Bulking agents: an analysis of 500 cases and review of the literature

Int Urogynecol J. 2013 Feb;24(2):241-7. doi: 10.1007/s00192-012-1834-8. Epub 2012 Jun 16.


Introduction and hypothesis: Stress urinary incontinence (SUI) is common, impacts women's quality of life, and generates high costs. Physiotherapy is the first-line therapy, and if it fails, suburethral slings are the gold standard in SUI surgery. Bulking agents injected periurethrally might be a beneficial alternative, but there is a paucity of data on bulking therapy. The aim of this study was to prospectively analyze the efficacy and safety of bulking agents in the setting of a tertiary referral center.

Methods: In the last 13 years, 514 elderly women with SUI were treated by injection therapy with either collagen (Contigen), hyaluronic acid (Zuidex), ethylene vinyl alcohol (Tegress), or polyacrylamide hydrogel (Bulkamid). Subjective and objective outcome was recorded at the 12-month postoperative appointment using the King's Health Questionnaire, visual analogue scale (VAS) describing their incontinence severity, standardized pad test, and urethral pressure profile.

Results: Demographic data were equally distributed in all four groups of agents used. Sixty-one patients were lost to follow-up (10.6 %). Statistically significant changes were found for maximum urethral closure pressure (MUCP), pad weight, and VAS before and after bulking for the four agents used. Pad test was negative in 73.2 % of patients after bulking therapy. Subjective assessment showed improvements in general health and role limitations. The overall complication rate was low for all agents.

Conclusions: This study shows improvement in incontinence after bulking therapy according to subjective and objective outcomes in an elderly population. In contrast to earlier reports, side effects due to injections were few and mild. We can advocate bulking therapy for treating SUI, as it is simple, safe, and shows both objective and subjective improvement and relief.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Biocompatible Materials / administration & dosage
  • Biocompatible Materials / adverse effects
  • Biocompatible Materials / therapeutic use
  • Collagen / administration & dosage
  • Collagen / adverse effects
  • Collagen / therapeutic use*
  • Female
  • Follow-Up Studies
  • Humans
  • Hyaluronic Acid / administration & dosage
  • Hyaluronic Acid / adverse effects
  • Hyaluronic Acid / therapeutic use*
  • Injections
  • Middle Aged
  • Polyvinyls / administration & dosage
  • Polyvinyls / adverse effects
  • Polyvinyls / therapeutic use*
  • Prospective Studies
  • Quality of Life
  • Treatment Outcome
  • Urinary Incontinence, Stress / therapy*


  • Biocompatible Materials
  • Polyvinyls
  • ethylene-vinyl alcohol copolymer
  • Hyaluronic Acid
  • Collagen