Stress urinary incontinence (SUI) is one of the most common diseases among women in Korea. The treatment of SUI usually comprises of behavioral, medical, and surgical therapies. Physicians usually recommend surgery when patients continue to have SUI after nonoperative management (i.e., pelvic floor muscle training, vaginal support device, or anticholinergic agents) [1]. The surgical treatment of SUI has evolved rapidly and various new surgical techniques have been introduced as a result [2]. The sling procedure has become the most common SUI surgery technique [3]. The sling procedure is commonly performed in Korea by physicians due to its simplicity and low morbidity rate.

The national health insurance system in Korea is different from other countries [4]. The healthcare system provides coverage to all people. Health care benefits include both primary and secondary care. Patients who are insured must receive primary care at a clinic, hospital, or general hospital before receiving secondary care from a tertiary hospital. Specialists are usually accessible in primary care clinics in Korea due to the high proportion of specialists in each treatment specialty. The introduction of minimally invasive synthetic slings enabled physicians in clinics to perform more sling procedures for women with SUI over the past decade. Nationwide information regarding SUI is important for evaluating treatment patterns for SUI and establishing an appropriate national policy for the management of patients with SUI. However, nationwide data regarding treatment patterns of SUI procedures have not been previously analyzed.

In this study, we investigated surgical treatment patterns for women with SUI and analyzed the current status of SUI management in Korea using a nationwide database. This information will be helpful for formulating a new treatment policy related to SUI similar to that of other countries.

The number of surgical cases decreased continuously from 2008 to 2011. However, the number of transvaginal surgeries using a midurethral sling (R3565) increased continuously. Only a few of the SUI surgeries involved the Burch operation and injection therapy (Table 1).

When we analyzed only the cases with a R3565 code cases according to the 10-year age group, the proportion of patients aged >50 years increased continuously from 31.1% to 37.0% in the fifties, from 9.4% to 11.7% in their sixties, and from 2.5% to 3.4% in their seventies (Table 2). Sling procedures were performed most commonly for women in their 40s followed by women in their 50s. The total annual medical expense for women in their 40s and 50s were about fifteen to twenty billion Korean won (approximately 15 to 20 million USD) (Table 3).

Most of the women who had undergone sling procedures in tertiary hospitals were hospitalized for a single night after routine operation. However, the percentage of women who had undergone sling procedures at a day-surgery hospital or clinic center was >85%.

Transvaginal surgery using a single sling or a readjustable sling was performed from 5.6% to 6.1%, which showed no significant change in the number of surgical cases (Table 4).

SUI is a more common problem than we assume. The incidence of SUI seems to increase with age. SUI can cause detrimental social and hygienic problems that reduce the quality of life [5]. The effects of SUI on the health-related quality of life of patients have been established in previous investigations [6]. Various assessments of a patient's quality of life are available [5], which mainly depend on the severity of the incontinence episodes and the social activity of the patients.

As shown in our findings, SUI is not merely an age-related process. The proportion of women in their 30s who needed surgical treatment for SUI was about 10%, which means that many factors are related to the occurrence of SUI. The average age of women diagnosed with SUI is gradually increasing, which has fueled a recent growing interest in research regarding SUI and health-related quality of life [5,6]. Therefore, necessary medical support is important for women with SUI who are willing to maintain their activities of daily living. As shown in this study, women with SUI in their 40s and 50s were more likely to undergo the surgical procedure compared to women in their 30s. We believe that SUI causes more detrimental effects on activities of daily living for middle-aged women, which is reflective of their desire to seek medical support. Therefore, proper education regarding SUI prevention and nonoperative management is also important. Since very few women with SUI seek medical support [7], the detection and early intervention of silent SUI should be actively considered as an important preventive strategy for improving patients' quality of life.

As mentioned previously, Korea has a unique healthcare system. Everyone, including foreign workers, can obtain social insurance, which consists of health insurance and medical aid. We were able to obtain very accurate data by using the nationwide database. As shown in the results of this study, women with SUI who were in their 40s and 50s were more likely to obtain medical support. South Korea is becoming an aging society [8] and therefore, troublesome SUI symptoms have prompted women in their 70s and 80s to actively seek medical support. Additionally, Korea is expected to have a super-aged population in several decades and the quality of life issue would be increasingly important in Korea in the future. We observed that total medical expenses increased for women in their 60s and 70s (Table 3). Therefore, there is a growing need to prepare an appropriate national welfare policy and budget to prepare for an aging and a super-aged society.

There were several limitations to this study. Compared to a previous investigation [9], total medical costs decreased approximately 4 billion Korean Won. However, we were not able to determine the reasons for this decrease in medical expenses and therefore, it should be investigated in future studies. The cost of SUI treatment decreased in 2007, which may be associated with the raised HIRA standards for approving patients who prefer to undergo SUI surgery. However, total medical costs gradually decreased from 2007. We should consider medical costs [9], but also indirect costs of labor productivity loss. However, we could not evaluate the changes in medical expenses during the development of surgical techniques or medications. Furthermore, the present study only included data from the HIRA. Not all women with SUI have access to clinics or hospitals and we were not able to evaluate the relationship between noncovered insurance services and the types of medical institutions. Despite these limitations, the findings of this large-scale study provide reliable information for further investigation and enable public health authorities to develop nationwide policies for managing patients with SUI.

In conclusion, women in their 30s to 70s may have symptoms of SUI that reduce their quality of life. There is a growing need to prepare an appropriate national welfare policy and budget for the aging and super-aged women population in Korea. Furthermore, the detection and early intervention of silent SUI should be actively considered as an important preventive strategy for improving the quality of life in younger women.