Transurethral Injection of Intramural Bulking Agent

Surgical Treatment of Stress Urinary Incontinence

The patient’s reduced quality of life is the indication for treatment of stress urinary incontinence. Failed conservative treatment may lead to surgical treatment options.

Treatment Options

Retropubic midurethral sling, autologous rectus fascial sling and colposuspension are all validated surgical treatments for stress urinary incontinence. Although there are plenty of options, sometimes alternatives are sought. This can be due to procedure-related risks, comorbidities, unfavorable factors like intrinsic sphincter deficiency and fixed urethra, or failed previous surgical treatment (1).

Bulking agents

Bulking agents to treat stress urinary incontinence appeared as early as 1938, when Murless injected sodium morrhuate into the anterior vaginal wall (2). Over the years they have proven themselves as a minimally invasive treatment with rapid recovery and a low morbidity rate (1). As patients become more informed of the potential side effects of meshes, they may opt for injections of bulking agents even if the chance of cure is reduced (2).


Polyacrylamide hydrogel (Bulkamid®) was introduced in Europe in 1996. It is considered a safe intervention for treating women with stress urinary incontinence. Sometimes repeat injections may be required (3). Concerning the outcome, a prospective multicenter study in the U.S. with 229 patients treated with Bulkamid® reported that 47,2% of them had no incontinence episodes and 77,1% of them felt cured or improved after 1 year (4).


Watch the video of a transurethral injection on youtube by clicking here.


  • Pain at the injection site.
  • Urinary tract infection.
  • Temporary urinary retention, outlet obstruction.
  • Transient hematuria.
  • Prolapse of the urethral mucosa.
  • Bladder masses.
  • Extremely rare: periurethral abscess (2).

Postoperative Management

  • Sonographic documentation of residual bladder volume.
  • Sonographic documentation of depots.
  • Early discharge.
  • Postoperative restrictions for 2 weeks.
  • Consider laxatives to avoid straining.
  • Follow-up in 6 weeks.


  1. Matsuoka, P. K., Locali, R. F., Pacetta, A. M., Baracat, E. C., & Haddad, J. M. (2016). The efficacy and safety of urethral injection therapy for urinary incontinence in women: a systematic review. Clinics (Sao Paulo, Brazil)71(2), 94–100.
  2. Hussain, SM, Bray, R. Urethral bulking agents for female stress urinary incontinence. Neurourology and Urodynamics. 2019; 38: 887– 892.
  3. Kasi, A.D., Pergialiotis, V., Perrea, D.N. et al. Polyacrylamide hydrogel (Bulkamid®) for stress urinary incontinence in women: a systematic review of the literature. Int Urogynecol J 27, 367–375 (2016).
  4. Sokol, E.R., Karram, M.M., & Dmochowski, R. (2014). Efficacy and Safety of Polyacrylamide Hydrogel for the Treatment of Female Stress Incontinence: A Randomized, Prospective, Multicenter North American Study. Journal of Urology, 192(3), 843–849.

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