What is the initial management for stress incontinence?

Initial Management of Stress Urinary Incontinence

Pelvic floor muscle training (PFMT) should be offered as first-line treatment for stress urinary incontinence, with supervised training for at least three months before considering surgical options. 1

Assessment and Diagnosis

The diagnosis of stress urinary incontinence (SUI) is based on:

• Involuntary urine loss from the urethral meatus coincident with increased abdominal pressure (positive stress test) 2
• Patient complaints of stress incontinence symptoms

Key elements of the initial evaluation should include:

• Characterization of incontinence (stress, urge, mixed)
• Frequency, bother, and severity of incontinence episodes
• Impact of symptoms on lifestyle and quality of life
• Patient expectations of treatment 2

First-Line Management Options

1. Pelvic Floor Muscle Training (PFMT)

• Most effective when it includes proper technique instruction and regular follow-up 1
• Should be supervised for at least 3 months before considering surgical options
• May be combined with biofeedback using vaginal EMG for visual feedback 1
• Success rates are significant, with one study showing cure rates of 15.2% higher than alternative methods 3

2. Lifestyle Modifications

• Weight loss for obese patients (strongly recommended with moderate-quality evidence) 1
• Adequate hydration without excessive fluid intake
• Regular voiding intervals to reduce urgency incontinence episodes 4

3. Mechanical Devices

• Continence pessary or vaginal inserts can be offered as adjuncts to PFMT 2, 1
• These are low-risk options but generally have lower success rates than PFMT 5

Important Considerations

• The degree of bother that symptoms cause should guide treatment decisions 2
• Since SUI impacts quality of life, treatment decisions should be linked to the ability of interventions to improve patient's symptoms 2
• Only 25% of women with urinary incontinence seek or receive treatment despite effective options being available 4
• Conservative management is not as effective as surgical methods but can be very successful in properly indicated cases 5

When to Consider Further Evaluation

Indications for further testing include:

• Inability to make a definitive diagnosis based on symptoms and initial evaluation
• Concomitant overactive bladder symptoms
• Prior lower urinary tract surgery
• Known or suspected neurogenic bladder
• Negative stress test
• Abnormal urinalysis
• Excessive residual urine volume
• Grade III or greater pelvic organ prolapse
• Any evidence for dysfunctional voiding 2

Progression to Surgical Management

If conservative measures fail after an adequate trial (at least 3 months), surgical options may be considered:

• Midurethral synthetic slings (success rates 51-88%)
• Urethral bulking agents (less invasive but generally lower success rates)
• Autologous fascia pubovaginal sling (85-92% success rate)
• Burch colposuspension (especially if undergoing concomitant abdominal surgery) 1

Pitfalls to Avoid

• Rushing to surgical intervention without an adequate trial of conservative management
• Incorrect performance of PFMT (ensure proper technique is taught)
• Failing to recognize that SUI in postmenopausal women may be complicated by vaginal atrophy requiring local estrogen therapy 1
• Systemic pharmacologic therapy is not recommended for stress UI 1
• Not addressing comorbid conditions that may exacerbate symptoms

Remember that observation is appropriate for patients who are not bothered enough to pursue therapy, not interested in further therapy, or who are not candidates for other forms of treatment 2.