Restoration of continence by PUL support. Upper image shows SUI. If PUL is weak, it lengthens to “L” on effort and cannot hold the posterior urethral wall and vagina (to which it is attached) against the powerful LP/LMA opening forces; PCM cannot stretch the distal vaginal hammock “H” forward sufficiently to close the distal urethra from behind; LP/LMA forces stretch the trigone backward to open “H” and the posterior urethral wall, from “C” (closed) to “O” (open), broken lines. The hemostat mimics what a suburethral sling does; it prevents PUL extension to “L” and restores urethral closure, as seen in the right ultrasound frame (white arrow). Lower images show transperineal ultrasound in a patient with SUI. Rest (left image): three small white circles represent PUL. The organs are in the correct anatomical position. S, symphysis; U, urethra; a & p, anterior and posterior vaginal walls. Strain (middle image): note elongation of PUL on straining (4 white circles). The funneling of the bladder neck and expansion of the urethral diameter along the whole urethra exponentially lowers the urethral resistance to urine flow and urine is lost on coughing. Hemostat test (right image): the white arrow represents the hemostat. The hemostat mechanically supports a weak PUL, prevents elongation “L”, and prevents opening by LP/LMA to cause SUI.