What is the best treatment approach for a patient with stress incontinence?

Treatment of Stress Urinary Incontinence

Begin with supervised pelvic floor muscle training (PFMT) for at least 3 months as first-line therapy for all women with stress urinary incontinence, as this achieves up to 70% symptom improvement and should be exhausted before considering surgical options. 1, 2

Initial Patient Evaluation

Before initiating treatment, complete the following assessment components:

• Focused history assessing degree of bother and impact on quality of life 3
• Pelvic examination with objective demonstration of stress incontinence with comfortably full bladder (cough or Valsalva maneuver) 3, 4
• Post-void residual measurement using any method 3
• Urinalysis to exclude hematuria or infection 3

Perform additional evaluation if the patient has neurogenic bladder dysfunction, elevated post-void residual, urgency-predominant mixed incontinence, or high-grade pelvic organ prolapse (stage 3-4), as these are non-index patients requiring specialized management. 3

First-Line Conservative Management (Minimum 3 Months)

Supervised pelvic floor muscle training is mandatory as initial therapy and must involve repeated voluntary pelvic floor muscle contractions taught by a trained healthcare professional or physiotherapist—unsupervised training is more than 5 times less effective than supervised programs. 1, 2

• Continue PFMT for at least 3 months before declaring treatment failure, as this duration is required for meaningful clinical benefit 2, 5
• For obese patients (BMI ≥30), add weight loss targeting 5-10% body weight reduction, which provides additional benefit specifically for the stress component with a number needed to treat of 4 1, 5
• Consider continence pessaries or vaginal inserts if PFMT alone provides insufficient relief 2

Critical Pitfall to Avoid

Do not use systemic pharmacologic therapy for stress urinary incontinence—no medications have demonstrated effectiveness for pure stress incontinence, and this represents wasted time and resources. 1, 5

Second-Line Surgical Management

Proceed to surgery only when conservative measures fail after adequate trial (minimum 3 months of supervised PFMT) and symptoms significantly impair quality of life. 2, 4

Surgical Options in Order of Evidence Strength:

Midurethral slings (MUS) are the most extensively studied and most common primary surgical treatment, with the strongest supporting evidence and success rates of 51-88%. 1, 2, 5

• Retropubic midurethral sling provides better long-term outcomes for severe stress incontinence cases 2
• Synthetic mesh achieves 100% symptomatic relief in some studies at 3-month follow-up 6

Autologous fascia pubovaginal sling is the preferred alternative for patients concerned about mesh complications, with success rates of 85-92% at 3-15 years follow-up. 2

Retropubic colposuspension (Burch procedure) remains effective with robust long-term evidence. 2, 5

Urethral bulking agents reduce leakage but effectiveness decreases after 1-2 years, making them less durable options. 2

Pre-Operative Counseling Requirements

Counsel all surgical candidates about potential complications including direct injury to lower urinary tract, hemorrhage, infection, bowel injury, wound complications, and mesh-specific complications. 1, 5 Pre-operative counseling specifically about mesh complications reduces patient concern, increases willingness to proceed, and improves satisfaction. 2

Inform patients that symptoms may recur requiring additional treatment, as success is defined as ≥50% reduction in incontinence episodes, not complete cure. 1, 2

Treatment Algorithm

1. Confirm diagnosis with objective demonstration of stress incontinence on examination 3
2. Initiate supervised PFMT for minimum 3 months; add weight loss if BMI ≥30 1, 2, 5
3. Add pessary or vaginal insert if PFMT provides partial but insufficient benefit 2
4. Consider surgery only after adequate conservative trial fails and patient desires definitive treatment 2, 4
5. Select surgical approach based on severity (retropubic MUS for severe cases), patient preference regarding mesh (autologous fascia if mesh-averse), and anatomic factors 2

Special Consideration for Mixed Incontinence

If stress-predominant mixed incontinence is present, the same algorithm applies—start with combined PFMT plus bladder training, then proceed to midurethral sling surgery if conservative measures fail, as slings can cure both stress and urge components in 40-50% of cases. 1