International Urogynecology Journal

, Volume 24, Issue 6, pp 913–919 | Cite as

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

Review Article


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.


Stress urinary incontinence Urethral bulking agent Urethral biomaterials 



Intrinsic sphincteric deficiency


Matrix metalloproteinase


Stress urinary incontinence


Conflicts of interest



  1. 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 158:875–880PubMedCrossRefGoogle Scholar
  2. 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 19:391–396PubMedCrossRefGoogle Scholar
  3. 3.
    Isom-Batz G, Zimmern PE (2009) Collagen injection for female urinary incontinence after urethral or periurethral surgery. J Urol 181:701–704PubMedCrossRefGoogle Scholar
  4. 4.
    Keegan PE, Atiemo K, Cody J, McClinton S, Pickard R (2007) Periurethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev CD003881Google Scholar
  5. 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 172:247–248PubMedCrossRefGoogle Scholar
  6. 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 153:2039–2043PubMedCrossRefGoogle Scholar
  7. 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 18:869–873PubMedCrossRefGoogle Scholar
  8. 8.
    Delancey JO, Ashton-Miller JA (2004) Pathophysiology of adult urinary incontinence. Gastroenterology 126:S23–S32PubMedCrossRefGoogle Scholar
  9. 9.
    Petros PE, Woodman PJ (2008) The integral theory of continence. Int Urogynecol J Pelvic Floor Dysfunct 19:35–40PubMedGoogle Scholar
  10. 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 23:198–203PubMedCrossRefGoogle Scholar
  11. 11.
    Cardozo L (2005) Neurobiology of stress urinary incontinence: new insights and implications for treatment. J Obstet Gynaecol 25:539–543PubMedCrossRefGoogle Scholar
  12. 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 72:195–198PubMedCrossRefGoogle Scholar
  13. 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–S11PubMedGoogle Scholar
  14. 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 23:1373–1378PubMedCrossRefGoogle Scholar
  15. 15.
    Klarskov N, Lose G (2008) Urethral injection therapy: what is the mechanism of action? Neurourol Urodyn 27:789–792PubMedCrossRefGoogle Scholar
  16. 16.
    Dmochowski R, Appell RA (2003) Advancements in minimally invasive treatments for female stress urinary incontinence: radiofrequency and bulking agents. Curr Urol Rep 4:350–355PubMedCrossRefGoogle Scholar
  17. 17.
    Faerber GJ (1996) Endoscopic collagen injection therapy in elderly women with type I stress urinary incontinence. J Urol 155:512–514PubMedCrossRefGoogle Scholar
  18. 18.
    Herschorn S, Radomski SB, Steele DJ (1992) Early experience with intraurethral collagen injections for urinary incontinence. J Urol 148:1797–1800PubMedGoogle Scholar
  19. 19.
    Winters JC, Chiverton A, Scarpero HM, Prats LJ Jr (2000) Collagen injection therapy in elderly women: long-term results and patient satisfaction. Urology 55:856–861PubMedCrossRefGoogle Scholar
  20. 20.
    Dmochowski RR, Appell RA (2000) Injectable agents in the treatment of stress urinary incontinence in women: where are we now? Urology 56:32–40PubMedCrossRefGoogle Scholar
  21. 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 29:559–574PubMedCrossRefGoogle Scholar
  22. 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 15:261–265PubMedGoogle Scholar
  23. 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 CD003881Google Scholar
  24. 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 4:124–127PubMedGoogle Scholar
  25. 25.
    Murless B (1938) The injection treatment of stress incontinence. J Obstet Gynaecol Br Emp 45:521–524CrossRefGoogle Scholar
  26. 26.
    Sachse H (1963) Treatment of urinary incontinence with sclerosing solutions. Indications, results, complications. Urol Int 15:225–244PubMedCrossRefGoogle Scholar
  27. 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) 95:363–366Google Scholar
  28. 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 165:153–158PubMedCrossRefGoogle Scholar
  29. 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 74:771–775PubMedCrossRefGoogle Scholar
  30. 30.
    Dmochowski R (2004) Interventions and outcomes. What is important (and what is not)? J Urol 172:8–9PubMedCrossRefGoogle Scholar
  31. 31.
    Hurtado EA, Appell RA (2009) Complications of Tegress injections. Int Urogynecol J Pelvic Floor Dysfunct 20:127, author reply 129PubMedCrossRefGoogle Scholar
  32. 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. 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 20:177–183PubMedCrossRefGoogle Scholar
  34. 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 112:797–801PubMedCrossRefGoogle Scholar
  35. 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 181:204–210PubMedCrossRefGoogle Scholar
  36. 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 69:876–880PubMedCrossRefGoogle Scholar
  37. 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 150PubMedCrossRefGoogle Scholar
  38. 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 65:898–904PubMedCrossRefGoogle Scholar
  39. 39.
    Lightner DJ (2002) Review of the available urethral bulking agents. Curr Opin Urol 12:333–338PubMedCrossRefGoogle Scholar
  40. 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 58:12–15PubMedCrossRefGoogle Scholar
  41. 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 6:239–243PubMedCrossRefGoogle Scholar
  42. 42.
    Lose G, Mouritsen L, Nielsen JB (2006) A new bulking agent (polyacrylamide hydrogel) for treating stress urinary incontinence in women. BJU Int 98:100–104PubMedCrossRefGoogle Scholar
  43. 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:CD003881PubMedGoogle Scholar
  44. 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 19:881–883PubMedCrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2012

Authors and Affiliations

  1. 1.Department of UrologyBeaumont HospitalCo. DublinIreland

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