Skip to main content

Advertisement

SpringerLink
Log in

Injectable biomaterials for the treatment of stress urinary incontinence: their potential and pitfalls as urethral bulking agents

  • Review Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Injectable urethral bulking agents composed of synthetic and biological biomaterials are minimally invasive treatment options for stress urinary incontinence (SUI). The development of an ideal urethral bulking agent remains challenging because of clinical concerns over biocompatibility and durability. Herein, the mechanical and biological features of injectable urethral biomaterials are investigated, with particular emphasis on their future potential as primary and secondary treatment options for SUI. A literature search for English language publications using the two online databases was performed. Keywords included “stress urinary incontinence”, “urethral bulking agent” and “injectable biomaterial”. A total of 98 articles were analysed, of which 45 were suitable for review based on clinical relevance and importance of content. Injectable biomaterials are associated with a lower cure rate and fewer postoperative complications than open surgery for SUI. They are frequently reserved as secondary treatment options for patients unwilling or medically unfit to undergo surgery. Glutaraldehyde cross-linked bovine collagen remains the most commonly injected biomaterial and has a cure rate of up to 53 %. Important clinical features of an injectable biomaterial are durability, biocompatibility and ease of administration, but achieving these requirements is challenging. In carefully selected patients, injectable biomaterials are feasible alternatives to open surgical procedures as primary and secondary treatment options for SUI. In future, higher cure rates may be feasible as researchers investigate alternative biomaterials and more targeted injection techniques for treating SUI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ISD:

Intrinsic sphincteric deficiency

MMP:

Matrix metalloproteinase

SUI:

Stress urinary incontinence

References

  1. Leach GE, Dmochowski RR, Appell RA, Blaivas JG, Hadley HR et al (1997) Female stress urinary incontinence clinical guidelines panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol 158:875–880

    Article  PubMed  CAS  Google Scholar 

  2. Kulseng-Hanssen S, Husby H, Schiotz HA (2008) Follow-up of TVT operations in 1,113 women with mixed urinary incontinence at 7 and 38 months. Int Urogynecol J Pelvic Floor Dysfunct 19:391–396

    Article  PubMed  Google Scholar 

  3. Isom-Batz G, Zimmern PE (2009) Collagen injection for female urinary incontinence after urethral or periurethral surgery. J Urol 181:701–704

    Article  PubMed  CAS  Google Scholar 

  4. Keegan PE, Atiemo K, Cody J, McClinton S, Pickard R (2007) Periurethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev CD003881

  5. Bedir S, Kilciler M, Ozgok Y, Deveci G, Erduran D (2004) Long-term complication due to dextranomer based implant: granuloma causing urinary obstruction. J Urol 172:247–248

    Article  PubMed  Google Scholar 

  6. Henly DR, Barrett DM, Weiland TL, O’Connor MK, Malizia AA et al (1995) Particulate silicone for use in periurethral injections: local tissue effects and search for migration. J Urol 153:2039–2043

    Article  PubMed  CAS  Google Scholar 

  7. Hurtado E, McCrery R, Appell R (2007) The safety and efficacy of ethylene vinyl alcohol copolymer as an intra-urethral bulking agent in women with intrinsic urethral deficiency. Int Urogynecol J Pelvic Floor Dysfunct 18:869–873

    Article  PubMed  Google Scholar 

  8. Delancey JO, Ashton-Miller JA (2004) Pathophysiology of adult urinary incontinence. Gastroenterology 126:S23–S32

    Article  PubMed  Google Scholar 

  9. Petros PE, Woodman PJ (2008) The integral theory of continence. Int Urogynecol J Pelvic Floor Dysfunct 19:35–40

    PubMed  Google Scholar 

  10. Kushner L, Mathrubutham M, Burney T, Greenwald R, Badlani G (2004) Excretion of collagen derived peptides is increased in women with stress urinary incontinence. Neurourol Urodyn 23:198–203

    Article  PubMed  CAS  Google Scholar 

  11. Cardozo L (2005) Neurobiology of stress urinary incontinence: new insights and implications for treatment. J Obstet Gynaecol 25:539–543

    Article  PubMed  CAS  Google Scholar 

  12. Falconer C, Ekman-Ordeberg G, Hilliges M, Johansson O (1997) Decreased innervation of the paraurethral epithelium in stress urinary incontinent women. Eur J Obstet Gynecol Reprod Biol 72:195–198

    Article  PubMed  CAS  Google Scholar 

  13. Kerr LA (2005) Bulking agents in the treatment of stress urinary incontinence: history, outcomes, patient populations, and reimbursement profile. Rev Urol 7 [Suppl 1]:S3–S11

    PubMed  Google Scholar 

  14. Toozs-Hobson P, Al-Singary W, Fynes M, Tegerstedt G, Lose G (2012) Two-year follow-up of an open-label multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and stress-predominant mixed incontinence. Int Urogynecol J 23:1373–1378

    Article  PubMed  Google Scholar 

  15. Klarskov N, Lose G (2008) Urethral injection therapy: what is the mechanism of action? Neurourol Urodyn 27:789–792

    Article  PubMed  Google Scholar 

  16. Dmochowski R, Appell RA (2003) Advancements in minimally invasive treatments for female stress urinary incontinence: radiofrequency and bulking agents. Curr Urol Rep 4:350–355

    Article  PubMed  Google Scholar 

  17. Faerber GJ (1996) Endoscopic collagen injection therapy in elderly women with type I stress urinary incontinence. J Urol 155:512–514

    Article  PubMed  CAS  Google Scholar 

  18. Herschorn S, Radomski SB, Steele DJ (1992) Early experience with intraurethral collagen injections for urinary incontinence. J Urol 148:1797–1800

    PubMed  CAS  Google Scholar 

  19. Winters JC, Chiverton A, Scarpero HM, Prats LJ Jr (2000) Collagen injection therapy in elderly women: long-term results and patient satisfaction. Urology 55:856–861

    Article  PubMed  CAS  Google Scholar 

  20. Dmochowski RR, Appell RA (2000) Injectable agents in the treatment of stress urinary incontinence in women: where are we now? Urology 56:32–40

    Article  PubMed  CAS  Google Scholar 

  21. Kershen RT, Dmochowski RR, Appell RA (2002) Beyond collagen: injectable therapies for the treatment of female stress urinary incontinence in the new millennium. Urol Clin North Am 29:559–574

    Article  PubMed  Google Scholar 

  22. Schulz JA, Nager CW, Stanton SL, Baessler K (2004) Bulking agents for stress urinary incontinence: short-term results and complications in a randomized comparison of periurethral and transurethral injections. Int Urogynecol J Pelvic Floor Dysfunct 15:261–265

    PubMed  Google Scholar 

  23. Pickard R, Reaper J, Wyness L, Cody DJ, McClinton S et al (2003) Periurethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev CD003881

  24. Faerber GJ, Belville WD, Ohl DA, Plata A (1998) Comparison of transurethral versus periurethral collagen injection in women with intrinsic sphincter deficiency. Tech Urol 4:124–127

    PubMed  CAS  Google Scholar 

  25. Murless B (1938) The injection treatment of stress incontinence. J Obstet Gynaecol Br Emp 45:521–524

    Article  Google Scholar 

  26. Sachse H (1963) Treatment of urinary incontinence with sclerosing solutions. Indications, results, complications. Urol Int 15:225–244

    Article  PubMed  CAS  Google Scholar 

  27. Gonzalez Garibay S, Jimeno C, York M, Gomez P, Borruell S (1989) Endoscopic autotransplantation of fat tissue in the treatment of urinary incontinence in the female. J Urol (Paris) 95:363–366

    CAS  Google Scholar 

  28. Lee PE, Kung RC, Drutz HP (2001) Periurethral autologous fat injection as treatment for female stress urinary incontinence: a randomized double-blind controlled trial. J Urol 165:153–158

    Article  PubMed  CAS  Google Scholar 

  29. Lightner D, Rovner E, Corcos J, Payne C, Brubaker L et al (2009) Randomized controlled multisite trial of injected bulking agents for women with intrinsic sphincter deficiency: mid-urethral injection of Zuidex via the Implacer versus proximal urethral injection of Contigen cystoscopically. Urology 74:771–775

    Article  PubMed  Google Scholar 

  30. Dmochowski R (2004) Interventions and outcomes. What is important (and what is not)? J Urol 172:8–9

    Article  PubMed  Google Scholar 

  31. Hurtado EA, Appell RA (2009) Complications of Tegress injections. Int Urogynecol J Pelvic Floor Dysfunct 20:127, author reply 129

    Article  PubMed  Google Scholar 

  32. Ghoniem GM, Miller CJ (2012) A systematic review and meta-analysis of Macroplastique for treating female stress urinary incontinence. Int Urogynecol J doi: 10.1007/s00192-012-1825-9

    Google Scholar 

  33. ter Meulen PH, Berghmans LC, Nieman FH, van Kerrebroeck PE (2009) Effects of macroplastique implantation system for stress urinary incontinence and urethral hypermobility in women. Int Urogynecol J Pelvic Floor Dysfunct 20:177–183

    Article  PubMed  Google Scholar 

  34. Maher CF, O’Reilly BA, Dwyer PL, Carey MP, Cornish A et al (2005) Pubovaginal sling versus transurethral Macroplastique for stress urinary incontinence and intrinsic sphincter deficiency: a prospective randomised controlled trial. BJOG 112:797–801

    Article  PubMed  Google Scholar 

  35. Ghoniem G, Corcos J, Comiter C, Bernhard P, Westney OL et al (2009) Cross-linked polydimethylsiloxane injection for female stress urinary incontinence: results of a multicenter, randomized, controlled, single-blind study. J Urol 181:204–210

    Article  PubMed  Google Scholar 

  36. Mayer RD, Dmochowski RR, Appell RA, Sand PK, Klimberg IW et al (2007) Multicenter prospective randomized 52-week trial of calcium hydroxylapatite versus bovine dermal collagen for treatment of stress urinary incontinence. Urology 69:876–880

    Article  PubMed  CAS  Google Scholar 

  37. Bano F, Barrington JW, Dyer R (2005) Comparison between porcine dermal implant (Permacol) and silicone injection (Macroplastique) for urodynamic stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 16:147–150, discussion 150

    Article  PubMed  CAS  Google Scholar 

  38. Corcos J, Collet JP, Shapiro S, Herschorn S, Radomski SB et al (2005) Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence. Urology 65:898–904

    Article  PubMed  CAS  Google Scholar 

  39. Lightner DJ (2002) Review of the available urethral bulking agents. Curr Opin Urol 12:333–338

    Article  PubMed  Google Scholar 

  40. Lightner D, Calvosa C, Andersen R, Klimberg I, Brito CG et al (2001) A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere. Urology 58:12–15

    Article  PubMed  CAS  Google Scholar 

  41. Andersen RC (2002) Long-term follow-up comparison of durasphere and contigen in the treatment of stress urinary incontinence. J Low Genit Tract Dis 6:239–243

    Article  PubMed  Google Scholar 

  42. Lose G, Mouritsen L, Nielsen JB (2006) A new bulking agent (polyacrylamide hydrogel) for treating stress urinary incontinence in women. BJU Int 98:100–104

    Article  PubMed  CAS  Google Scholar 

  43. Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD et al (2012) Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev 2:CD003881

    PubMed  Google Scholar 

  44. Carr LK, Steele D, Steele S, Wagner D, Pruchnic R et al (2008) 1-year follow-up of autologous muscle-derived stem cell injection pilot study to treat stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 19:881–883

    Article  PubMed  CAS  Google Scholar 

Download references

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Urology, Beaumont Hospital, Co. Dublin, Ireland

    Niall F. Davis, F. Kheradmand & T. Creagh

Authors
  1. Niall F. Davis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. F. Kheradmand
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. T. Creagh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Niall F. Davis.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Davis, N.F., Kheradmand, F. & Creagh, T. Injectable biomaterials for the treatment of stress urinary incontinence: their potential and pitfalls as urethral bulking agents. Int Urogynecol J 24, 913–919 (2013). https://doi.org/10.1007/s00192-012-2011-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-012-2011-9

Keywords

Search

Navigation