Treatment of Stress Urinary Incontinence
Begin with supervised pelvic floor muscle training (PFMT) for at least 3 months before considering any surgical intervention, as this first-line conservative approach achieves up to 70% symptom improvement and is more than 5 times as effective as no treatment. 1, 2
First-Line Conservative Management
Pelvic floor muscle training (PFMT) is the mandatory initial treatment for all women with stress urinary incontinence, requiring 8-12 strong contractions performed 3 times every other day under professional supervision. 1, 3 Supervised programs dramatically outperform unsupervised attempts, making professional guidance non-negotiable for optimal outcomes. 2
Add dynamic lumbopelvic stabilization (DLS) to standard PFMT to enhance day and night urine control, reduce leakage severity, and improve quality of life beyond PFMT alone, with benefits increasing over time. 1
Weight loss of 5-10% is mandatory for obese patients (BMI ≥30), as this intervention has a number needed to treat of 4 for symptom improvement and specifically targets the stress component of incontinence. 4, 2 This should run concurrently with PFMT, not sequentially.
Continence pessaries (particularly ring pessaries) serve as alternative conservative options for women who prefer non-surgical management or are not bothered enough to pursue surgery, working by mechanically supporting the urethra and bladder neck to restore the urethrovesical angle. 4 However, recognize that pessary recommendations are classified as "Expert Opinion" due to lack of high-quality comparative trials. 4
When Conservative Management Fails
Proceed to surgical evaluation only after a minimum 3-month trial of supervised PFMT combined with weight loss if applicable. 1, 2 Proceeding to surgery prematurely represents a critical pitfall that bypasses effective, low-risk interventions. 1
Surgical Treatment Options
Midurethral slings (MUS) are the most extensively studied and effective surgical option with the strongest evidence base, representing the gold standard for surgical management. 1, 4
Choose retropubic midurethral sling (RMUS) for severe stress incontinence cases as this approach demonstrates superior long-term outcomes compared to transobturator approaches, though it carries higher risk of bladder perforation. 1, 4
Offer autologous fascia pubovaginal sling (PVS) to patients concerned about mesh complications, as this achieves 85-92% success rates at 3-15 years follow-up without synthetic material. 1, 4
Single-incision slings (SIS) are emerging as viable alternatives with accumulating long-term data, though their durability requires further confirmation compared to traditional MUS. 1
Colposuspension (Burch procedure) remains an effective option supported by robust evidence for women who are not candidates for or decline mesh-based procedures. 1
Urethral bulking agents reduce leakage but effectiveness decreases after 1-2 years, making them less durable options suitable only for patients seeking minimally invasive approaches with acceptance of likely retreatment. 1
Critical Pre-Operative Counseling
Counsel all surgical candidates about mesh complications before proceeding, as this discussion reduces patient concern, increases willingness to proceed, and enhances post-operative satisfaction. 1, 4 This is not optional—it directly impacts outcomes.
Inform patients that surgical success rates range from 51-88% and symptoms may recur requiring additional treatment, setting realistic expectations about the possibility of revision procedures. 1
Identify and address coexisting conditions before surgery, including high-grade prolapse (grade 3-4), urgency-predominant mixed incontinence, incomplete bladder emptying, or dysfunctional voiding, as these significantly affect treatment selection and outcomes. 5, 1
What NOT to Do
Never use systemic pharmacologic therapy for pure stress incontinence—no medication has proven effective for this condition, and duloxetine is not recommended in current guidelines despite older literature mentions. 2, 6
Never skip the 3-month supervised PFMT trial unless there are specific contraindications, as this represents abandoning a highly effective, zero-risk intervention. 1, 2
Never ignore body mass index—failing to address obesity in surgical candidates compromises outcomes and represents inadequate pre-operative optimization. 4, 2