Treatment Options for Mixed Stress Urge Incontinence Related to Cystocele with Prolapse
While awaiting urology consultation, patients with mixed stress urge incontinence related to cystocele with prolapse should receive conservative management including pelvic floor muscle training combined with bladder training as first-line treatment to improve both stress and urge components of incontinence.
Initial Assessment and Conservative Management
Behavioral Therapy (First-Line)
- Pelvic floor muscle training (PFMT): Should be prescribed for at least 3 months as first-line treatment for both stress and urge components 1
- Bladder training: Implement timed voiding schedules to help manage urgency symptoms 1
- Fluid management: Counsel on appropriate fluid intake timing and volume to reduce symptoms
- Weight loss: Recommend for patients with elevated BMI as this can improve both stress and urge symptoms 1
Pessary Trial
- Consider a pessary trial while awaiting urology consultation to:
- Temporarily reduce the prolapse
- Assess for occult stress urinary incontinence (SUI) 2
- Provide symptomatic relief from both prolapse and incontinence symptoms
- Help predict post-surgical outcomes
Pharmacologic Management
For Urgency Component
- Antimuscarinic medications (e.g., tolterodine) can be considered for the urge component while awaiting specialist evaluation 1, 3
- Evidence shows tolterodine significantly reduces incontinence episodes in women with mixed symptoms 3
- Important caveat: Monitor for urinary retention, especially in patients with significant prolapse
For Stress Component
- Pharmacologic therapy is generally not recommended for the stress component of mixed incontinence 1
- Focus should remain on conservative measures while awaiting specialist evaluation
Special Considerations for Mixed Incontinence with Prolapse
Diagnostic Challenges
- Prolapse may mask underlying stress incontinence that becomes apparent only after prolapse reduction 2
- Stress testing with prolapse reduction (using pessary or manual reduction) should be performed to evaluate for occult SUI 2
Treatment Planning
- Patients with mixed incontinence are at significant risk for persistent postoperative urgency symptoms even after successful prolapse and SUI correction 4
- Preoperative detrusor overactivity on urodynamics is not predictive of postoperative urgency symptoms 4
- Thorough counseling regarding the potential for persistent urgency symptoms is essential 4
Surgical Considerations (for specialist)
- Surgical procedures for SUI and prolapse may be safely performed concomitantly 2
- Tensioning of any sling should not be performed until prolapse surgery is completed 2
- Urodynamic studies may be helpful to assess detrusor function with the prolapse reduced 2
Patient Education and Expectations
- Explain that mixed incontinence often responds less completely to treatment than pure stress or pure urge incontinence 3
- Approximately 30% of patients may continue to experience urgency symptoms even after successful surgical correction of prolapse and stress incontinence 4
- Set realistic expectations about treatment outcomes while awaiting specialist consultation
Monitoring and Follow-up
- Document baseline symptom severity using validated questionnaires or voiding diaries
- Assess post-void residual to rule out urinary retention, especially important in patients with significant prolapse 2
- Schedule appropriate follow-up to assess response to conservative measures while awaiting urology consultation
Common Pitfalls to Avoid
- Failing to distinguish between different types of incontinence (stress, urge, mixed)
- Not assessing for occult stress incontinence when prolapse is reduced
- Starting antimuscarinic medications without checking post-void residual in patients with significant prolapse
- Setting unrealistic expectations for complete resolution of mixed incontinence symptoms with any single intervention