What are the treatment options for stress incontinence?

Treatment Options for Stress Urinary Incontinence

The first-line treatment for stress urinary incontinence should be pelvic floor muscle training (PFMT), which can result in up to 70% improvement in symptoms when properly performed under supervision. 1

Conservative Management Options

First-Line Treatments

• Pelvic Floor Muscle Training (PFMT)

  • Should be supervised by a healthcare professional for optimal results
  • Requires 8-12 weeks of supervised training to evaluate effectiveness 1
  • PFMT with biofeedback shows superior results compared to PFMT alone 1
  • Vaginal electromyography probe with PFMT improves patient awareness and proper muscle engagement 1

• Enhanced PFMT Options

  • Dynamic lumbopelvic stabilization (DLS) can be added to short pelvic floor muscle and lumbar muscle resistance training for improved outcomes 2

Lifestyle Modifications

• Weight loss and exercise for obese women (strong recommendation, moderate-quality evidence)
  • Number needed to benefit: 4 1
• Adequate hygiene and skin care to prevent irritation 1
• Fluid management:
  • Reduce fluid intake at night to decrease nocturnal incontinence
  • Increase daytime fluid intake to reduce risk of urinary tract infections 1

Other Non-Surgical Options

• Bladder training programs
  • Offer bathroom access every 2 hours during day and every 4 hours at night 1
  • Goal is to reduce incontinence episodes by at least 50% 1
• Vaginal devices and urethral inserts 3
• Bulking agents
  • Can reduce leakage but effectiveness generally decreases after 1-2 years 3

Surgical Management Options

Surgical interventions may be considered as early as six months if incontinence is not improving despite conservative therapy 1.

Surgical Options (in order of preference)

1. Midurethral sling (MUS)

   • Gold standard for stress urinary incontinence
   • Success rates between 51-88%
   • Lower retention rates (3%) 1
   • Pre-operative counseling regarding mesh complications results in reduced patient concern and higher satisfaction 2

2. Alternative Procedures

   • Burch colposuspension (8% de novo urge incontinence)
   • Autologous fascial sling (8% retention rate) 1
   • Retropubic colposuspension 4

Patient Selection for Surgery

• The "index patient" is a healthy female with minimal or no prolapse who desires surgical therapy for pure SUI or stress-predominant mixed urinary incontinence 2
• "Non-index patients" have factors that may affect treatment options and outcomes:
  • High-grade prolapse (grade 3 or 4)
  • Urgency-predominant mixed incontinence
  • Neurogenic lower urinary tract dysfunction
  • Incomplete bladder emptying
  • Dysfunctional voiding
  • SUI following anti-incontinence treatment
  • Mesh complications
  • High BMI
  • Advanced age 2

Treatment Algorithm

1. Initial Assessment

   • Determine type of incontinence (stress, urgency, mixed)
   • Assess degree of bother and impact on quality of life
   • Perform cough stress test to confirm diagnosis 1, 4

2. Start with Conservative Management

   • Supervised PFMT for at least 3 months
   • Implement lifestyle modifications
   • Consider vaginal devices if appropriate

3. Evaluate Response

   • Success defined as ≥50% reduction in incontinence episodes 1
   • If inadequate response after 3-6 months, consider surgical options

4. Surgical Decision-Making

   • For index patients: Consider midurethral sling as first-line surgical option
   • For non-index patients: Individualize approach based on specific factors

Important Caveats and Considerations

• The distinction between urodynamic stress incontinence associated with hypermobility and intrinsic sphincter deficiency should be viewed as a continuum rather than a dichotomy 3
• Estrogen is not indicated specifically for stress urinary incontinence treatment 3
• Supervised PFMT programs are significantly more effective than unsupervised or leaflet-based care 5
• Annual screening for urinary incontinence is recommended for women of all ages 1
• While there is renewed interest in conservative therapies, surgery remains a primary choice for many patients with persistent symptoms 6
• Shared decision-making between patient and physician is essential when choosing management strategy, especially for surgical interventions 4

The evidence strongly supports starting with supervised PFMT for all women with stress incontinence, with consideration of surgical options for those who fail to achieve adequate symptom improvement after 3-6 months of conservative management.