What are the treatment options for stress urinary incontinence?

Treatment for Stress Urinary Incontinence

Pelvic floor muscle training (PFMT) is the first-line treatment for stress urinary incontinence and should be implemented as a supervised program for at least 3 months before considering surgical options. 1, 2

First-Line Conservative Treatment

Pelvic Floor Muscle Training

• Supervised PFMT programs demonstrate up to 70% improvement in symptoms when properly performed, making this the cornerstone of initial management. 1, 2, 3
• Supervision by specialist physiotherapists or continence nurses produces superior outcomes compared to unsupervised or leaflet-based programs. 3
• The training should continue for a minimum of 3 months before declaring treatment failure. 2, 4
• Adding dynamic lumbopelvic stabilization (DLS) to standard PFMT improves day and night urine control, reduces severity of leakage, and enhances quality of life compared to PFMT alone, with effects increasing over time following training. 1, 4

Weight Loss and Lifestyle Modifications

• Weight loss programs are strongly recommended for obese patients, as obesity directly worsens stress incontinence symptoms. 2, 4
• Behavioral modifications including timed voiding and fluid management complement other treatments. 2

Alternative Conservative Options

• Continence pessaries and vaginal inserts serve as viable alternatives for women preferring non-surgical approaches. 2, 4
• These devices show varying degrees of success and can be considered if PFMT fails or as adjunctive therapy. 4

Second-Line Surgical Treatment

When to Consider Surgery

Surgical intervention should be offered when conservative measures fail to adequately control symptoms after at least 3 months of proper PFMT and the incontinence significantly impacts quality of life. 2, 4

Midurethral Slings (First Choice for Surgery)

• Midurethral slings (MUS) represent the most extensively studied surgical option with the strongest evidence supporting their effectiveness. 1, 2, 4
• Retropubic midurethral sling (RMUS) demonstrates better long-term outcomes for severe stress incontinence cases, with objective cure rates of 80-83% at 5-7 years. 2, 4, 5
• Transobturator midurethral sling (TMUS) carries lower risk of bladder perforation but higher risk of groin pain and repeat incontinence surgery. 4, 5
• Single-incision slings (SIS) are emerging as viable options with accumulating long-term data, though their long-term efficacy requires further confirmation. 1, 4

Autologous Fascia Pubovaginal Sling (Mesh-Free Alternative)

• For patients concerned about mesh complications or with contraindications to synthetic mesh, autologous fascia pubovaginal sling achieves 85-92% success rates at 3-15 years follow-up. 2, 4, 5
• This represents an excellent alternative with comparable long-term outcomes to synthetic slings. 1, 2

Other Surgical Options

• Colposuspension (Burch procedure) remains an effective surgical treatment supported by robust evidence. 1, 6
• Urethral bulking agents reduce leakage but effectiveness generally decreases after 1-2 years, making them less durable options. 1, 5
• Artificial urinary sphincters are reserved for complicated and severe SUI cases, though high-quality comparative data remain limited. 1

Treatment Algorithm

Step 1: Initial Assessment and Conservative Management

• Evaluate the degree of bother and impact on quality of life. 2
• Initiate supervised PFMT for at least 3 months. 2, 4
• Add weight loss program if patient is obese. 2, 4
• Consider adding DLS to standard PFMT for enhanced outcomes. 1, 4

Step 2: If Conservative Treatment Fails

• Consider continence pessaries or vaginal inserts as intermediate options. 2, 4
• Discuss surgical options based on severity, patient preferences regarding mesh, and presence of coexisting conditions. 2, 4

Step 3: Surgical Selection

• For severe stress incontinence: Retropubic midurethral sling is preferred. 2, 5
• For patients concerned about mesh: Autologous fascia pubovaginal sling is the optimal choice. 2, 4
• For patients with concurrent prolapse: Combined surgical correction is appropriate with mean complete continence rates of 80% at 22-month follow-up. 5

Critical Counseling Points

Pre-Operative Mesh Counseling

• Pre-operative counseling regarding MUS mesh complications results in reduced patient concern, greater willingness to proceed, and higher satisfaction. 1, 4, 5
• Patients must understand specific mesh-related risks including bladder perforation, urethral injury, mesh exposure, and voiding dysfunction. 5
• Success rates for surgical interventions range from 51-88%, and symptoms may recur requiring additional treatment. 2

Risk Profile Differences

• RMUS carries higher risks of bladder perforation, vascular injury, and voiding dysfunction. 5
• TMUS has higher risks of groin pain and repeat incontinence surgery. 5
• Surgical procedures are more likely to cure stress incontinence than nonsurgical procedures but are associated with more adverse events. 6

Common Pitfalls to Avoid

• Never proceed to surgery before completing an adequate 3-month trial of supervised conservative management. 2
• Do not ignore coexisting conditions such as high-grade prolapse, urgency-predominant mixed incontinence, or incomplete bladder emptying, as these affect treatment selection and outcomes. 1, 2
• Avoid inadequate counseling about the potential need for additional treatments if symptoms recur. 2
• Do not recommend estrogen therapy for stress urinary incontinence, as it is not indicated for this condition. 6