What are the treatment options for stress incontinence?

Treatment for Stress Incontinence

Pelvic floor muscle training (PFMT) is the first-line treatment for stress urinary incontinence and must be implemented as a supervised program for at least 3 months before considering surgical options, with supervised programs demonstrating up to 70% improvement in symptoms. 1, 2

First-Line Conservative Management

Pelvic Floor Muscle Training

• PFMT should be supervised by specialist physiotherapists or continence nurses rather than unsupervised or leaflet-based programs, as supervised training yields significantly better outcomes. 2, 3
• The training program must continue for a minimum of 3 months before determining treatment failure. 2, 4
• Adding dynamic lumbopelvic stabilization (DLS) to standard PFMT improves day and night urine control, reduces leakage severity, and enhances quality of life compared to PFMT alone, with effects increasing over time. 2, 4
• Biofeedback therapy with vaginal probes (perineometers) helps patients identify the correct muscle and provides immediate feedback for improved compliance. 5

Adjunctive Conservative Measures

• Weight loss programs are mandatory for obese patients, as obesity reduction directly improves stress incontinence symptoms. 2, 4
• Behavioral modifications including timed voiding and fluid management complement PFMT but should not replace it. 2
• Continence pessaries or vaginal inserts serve as alternative conservative options for women preferring non-surgical approaches, though with variable success rates. 4, 6

Second-Line Surgical Interventions

When to Consider Surgery

• Surgical treatment should be offered when conservative measures fail after adequate trial (minimum 3 months) and incontinence significantly impacts quality of life. 1, 2
• The escalation from conservative to surgical management involves a notable increase in invasiveness and complication rates, which has created patient hesitance particularly regarding mesh-related complications. 1

Surgical Options by Evidence Strength

Midurethral Slings (Most Extensively Studied)

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

Autologous Fascial Slings

• Autologous fascia pubovaginal sling is the preferred alternative for patients concerned about mesh complications, with 85-92% success rates at 3-15 years follow-up. 2, 4, 7
• This option avoids mesh-related complications entirely while maintaining excellent long-term durability. 4, 7

Other Surgical Options

• Colposuspension (Burch procedure) remains effective with robust evidence supporting its use, though it is less commonly performed than MUS. 1, 2, 6
• Urethral bulking agents reduce leakage but effectiveness generally decreases after 1-2 years, making them less durable options suitable primarily for patients wishing to avoid more invasive procedures. 1, 2, 6
• Artificial urinary sphincters are reserved for complicated and severe SUI cases, though high-quality comparative data remain limited. 1, 2

Treatment Algorithm

Step 1: Initial Assessment and Conservative Treatment

• Determine the degree of bother and impact on quality of life. 2
• Begin with supervised PFMT for at least 3 months. 2, 4
• Add weight loss program if patient is obese. 2, 4
• Consider adding dynamic lumbopelvic stabilization to enhance outcomes. 2, 4

Step 2: If Conservative Treatment Fails

• Consider continence pessaries or vaginal inserts as intermediate options. 2, 4
• Evaluate for coexisting conditions such as high-grade prolapse, urgency-predominant mixed incontinence, or incomplete bladder emptying, as these affect treatment selection. 2

Step 3: Surgical Intervention Selection

• For severe stress incontinence: retropubic midurethral sling is preferred. 2, 7
• For patients concerned about mesh: autologous fascia pubovaginal sling is the best alternative. 2, 4, 7
• For patients desiring less invasive options: consider urethral bulking agents with understanding of limited durability. 1, 6

Critical Counseling Requirements

Pre-Operative Discussion

• Pre-operative counseling regarding MUS mesh complications results in reduced patient concern, greater willingness to proceed, and higher satisfaction. 2, 7
• Patients must understand that surgical success rates range from 51-88%, and symptoms may recur requiring additional treatment. 2
• Specific complications to discuss include bladder perforation, urethral injury, mesh exposure, voiding dysfunction, and groin pain (depending on approach). 7

Mesh vs. Non-Mesh Options

• Thoroughly counsel about mesh-specific risks versus alternatives, as this directly impacts patient decision-making and satisfaction. 2, 7
• Autologous fascia slings avoid mesh complications but involve longer operative time and potential donor site morbidity. 4, 7

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 prolapse or mixed incontinence, as these require modified treatment approaches. 2
• Avoid unsupervised or leaflet-based PFMT programs, as these have significantly inferior outcomes compared to supervised training. 3
• Do not neglect to counsel patients about potential need for additional treatments if symptoms recur. 2
• Avoid assigning treatment empirically based solely on the diagnosis of stress incontinence without assessing the specific status of each component of the continence mechanism. 8