Multimedia
 | Media file 1: The female urethra is composed of 4 separate tissue layers that keep it closed. The inner mucosal lining keeps the urothelium moist and the urethra supple. The vascular spongy coat produces the mucus important in the mucosal seal mechanism. Compression from the middle muscular coat helps to maintain the resting urethral closure mechanism. The outer seromuscular layer augments the closure pressure provided by the muscular layer. |
 | Media file 2: The female urethra contains an internal sphincter and an external sphincter. The internal sphincter is more of a functional concept than a distinct anatomic entity. The external sphincter is the muscle strengthened by Kegel exercises. |
 | Media file 3: The pubourethral ligaments suspend the female urethra under the pubic arch. |
 | Media file 4: The pelvic diaphragm (ie, levator ani musculature) is composed of pubococcygeus, iliococcygeus, ischiococcygeus, and coccygeus muscles. It contains 3 openings through which the rectum, urethra, and cervix pass. |
 | Media file 5: This is the side view of the pelvic diaphragm. The pelvic diaphragm supports the pelvic organs (eg, bladder, uterus, rectum). |
 | Media file 6: This photo illustrates a variety of pelvic organ prolapses, including grade-IV cystocele, uterine descensus, enterocele, and rectocele alone or in combination. In situations where a significant prolapse (eg, uterus, bladder) has occurred, evaluate for possible ureteral obstruction at the level of the pelvic inlet. |
 | Media file 7: A cotton swab angle greater than 30° denotes urethral hypermobility. Figure 1 shows that the cotton swab at rest is zero with respect to the floor. Figure 2 shows that the cotton swab at stress is 45° with respect to the floor. |
 | Media file 8: This illustration shows videourodynamic equipment (Aquarius XLT, Laborie Medical Technologies) used for evaluation of a patient with incontinence. |
 | Media file 9: Videourodynamics allow a comprehensive evaluation of a patient with incontinence. Information provided by videourodynamics includes filling cystometrogram, abdominal leak point pressure, pressure-flow, static and voiding cystograms, and electromyogram recordings. |
 | Media file 10: A flexible cystoscope is used to evaluate the anatomy of the bladder and the urethra. A flexible cystoscope is less rigid and more comfortable for the patient than the rigid cystoscope. |
 | Media file 11: This shows normal findings from a dynamic retrograde urethroscopy; the urinary sphincter is closed at rest (Figure a), closed with stress maneuvers (Figure b), and has excellent guarding reflex (Figure c). Note the urinary sphincter is contracted and elevated in Figure c; this is a normal guarding reflex. |
 | Media file 12: This shows classic type-II stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is closed at rest (Figure a), remains open with stress maneuvers (Figure b), and has good guarding reflex (Figure c). Patients with classic type-II stress urinary incontinence are able to close their urinary sphincters voluntarily. |
 | Media file 13: This shows classic type-III stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is open at rest (Figure a), remains open with stress maneuvers (Figure b), and has weak guarding reflex (Figure c). Patients with classic intrinsic sphincter deficiency a have difficult time closing their urinary sphincters voluntarily. |
 | Media file 14: This diagram shows the 6-point fixation technique that allows even, lateral dispersion of force vectors on the implanted sling. The edges of the sling proper are affixed to the underlying pubourethral fascia to prevent folding over or migration. When the force vectors are lateralized rather than directed anteriorly toward the pubis, the tendency to pull up on the sling to cause urethral obstruction is reduced. |
 | Media file 15: When a weight-adjusted spacing nomogram is used for women with normal body weight, tie the sling sutures over the shod-covered hemostats by leaving a 2-mm gap between the hemostat and the rectus fascia. For women who are obese, increase this gap incrementally depending on their mass over the ideal body weight (eg, 2-mm gap/25 lb). When using this method, tie the suspension sutures looser for women who are obese. |
 | Media file 16: Weight-adjusted spacing nomogram: To tie the suspension sutures on the abdominal side, gauge the tension on the suspension sutures inversely proportional to the patient's body weight. Prior to tying the suspension sutures, clamp the sutures with shod-covered hemostats to prevent inadvertent pulling up of the sutures. |
 | Media file 17: Rectus fascia or fascia lata pubovaginal sling: Harvest a long ribbon of fascia from the abdomen or from the side of a leg (eg, fascia lata), place under the bladder neck, and secure to the lower abdomen below the skin. |
 | Media file 18: Rectus fascia or fascia lata suburethral (patch) sling: Prepare a short strip of fascia from the abdomen or from the side of a leg, place under the bladder neck, and hang by suspension sutures tied over the suprapubic area. |
 | Media file 19: Rectus fascia or fascia lata suburethral (patch) sling: Prepare a short strip of fascia from the abdomen or from the side of a leg, place under the bladder neck, and hang by suspension sutures tied over the suprapubic area. |
 | Media file 20: Gore-Tex suburethral sling: Implant a short strip of Gore-Tex under the bladder neck, and support it with suspension sutures tied adjacent to the pubic bone. |
 | Media file 35: One ampule of indigo carmine is administered intravenously. Cystoscopy is performed to confirm that the suspension sutures have not traversed the bladder. A clear efflux of blue urine indicates the ureteral patency. |
 | Media file 36: Note that the lead-pipe urethra (Figure a) was converted to a normal urethra with excellent mucosal coaptation (Figure b) using a proper sling surgery. The surgery cured this patient of stress urinary incontinence. |
 | Media file 37: Tension-free vaginal tape: This device comes with polypropylene mesh tape anchored to 2 stainless steel needles. Use the introducer to insert the needles into the space of Retzius. Use the rigid catheter guide to manipulate the urethra during the needle insertion. |
More on Pubovaginal Sling |
| Overview: Pubovaginal Sling |
| Workup: Pubovaginal Sling |
| Treatment: Pubovaginal Sling |
| Follow-up: Pubovaginal Sling |
 Multimedia: Pubovaginal Sling |
| References |
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References
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Further Reading
Keywords
pubovaginal sling, incontinence, urinary incontinence, stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, reflex incontinence, decompensated bladder, detrusor instability, Marshall test, Kegel exercises, detrusor hyperreflexia, overactive bladder, SUI, urethral hypermobility, intrinsic sphincter deficiency, ISD, sling, pubovaginal sling, bladder sling, suburethral sling, bladder neck suspension, urethropexy, transvaginal urethropexy, retropubic urethropexy, MUI, mixed urinary incontinence, stress urinary incontinence, urge urinary incontinence
