The management of recurrent stress urinary incontinence (SUI) remains a significant challenge, particularly in patients with a complex surgical history. We present the case of a 67-year-old female with a 10-year history of mixed urinary incontinence, where stress symptoms were predominant. Her extensive surgical background includes a bladder injury during childbirth in 1980, a subsequent hysterectomy, four vaginal reconstructive surgeries, and a prior anti-incontinence sling procedure. Despite conservative management and a 5-year regimen of combined pharmacological therapy (Duloxetine and multiple anticholinergics), her symptoms persisted, significantly impacting her quality of life.

A comprehensive diagnostic workup was performed to identify the underlying etiology of her recurrent SUI.Physical Examination: Revealed no significant pelvic organ prolapse. A stress test was positive. Notably, the Q-tip test showed an angle of 30°, indicating a fixed, non-hypermobile urethra, which suggested Intrinsic Sphincter Deficiency (ISD).Urodynamic Study: Cystometry showed a total capacity of 400 cc with no detrusor overactivity. However, the Abdominal Leak Point Pressure (ALPP) was critically low at < 33 cmH2O , confirming severe ISD.Imaging: A bladder MRI showed no structural abnormalities.Given the patient’s history of multiple failed surgeries and the presence of a "lead-pipe" (non-mobile) urethra, a minimally invasive approach using a polyacrylamide hydrogel (Bulkamid) was selected to provide urethral coaptation without the risks of further invasive dissection.

In December 2025, the patient underwent a transurethral injection of Bulkamid. The procedure was performed under local anesthesia/sedation without complications. The primary objective was to augment the urethral mucosal seal.

Follow-up: At the 3-month post-operative evaluation, the patient reported complete resolution of her stress urinary incontinence.

Clinical Outcome: Physical examination confirmed a negative stress test. The patient expressed high satisfaction, noting a significant improvement in daily activities compared to her previous decade of failed treatments.

This case demonstrates that Bulkamid injection is a highly effective and safe treatment option for recurrent SUI, even in "end-stage" scenarios characterized by multiple surgical failures and intrinsic sphincter deficiency. In patients where urethral hypermobility is absent and the urethral tissue is scarred or fixed, urethral bulking agents offer a successful alternative to more invasive repeat sling surgeries or artificial urinary sphincters.

Itkonen Freitas, A. M., et al. (2020). "Polyacrylamide Hydrogel (Bulkamid®) for Stress Urinary Incontinence: A 7-year Follow-up Study." International Urogynecology Journal.
Siddiqui, N. Y., et al. (2023). "Management of Recurrent Stress Urinary Incontinence: A Systematic Review." Journal of Urology.
Kasi, A. D., et al. (2016). "The use of bulking agents in the management of stress urinary incontinence in women with a non-hypermobile urethra." International Urogynecology Journal.