A 58-year-old woman presents with stress urinary incontinence (SUI) confirmed on urodynamics. She fails 3 months of supervised pelvic floor muscle training. She has no detrusor overactivity. POP-Q staging shows Stage I anterior vaginal wall prolapse. According to current NICE/IUGA guidelines, the MOST appropriate next intervention is:

• A Mid-urethral sling (tension-free vaginal tape, TVT) procedure ✓
• B Colposuspension (Burch procedure) as the gold standard with longest durability data
• C Duloxetine (SNRI) 40 mg twice daily as the only licensed pharmacotherapy for SUI
• D Periurethral bulking agents (e.g., polyacrylamide hydrogel) as first surgical option

Explanation

For confirmed SUI failing conservative management (pelvic floor training), mid-urethral sling (MUS) — either retropubic (TVT, tension-free vaginal tape) or transobturator (TOT) — is the recommended first surgical option per NICE, IUGA, and AUGS guidelines. MUS achieves 80–85% success rates at 5 years with minimal recovery time. While Burch colposuspension (B) has comparable long-term data, it requires open or laparoscopic surgery and is preferred when concurrent abdominal procedures are planned or when MUS is contraindicated. Duloxetine (C) is an option for patients who decline surgery or as an adjunct, but it is not preferred over surgery after failed conservative therapy, and has a significant side-effect profile. Bulking agents (D) have lower long-term efficacy (~50% at 3 years) and are preferred for patients unsuitable for surgery.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.