Is occult stress urinary incontinence truly "occult"?

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) frequently coexist due to shared pathophysiological mechanisms. In some cases, SUI becomes evident only after the reduction of prolapse, a condition referred to as occult stress urinary incontinence (OSUI). Conventional understanding attributes OSUI to urethral obstruction caused by mechanical kinking or compression from the descending bladder base. This perception has led to ongoing controversy regarding the necessity of concomitant anti-incontinence procedures during POP repair. However, is this conventional interpretation accurate? This review challenges the traditional concept and argues that OSUI is not truly "occult". Instead, it results from alterations in the biomechanics of urinary control following apical suspension surgery, which often fails to restore physiological function or ensure the integrity of urinary control structures. Through an analysis of different surgical approaches-including posterior, anterior, lateral, and mesh-based suspensions-this article suggests that postoperative SUI may often be attributable to uncorrected support deficits, such as levator ani fissure enlargement, perineal body laceration, and inadequate vaginal wall support. The review emphasizes that apical suspension alone merely repositions the cervix horizontally without addressing underlying functional defects, thereby predisposing patients to OSUI. Consequently, physiological reconstruction, rather than mere anatomical correction, is proposed as a potentially important biomechanical strategy for reducing the risk of OSUI.