A 24-year-old women (married, two vaginal deliveries) presented to our outpatient department because of primary urinary incontinence. Because of primary involuntary and total urinary incontinence during normal activities and movements, she had been previously evaluated and medically treated for incontinence. No doctor had done a proper physical examination, and in spite of two vaginal deliveries the diagnosis of distal epispadias was not made. Due to the failure of treatment, the patient developed psychological problems (anxiety and depression). Physical examination and cystoscopy revealed the absence of the anterior labial commissure, a bifid clitoris, a very short urethra with a wide external urethral orifice and an immature bladder neck. The bladder capacity was 315 mL. The patient had total urinary incontinence and the 24 h pad test resulted in more than 1000 mg (20 pads) preoperative. No other urogynecologic pathology was noted. Endoluminal ultrasonography (Acuson Sequoia; Alphatek Imaging, New York, NY) with a 10-Fr 10 mHz AcuNav probe revealed rhabdosphincter function, although minimal. A video urodynamic examination was performed preoperatively, which in summary showed: a functional capacity in the supine position of 315 mL, with loss of urine at a leak point pressure of less than 10 cmH2O as soon as the intra-abdominal pressure was raised. We could demonstrate no proper detrusor contractility, even when the bladder outlet was obstructed with a balloon catheter. The bladder compliance up to 300 mL was normal (>15 mL/cmH2O), after which it rapidly decreased on further filling (<10 mL/cmH2O). Micturition resulted from increased abdominal pressure, and the functional capacity before leakage in the upright position was about 100 mL. Residual urine was 0 mL. It was not possible to perform a urethral pressure profile, because the functional length of the urethra was too small. The patient could not effectively contract her pelvic floor to prevent loss of urine. The patient did not want a major reconstructive procedure. Via a Pfannenstiel incision, the bladder neck was tightened by three non-dissolvable sutures (Prolene 4/0) in the 12 o’clock position, without partly excising bladder wall or neck. After opening the rectus fascia, the diverging pyramidalis muscles could be appreciated, indicating increased width of the symphysis pubis (Figs 1,2). A lateral colposuspension (similar to a Burch) was done to lift the whole urethra and sphincter mechanism, using three non-dissolvable sutures (Goretex 1) bilaterally fixing the lateral vaginal wall to Coopers’ ligament. After surgery the patient was nearly fully continent needing one pad per day, after initially needing up to twenty. Macroplastique (Macroplastic Innovamech, Salzburg, Austria) was injected at the level of the bladder neck proximal to the rhabdosphincter, after which the patient was continent in the short term (3 months).