Skip to main content

Advertisement

Log in

Bulking agents: an analysis of 500 cases and review of the literature

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

Abstract

Introduction and hypothesis

Stress urinary incontinence (SUI) is common, impacts women’s quality of life, and generates high costs. Physiotherapy is the first-line therapy, and if it fails, suburethral slings are the gold standard in SUI surgery. Bulking agents injected periurethrally might be a beneficial alternative, but there is a paucity of data on bulking therapy. The aim of this study was to prospectively analyze the efficacy and safety of bulking agents in the setting of a tertiary referral center.

Methods

In the last 13 years, 514 elderly women with SUI were treated by injection therapy with either collagen (Contigen®), hyaluronic acid (Zuidex®), ethylene vinyl alcohol (Tegress®), or polyacrylamide hydrogel (Bulkamid®). Subjective and objective outcome was recorded at the 12-month postoperative appointment using the King’s Health Questionnaire, visual analogue scale (VAS) describing their incontinence severity, standardized pad test, and urethral pressure profile.

Results

Demographic data were equally distributed in all four groups of agents used. Sixty-one patients were lost to follow-up (10.6 %). Statistically significant changes were found for maximum urethral closure pressure (MUCP), pad weight, and VAS before and after bulking for the four agents used. Pad test was negative in 73.2 % of patients after bulking therapy. Subjective assessment showed improvements in general health and role limitations. The overall complication rate was low for all agents.

Conclusions

This study shows improvement in incontinence after bulking therapy according to subjective and objective outcomes in an elderly population. In contrast to earlier reports, side effects due to injections were few and mild. We can advocate bulking therapy for treating SUI, as it is simple, safe, and shows both objective and subjective improvement and relief.

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

Access this article

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

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Blaivas JG, Appell RA, Fantl JA, Leach G, McGuire EJ, Resnick NM et al (1997) Definition and classification of urinary incontinence: recommendations of the urodynamic society. Neurourol Urodyn 16:149–151

    Article  PubMed  CAS  Google Scholar 

  2. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U et al (2003) The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the international continence society. Urology 61:37–49

    Article  PubMed  Google Scholar 

  3. Mohr S, Kuhn P, Mueller MD, Kuhn A (2011) Painful love-"hispareunia" after sling erosion of the female partner. J Sex Med 8:1740–1746

    Article  PubMed  Google Scholar 

  4. 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 

  5. Papanicolaou S, Pons ME, Hampel C, Monz B, Quail D, Schulenburg MG et al (2005) Medical resource utilisation and cost of care for women seeking treatment for urinary incontinence in an outpatient setting. Examples from three countries participating in the PURE study. Maturitas 52(Suppl 2):S35–S47

    Article  PubMed  Google Scholar 

  6. Shamliyan TA, Kane RL, Wyman J, Wilt TJ (2008) Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 148:459–473

    PubMed  Google Scholar 

  7. Serati M, Salvatore S, Uccella S, Artibani W, Novara G, Cardozo L et al (2009) Surgical treatment for female stress urinary incontinence: what is the gold-standard procedure? Int Urogynecol J Pelvic Floor Dysfunct 20:619–621

    Article  PubMed  Google Scholar 

  8. Davila GW (2011) Nonsurgical outpatient therapies for the management of female stress urinary incontinence: long-term effectiveness and durability. Adv Urol 2011:176498

    PubMed  Google Scholar 

  9. Sassani P, Aboseif SR (2009) Stress urinary incontinence in women. Curr Urol Rep 10:333–337

    Article  PubMed  Google Scholar 

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

  11. Chapple CR, Wein AJ, Brubaker L, Dmochowski R, Pons ME, Haab F et al (2005) Stress incontinence injection therapy: what is best for our patients? Eur Urol 48:552–565

    Article  PubMed  Google Scholar 

  12. Plotti F, Zullo MA, Sansone M, Calcagno M, Bellati F, Angioli R et al (2009) Post radical hysterectomy urinary incontinence: a prospective study of transurethral bulking agents injection. Gynecol Oncol 112:90–94

    Article  PubMed  Google Scholar 

  13. McGuire EJ (2006) Urethral bulking agents. Nat Clin Pract Urol 3:234–235

    Article  PubMed  Google Scholar 

  14. Kotb AF, Campeau L, Corcos J (2009) Urethral bulking agents: techniques and outcomes. Curr Urol Rep 10:396–400

    Article  PubMed  Google Scholar 

  15. Lose G, Sorensen HC, Axelsen SM, Falconer C, Lobodasch K, Safwat T (2010) An open multicenter study of polyacrylamide hydrogel (Bulkamid(R)) for female stress and mixed urinary incontinence. Int Urogynecol J 21:1471–1477

    Article  PubMed  Google Scholar 

  16. 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 

  17. Kelleher CJ, Cardozo LD, Khullar V, Salvatore S (1997) A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 104:1374–1379

    Article  PubMed  CAS  Google Scholar 

  18. Bjelic-Radisic V, Dorfer M, Tamussino K, Greimel E (2005) Psychometric properties and validation of the German-language King's Health Questionnaire in women with stress urinary incontinence. Neurourol Urodyn 24:63–68

    Article  PubMed  Google Scholar 

  19. Zhang XH, Xie F, Wee HL, Thumboo J, Li SC (2008) Applying the expectancy-value model to understand health values. Value Health 11(Suppl 1):S61–S68

    Article  PubMed  Google Scholar 

  20. Ryhammer AM, Djurhuus JC, Laurberg S (1999) Pad testing in incontinent women: a review. Int Urogynecol J Pelvic Floor Dysfunct 10:111–115

    Article  PubMed  CAS  Google Scholar 

  21. Lightner D, Rovner E, Corcos J, Payne C, Brubaker L, Drutz H 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 

  22. Kuhn A, Stadlmayr W, Sohail A, Monga A (2008) Long-term results and patients' satisfaction after transurethral ethylene vinyl alcohol (Tegress) injections: a two-centre study. Int Urogynecol J Pelvic Floor Dysfunct 19:503–507

    Article  PubMed  Google Scholar 

  23. Koski ME, Enemchukwu EA, Padmanabhan P, Kaufman MR, Scarpero HM, Dmochowski RR (2011) Safety and efficacy of sling for persistent stress urinary incontinence after bulking injection. Urology 77:1076–1080

    Article  PubMed  Google Scholar 

  24. Lee HN, Lee YS, Han JY, Jeong JY, Choo MS, Lee KS (2010) Transurethral injection of bulking agent for treatment of failed mid-urethral sling procedures. Int Urogynecol J 21:1479–1483

    Article  PubMed  Google Scholar 

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

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

    Article  PubMed  Google Scholar 

  27. Gorton E, Stanton S, Monga A, Wiskind AK, Lentz GM, Bland DR (1999) Periurethral collagen injection: a long-term follow-up study. BJU Int 84:966–971

    Article  PubMed  CAS  Google Scholar 

  28. van KP, ter MF, Farrelly E, Larsson G, Edwall L, Fianu-Jonasson A (2003) Treatment of stress urinary incontinence: recent developments in the role of urethral injection. Urol Res 30:356–362

    Google Scholar 

  29. Kuhn A, Stadlmayr W, Lengsfeld D, Mueller MD (2008) Where should bulking agents for female urodynamic stress incontinence be injected? Int Urogynecol J Pelvic Floor Dysfunct 19:817–821

    Article  PubMed  Google Scholar 

  30. Sharifi-Aghdas F (2005) Surgical management of stress urinary incontinence. Urol J 2:175–182

    PubMed  Google Scholar 

  31. Monga AK, Robinson D, Stanton SL (1995) Periurethral collagen injections for genuine stress incontinence: a 2-year follow-up. Br J Urol 76:156–160

    Article  PubMed  CAS  Google Scholar 

  32. Lightner D, Calvosa C, Andersen R, Klimberg I, Brito CG, Snyder J 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 

  33. Mayer RD, Dmochowski RR, Appell RA, Sand PK, Klimberg IW, Jacoby K 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 

  34. 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

    Article  PubMed  CAS  Google Scholar 

  35. Ghoniem G, Corcos J, Comiter C, Bernhard P, Westney OL, Herschorn S (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. Ghoniem G, Corcos J, Comiter C, Westney OL, Herschorn S (2010) Durability of urethral bulking agent injection for female stress urinary incontinence: 2-year multicenter study results. J Urol 183:1444–1449

    Article  PubMed  Google Scholar 

  37. Mazouni C, Bladou F, Karsenty G, Giorgi R, Andre M, Serment G (2004) Minimally invasive surgery for female urinary incontinence: experience with periurethral microballoon implantation. J Endourol 18:901–905

    Article  PubMed  Google Scholar 

  38. 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 

  39. Lottmann HB, Margaryan M, Lortat-Jacob S, Bernuy M, Lackgren G (2006) Long-term effects of dextranomer endoscopic injections for the treatment of urinary incontinence: an update of a prospective study of 61 patients. J Urol 176:1762–1766

    Article  PubMed  CAS  Google Scholar 

  40. Lottmann HB, Margaryan M, Bernuy M, Grosz A, Aigrain Y, Lortat-Jacob S et al (2006) Long-term effects of dextranomer endoscopic injections for treatment of urinary incontinence: an update of a prospective study of 31 patients. J Urol 175:1485–1489

    Article  PubMed  CAS  Google Scholar 

  41. Tsai CC, Lin V, Tang L (2006) Injectable biomaterials for incontinence and vesico-ureteral reflux: current status and future promise. J Biomed Mater Res B Appl Biomater 77:171–178

    PubMed  Google Scholar 

  42. Palma PC, Riccetto CL, Martins MH, Herrmann V, de FR, Billis A et al (2006) Massive prolapse of the urethral mucosa following periurethral injection of calcium hydroxylapatite for stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 17:670–671

    Article  PubMed  Google Scholar 

  43. Kumar D, Kaufman MR, Dmochowski RR (2011) Case reports: periurethral bulking agents and presumed urethral diverticula. Int Urogynecol J 22:1039–1043

    Article  PubMed  Google Scholar 

  44. Madjar S, Sharma AK, Waltzer WC, Frischer Z, Secrest CL (2006) Periurethral mass formations following bulking agent injection for the treatment of urinary incontinence. J Urol 175:1408–1410

    Article  PubMed  CAS  Google Scholar 

  45. Sweat SD, Lightner DJ (1999) Complications of sterile abscess formation and pulmonary embolism following periurethral bulking agents. J Urol 161:93–96

    Article  PubMed  CAS  Google Scholar 

  46. Hartanto VH, Lightner DJ, Nitti VW (2003) Endoscopic evacuation of Durasphere. Urology 62:135–137

    Article  PubMed  Google Scholar 

  47. Kreder KJ, Austin JC (1996) Treatment of stress urinary incontinence in women with urethral hypermobility and intrinsic sphincter deficiency. J Urol 156:1995–1998

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Stefan Mohr.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mohr, S., Siegenthaler, M., Mueller, M.D. et al. Bulking agents: an analysis of 500 cases and review of the literature. Int Urogynecol J 24, 241–247 (2013). https://doi.org/10.1007/s00192-012-1834-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-012-1834-8

Keywords

Navigation