Is occult stress urinary incontinence truly “occult”?

Introduction

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common forms of female pelvic floor dysfunction (FPFD). POP may objectively coexist with SUI, as descent of the bladder base can cause mechanical kinking or compression of the urethra, thereby masking SUI symptoms subjectively (1). Occult stress urinary incontinence (OSUI) is defined as the emergence of SUI following reduction of POP (2). The reported incidence of OSUI varies from 8% to 57% (3), which reflects the lack of standardized diagnostic criteria (e.g., cough test, urodynamic studies) (4). To reduce postoperative urinary incontinence, a midurethral sling (MUS) procedure is often performed concurrently with POP repair (5). Although this combined approach can reduce postoperative SUI, it also increases the risks of complications such as voiding dysfunction, tape erosion, and bladder injury (6,7). But is this conceptualization of OSUI really accurate? How can we preoperatively detect this “occult” condition? Is it necessary to combine anti-incontinence surgery with POP repair? Is OSUI truly occult?

The current definition of OSUI does not explain its pathology and urinary control mechanisms. Therefore, it is essential to analyze changes in the structural balance of urinary control after POP surgery to refine treatment strategies and prevent the occurrence of so-called “occult” incontinence. This review aims to explore the mechanisms of OSUI.

Pathological mechanisms of OSUI

Determining whether occult incontinence is truly occult first requires clarifying the pathogenesis of SUI. The International Continence Society (ICS) defines SUI as the “involuntary loss of urine on effort or physical exertion, or on sneezing or coughing, when the intravesical pressure exceeds the maximum urethral pressure” (8). The mechanisms of urinary control involve: (I) function of the external urethral sphincter; (II) function of the internal urethral sphincter; (III) closure competence of the bladder neck; (IV) functional urethral length; (V) urethral mucosal sealing effect; (VI) support structures of the bladder neck and urethra; (VII) contraction force of the levator ani muscle (LAM); (VIII) urethral wall elasticity; (IX) pubourethral ligaments; (X) pelvic floor neural factors (9-12). The primary risk factors for SUI in women include pregnancy and advanced age, both of which can alter these mechanisms. Notably, the role of the posterior vaginal wall and perineal body (PB) in supporting the bladder neck and urethra, as well as the contribution of LAM contraction to urinary control, has been relatively underrecognized in previous work. Based on a three-dimensional finite element mechanical model (13), our team analyzed the stress distribution patterns in the bladder, urethra, levator plate, and PB under different abdominal pressures (8.4–208.9 cmH₂O). The results demonstrate that increased intra-abdominal pressure is transmitted through the bladder and uterus to the bladder base, leading to posterior displacement of the bladder neck. Concurrently, contraction of the levator ani plate drives the PB in an anterosuperior direction, generating a counteracting force. This dynamic interaction stabilizes the bladder neck and prevents opening of the urethral orifice (Figure 1).

Figure 1 Three-dimensional geometric modelling and finite element modelling of the pelvic floor. The color spectrum represents the stress magnitude, where colors trending towards red indicate greater stress, and colors trending towards blue indicate lesser stress. (A) Comparison of displacement trends from the pelvic floor biomechanical analysis, under increased abdominal pressure, the posterior horn of the bladder opens and moves backward and the bladder moves downward. (B) Bladder and urethra displacement cloud map. (C) Cloud view of levator ani muscle displacement with a general trend toward the ventral side, toward the bladder. (D) Cloud view of the displacement of the perineal body, with a general trend toward the ventral side, toward the bladder.

Previous studies have identified a correlation between POP and voiding function (2,14-16). Overall, SUI is more common in mild to moderate POP, whereas voiding dysfunction is more prevalent in moderate to severe cases. One pathological mechanism is that anterior vaginal wall prolapse—which occurs in most POP patients—leads to herniation of the posterior bladder wall and proximal urethra, while the anterior bladder wall and proximal urethra remain relatively fixed. This results in a loss of support for the mid and distal urethra. Urinary control impairment primarily stems from inadequate bladder neck closure under increased abdominal pressure, shortened functional urethra, and weakened urethral support from the LAM. An important contributing factor may be the widening of the LAM fissure and laceration of the PB, which reduces support from the posterior to the anterior vaginal wall (17) (Figure 2).

Figure 2 Schematic diagram of pelvic stress in women without POPs versus those with POPs. ①: The posterior wall of the bladder is adjacent to the upper vagina and rests on the LP and the LAM; ②: The urethra is adjacent to the lower third of the vagina and rests on the PB and the LAM. LAM, levator ani muscle; LP, levator plate; PB, perineal body; POP, pelvic organ prolapse; PS, pubic symphysis; R, rectum; UB, urinary bladder; UT, uterus; U, urethra; V, vagina.

In many moderate to severe POP cases, the bladder neck and proximal urethra herniate outward synchronously with increased abdominal pressure, allowing the bladder neck to remain closed. However, increased urethral mobility can lead to mechanical kinking or compression as the bladder base descends, causing outflow obstruction and voiding dysfunction (18). Thus, from a pathological perspective, POP does not inherently hide SUI. Instead, so-called “occult” SUI results from surgical alteration of urethral support structures. Additionally, cystocele type is significantly associated with OSUI. Multivariable regression shows that the odds of OSUI are 10.9 times higher with type III cystocele (intact retrovesical angle) than with type II (open retrovesical angle; 95% confidence interval: 1.3–90.9) (19).

Pathological causes of OSUI in different surgical procedures

Based on the “three-compartment” and “three-level” support theories, current surgery for moderate to severe POP primarily involves apical suspension (20). Based on the suspension direction, procedures can be categorized as posterior, anterior, lateral, or mesh-based repairs.

Posterior suspension

Representative procedures include sacral colpopexy (SCP) and sacrospinous ligament fixation.

These procedures are indicated for severe POP (21). A common postoperative voiding symptom is SUI, which frequently manifests as OSUI. Pathological changes such as enlarged levator ani fissure, PB lacerations, vaginal laxity, and blunted vaginal folds—resulting from support structure injury—may remain uncorrected. This can reduce perineal support to the bladder neck and proximal urethra, thereby contributing to SUI. One of our team’s studies (22) used a finite element model to simulate both normal and pathological pelvic floor conditions. The normal condition was defined as an anteverted and anteflexed uterus (0°), whereas the pathological condition was defined as an upright uterine body position (90°). The results showed that the total displacement of the pelvic floor was greater in the pathological condition than in the normal condition. After sacral hysteropexy, both the total displacement and total stress of the pelvic floor were reduced compared with the damaged condition (Figure 3). In pelvic floor systems with combined impairment, the total displacement and total stress reached their highest levels. Following sacral hysteropexy, the total displacement and total stress of this system also decreased. When sacral hysteropexy was simulated under both the 0° normal condition and the 90° pathological condition, the anatomical position of the cervix was largely restored. However, posterior tilting of the cervix reduces the stress in the bladder neck and urethral region and may lead to posterior displacement of the bladder neck. Posterior displacement of the bladder neck can compromise its effective closure, thereby potentially inducing or worsening SUI.

Figure 3 Total displacement figure, total stress figure, total displacement, and total stress change patterns of the normal and 90° pathological pelvic floor systems under the conditions of no-impairment, 50% apical ligament impairment, 50% combined impairment, and surgical mesh implantation. (A) Total displacement figure of the pelvic floor system; (B) total stress figure of the pelvic floor system; (C) patterns of change of total displacement of pelvic floor system; (D) patterns of change of total stress of pelvic floor system.

SCP offers the strongest fixation and lowest recurrence rate and was once considered the “gold standard” for POP. However, it carries risks of serious complications such as hemorrhage, spondylitis, overactive bladder (OAB), ureteral or bowel injury, voiding dysfunction, and dyspareunia (23). SCP is more effective than sacrospinous ligament fixation in preventing recurrence (24).

Anterior suspension

Representative procedures include pectopexy and ligamentum teres fold fixation.

These are typically chosen for anterior POP, especially with concomitant SUI. The degree of prolapse is generally less severe than in cases requiring posterior suspension (25). Surgical approaches include transabdominal and transvaginal routes, with or without mesh (26). The goal is to reinforce the anterior vaginal wall by strengthening the iliopubic ligament and elevating the cervix. This stabilizes the posterior bladder wall and lengthens the functional urethra, reducing the likelihood of “occult” SUI. However, fixing the posterior bladder wall may impair bladder neck opening under abdominal pressure, potentially causing voiding difficulty—especially with mesh. Mesh scarring can further increase the risk of voiding dysfunction.

Lateral suspension

Representative procedures include laparoscopic lateral suspension (LLS).

LLS is popular due to its simplicity and low rate of serious complications (27). However, fixation to the abdominal wall is weaker, potentially leading to higher apical recurrence. Interestingly, rectovaginal prolapse is more common after LLS than anterior prolapse. Surgical design pulls the cervix anteriorly, similar to anterior suspension, leaving the posterior vaginal vault unsupported and predisposing to rectocele. Early postoperative OSUI is less common than with posterior suspension. Because of weaker bladder neck fixation, dyspareunia is also less frequent (28). However, POP recurrence and SUI may increase over time.

Mesh-based POP surgery

Various mesh procedures exist, including the classic Prolift system and other modalities (29). Postoperative voiding symptoms are predominantly SUI. Although mesh reinforces prolapsed organs, it often leads to loss of vaginal angulation, vaginal laxity, and reduced support from the LAM and PB to the bladder neck and proximal urethra. Anterior compartment support may fail again, allowing bladder neck descent and poor closure under stress, resulting in “occult” SUI. Long-term outcomes are summarized in Table 1.

Across different apical suspension procedures, the long-term outcomes demonstrate notable variations in recurrence, OSUI, and voiding dysfunction. SCP consistently shows low recurrence rates (0–11%) but a measurable incidence of OSUI ranging from 5% to 13%. Anterior suspension procedures, such as pectopexy, tend to preserve bladder neck support and are associated with relatively low early postoperative OSUI, although recurrence may accumulate with extended follow-up. LLS shows favorable perioperative safety and low short-term OSUI, but medium-term studies report progressive SUI or POP recurrence in a proportion of patients. In contrast, mesh-based POP repairs demonstrate the highest variability, with OSUI incidences reported up to 21%. These comparative findings are consistent with the interpretation that OSUI may not simply be a concealed condition, but may instead reflect the differential impact of each surgical route on the bladder neck, mid-urethral support, and posterior compartment biomechanics.

OSUI is not “occult”

OSUI should not be regarded as a truly “occult” condition that is simply unmasked after prolapse reduction. Instead, it can be understood as the clinical expression of disturbed pelvic floor biomechanics following apical suspension. The bladder base, urethra, vagina, uterus, and rectum function as an integrated load-bearing system. When posterior compartment structures—particularly the levator ani plate and PB—are not adequately restored, increases in intra-abdominal pressure are no longer balanced by a stable posterior “backboard”, and the bladder neck becomes unstable, resulting in leakage under stress. This biomechanical perspective explains why patterns of OSUI differ among posterior, anterior, lateral, and mesh-based repairs, and it highlights that apical suspension alone is unlikely to prevent postoperative SUI unless posterior support is simultaneously reconstructed and preserved.

Is it necessary to combine MUS with POP surgery?

Whether to combine anti-incontinence surgery with vaginal POP surgery for all patients with OSUI remains controversial (43,44). SUI after apical suspension of POP is mainly seen with posterior cervical suspension and transvaginal pelvic floor mesh implantation. Prophylactic placement of a midurethral sling may not routinely be required for anterior and lateral suspension of POP, based on their pathogenesis and surgical mechanism, and should be considered on a case-by-case basis. If apical lateral suspension is proposed, to predict the possibility of postoperative SUI, the patient should be asked to perform a trial Valsalva manoeuvre after retraction of the uterus to observe anterior vaginal wall mobility. Alternatively, a “speculum test” can be performed, in which a speculum is placed after retraction of the uterus and abdominal pressure is increased to observe whether urine leakage occurs. It is also useful to measure the area of levator ani fissure to determine the mobility of the anterior vaginal wall and whether SUI will occur after surgery.

The incidence of SUI after transvaginal pelvic floor mesh placement is also closely related to the mobility of the anterior vaginal wall. However, it may be possible to reduce the incidence of SUI by improving the surgical approach (45). For example, the anterior pelvic mesh can be placed anteriorly to reach the mid-urethra and posteriorly 2 cm in front of the bladder neck, while ensuring that the mesh is laid flat to maintain appropriate tension. Additionally, vaginal mucosal folding can be performed not only to prevent exposure of the pelvic floor mesh but also to provide support for the bladder neck and urethra, thus ensuring bladder neck closure competence and functional urethral length (46). A Cochrane review showed that anterior vaginal repair has up to 62% success rate in controlling SUI regardless of the coexistence of POP (47). There is a consensus on the implantation of a full pelvic mesh. Patients with OSUI undergoing posterior vaginal repair may have a higher incidence of postoperative SUI compared to those undergoing anterior vaginal repair, since posterior repair appears to have limited direct effect on SUI (43). In contrast to simply suturing the posterior pelvis, posterior pelvic mesh does not improve the healing rate and only increases the corresponding complications. However, the reconstruction of the posterior pelvis also requires biomechanical skills, in which reconstruction of the levator ani fissure and repair of PB may be important for optimizing healing and reducing the risk of SUI.

Physiological reconstruction is the key to resolving OSUI

Reconstructive pelvic floor surgery for POP currently remains largely limited to apical suspension procedures. Although physiological biomechanical reconstruction has been proposed as a potentially reasonable surgical approach for POP. This is due to limitations in understanding the biomechanical characteristics of the pelvic floor, a gap between pathology and surgical design, and unproven mechanical theories that require further validation. In practical surgical terms, physiological reconstruction aims to restore not only the anatomical position but also the functional biomechanics of the pelvic floor. This includes repairing the vagina, LAM, PB, and urogenital hiatus in a manner that aligns with the physiological axes and preserves dynamic urinary control. A recent multicenter self-controlled study demonstrated that physiological reconstruction significantly improved both anatomical and functional outcomes in patients with moderate to severe POP, with a notable reduction in postoperative OSUI rates (46). This approach emphasizes the integration of posterior compartment support restoration—such as levator ani fissure closure and PB repair—which is often neglected in conventional apical suspensions.

As the biomechanical understanding of the human pelvic floor advances, and as limitations of the traditional “three-chambers” and “three-level” support theories become apparent, a more holistic biomechanical theory is emerging. The subsequent development of physiologically oriented reconstructive techniques will inevitably lead to surgical strategies that not only correct prolapse but also prevent functional sequelae such as OSUI. In this context, the so-called “occult urinary incontinence” will no longer be considered a clinical issue.

Conclusions

In conclusion, OSUI is not truly “occult”. It results from altered biomechanics of urinary control following apical suspension. Apical suspension primarily achieves horizontal anatomical repositioning of the cervix without restoring physiological function. It may not consistently ensure the integrity of the urinary control structures or fundamentally resolve voiding dysfunction. Thus, the rationale for relying solely on apical suspension for POP treatment is questionable. Physiological reconstruction may represent a promising biomechanical approach to reducing the risk of OSUI, but further comparative clinical studies are needed to confirm its long-term effectiveness.

Acknowledgments

We would like to acknowledge Mr. Han Lin for her help with English editing.

Footnote

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-49/prf

Funding: This study was supported by the National Natural Science Foundation of China (No. 82260297) and the Research and Development Project for Key Technologies and Clinical Translation of Precision Diagnosis and Treatment of Common Major Kidney Diseases in Yunnan Province (No. 202505AJ310005).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-49/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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