Multiple pregnancies do strain or damage the pubo-urethralis muscle, which is anchored to the pubic bone, and slings around the urethra just below the bladder neck. When this support is lost or damaged, as after multiple pregnancies, there is a drop of the urethra (urethrocele) and incontinence on straining or coughing. When the incontinence is bothersome enough, surgery is advised. TVT, a synthetic ribbon inserted where the pubo-urethralis might have been, has become the simplest and most commonly performed procedure for stress incontinence, and it’s highly successful.

In a woman who’s undergoing hysterectomy, it would be reasonable to assess the patient for stress incontinence, including urodynamics, and to correct any problem at the time of the hysterectomy. It would be unreasonable to propose prophylactic surgery without evidence of established stress incontinence. Yoshinori Taguchi, MD

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