What is the management of stress urinary incontinence (SUI)?

From the Guidelines

The management of stress urinary incontinence (SUI) should prioritize a combination of lifestyle modifications, pelvic floor exercises, and medical interventions, with the most recent guideline from 2023 recommending a patient-centered approach to treatment 1. The treatment options for SUI include:

• Observation for patients who are not bothered enough to pursue further therapy
• Pelvic floor muscle training (± biofeedback) for patients interested in pursuing therapy that is less invasive than surgical intervention
• Other non-surgical options (e.g., continence pessary) for patients who prefer a non-invasive approach
• Surgical intervention, including bulking agents, colposuspension, and slings, for patients who have failed non-surgical treatments or have severe SUI According to the 2017 AUA/SUFU guideline, physicians should counsel patients regarding the availability of these treatment options 1. The 2014 American College of Physicians guideline also recommends nonpharmacologic therapies, such as pelvic floor muscle training, as an effective treatment for UI, with a large magnitude of benefit for increasing continence rates and a low risk for adverse effects 1. However, the most recent guideline from 2023 emphasizes the importance of establishing minimum standards for outcomes assessment to optimize treatment outcomes and advance the field of female pelvic medicine and reconstructive surgery 1. Therefore, the most appropriate management of SUI is a patient-centered approach that prioritizes lifestyle modifications, pelvic floor exercises, and medical interventions, with a focus on establishing minimum standards for outcomes assessment to optimize treatment outcomes 1.

From the Research

Management of Stress Urinary Incontinence (SUI)

The management of SUI involves a range of conservative and surgical interventions.

• Initially, conservative measures such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise, and/or the use of pessaries are recommended 2, 3.
• Pelvic floor muscle training (PFMT) has been shown to be beneficial in treating SUI, with moderate to high certainty evidence demonstrating its effectiveness in curing or improving UI 4.
• Lifestyle modifications, such as weight loss, can also lead to decreased incontinence 3, 4.
• In cases where conservative therapy is unsuccessful, surgical interventions such as tension-free suburethral sling insertions may be recommended, with cure rates of 80-90% 2.
• Autologous fascial slings, including rectus fascia slings, are also being reconsidered as a surgical option for SUI, with high long-term success rates and minimal risk of serious complications 5.
• Other surgical alternatives, such as bulking agents and Kelly's plication, may also be considered 2, 5.

Conservative Interventions

Conservative interventions are generally recommended as the first line of treatment for SUI.

• These interventions may include:
  • PFMT, with or without biofeedback or cones 4
  • Education, behavioural, and lifestyle advice 4
  • Mechanical devices, such as intravaginal devices or continence pessaries 4
  • Weight loss, for women with all types of UI 4
• The effectiveness of these interventions can be improved by increasing intensity, frequency, and individual supervision, and by combining them with behavioural interventions and adherence strategies 4.

Surgical Interventions

Surgical interventions may be considered in cases where conservative therapy is unsuccessful.

• Tension-free suburethral sling insertions are currently considered the gold standard of incontinence surgery, with high cure rates 2.
• Autologous fascial slings, including rectus fascia slings, are being reconsidered as a surgical option for SUI, with high long-term success rates and minimal risk of serious complications 5.
• Other surgical alternatives, such as bulking agents and Kelly's plication, may also be considered 2, 5.