**4. The evolution and trends in anti-incontinence treatments**

More than 100 types of anti-incontinence procedures have been invented for treating urinary incontinence in the past century. The choice of surgical method and route for treating urinary incontinence is done according to the type of incontinence, the patient's condition, the surgeon's preferences, and available materials (Wu et al., 2008). Based on the evidence of treatment outcomes, trends in anti-incontinence procedures range from the vaginal route (Kelly plication, anterior repair…), cystoscopy and needle procedures (Stamey, Pereyra,

of women with pelvic organ prolapse. The pathogenesis of pelvic organ prolapse is not completely understood. The development of pelvic organ prolapse may be multi-factorial. Vaginal childbirth, advancing age, and increasing body mass index are the most consistent risk factors of pelvic organ prolapse (Jelovsek et al., 2007). Other factors such as prolonged second stage of labor, constipation, chronic cough previous to pelvic surgery, and increased intra-abdominal pressure caused by heavy lifting have also been reported in association with the occurrence of stress urinary incontinence and pelvic organ prolapse (Dietz, 2008). The weakness in the supportive layer of the urethra and a lax anterior vaginal wall which results in stress urinary incontinence and/or pelvic organ prolapse seems to be caused by a

The exact prevalence of pelvic organ prolapse is difficult to estimate due to patient misunderstandings and misconceptions in presenting these issues to their health care providers. Most of the estimated prevalence rates for pelvic organ prolapse are derived from the incidence of surgery for this disease or from clinic-based samples (Lawreence et al., 2008). Pelvic organ prolapse has been estimated to affect about 50% of parous women aged 50 years or over whereas stress urinary incontinence occurs in 30%. These prevalence rates increase with age (Subak et al., 2001; Abou-Elela et al., 2009; Maher et al., 2010). Pelvic organ prolapse and stress urinary incontinence coexist in 15 to 80 percent of women (Bai et al., 2002). Experts estimate that up to 50% of women with pelvic organ prolapse with the uterus

This continence mechanism in advanced pelvic organ prolapse might be caused by urethral kinking or external urethral compression, which causes obstruction that can stop the demonstration of stress urinary incontinence (Romanzi et al. 2000; Elneil, 2009). However, during surgery to reduce the prolapsed uterus or anterior vaginal wall it may be noted from the urodynamic study that 36 to 80% of the women with pelvic organ prolapse have coexisting urodynamic stress incontinence. These patients have occult stress urinary incontinence (Haessler et al., 2005; Reena et al., 2007). In addition, postoperative stress urinary incontinence (de novo stress urinary incontinence) has been noted in 10 to 30% of women following prolapse repair (Bump et al., 1996; Hung et al., 2004; Reena et al., 2007). Other reports estimate that 11 to 65% of continent patients with pelvic organ prolapse develop de novo stress urinary incontinence following pelvic reconstructive procedures performed during prophylactic anti-incontinence surgery (Borstad E and Rud T, 1989;

More than 100 types of anti-incontinence procedures have been invented for treating urinary incontinence in the past century. The choice of surgical method and route for treating urinary incontinence is done according to the type of incontinence, the patient's condition, the surgeon's preferences, and available materials (Wu et al., 2008). Based on the evidence of treatment outcomes, trends in anti-incontinence procedures range from the vaginal route (Kelly plication, anterior repair…), cystoscopy and needle procedures (Stamey, Pereyra,

**3. Prevalence of pelvic organ prolapse associated stress urinary** 

in situ do not have stress urinary incontinence (Gallentine and Cespedes, 2001).

**4. The evolution and trends in anti-incontinence treatments** 

"multiple-hit" mechanism.

Ellerkmann et al., 2001; Gutman et al., 2008).

**incontinence** 

Raz…), bladder neck suspension and/or colposuspension to the conventional pubovaginal sling. Retropubic Burch colposuspension was considered the gold standard and the most popular anti-incontinence operation by 1995 (Jarvis, 1994). In recent decades, newer tensionfree, patch and prosthetic tapes with minimal invasive procedures have been used such as the tension-free vaginal tape (TVT) procedure which is based on the integral theory and was introduced by Petros and Ulmsten (1993). The treatment outcomes seem promising (Wu et al., 2008). The use of macroporous monofilament mesh has become a popular treatment in anti-incontinence surgery. However, long-term complications of these synthetic materials still need to be solved.

The goals of these procedures for achieving continence have shifted from suburethral fascia plication (Kelly procedure), lifting the urethra up to a higher retropubic position (MMK), elevating the bladder neck to enhance pressure transmission ratio (colposuspension), to stabilizing the bladder neck or proximal urethra to increase urethral closure pressure (sling operation). Now, the popular minimal invasive procedures, based on the integral theory (Petros and Ulmsten 1993), are trying to create a dynamic kinking of the mid-urethra at the level of the high pressure zone in the urethral pressure profile or in the urethral knee angle (terminology used in sonographic findings) (Wu et al., 2008; Lo et al., 2004).
