What is the recommended treatment approach for patients with urge and stress incontinence?

Treatment of Urge and Stress Incontinence (Mixed Incontinence)

For patients with mixed urinary incontinence, begin with pelvic floor muscle training (PFMT) combined with bladder training as first-line therapy, then add pharmacotherapy for persistent urgency symptoms if behavioral interventions fail. 1

Initial Assessment and Treatment Prioritization

When evaluating mixed incontinence, you must determine which component—stress or urge—causes greater bother and quality of life impairment, as this guides treatment sequencing. 2

First-Line Treatment: Combined Behavioral Therapy

• Start all patients with PFMT plus bladder training simultaneously for mixed incontinence, as this combination addresses both components and demonstrates 85-92% success rates in long-term studies. 1, 3
• PFMT must be supervised by a healthcare professional to ensure proper technique—unsupervised attempts frequently fail due to incorrect muscle engagement. 3
• Bladder training involves scheduled voiding with progressive interval increases, targeting the urgency component. 1

Universal Interventions (Apply to All Patients)

• Recommend weight loss and exercise for obese women with any type of incontinence—this shows particular benefit for the stress component with moderate-quality evidence. 1, 3
• Reduce caffeine intake and avoid excessive fluid consumption to minimize bladder irritation. 1
• Address constipation, as straining worsens pelvic floor dysfunction. 3

Second-Line Treatment: Pharmacotherapy for Persistent Urgency

If bladder training fails to control urgency symptoms after an adequate trial (typically 6-12 weeks), add antimuscarinic or beta-3 agonist medication. 1

Medication Selection Strategy

• Choose pharmacologic agents based on tolerability, adverse effect profile, ease of use, and cost—efficacy is similar across antimuscarinics. 1
• Solifenacin has the lowest discontinuation rate due to adverse effects, while oxybutynin has the highest. 1
• Tolterodine and darifenacin show discontinuation rates similar to placebo. 1, 4
• Beta-3 agonists (mirabegron) cause less dry mouth and constipation than antimuscarinics but may cause nasopharyngitis and gastrointestinal symptoms. 1
• Never start medications before attempting behavioral interventions—this violates evidence-based stepped care and wastes resources. 3

Expected Medication Outcomes

• Pharmacotherapy shows modest benefit with absolute risk difference <20% compared to placebo for urgency incontinence. 3
• Approximately 14% of patients experience persistent urge incontinence even after treatment. 1

Surgical Intervention for Refractory Stress Component

Stress incontinence procedures may be considered for patients with mixed incontinence when the stress component predominates and conservative measures fail. 1

Surgical Options and Outcomes

• Synthetic midurethral slings are the most common primary surgical treatment, showing 48-90% symptom improvement rates and 84% cure rates at 12-23 months. 1, 3
• Autologous fascia pubovaginal slings demonstrate 85-92% success with 3-15 years follow-up. 1, 3
• Open retropubic suspensions (Burch) show 82% cure rates at 12-23 months, declining to 73% at 48+ months. 1

Critical Surgical Considerations

• Counsel patients that surgery addresses only the stress component—urgency symptoms may persist or worsen postoperatively. 1
• The meta-analysis estimate of postoperative urge incontinence is 14% in patients with pre-existing urgency treated with open retropubic suspensions. 1
• Urethral erosion and vaginal extrusion of synthetic material can occur and are difficult to treat. 1
• Perforation of bowel and blood vessels poses life-threatening risk. 1
• Tensioning of any sling should not be performed until prolapse surgery is completed if performed concomitantly. 1

Treatment Algorithm Summary

1. Weeks 0-12: PFMT + bladder training + weight loss (if obese) + lifestyle modifications
2. Weeks 12-24: If urgency persists, add antimuscarinic or beta-3 agonist (choose based on tolerability profile)
3. After 6+ months: If stress component remains bothersome despite conservative therapy, consider surgical intervention with appropriate counseling about persistent urgency risk

Common Pitfalls to Avoid

• Do not proceed to surgery without documenting stress incontinence via history, physical exam with positive stress test, or ancillary testing. 1
• Do not assume surgery will cure urgency symptoms—set realistic expectations that stress component will improve but urgency may persist. 1, 5
• Do not skip supervised PFMT—self-directed exercises frequently fail due to improper technique. 3
• Do not use systemic pharmacologic therapy for stress incontinence—evidence shows no benefit. 1, 3