An Anatomical Pathogenesis for Science and Surgery of the Working Group's Recommendations for Female Stress Urinary Incontinence.

Aims: To provide a brief anatomical pathogenesis of the Working Group SUI publication recommendations.

Methods and results: The anatomical science and surgical practice presented here formed the original basis for the MUS and other bladder dysfunctions, updated to 2024 with videos: https://atm.amegroups.org/issue/view/1400. Bladder control is binary, from outside the bladder, with ONLY two modes, EITHER closed (continence) OR open (micturition). The key concept for surgical repair of stress (SUI) and other types of urinary dysfunctions, is the role of three balanced oppositely-acting muscle forces which contract against PUL (pubourethral ligament) and USL (uterosacral ligaments) to close urethra, open it before evacuation and stretch vagina to prevent premature activation of micturition, perceived as "urge to go." Collagen-induced weakness in PUL or USL may cause dysfunction in all three of these activities, which can be improved or cured by collagen-creating ligament repair techniques (e.g., slings). It is important to diagnose Tethered Vagina Syndrome (TVS), iatrogenic scarring at bladder neck, much more frequent since large vaginal mesh implantation. TVS is often confused with SUI, as its cardinal symptom is massive urine loss with the "effort" of getting out of bed. Sling surgery worsens TVS as it adds more scar. Vaginal skin graft is required to restore elasticity and continence.

Conclusions: "Anatomical defects in binary control may cause SUI, retention or urge," and are potentially repairable. With regard to SUI, "a normal PUL does not lengthen during effort."