What is the treatment for urinary mixed incontinence?

Treatment of Mixed Urinary Incontinence

For mixed urinary incontinence, start with combined pelvic floor muscle training (PFMT) and bladder training as first-line therapy, as this combination addresses both the stress and urgency components simultaneously and improves both continence and quality of life. 1, 2

First-Line Conservative Management

Begin with the combination approach:

• Supervised pelvic floor muscle training (PFMT) should be taught and supervised by a healthcare professional, involving repeated voluntary pelvic floor muscle contractions for at least 3 months to achieve meaningful clinical benefit 1, 2
• PFMT demonstrates up to 70% symptom improvement when properly supervised and is more than 5 times as effective as no active treatment 1, 2
• Bladder training should be implemented concurrently, involving scheduled voiding with progressively longer intervals between bathroom trips 1, 2
• This combined approach improves both continence rates and quality of life measures beyond just symptom reduction 2

Add lifestyle modifications:

• Weight loss specifically benefits the stress component more than the urgency component in obese women, with randomized trials showing significant symptom improvement 3, 2
• Adequate but not excessive fluid intake should be recommended 1
• No harms have been identified with behavioral interventions like PFMT or weight loss programs 3, 1

Second-Line Pharmacologic Treatment

If conservative measures fail after 3 months, add antimuscarinic medications to target the urgency component:

• Effective agents include oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium 1, 2, 4, 5
• Solifenacin and fesoterodine are preferred choices as they demonstrate dose-response effects on symptom improvement 3, 2
• Base medication selection on tolerability, adverse effect profile, ease of use, and cost rather than efficacy, as all agents show similar effectiveness 1
• The absolute risk difference for all medications versus placebo is less than 20%, indicating modest benefit 3

Counsel patients upfront about anticholinergic adverse effects:

• Dry mouth, constipation, heartburn, and urinary retention are common 3, 1
• Cognitive impairment is possible, particularly in older patients 1
• Poor adherence is common due to side effects, so setting realistic expectations improves treatment continuation 1

Do NOT use systemic pharmacologic therapy for the stress component:

• No pharmacologic therapy has been shown effective for stress urinary incontinence 1, 2
• This represents the wrong treatment for the wrong condition 1

Third-Line Surgical Intervention

Reserve surgery for women whose symptoms don't improve sufficiently with conservative and medical therapies:

• Synthetic midurethral mesh slings are the most common primary surgical treatment and can cure both stress and urge components in 40-50% of cases 3, 1, 2, 6
• Other surgical options include retropubic suspension and fascial slings 3, 1

Counsel patients about surgical complications:

• Direct injury to the lower urinary tract, hemorrhage, infection, bowel injury, wound complications, and mesh-specific complications are potential risks 3, 2

Critical Pitfalls to Avoid

• Do not treat only the "predominant" symptom first - the combination approach of PFMT plus bladder training addresses both components simultaneously and is more effective for mixed incontinence 1, 2
• Do not skip the 3-month trial of supervised PFMT - unsupervised training is significantly less effective 1
• Do not prescribe medications for the stress component - they are ineffective and waste resources 1, 2
• Do not rush to surgery - even modest symptom improvements with conservative measures may have important effects on daily functioning 2
• Clinically successful treatment is defined as reducing the frequency of incontinence episodes by at least 50% 1