Management of recurrent stress incontinence following a sling

Management of recurrent or persistent stress urinary incontinence (RSI) following primary insertion of a synthetic midurethral sling (MUS) remains a challenge for the urologist since no consensus is available to favor one treatment over another. Complete workup should be carried out, including cystoscopy, urodynamics and potentially a pelvic floor ultrasound as a diagnostic adjunct. Various surgical options have been described for RSI, apart from another MUS, including tightening of or shortening a previously placed MUS, a mini-sling, a salvage spiral sling, a colposuspension, the ACT® system, an artificial urinary sphincter or ultimately a urinary diversion. Treatment depends ultimately on the experience and the expertise of the surgeon but it appears most reasonable to offer a repeat MUS (retropubic or transobturator), a pubovaginal sling or bulking agents to women with RSI. Appropriate counseling of patients to set realistic outcomes is key as it may be more practical to aim more for symptomatic improvement than cure.