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Non-surgical Management of Stress Urinary Incontinence

1/1/2016 - Natalie A. Bowersox, MD

Mentor: Christine R. Isaacs, MD

Editor: Roger P. Smith, MD

Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine with cough, sneeze, or other activities that increase intraabdominal pressure. This problem affects up to 35% of women and often negatively impacts their quality of life.

An evaluation for SUI should include history, physical examination, urinalysis, demonstration of leak with cough or Valsalva, assessment of urethral mobility, and measurement of post-void residual (PVR) volume.  If urinary incontinence is not demonstrated with the cough test, a non-mobile urethra is present, or if the incontinence appears multifactorial in etiology, multichannel urodynamic testing may be appropriate.

Lack of urethral sphincter function is known as intrinsic sphincter deficiency (ISD). ISD may be present with a hypermobile or fixed, non-mobile urethra. ISD may be caused by neuromuscular damage or trauma, including prior surgery. In ISD, the sphincter can no longer coapt, and incontinence may be severe. Urodynamic evaluation typically demonstrates either low maximal urethral closure pressure or low leak-point pressures.

Initial treatment of SUI should include a review of co-morbidities and medications that that may be aggravating SUI such as the use of diuretics, narcotics, antihistamines, and anti-cholinergic medications. 

Lifestyle modifications should follow. Weight loss has been shown to help decrease symptoms of SUI. Reducing consumption of beverages that contain alcohol, caffeine, and carbonation as well as limiting consumption of excess amounts of liquids (>64 ounces of liquids daily), managing constipation, and quitting smoking can help alleviate or reduce symptoms.

Kegel exercises (voluntary contractions of the pelvic floor muscles) done regularly and with proper technique have been shown to be successful at managing SUI.  Supervised pelvic physical therapy with use of biofeedback or the use of vaginal weighted cones placed in the vagina and held in place while contracting the pelvic floor, can also improve symptoms.

The use of pessaries has been shown to be successful about 50% of the time. Success with pessaries tends to be in patients whose SUI is related to specific activities who can use a pessary to resume the activities without leaking urine.

When SUI is associated with vaginal atrophy, local estrogen treatment has been shown to improve symptoms.  It may take up to twelve weeks for patients to notice benefit.  While several other medications have been evaluated for the specific treatment of SUI, there are currently no FDA approved drugs for this purpose. 

For patients with ISD, injection of bulking agents into the proximal periurethral tissue (transurethrally or periurethrally) may be used. These agents may also be used for genuine SUI in women in whom operative intervention may be especially hazardous, as second-line therapy after surgery has failed, or when incontinence persists with a non-mobile bladder neck. Cure rates vary, depending on the indication, differences in injection techniques, types of material used, length of follow-up, and type of incontinence treated.

If patients continue to have bothersome symptoms of SUI following non-surgical management, surgical interventions may be recommended and high cure rates can be achieved.

Further Reading:

Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. Committee Opinion No. 603. The American College of Obstetricians and Gynecologists. Obstet Gynecol 2014; 123:1403–7.

Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e66–81.

Richter HE, Burgio KL. Stress urinary incontinence and pelvic organ prolapse:  non-surgical management.  In: Urogynecology and Reconstructive Pelvic Surgery. Walters MD, Karram MM (eds).  Fourth Edition. Philadelphia.  Elsevier Saunders, 2015.

Initially approved 11/2015;  Reaffirmed 5/2017.

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