Treatment of Stress Urinary Incontinence
Begin with supervised pelvic floor muscle training (PFMT) for at least 3 months as first-line therapy, and only proceed to surgical intervention with midurethral slings if conservative management fails and symptoms significantly impact quality of life. 1, 2
First-Line Conservative Management
Pelvic floor muscle training is the cornerstone of initial treatment, demonstrating up to 70% improvement in symptoms when properly performed under professional supervision. 2, 3 The evidence consistently shows that supervised programs are more than 5 times as effective as no active treatment, making this the mandatory starting point for all patients. 4
Key Components of Conservative Therapy:
PFMT must be supervised by a healthcare professional (continence nurse or physiotherapist) rather than self-directed or leaflet-based approaches, as supervised training shows significantly superior outcomes. 2, 4
Continue PFMT for a minimum of 3 months before declaring treatment failure and considering surgical options. 2, 3
Add weight loss programs for obese patients (BMI ≥30), as this specifically improves the stress component of incontinence with a number needed to treat of 4. 2, 4
Consider adding dynamic lumbopelvic stabilization (DLS) to standard PFMT, as this combination improves day and night urine control, reduces leakage severity, and enhances quality of life compared to PFMT alone. 2, 3
Continence pessaries or vaginal inserts can serve as alternative conservative options for women preferring non-surgical approaches, though acceptance varies. 2, 3
Critical Pitfall to Avoid:
Do not proceed to surgery without completing at least 3 months of supervised conservative therapy—this represents premature escalation and exposes patients to unnecessary surgical risks. 2, 4
Second-Line Surgical Management
When conservative measures fail after adequate trial and symptoms significantly affect quality of life, midurethral slings (MUS) represent the most extensively studied and effective surgical option. 1, 2
Surgical Options in Order of Evidence Strength:
Primary Surgical Choice:
- Midurethral slings (MUS) are the gold standard with the strongest evidence base and success rates of 51-88%. 1, 2
- Retropubic midurethral sling (RMUS) provides better long-term outcomes specifically for severe stress incontinence cases. 2, 3
- Transobturator midurethral sling (TMUS) has lower risk of bladder perforation but higher risk of groin pain compared to retropubic approach. 3
Alternative Surgical Options:
- Autologous fascia pubovaginal sling is the preferred choice for patients concerned about mesh complications, with 85-92% success rates at 3-15 years follow-up. 2, 3
- Colposuspension (Burch procedure) remains effective with robust supporting evidence, though less commonly performed than MUS. 1, 2
- Single-incision slings (SIS) are emerging as viable options with accumulating data, though long-term efficacy requires further confirmation. 1, 2
For Complicated/Severe Cases:
- Artificial urinary sphincters are reserved for complicated and severe SUI when other options have failed, though high-quality comparative data remain limited. 1, 2
- Urethral bulking agents reduce leakage but effectiveness generally decreases after 1-2 years, making them less durable options. 1, 2
Pre-Operative Counseling Requirements:
Thoroughly counsel patients about mesh-related complications before surgery, as proper pre-operative counseling results in reduced patient concern, greater willingness to proceed, and higher satisfaction. 2, 3 This is particularly important given the hesitance among patients to proceed with surgical interventions due to mesh-related complications. 1
Inform patients that success rates range from 51-88% and symptoms may recur, requiring additional treatment in the future. 2
Critical Surgical Decision Algorithm:
Assess severity and presence of complications: High-grade prolapse, urgency-predominant mixed incontinence, or incomplete bladder emptying affect treatment selection. 2
For severe stress incontinence without mesh concerns: Choose retropubic midurethral sling. 2, 3
For patients concerned about mesh: Choose autologous fascia pubovaginal sling. 2, 3
For patients desiring less invasive procedures: Consider single-incision slings, though acknowledge limited long-term data. 1, 2
Important Pharmacologic Note:
No pharmacologic therapy has been shown effective for stress urinary incontinence and should not be used. 4 This represents a common pitfall—prescribing systemic medications for stress incontinence is ineffective and wastes time and resources. 4
Coexisting Conditions That Must Be Addressed:
Do not ignore high-grade prolapse, urgency-predominant mixed incontinence, or incomplete bladder emptying, as these conditions affect treatment selection and outcomes. 2 For mixed incontinence, control the urgency component with bladder training and antimuscarinics before performing surgical interventions for the stress component. 4, 5