread use of onabotulinum toxin injections into the bladder wall and the increasing use of sacral neuromodulation have meant that significantly fewer bladder augmentations or
urinary diversions have been indicated in recent years.
Consensus-based recommendation E6-08
Expert consensus
Level of consensus ++
Bladder augmentation or urinary diversion to treat female patients with overactive bladder may be offered in selected cases if other treatment methods have failed
(open recommendation) .
Consensus-based recommendation E6-09
Expert consensus
Level of consensus +++
Detrusor myectomy to treat urinary incontinence must not be offered to patients (strong recommendation) .
1.4 Surgical apical fixation to treat overactive bladder
Consensus-based recommendation E6-10
Expert consensus
Level of consensus +++
Because the data is still insufficient, surgical apical fixation to treat overactive bladder should only be carried out in cases with grade 0 – 1 apical prolapse
(according to the POP-Q classification system) in the context of prospective studies (recommendation) .
2 Surgical therapy of stress urinary incontinence
Surgical therapy to treat stress urinary incontinence should only be considered after having exhausted conservative treatment options.
2.1 Surgical therapy of uncomplicated stress urinary incontinence
Uncomplicated stress urinary incontinence is present if the patient does not have a previous history of incontinence surgery, has no neurological symptoms and no symptomatic pelvic
organ/uterine prolapse and the patient does not wish to bear children. Complicated stress urinary incontinence is present if women meet one or more of the above-listed criteria.
Open and laparoscopic colposuspension
Laparoscopic colposuspension has shown to have the same high level of effectiveness to heal stress urinary incontinence as open colposuspension for up to two years postoperatively.
Open and laparoscopic colposuspension versus suburethral tape
Systematic Cochrane reviews found no difference in continence levels or improvements in incontinence between open or laparoscopic colposuspension and suburethral tape procedures.
Consensus-based statement S7-01
Expert consensus
Level of consensus +++
In cases with uncomplicated stress urinary incontinence, colposuspension results in similar objective and subjective success rates as suburethral tension-free tape.
Consensus-based statement S7-02
Expert consensus
Level of consensus ++
Colposuspension is associated with a higher long-term risk of posterior compartment prolapse compared to suburethral tension-free tape.
Consensus-based statement S7-03
Expert consensus
Level of consensus ++
Laparoscopic colposuspension is less invasive than open colposuspension and results in similar continence rates with shorter convalescence times.
Consensus-based statement S7-04
Expert consensus
Level of consensus +++
Colposuspension can elevate and stabilize the bladder neck in cases with significant bladder neck descent and greater rotation of the urethra, significant funneling or lateral
defect.
Fascial sling
Consensus-based statement S7-05
Expert consensus
Level of consensus +++
Autologous fascial sling (AFS) procedures to treat female stress incontinence have similar subjective and objective success rates as synthetic suburethral tape. Synthetic
tapes have lower complication rates and require a shorter operating time.
Consensus-based statement S7-06
Expert consensus
Level of consensus +++
Autologous fascial sling procedures at the bladder neck may be considered in patients with hypotonic urethra, a high risk of tape erosion or following failure of a
suburethral tape procedure.
Tension-free suburethral tape
Long-term outcomes of mid-urethral tape procedures
Consensus-based statement S7-07
Expert consensus
Level of consensus +++
Long-term data have shown long-lasting success rates for suburethral tape procedures with a follow-up (FU) of 10 years and more.
Consensus-based statement S7-08
Expert consensus
Level of consensus +++
The retropubic and transobturator implantation techniques for suburethral tapes are comparable with respect to their 5-year effectivity rate.
Consensus-based statement S7-09
Expert consensus
Level of consensus +++
Retropubic suburethral tapes have been shown to have a higher objective healing rate over a follow-up period of 8 years.
Consensus-based statement S7-10
Expert consensus
Level of consensus +++
The retropubic tape technique is associated with a higher risk of bladder perforation and bladder voiding disorders compared to the transobturator technique.
Consensus-based statement S7-11
Expert consensus
Level of consensus +++
Pain in the groin/inner thigh area and vaginal sulcus perforation are more common after placement of a transobturator tape.
Urinary stress incontinence surgery for special patient groups
Obese female patients
Studies of retropubic and transobturator tape procedures performed in normal-weight and overweight women have found them to be similarly effective.
Studies have confirmed that losing weight has a positive effect on reducing the incidence of incontinence events.
Consensus-based statement S7-12
Expert consensus
Level of consensus +++
Obese patients can also benefit from urinary incontinence procedures.
Older female patients (> 65 years)
Consensus-based statement S7-13
Expert consensus
Level of consensus +++
Good success rates and low complication rates can also be achieved in older patients following suburethral tape procedures; however, the risk of surgical failure appears to
increase with increasing age.
Single-incision sling (“mini sling”)
Single-incision sling procedures have been shown to have a similarly high stress urinary incontinence healing rate as retropubic or transobturator tapes for up to 12 months
postoperatively. This equivalence has not yet been demonstrated for longer follow-up periods.
Consensus-based statement S7-14
Expert consensus
Level of consensus +++
There is no evidence that the outcomes of single-incision sling procedures are equivalent to those of conventional suburethral tapes for follow-up periods of more than 12
months.
Consensus-based statement S7-15
Expert consensus
Level of consensus +++
Immediate postoperative pain in the thigh area is lower after single-incision tape procedures compared to transobturator tape procedures.
Consensus-based statement S7-16
Expert consensus
Level of consensus +++
There are no long-term data showing that other side effects or complications following single-incision tape procedures are rarer or more common than after placement of other
suburethral tapes.
Consensus-based statement S7-17
Expert consensus
Level of consensus ++
Sexual function appears to improve more after single-incision tape procedures than after other suburethral tape procedures.
Adjustable slings
Consensus-based statement S7-18
Expert consensus
Level of consensus ++
There is no evidence showing that an adjustable sling offers superior outcomes to a standard sling.
Consensus-based statement S7-19
Expert consensus
Level of consensus ++
We do not recommend implanting an adjustable sling to treat uncomplicated stress urinary incontinence.
Bulking agents
Clinical experience has shown that this procedure is particularly suitable for female patients with hypotonic or immobile (frozen) urethra, e.g., following colposuspension, for whom a
suburethral tape procedure is not a suitable surgical option.
Consensus-based statement S7-20
Expert consensus
Level of consensus +++
A single transurethral submucosal injection of a bulking agent may result in short-term improvement or healing (for up to 12 months) in female patients with stress urinary
incontinence.
Consensus-based statement S7-21
Expert consensus
Level of consensus +++
Bulking agents are not as effective to heal stress urinary incontinence as colposuspension, autologous fascial sling or suburethral tape procedures.
Consensus-based statement S7-22
Expert consensus
Level of consensus +++
Bulking agents have the lowest surgery-related morbidity rates of all invasive treatment options.
Consensus-based recommendation E7-01
Expert consensus
Level of consensus +++
Bulking agents may be offered to female patients with stress urinary incontinence after the patient has been informed about their lower effectivity compared to
suburethral tape procedures and the potential necessity of having a repeat injection (open recommendation) .
Consensus-based recommendation E7-02
Expert consensus
Level of consensus ++
Because of the low morbidity rate, bulking agents may be especially offered to female patients with a higher surgical risk (open recommendation) .
2.2 Surgical therapy of complicated stress urinary incontinence (recurrent incontinence)
The failure rate after incontinence surgery varies greatly and depends on the definition of surgical failure. Failure may occur immediately postoperatively (persistent incontinence) or
years after the operation (recurrent incontinence).
Consensus-based statement S7-23
Expert consensus
Level of consensus ++
Most operative procedures carried out in cases with recurrence are less likely to have a promising outcome.
Artificial urethral sphincter (AUS)
Consensus-based statement S7-24
Expert consensus
Level of consensus +++
The implantation of an artificial urethral sphincter may improve or heal stress urinary incontinence caused by urethral insufficiency.
Consensus-based statement S7-25
Expert consensus
Level of consensus +++
Complications, mechanical failure and explantation are relatively common after implantation of an artificial urethral sphincter.
Consensus-based statement S7-26
Expert consensus
Level of consensus +++
Explantation rates are higher in geriatric patients and after surgical colposuspension or pelvic radiotherapy.
2.3 Surgical therapy of stress urinary incontinence in women with mixed urinary incontinence
Consensus-based statement S7-27
Expert consensus
Level of consensus +++
Women with mixed urinary incontinence are less likely to experience healing of their incontinence following a procedure than women who only have stress urinary incontinence.
Consensus-based statement S7-28
Expert consensus
Level of consensus ++
The development of urge symptoms after surgery for stress urinary incontinence cannot be predicted with any certainty.
2.4 Surgical therapy of urinary incontinence in women with urogenital prolapse
There is a clear association between incontinence and urogenital prolapse. Based on current studies, it is difficult to judge whether concurrent prolapse and incontinence surgery reduces
the incidence of de novo stress urinary incontinence. Studies in which suburethral tapes were placed have shown better results compared to other surgical incontinence procedures. The
patientʼs individual circumstances clearly play an important role when planning surgery. It is important to be aware that, although more women are continent postoperatively if they have
undergone combined surgery, the risk of requiring repeat surgery is higher.
Women with both prolapse and manifest stress urinary incontinence
Consensus-based statement S7-29
Expert consensus
Level of consensus ++
Women with stress urinary incontinence and prolapse have a higher healing rate of stress urinary incontinence following concurrent surgery for prolapse and incontinence.
Consensus-based statement S7-30
Expert consensus
Level of consensus +++
Combined prolapse surgery and incontinence procedures have more side effects than prolapse surgery performed alone.
Continent women with prolapse
Consensus-based statement S7-31
Expert consensus
Level of consensus +++
Continent women with prolapse are at risk of suffering from urinary incontinence postoperatively.
Consensus-based statement S7-32
Expert consensus
Level of consensus ++
An additional prophylactic continence procedure may reduce the risk of postoperative urinary incontinence.
Consensus-based statement S7-33
Expert consensus
Level of consensus +++
An additional prophylactic continence procedure increases the risk of complications (particularly of overcorrection).
Women with prolapse and overactive bladder
Consensus-based statement S7-34
Expert consensus
Level of consensus +++
There is evidence that prolapse surgery may improve the symptoms of overactive bladder.
2.5 Summary
Recommendations for surgical therapy for uncomplicated female stress urinary incontinence
Consensus-based recommendation E7-03
Expert consensus
Level of consensus ++
Suburethral (retropubic or transobturator) tape placement must be offered to women with uncomplicated stress urinary incontinence as the primary surgical therapeutic
option (strong recommendation) .
Consensus-based recommendation E7-04
Expert consensus
Level of consensus +++
Open or laparoscopic colposuspension or autologous fascial sling procedures must be offered to women with stress urinary incontinence if suburethral (retropubic or
transobturator) tape placement has been ruled out. Colposuspension may also be appropriate in cases with concurrent traction cystocele or if a laparoscopic/open approach was
already selected for other reasons (strong recommendation) .
Consensus-based recommendation E7-05
Expert consensus
Level of consensus +++
Laparoscopic colposuspension should be chosen (if the surgeon has the required expertise) in preference to open colposuspension. It is associated with a shorter
hospital stay than open procedures and is equally effective (recommendation) .
Consensus-based recommendation E7-06
Expert consensus
Level of consensus +++
Female patients who are offered colposuspension must be informed about the longer operating time and convalescence time, the longer stay in hospital and the higher risk
of postoperative bladder voiding disorders and urogenital prolapse (particularly rectoceles) (strong recommendation) .
Consensus-based recommendation E7-07
Expert consensus
Level of consensus ++
Female patients with stress urinary incontinence who are offered placement of a retropubic sling must be informed about the higher perioperative risk of complications
compared to placement of a transobturator sling (strong recommendation) .
Consensus-based recommendation E7-08
Expert consensus
Level of consensus ++
Female patients with stress urinary incontinence who are offered placement of a transobturator sling must be informed about the higher long-term risk of dyspareunia and
pain (strong recommendation) .
Consensus-based recommendation E7-09
Expert consensus
Level of consensus ++
Autologous fascial sling procedures performed by experienced surgeons may have a higher success rate than Burch colposuspension. Female patients with stress urinary
incontinence who are treated with autologous fascial sling must be informed about the high risk of intraoperative complications, particularly of postoperative bladder voiding
disorders and postoperative urinary tract infections along with the potential necessity of intermittent self-catheterization; it is important to ensure that they are both
capable of doing so and will agree to do so (open recommendation) .
Consensus-based recommendation E7-10
Expert consensus
Level of consensus +++
Intraoperative urethrocystoscopy must be carried out during every placement of a retropubic suburethral tape and, if any difficulties occur, during placement of a
suburethral transobturator tape (strong recommendation) .
Consensus-based recommendation E7-11
Expert consensus
Level of consensus +++
Female patients with stress urinary incontinence who are offered a mini sling (single-incision tape) should be informed that this procedure could be less effective than
placement of a standard suburethral sling and that it is not yet clear whether this procedure is effective for more than one year (recommendation) .
Consensus-based recommendation E7-12
Expert consensus
Level of consensus +++
Periurethral bulking agents may be offered to women who want to have a very low risk procedure and who understand that repeat injections may be necessary (open
recommendation) .
Recommendations for the surgical therapy of complicated female stress urinary incontinence
Consensus-based recommendation E7-13
Expert consensus
Level of consensus +++
The surgical therapy for complicated stress urinary incontinence should be chosen based on the patientʼs individual circumstances and condition after carrying out
urodynamic and imaging (ultrasound) investigations (recommendation) .
Consensus-based recommendation E7-14
Expert consensus
Level of consensus +++
Female patients must be informed that the surgical success of a repeat procedure is lower than that of primary therapy, both in terms of a lower benefit and a higher
risk of complications (strong recommendation) .
Consensus-based recommendation E7-15
Expert consensus
Level of consensus +++
In principle, all procedures which are used in primary therapy can be used to treat complicated stress urinary incontinence. It should be assessed whether repeat
placement of a suburethral tape, colposuspension or fascial sling procedure or AUS implantation would be advisable (recommendation) .
Consensus-based recommendation E7-16
Expert consensus
Level of consensus +++
Implantation of an AUS should be carried out in specialized centers (recommendation) .
Consensus-based recommendation E7-17
Expert consensus
Level of consensus +++
The symptom subjectively experienced by the patient as the main symptom should be treated primarily in cases with mixed urinary incontinence
(recommendation) .
Consensus-based recommendation E7-18
Expert consensus
Level of consensus +++
Women must be informed that surgical procedures are less likely to be successful to treat mixed urinary incontinence than to treat cases who only have stress urinary
incontinence and that a single therapeutic measure may not be sufficient to treat mixed urinary incontinence (strong recommendation) .
Recommendations for the surgical therapy of symptomatic stress urinary incontinence and prolapse
Consensus-based recommendation E7-19
Expert consensus
Level of consensus ++
A concurrent prolapse and incontinence procedure may be offered to patients. A two-stage approach is possible (open recommendation) .
Recommendations for female patients with asymptomatic or masked stress urinary incontinence and prolapse
Consensus-based recommendation E7-20
Expert consensus
Level of consensus +++
Women must be informed about the risk of postoperative stress urinary incontinence following prolapse surgery (strong recommendation) .
Consensus-based recommendation E7-21
Expert consensus
Level of consensus +++
Female patients must be informed that the benefit of an incontinence operation may involve the disadvantage of increased complications (strong
recommendation) .
Consensus-based recommendation E7-22
Expert consensus
Level of consensus +++
Surgical rectification of stress urinary incontinence should be carried out after the patient no longer wishes to have further children as subsequent pregnancy and
childbirth factors may negatively affect the positive continence outcome of surgery (recommendation) .
Consensus-based recommendation E7-23
Expert consensus
Level of consensus +++
The decision that surgical treatment is indicated and the choice of surgical procedure for women with stress urinary incontinence who still wish to have children should
be made in a center by a surgeon with the appropriate expertise (recommendation) .
[Fig. 1 ] shows the algorithm used for the diagnostic workup and for the conservative and surgical treatment of different forms of urinary
incontinence.
Fig. 1 Flowchart for the diagnosis and therapy of female urinary incontinence. [rerif]
3 Iatrogenic urogenital fistula
3.1 Introduction
Most non-childbirth-related urogenital fistulas are of iatrogenic origin; causes include pelvic surgery, especially following hysterectomy, pessary therapy, and radiotherapy. The risk
from a pelvic operation increases in proportion to the complexity of the procedure, the extent of the primary disease, and whether the patient has previously undergone radiotherapy. The
majority of all urinary/urogenital fistulas reported in German-speaking areas are of iatrogenic origin. In contrast to emerging countries, childbirth-related fistulas or malignant urinary
fistulas have become very rare in German-speaking countries.
3.2 Diagnostic workup
The cardinal symptom of urogenital fistula is uncontrollable loss of urine. Depending on the size or location of the fistula, urine loss may either be continuous or take the form of a
sudden gush of urine which depends on the patientʼs position, and it typically manifests equally strongly by day and by night. This is what differentiates extra-urethral incontinence
pathognomonically from stress urinary incontinence, which is usually more pronounced during the day compared to at night, and from incontinence after urinary diversion (e.g., ileal
neobladder), which is more noticeable at night for reasons related to the parasympathetic nervous system.
The diagnostic examination for vesicovaginal fistula (VVF) includes: patientʼs prior medical history, speculum examination, endoscopic examinations (urethrocystoscopy, ureteroscopy),
retrograde bladder filling, and adding dye to the solution if necessary (indigo carmine excretion test). Placement of a tampon in the vagina to identify staining may make it easier to
obtain a diagnosis.
CT and MRI may offer additional information in complex cases (e.g., malignancy-related fistulas).
3.3 Management of vesicovaginal fistula
Conservative management
Smaller fistulas may heal spontaneously if conservative management is started early and includes adequate emptying of the bladder using a bladder catheter or ureteral stent. But
conservative management should no longer be attempted if the fistula has already persisted for more than three months as the likelihood of spontaneous healing is minimal after three
months because epithelialization of the fistula canal will have already set in.
Surgical management
Timing of surgery
Results from non-controlled case series indicate that there are no differences in the success rates following early or delayed closure of a VVF, although it should be noted that the
definition of immediate and delayed closure was inconsistent across studies. The expert consensus is, however, that it is useful to avoid any time pressure to close the fistula and it
is better to delay closure until the local inflammatory response has subsided. This is expected to take 8 – 12 weeks.
Consensus-based statement S8-01
Expert consensus
Level of consensus +++
The primary approach depends on the location of the fistula, the patientʼs habits, and the surgeonʼs preference/expertise.
Consensus-based recommendation E8-01
Expert consensus
Level of consensus +++
Conservative management of a vesicovaginal fistula detected early postoperatively (within the first 6 weeks) with continuous urinary diversion (for up to 12 weeks)
may result in spontaneous healing (open recommendation) .
Consensus-based recommendation E8-02
Expert consensus
Level of consensus +++
Conservative and surgical management of fistulas should be reserved for experienced surgeons/interdisciplinary centers which offer a wide range of therapies, allowing
the appropriate treatment to be selected according to the individual needs of the patient (recommendation) .
Consensus-based recommendation E8-03
Expert consensus
Level of consensus +++
The timing of surgical fistula closure must depend on the individual circumstances, i.e., when the wound edema, inflammation, tissue necrosis or infection has
subsided (strong recommendation) .
Consensus-based recommendation E8-04
Expert consensus
Level of consensus +++
Primary care for a fistula must include separation of the organs connected by the fistula, excision of the fistula canal/refreshing of the wound edges, and
tension-free suturing, possibly with interposition of tissue, irrespective of the chosen approach. Tissue interposition must be done when closing a radiogenic fistula
(strong recommendation) .
3.4 Surgical fistula closure
Vaginal techniques
When using a vaginal approach, the classic technique of de-epithelialization/partial colpocleisis, e.g., the Latzko procedure or the more commonly used technique of dissection with
closure of the fistula in layers, can be used to close vesicovaginal fistulas. There are currently no data comparing the outcomes of both techniques.
Abdominal procedure
An abdominal approach is indicated when fistulas are located high up in tissue and cannot be accessed via the vagina. A transvesical approach has the advantage that it is entirely
extraperitoneal. A simple transperitoneal approach is used less often, although it is preferred by surgeons who use a laparoscopic approach. Many urologists prefer using a combined
transperitoneal and transvesical approach.
Tisse interposition
Tissue flaps are often interposed to serve as an additional layer during VVF surgery. Although the evidence for this is limited, the expert consensus is that interposing tissue in
certain situations (e.g., recurrence, irradiation, large fistulas, lack of perfusion) may improve the outcome.
3.5 Management of post-radiogenic fistula
The results of surgical fistula closure are worse for post-radiogenic fistulas compared to iatrogenic fistulas. Because of the radiation-related changes to tissue, temporary or even
permanent urinary diversion and/or placement of an enterostomy may be unavoidable.
3.6 Management of ureteral fistula
Basic principles
Female patients with a high risk of ureteral injury should be operated on by experienced surgeons who are able to expose the ureter and recognize injuries. But many ureteral injuries
are only detected postoperatively (e.g., thermal lesions), meaning that an appropriate diagnostic workup should be initiated if the clinical symptoms appear to point to ureteral
injury.
Ureterovaginal fistula
The respective choice of ureteral reconstruction depends on the location and extent of the ureteral lesion and the chosen approach must depend on the individual circumstances.
3.7 Management of urethrovaginal fistula
Etiology
Although urethrovaginal fistulas are rare, most urethrovaginal fistulas in adults have an iatrogenic etiology. Causes of iatrogenic urethrovaginal fistula are surgical treatment of
stress urinary incontinence using bulking agents or synthetic slings, the excision of urethral diverticula, and genital reconstruction. Radiotherapy and even conservative prolapse
treatment using pessaries may lead to the formation of fistulas.
Diagnosis
A clinical vaginal examination which includes a standard three-swab test is often sufficient t diagnose the presence of a urethral fistula. Urethroscopy and cystoscopy may be carried
out to evaluate the extent and location of the fistula. Micturating cystourethrogram (MCUG) or ultrasound may be useful if the diagnosis is more difficult. CT and MRI are not part of the
standard diagnostic workup.
Surgical therapy
The choice of surgery depends on the size, location, and etiology of the fistula as well as the amount of tissue loss. Reconstruction must include identification of the fistula,
creation of a layer between the vaginal wall and the ureteral wall, watertight closure of the ureteral wall, interposition of tissue where possible, and closure of the vaginal wall.
Vaginal approach
Consensus-based recommendation E8-05
Expert consensus
Level of consensus +++
Treatment of a urethrovaginal fistula must be carried out primarily using a vaginal approach (strong recommendation) .
Flaps and neourethra
A vaginal Martius flap or pedicled labial skin flap may be used to cover the urethral suture and for tissue interposition. Labial skin may be used to cover a urethral defect or to form
a neourethra.
Consensus-based recommendation E8-06
Expert consensus
Level of consensus +++
After closure of a vesicovaginal and a urethrovaginal fistula, continuous urinary diversion must be ensured for at least 7 days (strong recommendation) .
Consensus-based recommendation E8-07
Expert consensus
Level of consensus +++
Ureteral fistula must be suspected if female patients exhibit fluid leakage or urinary stasis in the postoperative period following a pelvic procedure or if there are high
creatinine levels in the drainage fluid/free fluid in the abdominal cavity (strong recommendation) .
Consensus-based recommendation E8-08
Expert consensus
Level of consensus +++
Fistulas in the upper urinary tract should be primarily treated conservatively or with endoluminal techniques (recommendation) .
Consensus-based recommendation E8-09
Expert consensus
Level of consensus +++
Female patients treated for ureteral injuries must be followed up very closely after removal of the ureteral stent to exclude ureteral stricture which could limit renal
function (strong recommendation) .
Consensus-based recommendation E8-10
Expert consensus
Level of consensus ++
Depending on the location and extent of the lesion, surgical therapy of the ureter must be done on an individualized basis if conservative treatment of ureteral leakage
fails (strong recommendation) .
