What are the treatment options for stress incontinence?

Treatment Options for Stress Urinary Incontinence

The first-line treatment for stress urinary incontinence should be supervised pelvic floor muscle training (PFMT) for 8-12 weeks, which can reduce incontinence episodes by at least 50%. 1

Conservative Management Options

Pelvic Floor Muscle Training

• Supervised PFMT by specialist physiotherapists or continence nurses shows superior outcomes compared to unsupervised or leaflet-based care 1, 2
• Most effective for stress urinary incontinence with improvement rates up to 70% 2
• Should be performed for at least 8-12 weeks 1
• Individual supervision is comparable to group supervision for quality of life outcomes 3
• Training more days per week may significantly improve incontinence-related quality of life 3

Lifestyle Modifications

• Weight loss is strongly recommended for obese women (moderate-quality evidence) 1
• Fluid management strategies:
  • 25% reduction in fluid intake if excessive
  • Reducing caffeine consumption
  • Avoiding excessive fluids at night 1
• Exercise is recommended to alleviate symptoms of stress urinary incontinence 1

Other Non-Surgical Options

• Continence pessaries or vaginal inserts may be considered as treatment options 1
• Bladder training combined with PFMT is particularly effective for mixed incontinence 1

Surgical Management

Surgical procedures should only be considered after unsuccessful conservative therapy 4

Midurethral Slings

• Current gold standard for surgical treatment with success rates of 51-88% 1, 4
• Retention rate of approximately 3% 1
• High efficacy with low complication and morbidity rates 5

Alternative Surgical Options

• Autologous fascia pubovaginal sling:
  • 85-92% success rate with 3-15 years follow-up
  • Alternative for patients concerned about synthetic mesh 1
• Burch colposuspension:
  • Effective alternative, especially for patients undergoing concomitant abdominal-pelvic surgery
  • Retention rate of 8% (de novo urge incontinence) 1
• Bulking agents:
  • Minimally invasive option
  • Effectiveness generally decreases after 1-2 years 6

Treatment Algorithm

1. Initial Assessment:

   • Differentiate between stress, urgency, and mixed incontinence
   • Assess impact on quality of life using validated questionnaires
   • Rule out urinary tract infection with urinalysis

2. First-Line Treatment:

   • Supervised PFMT for 8-12 weeks
   • Implement appropriate lifestyle modifications (weight loss, fluid management)
   • Consider pessaries or vaginal inserts

3. If Conservative Treatment Fails:

   • Consider surgical options based on:
     • Severity of symptoms
     • Patient preference
     • Comorbidities
     • Previous surgeries

4. Surgical Options (in order of preference):

   • Midurethral sling (first choice for most patients)
   • Autologous fascial sling (for patients concerned about synthetic mesh)
   • Burch colposuspension (especially if undergoing other abdominal surgery)
   • Bulking agents (for patients who cannot tolerate more invasive procedures)

Common Pitfalls and Caveats

• Misdiagnosis: Ensure proper differentiation between stress, urgency, and mixed incontinence as treatment approaches differ 1
• Inadequate PFMT: Unsupervised PFMT is less effective than supervised training 1, 2
• Premature surgery: Surgical procedures should only be considered after unsuccessful conservative therapy 4
• Mesh complications: Surgical treatment using synthetic mesh must be chosen with care, taking into account potential complications 5
• Inadequate follow-up: Regular long-term follow-up is essential as recurrence can occur even after successful treatment 1