From the Guidelines
For mixed urinary incontinence in females, I strongly recommend a combination approach of pelvic floor muscle training with bladder training as the first-line treatment, as suggested by the American College of Physicians 1. This approach is based on strong recommendations and moderate-quality evidence. The treatment plan should include:
- Pelvic floor muscle exercises (Kegels), performing 3 sets of 10 contractions daily, holding each for 10 seconds
- Bladder training by gradually increasing time between voids by 15-30 minutes every few days
- Maintaining a bladder diary to track triggers and progress
- Avoiding bladder irritants like caffeine, alcohol, and artificial sweeteners If bladder training is unsuccessful, pharmacologic treatment may be considered for the urge component, with medications like oxybutynin, solifenacin, or mirabegron, as recommended by the American College of Physicians 1. Additionally, weight loss of 5-10% can significantly improve symptoms if the patient is overweight, as recommended by the American College of Physicians 1. It is essential to consult a urogynecologist if symptoms persist after 6-8 weeks of consistent effort for additional options, including potential surgical interventions. The key to managing mixed urinary incontinence is a comprehensive approach that addresses both stress and urge components, and a combination of pelvic floor muscle training and bladder training is the most effective first-line treatment, as supported by the highest quality evidence 1.
From the FDA Drug Label
CLINICAL STUDIES Tolterodine tartrate tablets were evaluated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in four randomized, double-blind, placebo-controlled, 12-week studies. The FDA drug label does not answer the question.
From the Research
Mixed Incontinence in Females
- Mixed urinary incontinence is a common diagnosis among women with urinary leakage, often present in women who are unable to characterize their incontinence 2.
- The evaluation of these patients should follow the same general principles as any assessment of any women with incontinence; however, it is essential to define whether urge or stress incontinence is the predominant symptom 2.
Management Strategies
- Behavioural therapy, weight loss, and pelvic floor muscle therapy are usually appropriate initial management strategies for mixed urinary incontinence in women 2.
- In postmenopausal women, vaginal estrogen can be considered, and in women with equal parts stress and urge incontinence or urge-predominant mixed incontinence, a trial of anticholinergics or beta-3 agonists is appropriate 2.
- Kegel exercise (also called pelvic floor muscle training) is a frequently suggested physical therapy treatment for women with stress incontinence or urge incontinence, and has been shown to improve urinary incontinence and quality of life in women with mixed urinary incontinence 3, 4.
- Home-based Kegel exercises have been found effective in women with stress and mixed urinary incontinence, with improvements in pelvic floor muscle strength and quality of life 4.
Surgical Options
- In women with stress-predominant or equal parts stress and urge incontinence, stress incontinence surgery can be considered, with the caveat that outcomes are generally worse among women with more severe levels of urgency 2.
- Midurethral synthetic slings, including retropubic and transobturator approaches, are safe and efficacious surgical options for stress urinary incontinence and have replaced more invasive bladder neck slings that use autologous or cadaveric fascia 5.