AUA/SUFU Guideline published 2019

Urinary incontinence after prostate treatment is one of the few urologic diseases that is iatrogenic, and, therefore, predictable and perhaps preventable. Evaluation of the incontinent patient, risk factors for IPT, the assessment of the patient prior to intervention, and a stepwise approach to management are covered in this guideline. Algorithms for patient evaluation, surgical management, and device failure are also provided.

Unabridged version of this guideline [pdf]
Evaluation Algorithm
Surgical Management Algorithm
AUS Failure Algorithm
Sling Failure Algorithm

Jaspreet S. Sandhu, MD; Benjamin Breyer, MD; Craig Comiter, MD; James A. Eastham, MD; Christopher Gomez, MD; Daniel J. Kirages, PT; Chris Kittle; Alvaro Lucioni, MD; Victor W. Nitti, MD; John T. Stoffel, MD; O. Lenaine Westney, MD; M. Hassan Murad, MD; Kurt Mc Cammon, MD

Purpose

Urinary incontinence after prostate treatment (IPT) is a clinically significant condition that causes a high degree of patient distress. It is one of the few urologic diseases that is iatrogenic, and, therefore, predictable and perhaps preventable. Although most clinicians are familiar with the more commonly known term “post-prostatectomy incontinence,” this guideline uses the term IPT, which is more inclusive given that it covers the management of patients who have incontinence after undergoing radical prostatectomy (RP), radiation treatment (RT), and treatment of benign prostatic hyperplasia (BPH). Evaluation of the patient; risk factors for IPT, which should be discussed with all patients prior to treatment; assessment of the patient prior to intervention; and a stepwise approach to management are covered in this guideline. Possible maneuvers to decrease rates of IPT, with specific focus placed on patients with stress urinary incontinence (SUI) are also explored. The multiple treatments that exist for patients with IPT are discussed and evaluated, including physical therapy, medications, and surgery.

Methodologies

The systematic review utilized to inform this guideline was conducted by a methodology team at the Mayo Clinic Evidence-Based Practice Research Program. The scope of the topic and the discussion of the final systematic review used to develop guideline statements was conducted in conjunction with the Incontinence after Prostate Treatment expert panel. A research librarian conducted searches in Ovid MEDLINE (from 2000 to December 21^st, 2017), Cochrane Central Register of Controlled Trials (from 2000 to December 21st, 2017) and Cochrane Databases of Systematic Reviews (from 2000 to December 21st, 2017). Searches of electronic databases were supplemented by reviewing reference lists of relevant articles. Panel members identified additional references through 12/31/2018.

Guideline Statements

Pre-Treatment

1. Clinicians should inform patients undergoing radical prostatectomy of all known factors that could affect continence. (Moderate Recommendation; Evidence Level: Grade B)

2. Clinicians should counsel patients regarding the risk of sexual arousal incontinence and climacturia following radical prostatectomy. (Strong Recommendation; Evidence Level: Grade B)

3. Clinicians should inform patients undergoing radical prostatectomy that incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment. (Strong Recommendation; Evidence Level: Grade A)

4. Prior to radical prostatectomy, patients may be offered pelvic floor muscle exercises or pelvic floor muscle training. (Conditional Recommendation; Evidence Level: Grade C)

5. Patients undergoing transurethral resection of the prostate after radiation therapy or radical prostatectomy after radiation therapy should be informed of the high rate of urinary incontinence following these procedures. (Moderate Recommendation; Evidence Level: Grade C)

Post-Prostate Treatment

6. In patients who have undergone radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate post-operative period. (Moderate Recommendation; Evidence Level: Grade B)

7. In patients with bothersome stress urinary incontinence after prostate treatment, surgery may be considered as early as six months if incontinence is not improving despite conservative therapy. (Conditional Recommendation; Evidence Level: Grade C)

8. In patients with bothersome stress urinary incontinence after prostate treatment, despite conservative therapy, surgical treatment should be offered at one year post-prostate treatment. (Strong Recommendation; Evidence Level: Grade B)

Evaluation of Incontinence after Prostate Treatment

9. Clinicians should evaluate patients with incontinence after prostate treatment with history, physical exam, and appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother. (Clinical Principle)

10. Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the American Urological Association Overactive Bladder guideline. (Clinical Principle)

11. Prior to surgical intervention for stress urinary incontinence, stress urinary incontinence should be confirmed by history, physical exam, or ancillary testing. (Clinical Principle)

12. Patients with incontinence after prostate treatment should be informed of management options for their incontinence, including surgical and non-surgical options. (Clinical Principle)

13. In patients with incontinence after prostate treatment, physicians should discuss risk, benefits, and expectations of different treatments using the shared decision-making model. (Clinical Principle)

14. Prior to surgical intervention for stress urinary incontinence, cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery. (Expert Opinion)

15. Clinicians may perform urodynamic testing in a patient prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling. (Conditional Recommendation; Evidence Level: Grade C)

Treatment Options

16. In patients seeking treatment for incontinence after radical prostatectomy, pelvic floor muscle exercises or pelvic floor muscle training should be offered. (Moderate Recommendation; Evidence Level: Grade B)

17. Artificial urinary sphincter should be considered for patients with bothersome stress urinary incontinence after prostate treatment. (Strong Recommendation; Evidence Level: Grade B)

18. Prior to implantation of artificial urinary sphincter, clinicians should ensure that patients have adequate physical and cognitive abilities to operate the device. (Clinical Principle)

19. In the patient who selects artificial urinary sphincter, a single cuff perineal approach is preferred. (Moderate Recommendation; Evidence Level: Grade C)

20. Male slings should be considered as treatment options for mild to moderate stress urinary incontinence after prostate treatment. (Moderate Recommendation; Evidence Level: Grade B)

21. Male slings should not be routinely performed in patients with severe stress incontinence. (Moderate Recommendation; Evidence Level: Grade C)

22. Adjustable balloon devices may be offered to patients with mild stress urinary incontinence after prostate treatment. (Moderate Recommendation; Evidence Level: Grade B)

23. Surgical management of stress urinary incontinence after treatment of benign prostatic hyperplasia is the same as that for patients after radical prostatectomy. (Moderate Recommendation; Evidence Level: Grade C)

24. In men with stress urinary incontinence after primary, adjuvant, or salvage radiotherapy who are seeking surgical management, artificial urinary sphincter is preferred over male slings or adjustable balloons. (Moderate Recommendation; Evidence Level: Grade C)

25. Patients with incontinence after prostate treatment should be counseled that efficacy is low and cure is rare with urethral bulking agents. (Strong Recommendation; Evidence Level: Grade B)

26. Other potential treatments for incontinence after prostate treatment should be considered investigational, and patients should be counseled accordingly. (Expert Opinion)

Complications after Surgery

27. Patients should be counseled that artificial urinary sphincter will likely lose effectiveness over time, and reoperations are common. (Strong Recommendation; Evidence Level: Grade B)

28. In patients with persistent or recurrent urinary incontinence after artificial urinary sphincter or sling, clinicians should again perform history, physical examination, and/or other investigations to determine the cause of incontinence. (Clinical Principle)

29. In patients with persistent or recurrent stress urinary incontinence after sling, an artificial urinary sphincter is recommended. (Moderate Recommendation; Evidence Level: Grade C)

30. In patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter, revision should be considered. (Strong Recommendation; Evidence Level: Grade B)

Special Situations

31. In a patient presenting with infection or erosion of an artificial urinary sphincter or sling, explantation should be performed and reimplantation should be delayed. (Clinical Principle)

32. A urinary diversion can be considered in patients who are unable to obtain long-term quality of life after incontinence after prostate treatment and who are appropriately motivated and counseled. (Expert Opinion)

33. In a patient with bothersome climacturia, treatment may be offered. (Conditional Recommendation; Evidence Level: Grade C)

34. Patients with stress urinary incontinence following urethral reconstructive surgery may be offered artificial urinary sphincter and should be counseled that complications rates are higher. (Conditional Recommendation; Evidence Level: Grade C)

35. In patients with incontinence after prostate treatment and erectile dysfunction, a concomitant or staged procedure may be offered. (Conditional Recommendation; Evidence Level: Grade C)

36. Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for incontinence after prostate treatment. (Clinical Principle)

IPT causes emotional and financial distress to patients afflicted with this condition by delaying patients’ re-entry into society, inhibiting relationships, and carrying an economic burden for families and stakeholders. It is a condition that has gained visibility not only due to the extensive use of surgery for prostate cancer but also given to the proliferation of men’s continence products available to the lay public.

Since IPT is caused by treatment of the prostate, it is, by definition iatrogenic and perhaps preventable or predictable. Understanding the nature of IPT is crucial for patients and practitioners during recovery and extended survivorship. Practitioners benefit from being able to assess which patient will likely experience further symptom recovery versus those who will not. This allows clinicians to set clear and reasonable expectations regarding the short-, medium-, and long-term sequela of IPT.

Although most clinicians are familiar with the more commonly known term “post-prostatectomy incontinence,” this guideline uses the term IPT, which is more inclusive given that it covers the management of patients who have incontinence after undergoing RP, RT, and treatment of BPH. Evaluation of the patient; risk factors for IPT, which should be discussed with all patients prior to treatment; assessment of the patient prior to intervention; and a stepwise approach to management are covered in this guideline. Possible maneuvers to decrease rates of IPT, with specific focus placed on patients with SUI, are also explored. The multiple treatments that exist for patients with IPT are discussed and evaluated, including physical therapy, medications, and surgery. Algorithms for patient evaluation, surgical management, and device failure are provided for practitioners.

Methodology

The systematic review utilized to inform this guideline was conducted by a methodology team at Mayo Clinic Evidence-Based Practice Research Program. Determination of the guideline scope and review of the final systematic review to inform guideline statements was conducted in conjunction with the Incontinence after Prostate Treatment expert panel.

Panel Formation

The IPT Panel was created in 2017 by the American Urological Association Education and Research, Inc. (AUAER). This guideline was developed in collaboration with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). The Practice Guidelines Committee (PGC) of the American Urological Association (AUA) selected the Panel Chair, who in turn appointed additional panel members with specific expertise in this area, in conjunction with SUFU. Funding of the panel was provided by the AUA with contributions from SUFU; panel members received no remuneration for their work.

Searches and Article Selection

A comprehensive search of several databases from 2000 to December 21st, 2017 was completed. Databases included Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced medical reference librarian with input from the guideline methodologist. Controlled vocabulary supplemented with keywords was used to search for studies on IPT. The search was restricted to studies published in English and available in full text in the peer reviewed literature.

Data Abstractions

Two reviewers independently selected studies and extracted data using standardized, pilot tested forms created in a systematic review software management system (Distiller SR, Evidence Partners, Ottawa, Canada). Disagreements were resolved by discussion between the two reviewers. Two main types of data were abstracted: baseline characteristics (study design, objective, inclusion and exclusion criteria, sample size, age, body mass index [BMI], intervention, period of follow up), and outcome data (number of patients who were incontinent and those with incontinence improvement, mean pads per day, quality of life [QoL], and complications).

Risk of Bias Assessment

The Newcastle Ottawa scale, which evaluates cohort selection, comparability and outcomes assessment, was used for non-randomized controlled trials (RCTs). The Cochrane risk of bias tool which evaluates random sequence generation, allocation concealment, blinding, and attrition was used for evaluation of RCTs.

Data Synthesis

When meta-analysis was appropriate, methodologists utilized the random-effects model a priori because of the anticipated heterogeneity across study populations and settings. Otherwise, outcomes were evaluated using narrative and descriptive approaches.

Determination of Evidence Strength

The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence available for a particular question and includes individual study quality in addition to consideration of study design; consistency of findings across studies; adequacy of sample sizes; and generalizability of samples, settings, and treatments for the purposes of the guideline. Investigators graded the strength of evidence for key comparisons and outcomes for each Key Question, using the approach described in the Agency for Healthcare Research and Quality Evidence-based Practice Center Methods Guide for Comparative Effectiveness and Effectiveness Reviews.¹ Strength of evidence assessments were based on the following domains:

• Study limitations, based on the overall risk of bias across studies (low, medium, or high)
• Consistency of results across studies
• Directness of the evidence linking the intervention and health outcomes
• Precision of the estimate of effect, based on the number and size of studies and confidence intervals for the estimates (precise or imprecise)
• Reporting bias, based on whether or not the studies defined and reported primary outcomes and whether or not we identified relevant unpublished studies (suspected or undetected)

The AUA categorizes body of evidence strength as Grade A (well-conducted and highly-generalizable RCTs or exceptionally strong observational studies with consistent findings), Grade B (RCTs with some weaknesses of procedure or generalizability or moderately strong observational studies with consistent findings), or Grade C (RCTs with serious deficiencies of procedure or generalizability or extremely small sample sizes or observational studies that are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data). By definition, Grade A evidence is evidence about which the Panel has a high level of certainty, Grade B evidence is evidence about which the Panel has a moderate level of certainty, and Grade C evidence is evidence about which the Panel has a low level of certainty.

AUA Nomenclature: Linking Statement Type to Evidence Strength

The AUA nomenclature system explicitly links statement type to body of evidence strength, level of certainty, magnitude of benefit or risk/burdens, and the Panel’s judgment regarding the balance between benefits and risks/burdens (Table 1). Strong Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is substantial. Moderate Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is moderate. Conditional Recommendations are non-directive statements used when the evidence indicates that there is no apparent net benefit or harm or when the balance between benefits and risks/burden is unclear. All three statement types may be supported by any body of evidence strength grade. Body of evidence strength Grade A in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, and that future research is unlikely to change confidence. Body of evidence strength Grade B in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but better evidence could change confidence. Body of evidence strength Grade C in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but better evidence is likely to change confidence. Body of evidence strength Grade C is only rarely used in support of a Strong Recommendation. Conditional Recommendations also can be supported by any evidence strength. When body of evidence strength is Grade A, the statement indicates that benefits and risks/burdens appear balanced, the best action depends on patient circumstances, and future research is unlikely to change confidence. When body of evidence strength Grade B is used, benefits and risks/burdens appear balanced, the best action also depends on individual patient circumstances, and better evidence could change confidence. When body of evidence strength Grade C is used, there is uncertainty regarding the balance between benefits and risks/burdens, alternative strategies may be equally reasonable, and better evidence is likely to change confidence.

Where gaps in the evidence existed, the Panel provides guidance in the form of Clinical Principles or Expert Opinions with consensus achieved using a modified Delphi technique if differences of opinion emerged.² A Clinical Principle is a statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members' clinical training, experience, knowledge, and judgment for which there is no evidence.

Peer Review and Document Approval

An integral part of the guideline development process at the AUA is external peer review. The AUA conducted a thorough peer review process to ensure that the document was reviewed by experts in the treatment of IPT. In addition to reviewers from the AUA PGC, Science and Quality Council (SQC), and Board of Directors (BOD), the document was reviewed by representatives from AUA and SUFU as well as external content experts. Additionally, a call for reviewers was placed on the AUA website from January 14-28, 2019 to allow any additional interested parties to request a copy of the document for review. The guideline was also sent to the Urology Care Foundation to open the document further to the patient perspective. The draft guideline document was distributed to 49 external peer reviewers. All peer review comments were blinded and sent to the Panel for review. In total, 33 reviewers (9 AUA PGC, SQC, and BOD reviewers; 22 external reviewers; and 2 public reviewers) provided comments. At the end of the peer review process, a total of 476 comments were received. Following comment discussion, the Panel revised the draft as needed. Once finalized, the guideline was submitted for approval to the AUA PGC, SQC and BOD as well as the governing bodies of SUFU for final approval.

Clinicians should inform patients undergoing radical prostatectomy of all known factors that could affect continence. (Moderate Recommendation; Evidence Level: Grade B)

Clinicians should counsel patients regarding the risk of sexual arousal incontinence and climacturia following radical prostatectomy. (Strong Recommendation; Evidence Level: Grade B)

Clinicians should inform patients undergoing radical prostatectomy that incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment. (Strong Recommendation; Evidence Level: Grade A)

Prior to radical prostatectomy, patients may be offered pelvic floor muscle exercises or pelvic floor muscle training. (Conditional Recommendation; Evidence Level: Grade C)

Patients undergoing transurethral resection of the prostate after radiation therapy or radical prostatectomy after radiation therapy should be informed of the high rate of urinary incontinence following these procedures. (Moderate Recommendation; Evidence Level: Grade C)

In patients who have undergone radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate post-operative period. (Moderate Recommendation; Evidence Level: Grade B)

In patients with bothersome stress urinary incontinence after prostate treatment, surgery may be considered as early as six months if incontinence is not improving despite conservative therapy. (Conditional Recommendation; Evidence Level: Grade C)

In patients with bothersome stress urinary incontinence after prostate treatment, despite conservative therapy, surgical treatment should be offered at one year post-prostate treatment. (Strong Recommendation; Evidence Level: Grade: B)

Clinicians should evaluate patients with incontinence after prostate treatment with history, physical exam, and appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother. (Clinical Principle)

Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the American Urological Association Overactive Bladder guideline. (Clinical Principle)

Prior to surgical intervention for stress urinary incontinence, stress urinary incontinence should be confirmed by history, physical exam, or ancillary testing. (Clinical Principle)

Patients with incontinence after prostate treatment should be informed of management options for their incontinence, including surgical and non-surgical options. (Clinical Principle)

In patients with incontinence after prostate treatment, physicians should discuss risk, benefits, and expectations of different treatments using the shared decision-making model. (Clinical Principle)

Prior to surgical intervention for  stress urinary incontinence, cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery. (Expert Opinion)

Clinicians may perform urodynamic testing in a patient prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling. (Conditional Recommendation; Evidence Level: Grade C)

In patients seeking treatment for incontinence after radical prostatectomy, pelvic floor muscle exercises or pelvic floor muscle training should be offered. (Moderate Recommendation; Evidence Level: Grade B)

Artificial urinary sphincter should be considered for patients with bothersome stress urinary incontinence after prostate treatment. (Strong Recommendation; Evidence Level: Grade B)

Prior to implantation of artificial urinary sphincter, clinicians should ensure that patients have adequate physical and cognitive abilities to operate the device. (Clinical Principle)

In the patient who selects artificial urinary sphincter, a single cuff perineal approach is preferred. (Moderate Recommendation; Evidence Level: Grade C)

Male slings should be considered as treatment options for mild to moderate stress urinary incontinence after prostate treatment. (Moderate Recommendation; Evidence Level: Grade B)

Male slings should not be routinely performed in patients with severe stress incontinence.  (Moderate Recommendation; Evidence Level: Grade C)

Adjustable balloon devices may be offered to patients with mild stress urinary incontinence after prostate treatment. (Moderate Recommendation; Evidence Level: Grade B)

Surgical management of stress urinary incontinence after treatment of benign prostatic hyperplasia is the same as that for patients after radical prostatectomy. (Moderate Recommendation; Evidence Level: Grade C)

In men with stress urinary incontinence after primary, adjuvant, or salvage radiotherapy who are seeking surgical management, artificial urinary sphincter is preferred over male slings or adjustable balloons. (Moderate Recommendation; Evidence Level: Grade C)

Patients with incontinence after prostate treatment should be counseled that efficacy is low and cure is rare with urethral bulking agents. (Strong Recommendation; Evidence Level: Grade B)

Other potential treatments for incontinence after prostate treatment should be considered investigational, and patients should be counseled accordingly. (Expert Opinion)

Patients should be counseled that the artificial urinary sphincter  will likely lose effectiveness over time, and reoperations are common. (Strong Recommendation; Evidence Level: Grade B)

In patients with persistent or recurrent urinary incontinence after artificial urinary sphincter or sling, clinicians should again perform history, physical examination, and/or other investigations to determine the cause of incontinence. (Clinical Principle)

In patients with persistent or recurrent stress urinary incontinence after sling, an artificial urinary sphincter is recommended. (Moderate Recommendation; Evidence Level: Grade C)

In patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter, revision should be considered. (Strong Recommendation; Evidence Level: Grade B)

In a patient presenting with infection or erosion of an artificial urinary sphincter or sling, explantation should be performed and reimplantation should be delayed. (Clinical Principle)

A urinary diversion can be considered in patients who are unable to obtain long-term quality of life after incontinence after prostate treatment and who are appropriately motivated and counseled. (Expert Opinion)

In a patient with bothersome climacturia, treatment may be offered. (Conditional Recommendation; Evidence Level: Grade C)

Patients with stress urinary incontinence following urethral reconstructive surgery may be offered artificial urinary sphincter and should be counseled that complications rates are higher. (Conditional Recommendation; Evidence Level: Grade C)

In patients with incontinence after prostate treatment and erectile dysfunction, a concomitant or staged procedure may be offered. (Conditional Recommendation; Evidence Level: Grade C)

Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for incontinence after prostate treatment. (Clinical Principle)

In the future significant changes are expected in the management of IPT, including enhancements in diagnostics and treatment options that will continue to improve patient continence and decrease the incidence of IPT. Since most papers are single center experiences, the Panel expects and hopes to have increased multicenter research collaboration. Patient reported outcome measures, which are very important in the treatment of QoL surgery have also become more prevalent; as such the Panel expects these to also improve in use and quality, allowing clinicians to fully address patient concerns.

Newer treatments will encompass not only improvements in surgical products such as the AUS and male slings, but also will include continued research into muscle injections, stem cells, and newer treatments for urgency and urge incontinence.

Developments regarding surgical products will likely include improvements to the current AUS, possibly improving the patient’s ability to use the pump. It may also include a more automated system controlled from an external device. With newer technologies the Panel hopes to see automatic adjustments in cuff pressures or fluid volumes that would allow increased pressures improving continence with any increase in abdominal pressure.

Male slings have continued to evolve from bone anchored slings to the current products on the market. As clinicians learn more about etiology, continued development and improvements will increase efficacy of newer products.

Some advances in the treatment of male SUI are expected to parallel those for female SUI. Regenerative medicine will continue to shape future treatments attempting to restore normal function with either autologous muscle-derived cells or multipotent mesenchymal stem cells injected into the sphincter. These cell-based therapies will continue to improve and provide clinicians with increased success rates. Ethical and legal issues associated with these regenerative treatments still need to be clarified.

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This document was written by the Incontinence After Prostate Treatment Guideline Panel of the American Urological Association Education and Research, Inc., which was created in 2017. The PGC of the AUA selected the committee chair. Panel members were selected by the chair. Membership of the Panel included specialists in urology with specific expertise on this disorder. The mission of the Panel was to develop recommendations that are analysis-based or consensus-based, depending on Panel processes and available data, for optimal clinical practices in the treatment of stress urinary incontinence. Funding of the Panel was provided by the AUA and SUFU. Panel members received no remuneration for their work. Each member of the Panel provides an ongoing conflict of interest disclosure to the AUA. While these guidelines do not necessarily establish the standard of care, AUA seeks to recommend and to encourage compliance by practitioners with current best practices related to the condition being treated. As medical knowledge expands and technology advances, the guidelines will change. Today these evidence-based guidelines statements represent not absolute mandates but provisional proposals for treatment under the specific conditions described in each document. For all these reasons, the guidelines do not pre-empt physician judgment in individual cases. Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. Conformance with any clinical guideline does not guarantee a successful outcome. The guideline text may include information or recommendations about certain drug uses ('off label') that are not approved by the Food and Drug Administration (FDA), or about medications or substances not subject to the FDA approval process. AUA urges strict compliance with all government regulations and protocols for prescription and use of these substances. The physician is encouraged to carefully follow all available prescribing information about indications, contraindications, precautions and warnings. These guidelines and best practice statements are not in-tended to provide legal advice about use and misuse of these substances. Although guidelines are intended to encourage best practices and potentially encompass available technologies with sufficient data as of close of the literature review, they are necessarily time-limited. Guidelines cannot include evaluation of all data on emerging technologies or management, including those that are FDA-approved, which may immediately come to represent accepted clinical practices. For this reason, the AUA does not regard technologies or management which are too new to be addressed by this guideline as necessarily experimental or investigational.