What are the treatment options for a patient with stress urinary incontinence?

Treatment of Stress Urinary Incontinence

Begin with supervised pelvic floor muscle training (PFMT) for at least 3 months before considering surgical intervention, as this first-line conservative approach achieves up to 70% symptom improvement and is recommended by all major guidelines. 1, 2, 3

First-Line Conservative Management

Pelvic Floor Muscle Training

• Supervised PFMT programs are more than 5 times as effective as no treatment and significantly superior to unsupervised or leaflet-based approaches. 2, 4, 5
• The training must involve repeated voluntary pelvic floor muscle contractions (Kegel exercises) taught by a healthcare professional such as a specialized physiotherapist or continence nurse. 2, 4
• Continue PFMT for a minimum of 3 months before declaring treatment failure, as benefits accumulate over time. 2, 3
• 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. 2, 3

Adjunctive Conservative Measures

• Weight loss programs should be implemented for obese patients (BMI ≥30), as this directly improves stress incontinence symptoms with a number needed to treat of 4. 2, 3, 4
• Continence pessaries (typically ring pessaries) provide mechanical support to the urethra and bladder neck, restoring the urethrovesical angle and preventing leakage during increased intra-abdominal pressure. 3, 6
• Pessaries are particularly appropriate for women not bothered enough to pursue surgical therapy or who prefer non-surgical management. 3

Critical Pitfall to Avoid

• Do not prescribe systemic pharmacologic therapy for pure stress urinary incontinence—no medication has been shown effective for this condition. 4, 6

Surgical Treatment Options

When to Consider Surgery

• Proceed to surgical evaluation only after an adequate trial (minimum 3 months) of supervised conservative management has failed to adequately control symptoms. 1, 2, 4
• The degree of bother and impact on quality of life should drive the decision for surgical intervention, not just the presence of leakage. 1, 2

Surgical Procedures (in order of evidence strength)

Midurethral Slings (MUS)

• Midurethral slings represent the most extensively studied surgical option with the strongest evidence supporting their effectiveness, achieving 51-88% success rates. 1, 2, 3
• Retropubic midurethral sling (RMUS) has better long-term outcomes for severe stress incontinence cases. 2, 3
• Transobturator midurethral sling (TMUS) has lower risk of bladder perforation but higher risk of groin pain. 3
• Single-incision slings (SIS) are emerging as viable options with accumulating long-term data, though their durability requires further confirmation. 2, 3

Autologous Fascia Pubovaginal Sling

• This is an excellent alternative for patients concerned about mesh complications, with 85-92% success rates at 3-15 years follow-up. 2, 3
• Consider this option particularly for patients who express anxiety about synthetic mesh after counseling. 2, 3

Colposuspension (Burch Procedure)

• Remains an effective surgical treatment supported by robust evidence, though less commonly performed than midurethral slings. 2, 6

Urethral Bulking Agents

• Reduce leakage but effectiveness generally decreases after 1-2 years, making them less durable options. 2, 6
• Reserve for patients who are poor surgical candidates or desire minimally invasive options. 6

Pre-Operative Counseling Requirements

• Pre-operative counseling regarding MUS mesh complications results in reduced patient concern, greater willingness to proceed, and higher satisfaction. 2, 3
• Inform patients that success rates range from 51-88% and symptoms may recur requiring additional treatment. 2
• Discuss potential complications including direct injury to the lower urinary tract, hemorrhage, infection, bowel injury, wound complications, and mesh-specific complications. 4

Intraoperative Requirements

• Perform cystoscopy during midurethral sling or fascial pubovaginal sling procedures to confirm lower urinary tract integrity and absence of foreign body within the bladder or urethra. 1

Additional Evaluations for Non-Index Patients

Perform urodynamic testing at your discretion for patients with: 1

• History of prior anti-incontinence surgery
• History of prior pelvic organ prolapse surgery
• Mismatch between subjective and objective measures
• Significant voiding dysfunction
• Significant urgency, urgency urinary incontinence, or overactive bladder symptoms
• Elevated post-void residual per clinical judgment
• Unconfirmed stress urinary incontinence
• Neurogenic lower urinary tract dysfunction

Common Pitfalls to Avoid

• Do not proceed to surgery before an adequate trial (minimum 3 months) of supervised conservative management. 2, 4
• Do not ignore coexisting conditions such as high-grade prolapse, urgency-predominant mixed incontinence, or incomplete bladder emptying, as these affect treatment selection and outcomes. 1, 2
• Do not perform cystoscopy for diagnostic evaluation in index patients unless there is concern for urinary tract abnormalities. 1
• Do not neglect to counsel patients about the potential need for additional treatments if symptoms recur. 2