What is the treatment for stress incontinence in females?

Treatment of Female Stress Urinary Incontinence

Pelvic floor muscle training (PFMT) should be the first-line treatment for women with stress urinary incontinence, followed by surgical options if conservative measures fail. 1

First-Line Conservative Treatment Options

• PFMT is the most effective non-surgical treatment for stress urinary incontinence (SUI), with up to 70% improvement in symptoms when properly performed 2
• PFMT is most effective when supervised by specialist physiotherapists or continence nurses rather than self-directed or leaflet-based care 2
• For optimal results, PFMT should be performed for at least three months 2
• Adding dynamic lumbopelvic stabilization (DLS) to PFMT can improve outcomes, with better day and night urine control and quality of life compared to PFMT alone 1
• Bladder training should be combined with PFMT for women with mixed urinary incontinence (stress and urgency components) 1
• Weight loss and exercise are strongly recommended for obese women with SUI 1
• Continence pessaries and vaginal inserts can be used as alternative conservative options for women who prefer non-surgical approaches 1, 3

Surgical Treatment Options

When conservative measures fail to adequately control symptoms, surgical options should be considered:

For Index Patients (otherwise healthy women with pure SUI or stress-predominant mixed UI)

• Midurethral slings (MUS) are the most extensively studied surgical option with strong evidence supporting their use 1

  • Retropubic midurethral sling (RMUS) has better long-term outcomes for severe SUI cases 4
  • Transobturator midurethral sling (TMUS) has lower risk of bladder perforation but higher risk of groin pain 4
  • Single-incision slings (SIS) are now recognized as a viable option with emerging long-term data 1

• Autologous fascia pubovaginal sling (PVS) is an excellent alternative for patients concerned about mesh complications, with 85-92% success rates at 3-15 years follow-up 1, 4

• Burch colposuspension remains a viable option, particularly for patients undergoing concomitant abdominal surgery or those concerned about mesh 1

• Urethral bulking agents are less invasive options but generally less effective than sling procedures 1, 4

Risk-Benefit Considerations

• RMUS has higher risks of bladder perforation, vascular injury, and voiding dysfunction 4
• TMUS has higher risks of groin pain and need for repeat incontinence surgery 4
• Pre-operative counseling regarding MUS mesh complications results in reduced patient concern, greater willingness to proceed, and higher satisfaction 1, 4

Treatment Algorithm

1. Initial Management: Start with supervised PFMT for at least 3 months 1, 2

   • For obese patients: Add weight loss program 1
   • For mixed UI: Combine with bladder training 1

2. If conservative treatment fails, consider surgical options based on:

   • Severity of symptoms: RMUS preferred for severe SUI 4
   • Presence of prolapse: Consider combined surgical correction if cystocele present 4
   • Patient concerns about mesh: Offer autologous fascia PVS or Burch colposuspension 1, 4
   • Desire for less invasive procedure: Consider urethral bulking agents 1, 4

3. For non-index patients (those with high-grade prolapse, urgency-predominant mixed UI, voiding dysfunction, prior SUI surgery, or neurogenic lower urinary tract dysfunction):

   • Additional evaluation is required before selecting surgical approach 1
   • Specialized treatment plans should be developed based on specific conditions 1

Common Pitfalls and Caveats

• Failure to properly supervise PFMT significantly reduces its effectiveness 2
• Systemic pharmacologic therapy is not recommended for stress UI 1
• Underestimating the importance of pre-operative counseling about mesh complications can lead to patient dissatisfaction 1
• Ignoring concomitant conditions like prolapse when planning SUI treatment can result in suboptimal outcomes 4
• Inadequate duration of conservative treatment (less than 3 months) before proceeding to surgery 2

The most recent evidence strongly supports starting with supervised PFMT for all women with SUI, with surgical intervention reserved for those who fail conservative management, with midurethral slings being the most effective surgical option for most women 1.