• The following treatments are recommended by the National Institute for Health and Clinical Excellence (NICE):
• Retropubic mid-urethral tape procedures using a 'bottom up' approach. Open colposuspension and autologous rectal fascial sling are recommended alternatives.
• Synthetic slings using a retropubic 'top down' approach or a transobturator foramen approach are also alternatives, provided the woman is made aware of the lack of long-term outcome data. Long-term complications include voiding difficulties and the development of urgency and urge incontinence.
• Intramural urethral bulking agents are also an acceptable alternative, provided the woman is made aware that:
• Adverse effects are common but mainly transient and include acute retention, haematuria, dysuria, frequency, and urinary tract infection.
• Repeat injections may be required to achieve efficacy.
• Efficacy diminishes with time.
• The procedure is not as effective as a retropubic suspension or sling.
• An artificial urinary sphincter should be recommended only if previous surgery failed. Subjective cure rates are high, but:
• Adverse effects included pump malfunction and urinary retention.
• Device removal and revision were common.
• NICE does not recommend:
• Laparoscopic colposuspension as a routine procedure.
• Anterior colporrhaphy, needle suspensions, paravaginal defect repair, and the Marshell–Marchetti–Krannz procedure.

• Treatment aims to augment urethral closure or support or stabilize the bladder neck or urethra.
• Operations that augment urethral sphincter closure include:
• Injection of urethral bulking agents into the submucosal tissue of the urethra or bladder neck aims to prevent stress incontinence by increasing the resistance to flow.
• Artificial urinary sphincters: an occlusive cuff is inserted around the urethra and, when inflated, exerts a constant closure pressure which is maintained by an inflated pressure-regulated balloon. When the woman wishes to pass urine, she manually operates a small pump in the labium.
• Procedures to stabilize the bladder neck and urethra include:
• Procedures that prevent the downward displacement of the urethra by using sutures to secure the paraurethral or vaginal tissues to a fixed structure, such as Burch colposuspension, the Marshall–Marchetti–Kranz procedure, and the vaginal obturator shelf procedure.
• Minimally invasive procedures that suspend the paraurethral tissues by means of a suspensory suture secured to the rectus sheath and inserted under endoscopic control, such as the Raz, Pereyra, Stamey, and Gittes procedures.
• Sling operations that stabilize the urethra by placing a strip of material around the underside of the urethra and securing it to a fixed structure above. These may be:
• Fixed to the pubic arch or rectus sheath.
• Inserted by open surgery: abdominal or combined abdominal and vaginal.
• Minimally invasive: retropubic space (from bottom upwards or from top downwards or obturator foramen [from outside inwards, or from inside outwards]).

[National Collaborating Centre for Women's and Children's Health, 2006]

• These recommendations are based on expert advice from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2006].
• Retropubic suspension procedures:
• Good evidence from randomized controlled trials (RCTs) indicates that open colposuspension is effective and has longevity. Laparoscopic colposuspension is equally effective.
• When used solely for stress incontinence, long-term outcomes are poor for anterior colporrhaphy, needle suspensions, and paravaginal defect repair. There is no evidence that the Marshell–Marchetti–Krantz procedure offers any advantage over open colposuspension.
• Synthetic slings: evidence from RCTs shows a comparable effect for open or laparoscopic colposuspension.
• Bulking agents:
• Controlled trials evaluating bulking agents are few, mainly small, and of poor quality. NICE concluded that bulking agents have poor efficacy and may be less effective than open surgery.
• Case series show that any effect declines with time.
• Artificial urinary sphincter: data are limited to cases series. Subjective cure rates are high.