Intraurethral bulking agents for the management of female stress
urinary incontinence: a systematic review
Zain A. Siddiqui
Received: 3 December 2016 /Accepted: 16 January 2017 /Published online: 21 February 2017
The International Urogynecological Association 2017
Introduction and hypothesis The object of this review was to
assess the efficacy and safety of urethral bulking agents
(UBA), principally Macroplastique and Bulkamid, in the
treatment of female stress urinary incontinence (SUI).
Methods MEDLINE® and EMBASE® databases were sys-
tematically searched up to June 2016. Year of publication,
study type, outcome measures, urodynamics before and after
the procedure, number of participants, procedure complica-
tions, proportion requiring repeat injections or surgical proce-
dures, frequency of follow-up, and results were analysed.
Results The use of Bulkamid and Macroplastique for the treat-
ment of female SUI was described in 26 studies. Studies used
modalities including the visual analogue scale, Likert scale,
Questionnaire (ICIQ), Patient Global Improvement
Questionnaire (PGIQ) and Incontinence Impact Questionnaire
(IIQ) and showed success rates ranging from 66% to 89.7% at
12 months follow-up. Objective improvements in patient symp-
toms were measured using urodynamics, 24-h pad tests, cough
tests and voiding diaries. Studies showed variable objective suc-
cess rates ranging from 25.4% to 73.3%. Objective findings for
UBAs remain less well documented than those for the
midurethral sling procedure.
Conclusions There are a range of complications associated
with UBAs, the most common being urinary tract infection.
However, it remains a very well tolerated procedure in the
majority of patients. UBAs should be considered as an alter-
native in patients unsuitable for more invasive procedures and
those willing to accept the need for repeat injections. The
majority of the literature focuses on subjective improvement
measures rather than objective improvement measures.
Further randomized controlled trials directly comparing
UBAs are required to indicate the most effective agent.
Urethral bulking agent
Stress urinary incontinence (SUI) is a common socially debilitat-
ing condition predominantly affecting women with a prevalence
of between 10% and 40% . Managing and treating SUI comes
at a significant cost to the UK’s National Health Service (NHS),
estimated at approximately £353.6 million per annum .
Normal urinary continence relies on the functional coordination
of the anatomy by the nervous system. The pelvic floor creates
the support required by the bladder and urethra to sustain trans-
mission of abdominal pressure to the proximal urethra, ultimately
resulting in continence . It has been hypothesized that reduc-
tions in the urethral closure pressure superimposed on the trans-
mission of pressure from the abdomen to the urethra results in
SUI . Furthermore, recent findings have highlighted the role of
midurethral support in the maintenance of continence . Risk
factors include advancing age, higher parity, vaginal delivery,
obesity and postmenopausal status .
The current gold standard treatment of SUI is placement of a
midurethral sling via either the retropubic or the transobturator
route. These procedures aim to provide support at the midurethral
level with the sling acting as a hammock preventing the urethra
* Hamid Abboudi
Department of Urology, Birmingham City Hospital, Dudley Road,
Birmingham B18 7QH, UK
Department of Urology, Watford General Hospital, Vicarage Road,
Watford WD80 0HB, UK
Int Urogynecol J (2017) 28:1275–1284