The pubourethral ligaments are paired condensations of the endopelvic fascia that connect the midurethra to the posterior surface of the pubic symphysis in women. They form a critical component of the hammock hypothesis of continence, providing the fixed backstop against which the midurethra is compressed during increased intra-abdominal pressure. They are distinct from the pubovesical ligaments, which support the bladder neck.
Anchor the midurethra to the posterior pubic bone, providing the fixed point of urethral compression during stress events such as coughing, sneezing, and exercise. Intact pubourethral ligaments allow the urethra to be compressed against the suburethral hammock of pelvic floor fascia.
The integral theory of female stress urinary incontinence by Petros and Ulmsten identifies pubourethral ligament laxity as a primary cause of stress incontinence and urge symptoms. Mid-urethral slings (tension-free vaginal tape, transobturator tape) work by creating a new suburethral support that substitutes for deficient pubourethral ligament function without creating tension. Overcorrection of the sling can produce outlet obstruction requiring sling incision.
Laxity of the pubourethral ligaments and the suburethral support allows the mid-urethra to rotate and descend with increases in intra-abdominal pressure, causing involuntary urine leakage during coughing, sneezing, and exercise, treated by pelvic floor exercises, pessaries, or mid-urethral sling insertion.
