What are the treatment options for stress urinary incontinence?

Treatment of Stress Urinary Incontinence

Pelvic floor muscle training (PFMT) is the first-line treatment for stress urinary incontinence, with supervised programs showing up to 70% improvement in symptoms and should be evaluated after 8-12 weeks of training. 1

First-Line Conservative Management

Pelvic Floor Muscle Training (PFMT)

• Supervised PFMT is significantly more effective than unsupervised training 2
• Should include repeated voluntary pelvic floor muscle contractions taught by a healthcare professional 1
• Most beneficial when:
  • Performed for at least 3 months 2
  • Combined with biofeedback (using vaginal electromyography probe) 1
  • Performed in functional positions that mimic situations causing leakage 3

Lifestyle Modifications

• Weight loss for obese women (strong recommendation, moderate-quality evidence) with a number needed to benefit of 4 1
• Exercise to alleviate symptoms of urogenital atrophy and stress incontinence 1
• Fluid management to reduce excessive fluid consumption 1
• Bladder training programs offering bathroom visits every 2 hours during the day 1

Second-Line Options

Devices and Mechanical Support

• Pessaries or anti-incontinence devices may benefit patients who are not candidates for other treatments 4
• Vaginal devices can reduce stress incontinence symptoms 5

Surgical Interventions

• Consider if conservative therapy fails after six months 1
• Midurethral sling (MUS) is the gold standard surgical treatment:
  • Success rates between 51-88%
  • Low retention rates (3%) 1
• Alternative procedures:
  • Burch colposuspension (8% de novo urge incontinence)
  • Autologous fascial sling (8% retention rate) 1

Effectiveness of Treatments

PFMT Effectiveness

• Women with stress urinary incontinence who undergo PFMT are eight times more likely to report cure compared to no treatment (56% versus 6%) 6
• PFMT reduces leakage episodes by approximately one episode per 24 hours 6
• Significantly less urine loss on pad tests compared to controls 6

Surgical Effectiveness

• Midurethral sling has the highest success rate (51-88%) among surgical options 1
• Surgical procedures are more likely to cure stress incontinence than non-surgical procedures but carry more adverse events 5

Common Pitfalls and Caveats

• Inadequate PFMT supervision: Unsupervised or leaflet-based care is significantly less effective than supervised programs 2
• Insufficient treatment duration: PFMT should be continued for at least 3 months before evaluating effectiveness 2
• Improper technique: Using biofeedback improves awareness and proper muscle engagement 1
• Failure to address contributing factors: Weight, fluid intake, and exercise all impact treatment success 1
• Premature surgical intervention: Conservative approaches should be fully explored before considering surgery 1, 4

Treatment Algorithm

1. Start with supervised PFMT + lifestyle modifications (8-12 weeks)
2. Evaluate effectiveness after initial treatment period
3. If inadequate improvement, consider:
   • Adding biofeedback to PFMT
   • Mechanical devices/pessaries
4. If still inadequate after 6 months of conservative management:
   • Consider surgical options, with midurethral sling as preferred procedure