Mark D. Walters, MD

Watch 3 video clips illustrating midurethral sling procedures

• Placement of TVT-O transobturator tape
• Monarc transobturator procedure
• TVT Exact retropubic sling operation

These videos were selected by Mark D. Walters, MD, and presented courtesy of the International Academy of Pelvic Surgery (IAPS).

Only 15 years ago, when surgery was recommended for patients who had bothersome stress urinary incontinence (SUI), they were offered operations such as suburethral (Kelly) plication, needle urethropexy, open or laparoscopic Burch procedure, and pubovaginal fascial sling procedure. Today, virtually all of these operations have been replaced in general practice by retropubic or transobturator (TOT) midurethral synthetic slings.

Although Burch colposuspension and the pubovaginal fascial sling procedure are effective for both primary and recurrent SUI, they are more invasive than midurethral slings, cause more voiding dysfunction, and have significantly longer recovery times, making them less attractive for most primary and recurrent cases of SUI.

The evolution of SUI surgeries has shifted so far toward midurethral slings that Burch colposuspension and the pubovaginal sling procedure are rarely performed or taught in obstetrics and gynecology or urology residency programs; these procedures are now mostly done in fellowship programs by specialists in female pelvic medicine and reconstructive surgery.

In this article, we describe how an ObGyn generalist can approach the surgical treatment of women who have either primary or recurrent SUI. Using evidence-based principles, when available, we also discuss how different clinical characteristics—as well as the characteristics of the available slings—affect the suitability of the sling for individual patients.

One caveat: This article assumes that the surgeon knows how to, and is able to, perform retropubic and TOT sling procedures equally well. However, when this is not the case, the surgeon should perform the sling procedure that she or he does best, assuming that it is appropriate for that particular patient.

Almost all surgical procedures for stress urinary incontinence performed today involve placement of a retropubic or transobturator midurethral synthetic sling.
Illustration: Craig Zuckerman for OBG Management

CASE: SUI and Stage II anterior vaginal prolapse

A healthy 45-year-old G2P2 woman complains of a 5-year history of worsening SUI symptoms, mostly occurring during activities such as coughing, laughing, and running. The incontinence has become so severe that she requires several pads daily. She is able to void without difficulty or pain, and her bowel movements are normal. She has regular menses, has had a tubal ligation, and is sexually active.

She reports that she has been performing daily Kegel pelvic muscle exercises, without improvement.

On physical examination, she is found to have Stage II anterior vaginal prolapse and urethral hypermobility, with normal uterine and posterior vaginal support. The uterus and ovaries are of normal size.

A full bladder stress test in the office reveals immediate loss of urine from the urethra upon coughing in a semi-sitting position. She voids 325 mL after the examination and has a post-void residual urine volume, as measured by ultrasonography (US), of 25 mL. Urinalysis is negative.

When discussing her goals, the patient expresses a desire for a cure of her urinary incontinence, if possible.

What further testing and treatment options do you offer to her?

If you and the patient agree that surgery is warranted, which procedure do you recommend?

Recommended assessment of women who report SUI

Women who have bothersome urine loss during activities such as exercise, coughing, or laughing should undergo a history, physical examination, and urinalysis. During the pelvic examination, it is important to assess pelvic organ support defects, especially those involving the anterior vagina and urethra. Also note levator ani muscle contraction and strength. In addition, you can use this time to discuss whether the patient is doing, or has done, pelvic muscle (Kegel) exercises; teach the exercises, if necessary; and encourage her to do them in the future.

If the patient has no urinary infection, has performed Kegel exercises without further benefit, and wishes to consider surgical treatment, basic assessment of lower urinary function is indicated. Basic office urodynamic testing includes:

• a measured void
• measurement of post-void residual volume (by catheter or US)
• assessment of bladder sensation and capacity
• provocation for overactive bladder
• a full-bladder cough stress test (a positive test is direct observation of urethral loss of urine upon coughing).

Patients who have a complex history or mixed symptoms, previous failed surgery, or other characteristics that suggest a diagnosis other than simple SUI should undergo formal electronic urodynamic testing.¹

Patient selection criteria

Primary sling surgery is an option for patients who have:

• no urinary infection
• normal voiding and bladder-filling function
• urethral hypermobility on examination
• SUI on a cough-stress test
• failure to improve sufficiently with pelvic muscle exercises.

Types of slings

Suburethral slings were initially developed as a treatment for recurrent, urodynamically confirmed SUI, particularly SUI caused by intrinsic sphincter deficiency (ISD). Pubovaginal slings, usually consisting of autologous fascia, were placed at the bladder neck to both support and slightly compress the proximal urethra. Compared with synthetic slings, fascial slings are effective but take longer to place and have a higher rate of surgical morbidity and more postoperative voiding dysfunction. They are now mostly indicated for complex recurrent SUI, usually managed by specialists in female pelvic medicine and reconstructive surgery.

Current slings are lightweight polypropylene mesh

Most slings today are tension-free midurethral slings consisting of synthetic, large-pore polypropylene mesh; they are sold in kits available from several different companies. Sling procedures can also be performed using hand-cut polypropylene mesh and a reusable needle passer.

These slings are placed at the midurethra and work by mechanical kinking or folding of the urethra over the sling, with an increase in intra-abdominal pressure. Ideally, the midurethral sling will not compress the urethra at rest and have no effect on the normal voiding mechanism.

Three main techniques are used to place synthetic midurethral slings:

• the retropubic approach
• the TOT approach
• variations of single-incision “mini-sling” procedures.

Early studies of mini-slings showed few complications but lower effectiveness, compared with retropubic and TOT midurethral slings, according to short-term follow-up data.^2-4 A mini-sling might be an option for some patients in whom surgical complications must be kept to a minimum; otherwise, they will not be discussed further.

Retropubic midurethral slings

The tension-free vaginal tape (TVT) procedure described by Petros and Ulmsten was the first synthetic midurethral sling.⁵ This ambulatory procedure aims to restore the pubourethral ligament and suburethral vaginal hammock by using specially designed needles attached to synthetic sling material.

The synthetic sling consists of polypropylene, approximately 1 cm wide and 40 cm long. The sling material is attached to two stainless steel needles that are passed from a vaginal incision made at the level of the midurethra, through the retropubic space, and exiting at a previously created mark or stab incision in the suprapubic area (FIGURE 1).

Variations of the retropubic midurethral sling have been developed, with sling passers going from the vagina upward (“bottom to top”) and also from the suprapubic area downward (“top to bottom”). A recent Cochrane review reported that the bottom-to-top variation is slightly more effective.⁶

FIGURE 1 Retropubic sling
Placement of the tension-free vaginal tape trocar into the retropubic space.
Illustration: Craig Zuckerman for OBG Management

Transobturator midurethral slings

The TOT sling has become one of the most popular and effective surgical treatments for female SUI worldwide (Video 1 and Video 2). It is a relatively rapid and low-risk surgery that is comparable to other surgical options in effectiveness while avoiding an abdominal incision and the passage of a needle or trocar through the space of Retzius.

The TOT sling lies flatter under the urethra and carries a lower risk of urethral obstruction, urinary retention, and subsequent need for sling release, compared with retropubic slings.^7-9 Compared with the retropubic TVT, the TOT sling produces similar rates of cure, with fewer bladder perforations and less postoperative irritative voiding symptoms.^6,10-12 It nearly eliminates the rare but catastrophic risk of bowel or major vessel perforation. The trade-off is that patients experience more complications referable to the groin (pain and leg weakness or numbness) with the TOT approach.^9,13

All TOT slings on the market consist of a large-pore, lightweight, polypropylene mesh strip, usually covered with a plastic sheath. Various devices are used to place the sling, but most of them involve a helical trocar that curves around the ischiopubic ramus, passing through the inner thigh and obturator membrane to a space created in the ipsilateral peri-urethral tissues.

TOT slings can be placed outside-to-inside or inside-to-outside (FIGURE 2), and the indications, effectiveness, and frequency of complications seem to be similar between these two approaches.¹² One study found a higher frequency of new sexual dysfunction (tender, palpable sling; penile pain in male partner) in women after the “outside-in” approach,¹⁴ but this clinical issue has not been observed in all studies.^15,16

FIGURE 2 TOT sling variations
Placement of the transobturator (TOT) sling helical trocar using the (A) “outside-in” variation and (B) “inside-out” variation.
Illustration: Craig Zuckerman for OBG Management
Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography
© 2005-2012. All Rights Reserved.

Success rates are similar for retropubic and TOT slings

Despite differences in technique and brand of mesh used, treatment success rates for uncomplicated primary SUI are similar for the retropubic (Video 3) and TOT tension-free slings.^6-8,10-12,17 The percentage of patients treated successfully depends on the definition used, ranging from a high of 96% to a low of 60%. When the definition of success is restricted to stress incontinence symptoms, especially over a short period of time, the reported effectiveness is high.

In contrast, when the definition of success includes incontinence of any type, the reported effectiveness is lower. For example, in the study that reported 60% effectiveness, success was defined as no incontinence symptoms of any type, a negative cough stress test, and no retreatment for stress incontinence or postoperative urinary retention.¹¹

Retropubic slings, especially TVT, may be somewhat more effective for ISD,^18-20 although this conclusion must be tempered by the small number of studies addressing the issue and differences in the diagnosis of ISD.²¹

Some studies have reported good success in treating mixed urinary incontinence with the retropubic and TOT slings,^2,8 although other studies have reported that the initial benefit for urgency or urge incontinence is not sustained over time, compared with the benefit for stress incontinence.²² It is important to counsel patients before surgery that improvement in stress incontinence symptoms and general satisfaction is highly likely, but perfect bladder function is not.

Serious complications are uncommon

Complications are common after both retropubic and TOT slings, although serious complications are uncommon. Cystitis and temporary voiding difficulties are the most common problems after a sling procedure. If the patient is unable to void on the day of surgery, it is reasonable to discharge her with a Foley catheter in place for a few days or teach her to perform intermittent self-catheterization at home. In most cases, normal voiding will resume within a few days. Cystitis is at least partially related to the surgery itself and the duration of postoperative catheterization.

The frequency of some complications differs between the retropubic and TOT approaches to midurethral slings. For example, some literature suggests that irritative voiding symptoms such as urgency or voiding difficulty are somewhat less common after TOT slings, compared with retropubic slings. However, symptoms referable to the groin (pain and leg weakness or numbness) occur more commonly with the TOT approach.⁶

After placement of a TOT sling, 10% to 15% of women experience temporary inner thigh or groin pain or leg weakness and are usually managed conservatively with nonsteroidal anti-inflammatory drugs and physical therapy. Long-term or severe complications related to TOT sling passage are rare.

Major intraoperative complications are rare

The rate of these complications does not differ between retropubic and TOT approaches. Minor intraoperative complications—primarily, bladder perforation—occur more commonly with the retropubic approach.⁶

Bladder perforation with the TVT occurs in 4% to 7% of patients. However, the clinical significance of bladder perforation is minimal as long as the surgeon performs careful cystoscopy, recognizes bladder perforation, and repositions the trocar and mesh outside the bladder lumen. Bladder perforation caused by the trocar usually does not require specific treatment (except repositioning of the trocar outside the bladder lumen) and rarely results in later problems.

Mesh exposures occur with similar frequency for the different sling types as long as large-pore lightweight polypropylene is used. Dehiscence of the suburethral incision (mesh exposure) is uncommon with midurethral slings, occurring in 1% to 2% of patients. Dehiscence can be managed with estrogen cream or trimming of the exposed portion of the sling in the office. If symptoms or signs persist, removal of the exposed segment or the entire central portion of the sling, with closure of the vaginal epithelium, is indicated to allow for healing and resolution of symptoms. However, removal may lead to recurrence of the original SUI symptoms.

Retropubic hematomas occur in 1% to 2% of patients after placement of a retropubic sling, but major vascular injuries are rare—occurring in, perhaps, 3 in every 1,000 cases.

Bowel perforations are very rare but serious complications. A retropubic sling should be placed with caution or avoided in women who have a history of peritonitis, bowel surgery, ruptured appendix, or known extensive pelvic adhesions.

Major vascular injuries are also rare with TOT slings, occurring in approximately 1 to 2 cases in every 1,000.

Bladder injury occurs much less frequently after placement of a TOT sling, compared with the retropubic approach, although one study reported bladder injury in 2% of TOT cases.¹⁷ Although bladder injury is uncommon with the TOT approach, the morbidity associated with delayed detection of bladder injury is much higher than the morbidity associated with intraoperative detection and management. Therefore, we believe that cystoscopy should be performed in all TOT and retropubic sling procedures to either exclude bladder damage or detect and appropriately manage it.

For reassurance that intraoperative and postoperative blood loss is not excessive, it is reasonable to check one hemoglobin level before discharge, if desired.

How to individualize the choice of sling

Patients who have primary SUI: Retropubic or TOT sling. Objective and subjective success rates are similar, regardless of approach, and serious complications are infrequent. The retropubic approach has longer-term evidence of sustained benefit, compared with the newer TOT approach. We tend to treat younger patients with TVT and older patients with TOT. Surgeon experience and informed patient preferences may dictate the choice of sling (TABLE).

What we recommend surgically for our patients who have SUI—and why

Patients who have recurrent SUI: Retropubic sling. Comparative data are limited regarding the retropubic and TOT approaches for recurrent SUI that does not involve ISD. One case series reported good results with the use of retropubic TVT for recurrent SUI after an initial TOT approach.²³

Patients who have ISD: Retropubic sling (synthetic midurethral sling or fascial sling placed at the bladder neck). A few studies suggest that patients with ISD have better outcomes with the retropubic approach.^19,20 However, with differing definitions of ISD and relatively few patients with ISD included in these trials, it is not possible to conclude definitively that the retropubic approach is more effective than the TOT approach for patients who have SUI and ISD. However, the retropubic approach has longer-term data to support its effectiveness; therefore, with some but not all evidence suggesting its superiority for ISD, it is reasonable to choose the retropubic midurethral approach.

A pubovaginal fascial sling placed at the proximal urethra is also an effective option, based on numerous cohort studies.¹²

Patients who have recurrent SUI or ISD, or both, with a non-mobile bladder neck: Urethral bulking. Although data are scant, urethral injection therapy is beneficial for SUI in the short-term, but long-term studies are lacking. Bulking agents include silicone particles, calcium hydroxylapatite, and carbon spheres; studies have not shown one to be more or less efficacious than the others.²⁴

It is reasonable to use urethral bulking first in these patients as the morbidity is very low and some patients become continent. A retropubic sling can be performed if urethral bulking fails to adequately improve symptoms, although the effectiveness is lower in this population than in women with SUI and urethral hypermobility.

Patients who have mixed stress and urge incontinence or voiding dysfunction: TOT sling. Limited data suggest that the TOT approach improves symptoms of mixed incontinence—or, at least, exacerbates them to a lesser degree than the retropubic approach. Rarely is a sling release needed to treat obstructive urinary symptoms after the TOT approach.

Patients who have prolapse and SUI: Retropubic or TOT sling. When a sling procedure is performed at the same time as reconstructive surgery for prolapse, it has similar effectiveness, regardless of whether the retropubic or TOT approach is selected.^8,11 A sling placed during prolapse surgery (placed through a separate midurethral incision) appears to be as effective as a sling placed as a sole procedure.

Patients who have prolapse and occult SUI: TOT sling. If you recommend a sling to prevent SUI after prolapse surgery by any route, pick the sling with acceptable efficacy and the lowest rates of complications and voiding dysfunction. Patients are especially intolerant of complications from a sling to prevent SUI. Given the ease of placement and low morbidity of a later outpatient sling procedure, it is also reasonable to offer patients the “wait-and-see” alternative to see if SUI develops after prolapse surgery and only then proceeding with sling surgery. In this way, overtreatment is avoided, and any complications that occur after sling surgery for SUI treatment may be better tolerated by the patient. The preferences of an informed patient may guide decisions in this setting.

Patients who have recurrent SUI with mesh complication: Pubovaginal fascial sling or Burch colposuspension. These non-mesh options are effective for recurrent SUI and can be performed at the same time as mesh removal. They carry higher surgical morbidity, longer operative time, and greater postoperative voiding dysfunction.

An informed patient can help guide the approach

The retropubic and TOT approaches to tension-free midurethral slings are similar in effectiveness. Most women experience significant improvement of SUI symptoms after sling placement, although many women continue to have some urinary symptoms.

Depending on their training, experience, and personal results—as well as the preferences of an informed patient—surgeons may recommend one approach over the other. In addition, certain clinical situations may favor one sling over another. Studies with longer-term follow-up in different patient subgroups are needed to adequately counsel women about the durability of results.

CASE: Resolved

After discussing the options with your patient, she opts to undergo anterior prolapse repair with concurrent placement of a TOT sling. The surgery is completed without complication. She is discharged later that day without a catheter after demonstrating normal voiding with low residual urine volume. Postoperatively, she reports mild pain referred to the groin. You instruct her to take nonsteroidal anti-inflammatory drugs for pain relief. On her postoperative visit, she reports that the pain is gone and the SUI has almost completely resolved.

We want to hear from you! Tell us what you think.

Watch 3 video clips illustrating midurethral sling procedures

• Placement of TVT-O transobturator tape
• Monarc transobturator procedure
• TVT Exact retropubic sling operation

These videos were selected by Mark D. Walters, MD, and presented courtesy of the International Academy of Pelvic Surgery (IAPS).

Only 15 years ago, when surgery was recommended for patients who had bothersome stress urinary incontinence (SUI), they were offered operations such as suburethral (Kelly) plication, needle urethropexy, open or laparoscopic Burch procedure, and pubovaginal fascial sling procedure. Today, virtually all of these operations have been replaced in general practice by retropubic or transobturator (TOT) midurethral synthetic slings.

Although Burch colposuspension and the pubovaginal fascial sling procedure are effective for both primary and recurrent SUI, they are more invasive than midurethral slings, cause more voiding dysfunction, and have significantly longer recovery times, making them less attractive for most primary and recurrent cases of SUI.

The evolution of SUI surgeries has shifted so far toward midurethral slings that Burch colposuspension and the pubovaginal sling procedure are rarely performed or taught in obstetrics and gynecology or urology residency programs; these procedures are now mostly done in fellowship programs by specialists in female pelvic medicine and reconstructive surgery.

In this article, we describe how an ObGyn generalist can approach the surgical treatment of women who have either primary or recurrent SUI. Using evidence-based principles, when available, we also discuss how different clinical characteristics—as well as the characteristics of the available slings—affect the suitability of the sling for individual patients.

One caveat: This article assumes that the surgeon knows how to, and is able to, perform retropubic and TOT sling procedures equally well. However, when this is not the case, the surgeon should perform the sling procedure that she or he does best, assuming that it is appropriate for that particular patient.

Almost all surgical procedures for stress urinary incontinence performed today involve placement of a retropubic or transobturator midurethral synthetic sling.
Illustration: Craig Zuckerman for OBG Management

CASE: SUI and Stage II anterior vaginal prolapse

A healthy 45-year-old G2P2 woman complains of a 5-year history of worsening SUI symptoms, mostly occurring during activities such as coughing, laughing, and running. The incontinence has become so severe that she requires several pads daily. She is able to void without difficulty or pain, and her bowel movements are normal. She has regular menses, has had a tubal ligation, and is sexually active.

She reports that she has been performing daily Kegel pelvic muscle exercises, without improvement.

On physical examination, she is found to have Stage II anterior vaginal prolapse and urethral hypermobility, with normal uterine and posterior vaginal support. The uterus and ovaries are of normal size.

A full bladder stress test in the office reveals immediate loss of urine from the urethra upon coughing in a semi-sitting position. She voids 325 mL after the examination and has a post-void residual urine volume, as measured by ultrasonography (US), of 25 mL. Urinalysis is negative.

When discussing her goals, the patient expresses a desire for a cure of her urinary incontinence, if possible.

What further testing and treatment options do you offer to her?

If you and the patient agree that surgery is warranted, which procedure do you recommend?

Recommended assessment of women who report SUI

Women who have bothersome urine loss during activities such as exercise, coughing, or laughing should undergo a history, physical examination, and urinalysis. During the pelvic examination, it is important to assess pelvic organ support defects, especially those involving the anterior vagina and urethra. Also note levator ani muscle contraction and strength. In addition, you can use this time to discuss whether the patient is doing, or has done, pelvic muscle (Kegel) exercises; teach the exercises, if necessary; and encourage her to do them in the future.

If the patient has no urinary infection, has performed Kegel exercises without further benefit, and wishes to consider surgical treatment, basic assessment of lower urinary function is indicated. Basic office urodynamic testing includes:

• a measured void
• measurement of post-void residual volume (by catheter or US)
• assessment of bladder sensation and capacity
• provocation for overactive bladder
• a full-bladder cough stress test (a positive test is direct observation of urethral loss of urine upon coughing).

Patients who have a complex history or mixed symptoms, previous failed surgery, or other characteristics that suggest a diagnosis other than simple SUI should undergo formal electronic urodynamic testing.¹

Patient selection criteria

Primary sling surgery is an option for patients who have:

• no urinary infection
• normal voiding and bladder-filling function
• urethral hypermobility on examination
• SUI on a cough-stress test
• failure to improve sufficiently with pelvic muscle exercises.

Types of slings

Suburethral slings were initially developed as a treatment for recurrent, urodynamically confirmed SUI, particularly SUI caused by intrinsic sphincter deficiency (ISD). Pubovaginal slings, usually consisting of autologous fascia, were placed at the bladder neck to both support and slightly compress the proximal urethra. Compared with synthetic slings, fascial slings are effective but take longer to place and have a higher rate of surgical morbidity and more postoperative voiding dysfunction. They are now mostly indicated for complex recurrent SUI, usually managed by specialists in female pelvic medicine and reconstructive surgery.

Current slings are lightweight polypropylene mesh

Most slings today are tension-free midurethral slings consisting of synthetic, large-pore polypropylene mesh; they are sold in kits available from several different companies. Sling procedures can also be performed using hand-cut polypropylene mesh and a reusable needle passer.

These slings are placed at the midurethra and work by mechanical kinking or folding of the urethra over the sling, with an increase in intra-abdominal pressure. Ideally, the midurethral sling will not compress the urethra at rest and have no effect on the normal voiding mechanism.

Three main techniques are used to place synthetic midurethral slings:

• the retropubic approach
• the TOT approach
• variations of single-incision “mini-sling” procedures.

Early studies of mini-slings showed few complications but lower effectiveness, compared with retropubic and TOT midurethral slings, according to short-term follow-up data.^2-4 A mini-sling might be an option for some patients in whom surgical complications must be kept to a minimum; otherwise, they will not be discussed further.

Retropubic midurethral slings

The tension-free vaginal tape (TVT) procedure described by Petros and Ulmsten was the first synthetic midurethral sling.⁵ This ambulatory procedure aims to restore the pubourethral ligament and suburethral vaginal hammock by using specially designed needles attached to synthetic sling material.

The synthetic sling consists of polypropylene, approximately 1 cm wide and 40 cm long. The sling material is attached to two stainless steel needles that are passed from a vaginal incision made at the level of the midurethra, through the retropubic space, and exiting at a previously created mark or stab incision in the suprapubic area (FIGURE 1).

Variations of the retropubic midurethral sling have been developed, with sling passers going from the vagina upward (“bottom to top”) and also from the suprapubic area downward (“top to bottom”). A recent Cochrane review reported that the bottom-to-top variation is slightly more effective.⁶

FIGURE 1 Retropubic sling
Placement of the tension-free vaginal tape trocar into the retropubic space.
Illustration: Craig Zuckerman for OBG Management

Transobturator midurethral slings

The TOT sling has become one of the most popular and effective surgical treatments for female SUI worldwide (Video 1 and Video 2). It is a relatively rapid and low-risk surgery that is comparable to other surgical options in effectiveness while avoiding an abdominal incision and the passage of a needle or trocar through the space of Retzius.

The TOT sling lies flatter under the urethra and carries a lower risk of urethral obstruction, urinary retention, and subsequent need for sling release, compared with retropubic slings.^7-9 Compared with the retropubic TVT, the TOT sling produces similar rates of cure, with fewer bladder perforations and less postoperative irritative voiding symptoms.^6,10-12 It nearly eliminates the rare but catastrophic risk of bowel or major vessel perforation. The trade-off is that patients experience more complications referable to the groin (pain and leg weakness or numbness) with the TOT approach.^9,13

All TOT slings on the market consist of a large-pore, lightweight, polypropylene mesh strip, usually covered with a plastic sheath. Various devices are used to place the sling, but most of them involve a helical trocar that curves around the ischiopubic ramus, passing through the inner thigh and obturator membrane to a space created in the ipsilateral peri-urethral tissues.

TOT slings can be placed outside-to-inside or inside-to-outside (FIGURE 2), and the indications, effectiveness, and frequency of complications seem to be similar between these two approaches.¹² One study found a higher frequency of new sexual dysfunction (tender, palpable sling; penile pain in male partner) in women after the “outside-in” approach,¹⁴ but this clinical issue has not been observed in all studies.^15,16

FIGURE 2 TOT sling variations
Placement of the transobturator (TOT) sling helical trocar using the (A) “outside-in” variation and (B) “inside-out” variation.
Illustration: Craig Zuckerman for OBG Management
Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography
© 2005-2012. All Rights Reserved.

Success rates are similar for retropubic and TOT slings

Despite differences in technique and brand of mesh used, treatment success rates for uncomplicated primary SUI are similar for the retropubic (Video 3) and TOT tension-free slings.^6-8,10-12,17 The percentage of patients treated successfully depends on the definition used, ranging from a high of 96% to a low of 60%. When the definition of success is restricted to stress incontinence symptoms, especially over a short period of time, the reported effectiveness is high.

In contrast, when the definition of success includes incontinence of any type, the reported effectiveness is lower. For example, in the study that reported 60% effectiveness, success was defined as no incontinence symptoms of any type, a negative cough stress test, and no retreatment for stress incontinence or postoperative urinary retention.¹¹

Retropubic slings, especially TVT, may be somewhat more effective for ISD,^18-20 although this conclusion must be tempered by the small number of studies addressing the issue and differences in the diagnosis of ISD.²¹

Some studies have reported good success in treating mixed urinary incontinence with the retropubic and TOT slings,^2,8 although other studies have reported that the initial benefit for urgency or urge incontinence is not sustained over time, compared with the benefit for stress incontinence.²² It is important to counsel patients before surgery that improvement in stress incontinence symptoms and general satisfaction is highly likely, but perfect bladder function is not.

Serious complications are uncommon

Complications are common after both retropubic and TOT slings, although serious complications are uncommon. Cystitis and temporary voiding difficulties are the most common problems after a sling procedure. If the patient is unable to void on the day of surgery, it is reasonable to discharge her with a Foley catheter in place for a few days or teach her to perform intermittent self-catheterization at home. In most cases, normal voiding will resume within a few days. Cystitis is at least partially related to the surgery itself and the duration of postoperative catheterization.

The frequency of some complications differs between the retropubic and TOT approaches to midurethral slings. For example, some literature suggests that irritative voiding symptoms such as urgency or voiding difficulty are somewhat less common after TOT slings, compared with retropubic slings. However, symptoms referable to the groin (pain and leg weakness or numbness) occur more commonly with the TOT approach.⁶

After placement of a TOT sling, 10% to 15% of women experience temporary inner thigh or groin pain or leg weakness and are usually managed conservatively with nonsteroidal anti-inflammatory drugs and physical therapy. Long-term or severe complications related to TOT sling passage are rare.

Major intraoperative complications are rare

The rate of these complications does not differ between retropubic and TOT approaches. Minor intraoperative complications—primarily, bladder perforation—occur more commonly with the retropubic approach.⁶

Bladder perforation with the TVT occurs in 4% to 7% of patients. However, the clinical significance of bladder perforation is minimal as long as the surgeon performs careful cystoscopy, recognizes bladder perforation, and repositions the trocar and mesh outside the bladder lumen. Bladder perforation caused by the trocar usually does not require specific treatment (except repositioning of the trocar outside the bladder lumen) and rarely results in later problems.

Mesh exposures occur with similar frequency for the different sling types as long as large-pore lightweight polypropylene is used. Dehiscence of the suburethral incision (mesh exposure) is uncommon with midurethral slings, occurring in 1% to 2% of patients. Dehiscence can be managed with estrogen cream or trimming of the exposed portion of the sling in the office. If symptoms or signs persist, removal of the exposed segment or the entire central portion of the sling, with closure of the vaginal epithelium, is indicated to allow for healing and resolution of symptoms. However, removal may lead to recurrence of the original SUI symptoms.

Retropubic hematomas occur in 1% to 2% of patients after placement of a retropubic sling, but major vascular injuries are rare—occurring in, perhaps, 3 in every 1,000 cases.

Bowel perforations are very rare but serious complications. A retropubic sling should be placed with caution or avoided in women who have a history of peritonitis, bowel surgery, ruptured appendix, or known extensive pelvic adhesions.

Major vascular injuries are also rare with TOT slings, occurring in approximately 1 to 2 cases in every 1,000.

Bladder injury occurs much less frequently after placement of a TOT sling, compared with the retropubic approach, although one study reported bladder injury in 2% of TOT cases.¹⁷ Although bladder injury is uncommon with the TOT approach, the morbidity associated with delayed detection of bladder injury is much higher than the morbidity associated with intraoperative detection and management. Therefore, we believe that cystoscopy should be performed in all TOT and retropubic sling procedures to either exclude bladder damage or detect and appropriately manage it.

For reassurance that intraoperative and postoperative blood loss is not excessive, it is reasonable to check one hemoglobin level before discharge, if desired.

How to individualize the choice of sling

Patients who have primary SUI: Retropubic or TOT sling. Objective and subjective success rates are similar, regardless of approach, and serious complications are infrequent. The retropubic approach has longer-term evidence of sustained benefit, compared with the newer TOT approach. We tend to treat younger patients with TVT and older patients with TOT. Surgeon experience and informed patient preferences may dictate the choice of sling (TABLE).

What we recommend surgically for our patients who have SUI—and why

Patients who have recurrent SUI: Retropubic sling. Comparative data are limited regarding the retropubic and TOT approaches for recurrent SUI that does not involve ISD. One case series reported good results with the use of retropubic TVT for recurrent SUI after an initial TOT approach.²³

Patients who have ISD: Retropubic sling (synthetic midurethral sling or fascial sling placed at the bladder neck). A few studies suggest that patients with ISD have better outcomes with the retropubic approach.^19,20 However, with differing definitions of ISD and relatively few patients with ISD included in these trials, it is not possible to conclude definitively that the retropubic approach is more effective than the TOT approach for patients who have SUI and ISD. However, the retropubic approach has longer-term data to support its effectiveness; therefore, with some but not all evidence suggesting its superiority for ISD, it is reasonable to choose the retropubic midurethral approach.

A pubovaginal fascial sling placed at the proximal urethra is also an effective option, based on numerous cohort studies.¹²

Patients who have recurrent SUI or ISD, or both, with a non-mobile bladder neck: Urethral bulking. Although data are scant, urethral injection therapy is beneficial for SUI in the short-term, but long-term studies are lacking. Bulking agents include silicone particles, calcium hydroxylapatite, and carbon spheres; studies have not shown one to be more or less efficacious than the others.²⁴

It is reasonable to use urethral bulking first in these patients as the morbidity is very low and some patients become continent. A retropubic sling can be performed if urethral bulking fails to adequately improve symptoms, although the effectiveness is lower in this population than in women with SUI and urethral hypermobility.

Patients who have mixed stress and urge incontinence or voiding dysfunction: TOT sling. Limited data suggest that the TOT approach improves symptoms of mixed incontinence—or, at least, exacerbates them to a lesser degree than the retropubic approach. Rarely is a sling release needed to treat obstructive urinary symptoms after the TOT approach.

Patients who have prolapse and SUI: Retropubic or TOT sling. When a sling procedure is performed at the same time as reconstructive surgery for prolapse, it has similar effectiveness, regardless of whether the retropubic or TOT approach is selected.^8,11 A sling placed during prolapse surgery (placed through a separate midurethral incision) appears to be as effective as a sling placed as a sole procedure.

Patients who have prolapse and occult SUI: TOT sling. If you recommend a sling to prevent SUI after prolapse surgery by any route, pick the sling with acceptable efficacy and the lowest rates of complications and voiding dysfunction. Patients are especially intolerant of complications from a sling to prevent SUI. Given the ease of placement and low morbidity of a later outpatient sling procedure, it is also reasonable to offer patients the “wait-and-see” alternative to see if SUI develops after prolapse surgery and only then proceeding with sling surgery. In this way, overtreatment is avoided, and any complications that occur after sling surgery for SUI treatment may be better tolerated by the patient. The preferences of an informed patient may guide decisions in this setting.

Patients who have recurrent SUI with mesh complication: Pubovaginal fascial sling or Burch colposuspension. These non-mesh options are effective for recurrent SUI and can be performed at the same time as mesh removal. They carry higher surgical morbidity, longer operative time, and greater postoperative voiding dysfunction.

An informed patient can help guide the approach

The retropubic and TOT approaches to tension-free midurethral slings are similar in effectiveness. Most women experience significant improvement of SUI symptoms after sling placement, although many women continue to have some urinary symptoms.

Depending on their training, experience, and personal results—as well as the preferences of an informed patient—surgeons may recommend one approach over the other. In addition, certain clinical situations may favor one sling over another. Studies with longer-term follow-up in different patient subgroups are needed to adequately counsel women about the durability of results.

CASE: Resolved

After discussing the options with your patient, she opts to undergo anterior prolapse repair with concurrent placement of a TOT sling. The surgery is completed without complication. She is discharged later that day without a catheter after demonstrating normal voiding with low residual urine volume. Postoperatively, she reports mild pain referred to the groin. You instruct her to take nonsteroidal anti-inflammatory drugs for pain relief. On her postoperative visit, she reports that the pain is gone and the SUI has almost completely resolved.

We want to hear from you! Tell us what you think.

Watch 3 video clips illustrating midurethral sling procedures

• Placement of TVT-O transobturator tape
• Monarc transobturator procedure
• TVT Exact retropubic sling operation

These videos were selected by Mark D. Walters, MD, and presented courtesy of the International Academy of Pelvic Surgery (IAPS).

Only 15 years ago, when surgery was recommended for patients who had bothersome stress urinary incontinence (SUI), they were offered operations such as suburethral (Kelly) plication, needle urethropexy, open or laparoscopic Burch procedure, and pubovaginal fascial sling procedure. Today, virtually all of these operations have been replaced in general practice by retropubic or transobturator (TOT) midurethral synthetic slings.

Although Burch colposuspension and the pubovaginal fascial sling procedure are effective for both primary and recurrent SUI, they are more invasive than midurethral slings, cause more voiding dysfunction, and have significantly longer recovery times, making them less attractive for most primary and recurrent cases of SUI.

The evolution of SUI surgeries has shifted so far toward midurethral slings that Burch colposuspension and the pubovaginal sling procedure are rarely performed or taught in obstetrics and gynecology or urology residency programs; these procedures are now mostly done in fellowship programs by specialists in female pelvic medicine and reconstructive surgery.

In this article, we describe how an ObGyn generalist can approach the surgical treatment of women who have either primary or recurrent SUI. Using evidence-based principles, when available, we also discuss how different clinical characteristics—as well as the characteristics of the available slings—affect the suitability of the sling for individual patients.

One caveat: This article assumes that the surgeon knows how to, and is able to, perform retropubic and TOT sling procedures equally well. However, when this is not the case, the surgeon should perform the sling procedure that she or he does best, assuming that it is appropriate for that particular patient.

Almost all surgical procedures for stress urinary incontinence performed today involve placement of a retropubic or transobturator midurethral synthetic sling.
Illustration: Craig Zuckerman for OBG Management

CASE: SUI and Stage II anterior vaginal prolapse

A healthy 45-year-old G2P2 woman complains of a 5-year history of worsening SUI symptoms, mostly occurring during activities such as coughing, laughing, and running. The incontinence has become so severe that she requires several pads daily. She is able to void without difficulty or pain, and her bowel movements are normal. She has regular menses, has had a tubal ligation, and is sexually active.

She reports that she has been performing daily Kegel pelvic muscle exercises, without improvement.

On physical examination, she is found to have Stage II anterior vaginal prolapse and urethral hypermobility, with normal uterine and posterior vaginal support. The uterus and ovaries are of normal size.

A full bladder stress test in the office reveals immediate loss of urine from the urethra upon coughing in a semi-sitting position. She voids 325 mL after the examination and has a post-void residual urine volume, as measured by ultrasonography (US), of 25 mL. Urinalysis is negative.

When discussing her goals, the patient expresses a desire for a cure of her urinary incontinence, if possible.

What further testing and treatment options do you offer to her?

If you and the patient agree that surgery is warranted, which procedure do you recommend?

Recommended assessment of women who report SUI

Women who have bothersome urine loss during activities such as exercise, coughing, or laughing should undergo a history, physical examination, and urinalysis. During the pelvic examination, it is important to assess pelvic organ support defects, especially those involving the anterior vagina and urethra. Also note levator ani muscle contraction and strength. In addition, you can use this time to discuss whether the patient is doing, or has done, pelvic muscle (Kegel) exercises; teach the exercises, if necessary; and encourage her to do them in the future.

If the patient has no urinary infection, has performed Kegel exercises without further benefit, and wishes to consider surgical treatment, basic assessment of lower urinary function is indicated. Basic office urodynamic testing includes:

• a measured void
• measurement of post-void residual volume (by catheter or US)
• assessment of bladder sensation and capacity
• provocation for overactive bladder
• a full-bladder cough stress test (a positive test is direct observation of urethral loss of urine upon coughing).

Patients who have a complex history or mixed symptoms, previous failed surgery, or other characteristics that suggest a diagnosis other than simple SUI should undergo formal electronic urodynamic testing.¹

Patient selection criteria

Primary sling surgery is an option for patients who have:

• no urinary infection
• normal voiding and bladder-filling function
• urethral hypermobility on examination
• SUI on a cough-stress test
• failure to improve sufficiently with pelvic muscle exercises.

Types of slings

Suburethral slings were initially developed as a treatment for recurrent, urodynamically confirmed SUI, particularly SUI caused by intrinsic sphincter deficiency (ISD). Pubovaginal slings, usually consisting of autologous fascia, were placed at the bladder neck to both support and slightly compress the proximal urethra. Compared with synthetic slings, fascial slings are effective but take longer to place and have a higher rate of surgical morbidity and more postoperative voiding dysfunction. They are now mostly indicated for complex recurrent SUI, usually managed by specialists in female pelvic medicine and reconstructive surgery.

Current slings are lightweight polypropylene mesh

Most slings today are tension-free midurethral slings consisting of synthetic, large-pore polypropylene mesh; they are sold in kits available from several different companies. Sling procedures can also be performed using hand-cut polypropylene mesh and a reusable needle passer.

These slings are placed at the midurethra and work by mechanical kinking or folding of the urethra over the sling, with an increase in intra-abdominal pressure. Ideally, the midurethral sling will not compress the urethra at rest and have no effect on the normal voiding mechanism.

Three main techniques are used to place synthetic midurethral slings:

• the retropubic approach
• the TOT approach
• variations of single-incision “mini-sling” procedures.

Early studies of mini-slings showed few complications but lower effectiveness, compared with retropubic and TOT midurethral slings, according to short-term follow-up data.^2-4 A mini-sling might be an option for some patients in whom surgical complications must be kept to a minimum; otherwise, they will not be discussed further.

Retropubic midurethral slings

The tension-free vaginal tape (TVT) procedure described by Petros and Ulmsten was the first synthetic midurethral sling.⁵ This ambulatory procedure aims to restore the pubourethral ligament and suburethral vaginal hammock by using specially designed needles attached to synthetic sling material.

The synthetic sling consists of polypropylene, approximately 1 cm wide and 40 cm long. The sling material is attached to two stainless steel needles that are passed from a vaginal incision made at the level of the midurethra, through the retropubic space, and exiting at a previously created mark or stab incision in the suprapubic area (FIGURE 1).

Variations of the retropubic midurethral sling have been developed, with sling passers going from the vagina upward (“bottom to top”) and also from the suprapubic area downward (“top to bottom”). A recent Cochrane review reported that the bottom-to-top variation is slightly more effective.⁶

FIGURE 1 Retropubic sling
Placement of the tension-free vaginal tape trocar into the retropubic space.
Illustration: Craig Zuckerman for OBG Management

Transobturator midurethral slings

The TOT sling has become one of the most popular and effective surgical treatments for female SUI worldwide (Video 1 and Video 2). It is a relatively rapid and low-risk surgery that is comparable to other surgical options in effectiveness while avoiding an abdominal incision and the passage of a needle or trocar through the space of Retzius.

The TOT sling lies flatter under the urethra and carries a lower risk of urethral obstruction, urinary retention, and subsequent need for sling release, compared with retropubic slings.^7-9 Compared with the retropubic TVT, the TOT sling produces similar rates of cure, with fewer bladder perforations and less postoperative irritative voiding symptoms.^6,10-12 It nearly eliminates the rare but catastrophic risk of bowel or major vessel perforation. The trade-off is that patients experience more complications referable to the groin (pain and leg weakness or numbness) with the TOT approach.^9,13

All TOT slings on the market consist of a large-pore, lightweight, polypropylene mesh strip, usually covered with a plastic sheath. Various devices are used to place the sling, but most of them involve a helical trocar that curves around the ischiopubic ramus, passing through the inner thigh and obturator membrane to a space created in the ipsilateral peri-urethral tissues.

TOT slings can be placed outside-to-inside or inside-to-outside (FIGURE 2), and the indications, effectiveness, and frequency of complications seem to be similar between these two approaches.¹² One study found a higher frequency of new sexual dysfunction (tender, palpable sling; penile pain in male partner) in women after the “outside-in” approach,¹⁴ but this clinical issue has not been observed in all studies.^15,16

FIGURE 2 TOT sling variations
Placement of the transobturator (TOT) sling helical trocar using the (A) “outside-in” variation and (B) “inside-out” variation.
Illustration: Craig Zuckerman for OBG Management
Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography
© 2005-2012. All Rights Reserved.

Success rates are similar for retropubic and TOT slings

Despite differences in technique and brand of mesh used, treatment success rates for uncomplicated primary SUI are similar for the retropubic (Video 3) and TOT tension-free slings.^6-8,10-12,17 The percentage of patients treated successfully depends on the definition used, ranging from a high of 96% to a low of 60%. When the definition of success is restricted to stress incontinence symptoms, especially over a short period of time, the reported effectiveness is high.

In contrast, when the definition of success includes incontinence of any type, the reported effectiveness is lower. For example, in the study that reported 60% effectiveness, success was defined as no incontinence symptoms of any type, a negative cough stress test, and no retreatment for stress incontinence or postoperative urinary retention.¹¹

Retropubic slings, especially TVT, may be somewhat more effective for ISD,^18-20 although this conclusion must be tempered by the small number of studies addressing the issue and differences in the diagnosis of ISD.²¹

Some studies have reported good success in treating mixed urinary incontinence with the retropubic and TOT slings,^2,8 although other studies have reported that the initial benefit for urgency or urge incontinence is not sustained over time, compared with the benefit for stress incontinence.²² It is important to counsel patients before surgery that improvement in stress incontinence symptoms and general satisfaction is highly likely, but perfect bladder function is not.

Serious complications are uncommon

Complications are common after both retropubic and TOT slings, although serious complications are uncommon. Cystitis and temporary voiding difficulties are the most common problems after a sling procedure. If the patient is unable to void on the day of surgery, it is reasonable to discharge her with a Foley catheter in place for a few days or teach her to perform intermittent self-catheterization at home. In most cases, normal voiding will resume within a few days. Cystitis is at least partially related to the surgery itself and the duration of postoperative catheterization.

The frequency of some complications differs between the retropubic and TOT approaches to midurethral slings. For example, some literature suggests that irritative voiding symptoms such as urgency or voiding difficulty are somewhat less common after TOT slings, compared with retropubic slings. However, symptoms referable to the groin (pain and leg weakness or numbness) occur more commonly with the TOT approach.⁶

After placement of a TOT sling, 10% to 15% of women experience temporary inner thigh or groin pain or leg weakness and are usually managed conservatively with nonsteroidal anti-inflammatory drugs and physical therapy. Long-term or severe complications related to TOT sling passage are rare.

Major intraoperative complications are rare

The rate of these complications does not differ between retropubic and TOT approaches. Minor intraoperative complications—primarily, bladder perforation—occur more commonly with the retropubic approach.⁶

Bladder perforation with the TVT occurs in 4% to 7% of patients. However, the clinical significance of bladder perforation is minimal as long as the surgeon performs careful cystoscopy, recognizes bladder perforation, and repositions the trocar and mesh outside the bladder lumen. Bladder perforation caused by the trocar usually does not require specific treatment (except repositioning of the trocar outside the bladder lumen) and rarely results in later problems.

Mesh exposures occur with similar frequency for the different sling types as long as large-pore lightweight polypropylene is used. Dehiscence of the suburethral incision (mesh exposure) is uncommon with midurethral slings, occurring in 1% to 2% of patients. Dehiscence can be managed with estrogen cream or trimming of the exposed portion of the sling in the office. If symptoms or signs persist, removal of the exposed segment or the entire central portion of the sling, with closure of the vaginal epithelium, is indicated to allow for healing and resolution of symptoms. However, removal may lead to recurrence of the original SUI symptoms.

Retropubic hematomas occur in 1% to 2% of patients after placement of a retropubic sling, but major vascular injuries are rare—occurring in, perhaps, 3 in every 1,000 cases.

Bowel perforations are very rare but serious complications. A retropubic sling should be placed with caution or avoided in women who have a history of peritonitis, bowel surgery, ruptured appendix, or known extensive pelvic adhesions.

Major vascular injuries are also rare with TOT slings, occurring in approximately 1 to 2 cases in every 1,000.

Bladder injury occurs much less frequently after placement of a TOT sling, compared with the retropubic approach, although one study reported bladder injury in 2% of TOT cases.¹⁷ Although bladder injury is uncommon with the TOT approach, the morbidity associated with delayed detection of bladder injury is much higher than the morbidity associated with intraoperative detection and management. Therefore, we believe that cystoscopy should be performed in all TOT and retropubic sling procedures to either exclude bladder damage or detect and appropriately manage it.

For reassurance that intraoperative and postoperative blood loss is not excessive, it is reasonable to check one hemoglobin level before discharge, if desired.

How to individualize the choice of sling

Patients who have primary SUI: Retropubic or TOT sling. Objective and subjective success rates are similar, regardless of approach, and serious complications are infrequent. The retropubic approach has longer-term evidence of sustained benefit, compared with the newer TOT approach. We tend to treat younger patients with TVT and older patients with TOT. Surgeon experience and informed patient preferences may dictate the choice of sling (TABLE).

What we recommend surgically for our patients who have SUI—and why

Patients who have recurrent SUI: Retropubic sling. Comparative data are limited regarding the retropubic and TOT approaches for recurrent SUI that does not involve ISD. One case series reported good results with the use of retropubic TVT for recurrent SUI after an initial TOT approach.²³

Patients who have ISD: Retropubic sling (synthetic midurethral sling or fascial sling placed at the bladder neck). A few studies suggest that patients with ISD have better outcomes with the retropubic approach.^19,20 However, with differing definitions of ISD and relatively few patients with ISD included in these trials, it is not possible to conclude definitively that the retropubic approach is more effective than the TOT approach for patients who have SUI and ISD. However, the retropubic approach has longer-term data to support its effectiveness; therefore, with some but not all evidence suggesting its superiority for ISD, it is reasonable to choose the retropubic midurethral approach.

A pubovaginal fascial sling placed at the proximal urethra is also an effective option, based on numerous cohort studies.¹²

Patients who have recurrent SUI or ISD, or both, with a non-mobile bladder neck: Urethral bulking. Although data are scant, urethral injection therapy is beneficial for SUI in the short-term, but long-term studies are lacking. Bulking agents include silicone particles, calcium hydroxylapatite, and carbon spheres; studies have not shown one to be more or less efficacious than the others.²⁴

It is reasonable to use urethral bulking first in these patients as the morbidity is very low and some patients become continent. A retropubic sling can be performed if urethral bulking fails to adequately improve symptoms, although the effectiveness is lower in this population than in women with SUI and urethral hypermobility.

Patients who have mixed stress and urge incontinence or voiding dysfunction: TOT sling. Limited data suggest that the TOT approach improves symptoms of mixed incontinence—or, at least, exacerbates them to a lesser degree than the retropubic approach. Rarely is a sling release needed to treat obstructive urinary symptoms after the TOT approach.

Patients who have prolapse and SUI: Retropubic or TOT sling. When a sling procedure is performed at the same time as reconstructive surgery for prolapse, it has similar effectiveness, regardless of whether the retropubic or TOT approach is selected.^8,11 A sling placed during prolapse surgery (placed through a separate midurethral incision) appears to be as effective as a sling placed as a sole procedure.

Patients who have prolapse and occult SUI: TOT sling. If you recommend a sling to prevent SUI after prolapse surgery by any route, pick the sling with acceptable efficacy and the lowest rates of complications and voiding dysfunction. Patients are especially intolerant of complications from a sling to prevent SUI. Given the ease of placement and low morbidity of a later outpatient sling procedure, it is also reasonable to offer patients the “wait-and-see” alternative to see if SUI develops after prolapse surgery and only then proceeding with sling surgery. In this way, overtreatment is avoided, and any complications that occur after sling surgery for SUI treatment may be better tolerated by the patient. The preferences of an informed patient may guide decisions in this setting.

Patients who have recurrent SUI with mesh complication: Pubovaginal fascial sling or Burch colposuspension. These non-mesh options are effective for recurrent SUI and can be performed at the same time as mesh removal. They carry higher surgical morbidity, longer operative time, and greater postoperative voiding dysfunction.

An informed patient can help guide the approach

The retropubic and TOT approaches to tension-free midurethral slings are similar in effectiveness. Most women experience significant improvement of SUI symptoms after sling placement, although many women continue to have some urinary symptoms.

Depending on their training, experience, and personal results—as well as the preferences of an informed patient—surgeons may recommend one approach over the other. In addition, certain clinical situations may favor one sling over another. Studies with longer-term follow-up in different patient subgroups are needed to adequately counsel women about the durability of results.

CASE: Resolved

After discussing the options with your patient, she opts to undergo anterior prolapse repair with concurrent placement of a TOT sling. The surgery is completed without complication. She is discharged later that day without a catheter after demonstrating normal voiding with low residual urine volume. Postoperatively, she reports mild pain referred to the groin. You instruct her to take nonsteroidal anti-inflammatory drugs for pain relief. On her postoperative visit, she reports that the pain is gone and the SUI has almost completely resolved.

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EDITOR’S NOTE: Brand names are given parenthetically in some places in the text solely to provide better recognition of methods discussed.

As other articles in this issue of OBG Management attest, medical science continues to focus attention on improving methods of family planning. That emphasis has meant a regular flow of new reports, studies, and guidelines for you to absorb and translate into better practice—no easy task.

Here is help: 10 (+ 1) practical, sensible recommendations for improving contraceptive care that have emerged from recent evidence and that are reasonably easy to incorporate into the care you provide. As with previous installments of this occasional “recommendations” series, we include a brief discussion and pertinent references for each tip.

1. Pelvic exam? It isn’t mandatory.

Do not require pelvic examination before you prescribe an oral contraceptive.

Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol. 2010;116(6):1257–1264.

The World Health Organization and ACOG recommend that you consider pelvic examination optional before prescribing an oral contraceptive (OC). Recent evidence indicates, however, that many health-care providers don’t follow that recommendation. Avoiding an unnecessary pelvic exam is a plus for a patient who may fear the procedure; following this guidance therefore removes a potential barrier to care and saves time in a busy practice.

2. Provide more, not less

Prescribe (when possible, dispense) 6 to 12 months of an OC at office visits.

Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol. 2011;117(3):551–557.

Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011;117(3):566–572.

Studies show that 1) women who are given six or more pill packages at a clinic visit have a lower discontinuation rate than women given one to five packs and 2) prescribing a 1-year supply of OC pill packages (as opposed to one to three packs) is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy and a 46% reduction in the odds of having an abortion.

3. Make the case for long-acting reversibles

Use intrauterine devices and subdermal implants as first-line contraception more often.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 59: Intrauterine device. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2005;105(1):223–232.

Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–1113.

Long-acting methods such as the copper intrauterine device (IUD) (Paragard) and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) are the most effective reversible contraceptives because they eliminate the difference between perfect and typical use. A woman at low risk does not need to have a negative cervical culture before having an IUD or the LNG-IUS inserted, and a woman does not need to be on her menses at the time of insertion. In addition, antibiotic prophylaxis is not recommended before or at the time of insertion.

IUDs—and this applies to the subdermal contraceptive implant (Implanon), too—also have the highest rates of satisfaction and 12-month continuation.

4. Take advantage of broader benefits

Use hormonal contraceptives for noncontraceptive indications.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(6):206–218.

Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–787.

Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.

Hormonal contraceptives have long been used for such indications as cycle control and treatment of acne. The LNG-IUS and OCs are highly effective, compared with placebo, for treating heavy menstrual bleeding in the absence of organic pathology.* As a potential alternative to surgical treatment of menorrhagia, OCs offer even broader benefit for many women.

*Mirena is approved by the Food and Drug Administration for treating heavy menstrual bleeding.

5. To encourage continuation, begin now

Get a “quick start” to improve adherence to oral contraceptives.

Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.

Starting OC pills immediately—instead of waiting for the Sunday after the next menses—can improve the short-term continuation rate for women patients who choose an OC.

6. Move away from every-day regimens

Consider a nondaily combined method, such as the transdermal patch or the vaginal ring, for current OC users.

Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 pt 1):267–277.

Many women who use an OC are satisfied with the positive effect the method has on menses and acne but find that they miss taking a pill some days; they might benefit from a method that involves nondaily administration. Studies show that switching from oral contraception to the transdermal patch (OrthoEvra) or vaginal ring (Nuvaring), for example, is acceptable to many women.

7. Preemptive prescribing

Prescribe emergency contraception before your patient needs it.

Jackson RA, Schwarz EB, Freedman L, Darney P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol. 2003;102(1):8–16.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100–1109.

Consider giving every sexually active woman a prescription for emergency contraception before she leaves your office. She can fill the prescription and keep it at home in case of an emergency.

8. Get to know ella

Become familiar with ulipristal acetate (ella) for emergency contraception.

Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.

Barbieri RL. Levonorgestrel or ulipristal: is one a better emergency contraceptive than the other? OBG Manage. 2011;23(3):8–11.

This new FDA-approved agent for emergency contraception is effective for as long as 5 days after intercourse and results in fewer pregnancies than levonorgestrel does. It is available by prescription only, however, and is more expensive than levonorgestrel.

9. Pursue two urogenital pathogens

When you are not performing a speculum examination, screen for N. gonorrhoeae and C. trachomatis with a vaginal swab specimen or urine-based specimen.

Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep. 2002;51(RR-15):1–38; quiz CE1–4.

Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32(12):725–728.

Under new screening guidelines for cervical cancer, Pap smears are not required for women who are younger than 21 years. Gonorrhea and chlamydial infection screening is still important in this population, however, and can be done without a speculum exam.The patient or provider collects a specimen for testing with a vaginal swab, or the patient submits a urine specimen.

10. Now not later: An IUD, post-evacuation

Consider immediate, rather than delayed, IUD insertion after uterine evacuation for spontaneous or elective abortion in women who desire this form of contraception.

Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208-2217.

A recent clinical trial enrolled 575 women who underwent uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks’ gestation and who desired an IUD. Subjects were randomized to IUD insertion immediately after the procedure or 2 to 6 weeks later. The 6-month expulsion rate was 5.0% after immediate insertion; 2.7%, after delayed insertion (P = NS). There were no differences in the rates of other adverse events. Only 71% of patients returned for their “delayed” IUD placement; five pregnancies occurred among these women. No pregnancies occurred in the immediate-insertion group.

We want to hear from you! Tell us what you think.

EDITOR’S NOTE: Brand names are given parenthetically in some places in the text solely to provide better recognition of methods discussed.

As other articles in this issue of OBG Management attest, medical science continues to focus attention on improving methods of family planning. That emphasis has meant a regular flow of new reports, studies, and guidelines for you to absorb and translate into better practice—no easy task.

Here is help: 10 (+ 1) practical, sensible recommendations for improving contraceptive care that have emerged from recent evidence and that are reasonably easy to incorporate into the care you provide. As with previous installments of this occasional “recommendations” series, we include a brief discussion and pertinent references for each tip.

1. Pelvic exam? It isn’t mandatory.

Do not require pelvic examination before you prescribe an oral contraceptive.

Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol. 2010;116(6):1257–1264.

The World Health Organization and ACOG recommend that you consider pelvic examination optional before prescribing an oral contraceptive (OC). Recent evidence indicates, however, that many health-care providers don’t follow that recommendation. Avoiding an unnecessary pelvic exam is a plus for a patient who may fear the procedure; following this guidance therefore removes a potential barrier to care and saves time in a busy practice.

2. Provide more, not less

Prescribe (when possible, dispense) 6 to 12 months of an OC at office visits.

Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol. 2011;117(3):551–557.

Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011;117(3):566–572.

Studies show that 1) women who are given six or more pill packages at a clinic visit have a lower discontinuation rate than women given one to five packs and 2) prescribing a 1-year supply of OC pill packages (as opposed to one to three packs) is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy and a 46% reduction in the odds of having an abortion.

3. Make the case for long-acting reversibles

Use intrauterine devices and subdermal implants as first-line contraception more often.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 59: Intrauterine device. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2005;105(1):223–232.

Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–1113.

Long-acting methods such as the copper intrauterine device (IUD) (Paragard) and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) are the most effective reversible contraceptives because they eliminate the difference between perfect and typical use. A woman at low risk does not need to have a negative cervical culture before having an IUD or the LNG-IUS inserted, and a woman does not need to be on her menses at the time of insertion. In addition, antibiotic prophylaxis is not recommended before or at the time of insertion.

IUDs—and this applies to the subdermal contraceptive implant (Implanon), too—also have the highest rates of satisfaction and 12-month continuation.

4. Take advantage of broader benefits

Use hormonal contraceptives for noncontraceptive indications.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(6):206–218.

Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–787.

Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.

Hormonal contraceptives have long been used for such indications as cycle control and treatment of acne. The LNG-IUS and OCs are highly effective, compared with placebo, for treating heavy menstrual bleeding in the absence of organic pathology.* As a potential alternative to surgical treatment of menorrhagia, OCs offer even broader benefit for many women.

*Mirena is approved by the Food and Drug Administration for treating heavy menstrual bleeding.

5. To encourage continuation, begin now

Get a “quick start” to improve adherence to oral contraceptives.

Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.

Starting OC pills immediately—instead of waiting for the Sunday after the next menses—can improve the short-term continuation rate for women patients who choose an OC.

6. Move away from every-day regimens

Consider a nondaily combined method, such as the transdermal patch or the vaginal ring, for current OC users.

Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 pt 1):267–277.

Many women who use an OC are satisfied with the positive effect the method has on menses and acne but find that they miss taking a pill some days; they might benefit from a method that involves nondaily administration. Studies show that switching from oral contraception to the transdermal patch (OrthoEvra) or vaginal ring (Nuvaring), for example, is acceptable to many women.

7. Preemptive prescribing

Prescribe emergency contraception before your patient needs it.

Jackson RA, Schwarz EB, Freedman L, Darney P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol. 2003;102(1):8–16.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100–1109.

Consider giving every sexually active woman a prescription for emergency contraception before she leaves your office. She can fill the prescription and keep it at home in case of an emergency.

8. Get to know ella

Become familiar with ulipristal acetate (ella) for emergency contraception.

Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.

Barbieri RL. Levonorgestrel or ulipristal: is one a better emergency contraceptive than the other? OBG Manage. 2011;23(3):8–11.

This new FDA-approved agent for emergency contraception is effective for as long as 5 days after intercourse and results in fewer pregnancies than levonorgestrel does. It is available by prescription only, however, and is more expensive than levonorgestrel.

9. Pursue two urogenital pathogens

When you are not performing a speculum examination, screen for N. gonorrhoeae and C. trachomatis with a vaginal swab specimen or urine-based specimen.

Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep. 2002;51(RR-15):1–38; quiz CE1–4.

Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32(12):725–728.

Under new screening guidelines for cervical cancer, Pap smears are not required for women who are younger than 21 years. Gonorrhea and chlamydial infection screening is still important in this population, however, and can be done without a speculum exam.The patient or provider collects a specimen for testing with a vaginal swab, or the patient submits a urine specimen.

10. Now not later: An IUD, post-evacuation

Consider immediate, rather than delayed, IUD insertion after uterine evacuation for spontaneous or elective abortion in women who desire this form of contraception.

Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208-2217.

A recent clinical trial enrolled 575 women who underwent uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks’ gestation and who desired an IUD. Subjects were randomized to IUD insertion immediately after the procedure or 2 to 6 weeks later. The 6-month expulsion rate was 5.0% after immediate insertion; 2.7%, after delayed insertion (P = NS). There were no differences in the rates of other adverse events. Only 71% of patients returned for their “delayed” IUD placement; five pregnancies occurred among these women. No pregnancies occurred in the immediate-insertion group.

We want to hear from you! Tell us what you think.

EDITOR’S NOTE: Brand names are given parenthetically in some places in the text solely to provide better recognition of methods discussed.

As other articles in this issue of OBG Management attest, medical science continues to focus attention on improving methods of family planning. That emphasis has meant a regular flow of new reports, studies, and guidelines for you to absorb and translate into better practice—no easy task.

Here is help: 10 (+ 1) practical, sensible recommendations for improving contraceptive care that have emerged from recent evidence and that are reasonably easy to incorporate into the care you provide. As with previous installments of this occasional “recommendations” series, we include a brief discussion and pertinent references for each tip.

1. Pelvic exam? It isn’t mandatory.

Do not require pelvic examination before you prescribe an oral contraceptive.

Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol. 2010;116(6):1257–1264.

The World Health Organization and ACOG recommend that you consider pelvic examination optional before prescribing an oral contraceptive (OC). Recent evidence indicates, however, that many health-care providers don’t follow that recommendation. Avoiding an unnecessary pelvic exam is a plus for a patient who may fear the procedure; following this guidance therefore removes a potential barrier to care and saves time in a busy practice.

2. Provide more, not less

Prescribe (when possible, dispense) 6 to 12 months of an OC at office visits.

Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol. 2011;117(3):551–557.

Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol. 2011;117(3):566–572.

Studies show that 1) women who are given six or more pill packages at a clinic visit have a lower discontinuation rate than women given one to five packs and 2) prescribing a 1-year supply of OC pill packages (as opposed to one to three packs) is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy and a 46% reduction in the odds of having an abortion.

3. Make the case for long-acting reversibles

Use intrauterine devices and subdermal implants as first-line contraception more often.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 59: Intrauterine device. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2005;105(1):223–232.

Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105–1113.

Long-acting methods such as the copper intrauterine device (IUD) (Paragard) and the levonorgestrel intrauterine system (LNG-IUS) (Mirena) are the most effective reversible contraceptives because they eliminate the difference between perfect and typical use. A woman at low risk does not need to have a negative cervical culture before having an IUD or the LNG-IUS inserted, and a woman does not need to be on her menses at the time of insertion. In addition, antibiotic prophylaxis is not recommended before or at the time of insertion.

IUDs—and this applies to the subdermal contraceptive implant (Implanon), too—also have the highest rates of satisfaction and 12-month continuation.

4. Take advantage of broader benefits

Use hormonal contraceptives for noncontraceptive indications.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(6):206–218.

Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–787.

Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.

Hormonal contraceptives have long been used for such indications as cycle control and treatment of acne. The LNG-IUS and OCs are highly effective, compared with placebo, for treating heavy menstrual bleeding in the absence of organic pathology.* As a potential alternative to surgical treatment of menorrhagia, OCs offer even broader benefit for many women.

*Mirena is approved by the Food and Drug Administration for treating heavy menstrual bleeding.

5. To encourage continuation, begin now

Get a “quick start” to improve adherence to oral contraceptives.

Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.

Starting OC pills immediately—instead of waiting for the Sunday after the next menses—can improve the short-term continuation rate for women patients who choose an OC.

6. Move away from every-day regimens

Consider a nondaily combined method, such as the transdermal patch or the vaginal ring, for current OC users.

Creinin MD, Meyn LA, Borgatta L, et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet Gynecol. 2008;111(2 pt 1):267–277.

Many women who use an OC are satisfied with the positive effect the method has on menses and acne but find that they miss taking a pill some days; they might benefit from a method that involves nondaily administration. Studies show that switching from oral contraception to the transdermal patch (OrthoEvra) or vaginal ring (Nuvaring), for example, is acceptable to many women.

7. Preemptive prescribing

Prescribe emergency contraception before your patient needs it.

Jackson RA, Schwarz EB, Freedman L, Darney P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol. 2003;102(1):8–16.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100–1109.

Consider giving every sexually active woman a prescription for emergency contraception before she leaves your office. She can fill the prescription and keep it at home in case of an emergency.

8. Get to know ella

Become familiar with ulipristal acetate (ella) for emergency contraception.

Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.

Barbieri RL. Levonorgestrel or ulipristal: is one a better emergency contraceptive than the other? OBG Manage. 2011;23(3):8–11.

This new FDA-approved agent for emergency contraception is effective for as long as 5 days after intercourse and results in fewer pregnancies than levonorgestrel does. It is available by prescription only, however, and is more expensive than levonorgestrel.

9. Pursue two urogenital pathogens

When you are not performing a speculum examination, screen for N. gonorrhoeae and C. trachomatis with a vaginal swab specimen or urine-based specimen.

Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections–2002. MMWR Recomm Rep. 2002;51(RR-15):1–38; quiz CE1–4.

Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32(12):725–728.

Under new screening guidelines for cervical cancer, Pap smears are not required for women who are younger than 21 years. Gonorrhea and chlamydial infection screening is still important in this population, however, and can be done without a speculum exam.The patient or provider collects a specimen for testing with a vaginal swab, or the patient submits a urine specimen.

10. Now not later: An IUD, post-evacuation

Consider immediate, rather than delayed, IUD insertion after uterine evacuation for spontaneous or elective abortion in women who desire this form of contraception.

Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364:2208-2217.

A recent clinical trial enrolled 575 women who underwent uterine aspiration for induced or spontaneous abortion at 5 to 12 weeks’ gestation and who desired an IUD. Subjects were randomized to IUD insertion immediately after the procedure or 2 to 6 weeks later. The 6-month expulsion rate was 5.0% after immediate insertion; 2.7%, after delayed insertion (P = NS). There were no differences in the rates of other adverse events. Only 71% of patients returned for their “delayed” IUD placement; five pregnancies occurred among these women. No pregnancies occurred in the immediate-insertion group.

We want to hear from you! Tell us what you think.

As a new year, and a new decade, open, attention to evidence-based guidelines and to outcomes for individual patients continues to drive medicine. As a busy practicing ObGyn, you’re challenged to sort through the great, and growing, mass of medical information so you can focus on key issues that improve care.

Faced with such a task, it’s not surprising that physicians are notoriously slow to make changes to their practice in response to new evidence.

Here is help. In this article, I present 10 succinct clinical topics and offer medical and surgical suggestions that are easy to put into practice and backed by evidence. If you haven’t already done so, implementing some of these ideas can immediately improve the quality of your care. For each suggestion, I’ve included the pertinent reference.

1. Banish error

Embrace, and immediately implement, surgical time-out and safety checklists for all your surgeries and office procedures.

Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg. 2007;204(4):527–532.

Surgical errors are rare, but we need to continually aim for “zero-error” conditions. These two quality assurance tools may help our efforts.

2. Route of hysterectomy

Make an effort to perform more vaginal hysterectomies and fewer open abdominal hysterectomies.

ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114(5):1156–1158.

In cases when vaginal hysterectomy isn’t feasible, consider laparoscopic (or, perhaps, robotic) hysterectomy more often. The role of robotic and single-port hysterectomies continues to evolve.

3. Cystoscopy

Learn, get credentialed for, and perform more diagnostic cystoscopies after certain gynecologic procedures.

ACOG Committee Opinion No. 372, July 2007. The role of cystourethroscopy in the generalist obstetrician-gynecologist practice. Obstet Gynecol. 2007;110(1):221–224.

Cystoscopy is appropriate when a gyn procedure carries at least a 1% risk of lower urinary tract injury. At most centers, that probably includes laparoscopic and robotic hysterectomy and colpopexy.

4. Oophorectomy

Perform fewer prophylactic oophorectomies at hysterectomy in low-risk women whose ovaries are normal. When you do remove ovaries as a preventive measure, do so with careful thought and informed consent—especially when the patient is premenopausal.

Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study. Obstet Gynecol. 2009;113(5):1027–1037.

In general, we probably perform too many “throw-in” oophorectomies at hysterectomy, with the aim of preventing cancer. But women who keep their ovaries may, in fact, live longer.

5. Preprocedure antibiotics

Give appropriate and properly timed (within 60 minutes of skin incision) antibiotic prophylaxis for hysterectomy, urogynecology procedures, hysterosalpingography or chromotubation, and surgical abortion.

ACOG Practice Bulletin No. 104: Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009;113(5):1180–1189.

A single-dose antibiotic is adequate before hysterectomy. Give a second dose when surgery will take more than 3 hours or, perhaps, blood loss is expected to be >1,500 mL. Subsequent doses are not indicated for prophylaxis alone. Antibiotic prophylaxis is unnecessary before diagnostic laparoscopy (level-A evidence), hysteroscopic surgery (level-B), or exploratory laparotomy (level-C).

6. Blind biopsy

For evaluation of abnormal uterine bleeding, perform fewer blind endometrial biopsies and more imaging studies, such as transvaginal ultrasonography or saline infusion sonography, or office hysteroscopy.

Goldstein SR. Modern evaluation of the endometrium. Obstet Gynecol. 2010;116(1):168–176.

Blind endometrial biopsy alone yields an unacceptably high rate of false-negative results when utilized to determine the cause of abnormal uterine bleeding.

7. Misoprostol

Pretreat with misoprostol before hysteroscopic procedures.

Choksuchat C. Clinical use of misoprostol in non-pregnant women: review article. J Minim Invasive Gynecol. 2010;17(4):449–455.

Misoprostol eases the force of cervical dilation, results in fewer cervical lacerations and less fluid absorption, and may lead to fewer uterine perforations. The dosage: 200–400 μg orally or intravaginally, at bedtime, for 1 or 2 days before the procedure.

8. Vaginal estrogen

Use intravaginal estrogen therapy as first-line treatment for postmenopausal women who experience vaginal irritation, dyspareunia, and frequent cystitis.

Krause M, Wheeler TL, Richter HE, Snyder TE. Systemic effects of vaginally administered estrogen therapy: a review. Female Pelvic Med Reconstr Surg. 2010;16(3):188–195.

Vaginal estrogen has many clear quality-of-life benefits and carries relatively low risk; risk is probably much lower than what is reported with systemic hormone replacement therapy. Delivery can be by cream, suppository, or vaginal ring. The relatively high cost of vaginal estrogen therapy remains a problem for some women.

9. Vaginal apical support

Consider adding or augmenting some vaginal apical support to help your cystocele repairs.

Summers A, Winkel LA, Hussain HK, DeLancey JOL. The relationship between anterior and apical compartment support. Am J Obstet Gynecol. 2006;194(5):1438– 1443.

In women who have anterior vaginal prolapse (cystocele), approximately half of the prolapse might be explained by a defect in apical attachment. In addition, consider performing prophylactic McCall’s culdoplasty or uterosacral cuff suspension at the time of all hysterectomies, by all routes—even in the absence of prolapse.

10. Pap tests

Perform fewer, but better-timed, Pap tests.

Sawaya GF. Cervical-cancer screening—new guidelines and the balance between benefits and harms. N Engl J Med. 2009;361(26):2503–2305.

ACOG Practice Bulletin No. 109, December 2009. Cervical cytology screening. Obstet Gynecol. 2009;114(6):1409–1420.

New guidelines for cervical cancer screening that were issued by ACOG in November 2009 are meant to maximize benefit and minimize harm. The guidelines are summarized in the TABLE.

ACOG’s 2009 guidelines for cervical cytology screening

We want to hear from you! Tell us what you think.

As a new year, and a new decade, open, attention to evidence-based guidelines and to outcomes for individual patients continues to drive medicine. As a busy practicing ObGyn, you’re challenged to sort through the great, and growing, mass of medical information so you can focus on key issues that improve care.

Faced with such a task, it’s not surprising that physicians are notoriously slow to make changes to their practice in response to new evidence.

Here is help. In this article, I present 10 succinct clinical topics and offer medical and surgical suggestions that are easy to put into practice and backed by evidence. If you haven’t already done so, implementing some of these ideas can immediately improve the quality of your care. For each suggestion, I’ve included the pertinent reference.

1. Banish error

Embrace, and immediately implement, surgical time-out and safety checklists for all your surgeries and office procedures.

Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg. 2007;204(4):527–532.

Surgical errors are rare, but we need to continually aim for “zero-error” conditions. These two quality assurance tools may help our efforts.

2. Route of hysterectomy

Make an effort to perform more vaginal hysterectomies and fewer open abdominal hysterectomies.

ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114(5):1156–1158.

In cases when vaginal hysterectomy isn’t feasible, consider laparoscopic (or, perhaps, robotic) hysterectomy more often. The role of robotic and single-port hysterectomies continues to evolve.

3. Cystoscopy

Learn, get credentialed for, and perform more diagnostic cystoscopies after certain gynecologic procedures.

ACOG Committee Opinion No. 372, July 2007. The role of cystourethroscopy in the generalist obstetrician-gynecologist practice. Obstet Gynecol. 2007;110(1):221–224.

Cystoscopy is appropriate when a gyn procedure carries at least a 1% risk of lower urinary tract injury. At most centers, that probably includes laparoscopic and robotic hysterectomy and colpopexy.

4. Oophorectomy

Perform fewer prophylactic oophorectomies at hysterectomy in low-risk women whose ovaries are normal. When you do remove ovaries as a preventive measure, do so with careful thought and informed consent—especially when the patient is premenopausal.

Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study. Obstet Gynecol. 2009;113(5):1027–1037.

In general, we probably perform too many “throw-in” oophorectomies at hysterectomy, with the aim of preventing cancer. But women who keep their ovaries may, in fact, live longer.

5. Preprocedure antibiotics

Give appropriate and properly timed (within 60 minutes of skin incision) antibiotic prophylaxis for hysterectomy, urogynecology procedures, hysterosalpingography or chromotubation, and surgical abortion.

ACOG Practice Bulletin No. 104: Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009;113(5):1180–1189.

A single-dose antibiotic is adequate before hysterectomy. Give a second dose when surgery will take more than 3 hours or, perhaps, blood loss is expected to be >1,500 mL. Subsequent doses are not indicated for prophylaxis alone. Antibiotic prophylaxis is unnecessary before diagnostic laparoscopy (level-A evidence), hysteroscopic surgery (level-B), or exploratory laparotomy (level-C).

6. Blind biopsy

For evaluation of abnormal uterine bleeding, perform fewer blind endometrial biopsies and more imaging studies, such as transvaginal ultrasonography or saline infusion sonography, or office hysteroscopy.

Goldstein SR. Modern evaluation of the endometrium. Obstet Gynecol. 2010;116(1):168–176.

Blind endometrial biopsy alone yields an unacceptably high rate of false-negative results when utilized to determine the cause of abnormal uterine bleeding.

7. Misoprostol

Pretreat with misoprostol before hysteroscopic procedures.

Choksuchat C. Clinical use of misoprostol in non-pregnant women: review article. J Minim Invasive Gynecol. 2010;17(4):449–455.

Misoprostol eases the force of cervical dilation, results in fewer cervical lacerations and less fluid absorption, and may lead to fewer uterine perforations. The dosage: 200–400 μg orally or intravaginally, at bedtime, for 1 or 2 days before the procedure.

8. Vaginal estrogen

Use intravaginal estrogen therapy as first-line treatment for postmenopausal women who experience vaginal irritation, dyspareunia, and frequent cystitis.

Krause M, Wheeler TL, Richter HE, Snyder TE. Systemic effects of vaginally administered estrogen therapy: a review. Female Pelvic Med Reconstr Surg. 2010;16(3):188–195.

Vaginal estrogen has many clear quality-of-life benefits and carries relatively low risk; risk is probably much lower than what is reported with systemic hormone replacement therapy. Delivery can be by cream, suppository, or vaginal ring. The relatively high cost of vaginal estrogen therapy remains a problem for some women.

9. Vaginal apical support

Consider adding or augmenting some vaginal apical support to help your cystocele repairs.

Summers A, Winkel LA, Hussain HK, DeLancey JOL. The relationship between anterior and apical compartment support. Am J Obstet Gynecol. 2006;194(5):1438– 1443.

In women who have anterior vaginal prolapse (cystocele), approximately half of the prolapse might be explained by a defect in apical attachment. In addition, consider performing prophylactic McCall’s culdoplasty or uterosacral cuff suspension at the time of all hysterectomies, by all routes—even in the absence of prolapse.

10. Pap tests

Perform fewer, but better-timed, Pap tests.

Sawaya GF. Cervical-cancer screening—new guidelines and the balance between benefits and harms. N Engl J Med. 2009;361(26):2503–2305.

ACOG Practice Bulletin No. 109, December 2009. Cervical cytology screening. Obstet Gynecol. 2009;114(6):1409–1420.

New guidelines for cervical cancer screening that were issued by ACOG in November 2009 are meant to maximize benefit and minimize harm. The guidelines are summarized in the TABLE.

ACOG’s 2009 guidelines for cervical cytology screening

We want to hear from you! Tell us what you think.

As a new year, and a new decade, open, attention to evidence-based guidelines and to outcomes for individual patients continues to drive medicine. As a busy practicing ObGyn, you’re challenged to sort through the great, and growing, mass of medical information so you can focus on key issues that improve care.

Faced with such a task, it’s not surprising that physicians are notoriously slow to make changes to their practice in response to new evidence.

Here is help. In this article, I present 10 succinct clinical topics and offer medical and surgical suggestions that are easy to put into practice and backed by evidence. If you haven’t already done so, implementing some of these ideas can immediately improve the quality of your care. For each suggestion, I’ve included the pertinent reference.

1. Banish error

Embrace, and immediately implement, surgical time-out and safety checklists for all your surgeries and office procedures.

Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg. 2007;204(4):527–532.

Surgical errors are rare, but we need to continually aim for “zero-error” conditions. These two quality assurance tools may help our efforts.

2. Route of hysterectomy

Make an effort to perform more vaginal hysterectomies and fewer open abdominal hysterectomies.

ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114(5):1156–1158.

In cases when vaginal hysterectomy isn’t feasible, consider laparoscopic (or, perhaps, robotic) hysterectomy more often. The role of robotic and single-port hysterectomies continues to evolve.

3. Cystoscopy

Learn, get credentialed for, and perform more diagnostic cystoscopies after certain gynecologic procedures.

ACOG Committee Opinion No. 372, July 2007. The role of cystourethroscopy in the generalist obstetrician-gynecologist practice. Obstet Gynecol. 2007;110(1):221–224.

Cystoscopy is appropriate when a gyn procedure carries at least a 1% risk of lower urinary tract injury. At most centers, that probably includes laparoscopic and robotic hysterectomy and colpopexy.

4. Oophorectomy

Perform fewer prophylactic oophorectomies at hysterectomy in low-risk women whose ovaries are normal. When you do remove ovaries as a preventive measure, do so with careful thought and informed consent—especially when the patient is premenopausal.

Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study. Obstet Gynecol. 2009;113(5):1027–1037.

In general, we probably perform too many “throw-in” oophorectomies at hysterectomy, with the aim of preventing cancer. But women who keep their ovaries may, in fact, live longer.

5. Preprocedure antibiotics

Give appropriate and properly timed (within 60 minutes of skin incision) antibiotic prophylaxis for hysterectomy, urogynecology procedures, hysterosalpingography or chromotubation, and surgical abortion.

ACOG Practice Bulletin No. 104: Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009;113(5):1180–1189.

A single-dose antibiotic is adequate before hysterectomy. Give a second dose when surgery will take more than 3 hours or, perhaps, blood loss is expected to be >1,500 mL. Subsequent doses are not indicated for prophylaxis alone. Antibiotic prophylaxis is unnecessary before diagnostic laparoscopy (level-A evidence), hysteroscopic surgery (level-B), or exploratory laparotomy (level-C).

6. Blind biopsy

For evaluation of abnormal uterine bleeding, perform fewer blind endometrial biopsies and more imaging studies, such as transvaginal ultrasonography or saline infusion sonography, or office hysteroscopy.

Goldstein SR. Modern evaluation of the endometrium. Obstet Gynecol. 2010;116(1):168–176.

Blind endometrial biopsy alone yields an unacceptably high rate of false-negative results when utilized to determine the cause of abnormal uterine bleeding.

7. Misoprostol

Pretreat with misoprostol before hysteroscopic procedures.

Choksuchat C. Clinical use of misoprostol in non-pregnant women: review article. J Minim Invasive Gynecol. 2010;17(4):449–455.

Misoprostol eases the force of cervical dilation, results in fewer cervical lacerations and less fluid absorption, and may lead to fewer uterine perforations. The dosage: 200–400 μg orally or intravaginally, at bedtime, for 1 or 2 days before the procedure.

8. Vaginal estrogen

Use intravaginal estrogen therapy as first-line treatment for postmenopausal women who experience vaginal irritation, dyspareunia, and frequent cystitis.

Krause M, Wheeler TL, Richter HE, Snyder TE. Systemic effects of vaginally administered estrogen therapy: a review. Female Pelvic Med Reconstr Surg. 2010;16(3):188–195.

Vaginal estrogen has many clear quality-of-life benefits and carries relatively low risk; risk is probably much lower than what is reported with systemic hormone replacement therapy. Delivery can be by cream, suppository, or vaginal ring. The relatively high cost of vaginal estrogen therapy remains a problem for some women.

9. Vaginal apical support

Consider adding or augmenting some vaginal apical support to help your cystocele repairs.

Summers A, Winkel LA, Hussain HK, DeLancey JOL. The relationship between anterior and apical compartment support. Am J Obstet Gynecol. 2006;194(5):1438– 1443.

In women who have anterior vaginal prolapse (cystocele), approximately half of the prolapse might be explained by a defect in apical attachment. In addition, consider performing prophylactic McCall’s culdoplasty or uterosacral cuff suspension at the time of all hysterectomies, by all routes—even in the absence of prolapse.

10. Pap tests

Perform fewer, but better-timed, Pap tests.

Sawaya GF. Cervical-cancer screening—new guidelines and the balance between benefits and harms. N Engl J Med. 2009;361(26):2503–2305.

ACOG Practice Bulletin No. 109, December 2009. Cervical cytology screening. Obstet Gynecol. 2009;114(6):1409–1420.

New guidelines for cervical cancer screening that were issued by ACOG in November 2009 are meant to maximize benefit and minimize harm. The guidelines are summarized in the TABLE.

ACOG’s 2009 guidelines for cervical cytology screening

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