What are the recommended treatment options for stress urinary incontinence?

Treatment for Stress Urinary Incontinence

Begin with supervised pelvic floor muscle training (PFMT) for at least 3 months as first-line therapy; if this fails and symptoms significantly impact quality of life, proceed to midurethral sling surgery, which represents the most extensively studied and effective surgical option. 1, 2

Initial Assessment and Patient Stratification

Before initiating treatment, determine whether the patient is an "index" or "non-index" case, as this fundamentally alters the treatment pathway. 1

Index patients are healthy females with minimal or no prolapse who have pure stress urinary incontinence (SUI) or stress-predominant mixed incontinence. 1

Non-index patients have complicating factors including high-grade prolapse (grade 3-4), urgency-predominant mixed incontinence, neurogenic lower urinary tract dysfunction, incomplete bladder emptying, prior failed anti-incontinence surgery, mesh complications, high body mass index, or advanced age. 1

The diagnosis requires witnessing involuntary urine loss from the urethral meatus during coughing or Valsalva maneuver with a comfortably full bladder—this is the definitive diagnostic criterion. 1

Treatment Algorithm Based on Symptom Bother

Step 1: Assess Degree of Bother

Treatment decisions must be directly linked to how much the symptoms bother the patient, since SUI is fundamentally a quality-of-life condition. 1

• Minimal bother: Observation with conservative measures (pads) is appropriate. 1, 3
• Moderate to severe bother: Proceed with active treatment. 1

Step 2: First-Line Conservative Management (3-Month Trial)

Supervised pelvic floor muscle training is mandatory as initial therapy, demonstrating up to 70% symptom improvement when properly performed. 2

• PFMT must be continued for at least 3 months before considering surgical options. 2
• Adding dynamic lumbopelvic stabilization to standard PFMT improves daytime and nighttime urine control, reduces leakage severity, and enhances quality of life compared to PFMT alone. 2
• For obese patients, concurrent weight loss programs should be implemented, as obesity reduction improves SUI symptoms. 2
• Behavioral modifications including timed voiding and fluid management complement PFMT. 2

Step 3: Second-Line Non-Surgical Options

If PFMT fails after 3 months, consider:

• Continence pessaries or vaginal inserts: These provide mechanical support and can be effective for patients who wish to avoid surgery. 1, 2
• Urethral bulking agents: These reduce leakage but effectiveness generally decreases after 1-2 years, making them less durable options. 2, 4

Step 4: Surgical Intervention

Surgery should be considered when conservative measures fail to adequately control symptoms and incontinence significantly affects quality of life. 2

Primary Surgical Options (in order of evidence strength):

Midurethral slings (MUS) are the most extensively studied surgical option with the strongest evidence supporting effectiveness. 1, 2

• Retropubic midurethral sling (RMUS): Has better long-term outcomes for severe stress incontinence cases. 2
• Success rates for surgical interventions range from 51-88%. 2
• Pre-operative counseling regarding MUS mesh complications results in reduced patient concern, greater willingness to proceed, and higher satisfaction. 1, 2

Autologous fascia pubovaginal sling: An excellent alternative for patients concerned about mesh complications, with 85-92% success rates at 3-15 years follow-up. 2

Colposuspension (Burch procedure): Remains an effective surgical treatment supported by robust evidence. 2, 4

Single-incision slings (SIS): Emerging as viable options with accumulating long-term data, though long-term efficacy requires further confirmation. 2

Artificial urinary sphincters: Reserved for complicated and severe SUI cases, though high-quality comparative data remain limited. 2

Special Considerations for Non-Index Patients

Non-index patients may require urodynamic testing at the clinician's discretion, particularly those with: 1

• History of prior anti-incontinence or pelvic organ prolapse surgery
• Mismatch between subjective and objective measures
• Significant voiding dysfunction or elevated post-void residual
• Significant urgency, urgency urinary incontinence, or overactive bladder symptoms
• Unconfirmed SUI or neurogenic lower urinary tract dysfunction

Cystoscopy is not indicated for routine evaluation of index patients unless there is concern for urinary tract abnormalities. 1 However, intraoperative cystoscopy should be performed during midurethral sling or fascial pubovaginal sling procedures to confirm lower urinary tract integrity. 1

Critical Counseling Points

Patients must be counseled that: 1, 2

• Symptoms may continue immediately after surgery or recur later, potentially requiring additional treatment
• Each surgical option has unique complications and success rates
• Surgical procedures are more effective than non-surgical options but carry more adverse events 4

Common Pitfalls to Avoid

• Proceeding to surgery before an adequate 3-month trial of supervised PFMT: This violates the evidence-based treatment hierarchy. 2
• Ignoring coexisting conditions: High-grade prolapse, urgency-predominant mixed incontinence, or incomplete bladder emptying significantly affect treatment selection and outcomes. 1, 2
• Failing to counsel about recurrence: Patients must understand that symptoms may recur and require additional treatments. 2
• Not addressing obesity: Weight loss should be incorporated into the treatment plan for obese patients. 2