Which procedure for incontinence?

Approximately 16-29% of women will complain of incontinence at the menopause. A multidisciplinary approach to treatment is essential and surgery is usually reserved for women who have failed to improve sufficiently with conservative measures, such as pelvic floor exercises. The Burch colposuspension remains the 'gold standard' procedure for stress urinary incontinence, against which all newer procedures are compared. It is normally carried out under general anaesthesia and requires an abdominal approach, most often by a low transverse incision. Tension-free vaginal tape (TVT) is the most popular procedure at present and has largely replaced colposuspension in many units. However, there are concerns about both its long-term safety and the lack of data on efficacy beyond the first few years. Initial reports of transobturator tape suggest that it may have a similar efficacy to TVT but with a lower rate of serious complications; however, large comparative studies and longterm follow-up data are currently unavailable. Collagen and silicone injected around the urethra can be used in a selected group of patients under local anaesthetic but the success rates are disappointingly low.