Mixed incontinence: Current evidence and future perspectives

Abstract

The epidemiology and treatment of mixed incontinence has received relatively little attention. However, mixed incontinence--defined as the combination of stress and urge incontinence accounts for approximately 33% of all cases of incontinence in women. The condition often responds poorly to treatment, either pharmacologic or surgical. Potential pharmacologic approaches for mixed incontinence include antimuscarinic agents, estrogen replacement therapy (for postmenopausal women), and dopamine, serotonin, or norepinephrine reuptake inhibitors. In a large-scale, multinational, placebo-controlled, clinical trial, the antimuscarinic agent tolterodine significantly reduced incontinence episodes in women with mixed symptoms. The benefits of tolterodine continued to increase during the 8 weeks of the trial and extended to additional end points, including frequency, urgency, and urge incontinence. A limited number of studies have examined the use of estrogen for mixed incontinence and have produced conflicting results. Duloxetine oxalate, a combined serotonin/norepinephrine reuptake inhibitor, has shown great promise in animal studies, as well as in phase 2 and 3 clinical trials. This agent is the first to demonstrate efficacy as a sole therapy for stress incontinence and has exhibited favorable effects on bladder capacity, suggesting possible benefits in mixed incontinence. Only five studies (two of which were conducted during the 1980s) have specifically examined the use of surgery for the treatment of mixed incontinence; the cure rates reported have varied. The current body of information supports use of an antimuscarinic agent as initial therapy for mixed incontinence, although long-term trials are needed to shed more light on the duration of benefit.

Diabetes and Vaginal Surgery Are Associated With Mixed Urinary Incontinence in Patients Treated in a Tertiary Unit of Rio De Janeiro Public Healthcare System

“…MUI was also the most common clinical diagnosis in studies conducted in older populations 3,4 . In addition, women seen at other Brazilian referral centers have been diagnosed with MUI more frequently 20 .…”

“…European epidemiological studies have shown that, based on each clinical category, 50% of all women with UI are classified as having stress urinary incontinence (SUI), followed by mixed urinary incontinence (MUI) and overactive bladder (OB) 2 . The prevalence of these subtypes varies with age, and older women show a higher prevalence of MUI [2][3][4] . Several factors related to the increasing prevalence of UI, such as age and parity, have already been cited in the literature at length 5,6 .…”

“…While SUI has well-established standards for diagnosis and treatment, MUI is a major challenge, since it combines SUI and urge urinary incontinence (UUI) 3 . This definition was standardized by international societies based on the clinical assessment of symptoms and may induce bias, as symptoms can be difficult to express in appropriate medical terms in different regions and countries around the world 15 .…”

Preoperative Factors as Predictors of Outcome of Midurethral Sling in Women with Mixed Urinary Incontinence

“…Investigators, however, often have grouped several different pathologies together under the category of ''mixed incontinence.'' (Khullar et al, 2010) Further compounding the definition of MUI is an acknowledged fact that stress incontinence may also be misperceived as an urgency event. The presence of urine in the posterior urethra may actually induce urinary urgency and eventuate in a secondary episode of detrusor overactivity (stress-induced detrusor overactivity).…”

“…Potential pharmacologic approaches to the treatment of mixed incontinence include antimuscarinic agents, estrogen replacement therapy (for postmenopausal women), and dopamine, serotonin, and norepinephrine reuptake inhibitors. (Khullar et al, 2010) Electrical stimulation is another conservative measure that could potentially be used for the treatment of MUI. (Sand, 1996) Surgery should be considered after failed medical management, proper work up, and careful counselling about the lower overall success rates of around 55%.…”