Mixed Urinary Incontinence: Diagnosis and Management

Abstract

The evaluation and treatment of mixed urinary incontinence receives relatively little attention as compared to other forms of incontinence. Mixed incontinence, however, defined as the combination of stress and urgency incontinence, accounts for the largest proportion of incontinence, with an increased incidence in older women. The condition can be very challenging to manage due to the coexistence of multiple pathologies. Treating either component can worsen the other, which means careful discussion of the risks and benefits, in addition to considerations of multimodal treatment approaches are required. In the older adult population, where this condition confers a significant impact on quality of life, there are many special considerations when evaluating and treating patients. Evaluation requires a careful assessment of the impact on QOL and goals of care and may need to involve caregivers and/or family members in the discussion, in addition to considerations of more advance evaluation on an individual basis prior to invasive treatments. Conservative treatments including behavioral and lifestyle modifications and pelvic floor physical therapy should be the mainstay of first-line treatment for older women with MUI, while taking into careful consideration how cognitive and/or physical limitations may impact treatment. Pharmacologic therapy should include a consideration of vaginal estrogen replacement, however oral medications for urgency and overactive bladder have increased risks in older women, which means more advanced treatments may want to be introduced sooner. There is really limited data on the use of third-line overactive bladder treatments in older women with mixed incontinence, however there may be some demonstrated benefits. Finally, when considering surgical interventions in this population, although the data demonstrate some benefit in mixed incontinence, providers may want to utilize a formalized assessment of frailty due to the increased morbidity associated with frailty in surgeries for incontinence.