Stress urinary incontinence (SUI) is a widespread condition characterised by involuntary urine leakage triggered by physical activities such as coughing, sneezing, laughing, or exercise. Despite significantly impacting the quality of life (QoL), SUI remains underdiagnosed and undertreated, creating a substantial burden on individuals and healthcare systems. Distinguishing SUI from other forms of urinary incontinence (UI), such as urgency, mixed, extraurethral, and overflow incontinence, is essential since treatment approaches differ. SUI is the most common type of UI in women, resulting from a weakened urethral closure mechanism and diminished anatomical support. Its prevalence rises with pregnancy, childbirth, and ageing, affecting 20–30% of young women and peaking at 30–50% between ages 45 and 59. However, only 25% of affected women seek medical care, and just 12% receive specialised treatment due to barriers such as social stigma, lack of awareness, and concerns over surgical complications, particularly regarding mesh implants. Diagnosing SUI primarily relies on patient-reported symptoms, validated questionnaires, and clinical tests. The European Association of Urology (EAU) recommends urinalysis and postvoid residual assessment as standard evaluations, with bladder diaries and non-invasive tests like transperineal ultrasound gaining attention. Although ultrasound can help detect pelvic floor and bladder abnormalities, its effectiveness depends on operator expertise. Invasive urodynamics (UDS) is the gold standard for lower urinary tract dysfunctions but may not be necessary for uncomplicated SUI cases. The ValUE trial, which included 523 women, found no significant difference in treatment outcomes between women evaluated with UDS and those assessed in-office. However, UDS remains recommended for complicated cases, such as those with additional symptoms, prior surgeries, or pelvic organ prolapse. First-line treatment for SUI includes conservative options like pelvic floor muscle training (PFMT), behavioural therapy, and lifestyle changes. PFMT, supported by strong evidence, improves symptoms significantly when performed correctly under supervision. A Cochrane review reported that PFMT increased the likelihood of symptom improvement sixfold compared to no treatment, though long-term success rates range from 41% to 85%. Vaginal pessaries, though under-researched, may offer a non-invasive alternative by increasing urethral resistance. The ATLAS trial compared pessaries, behavioural therapy, and combined treatment, showing similar short-term symptom improvements, with behavioural therapy slightly more favoured. Minimally invasive treatments, such as intraurethral bulking agents (UBAs) like Bulkamid® and Macroplastique®, provide non-surgical options by enhancing urethral coaptation. Though less effective than synthetic midurethral slings (MUS), UBAs have high patient satisfaction and minimal complications. Experimental therapies, including CO2 laser treatments, acupuncture, and platelet-rich plasma (PRP) injections, are under investigation but require further study before becoming standard. Surgery remains the most effective treatment for SUI. The introduction of synthetic MUS revolutionised care, offering a minimally invasive solution with high success rates. However, concerns over mesh complications, such as chronic pain, have reduced their use in some regions. Alternatives like autologous fascial slings (AFS) and Burch colposuspension are viable non-mesh options. The ESTER report, analysing 175 RCTs, found that retropubic MUSs and AFS procedures had the highest cure rates, followed by colposuspension and transobturator MUS. Each surgical method has unique risks, necessitating shared decision-making between patients and clinicians. Single-incision slings (SIS) were developed to reduce traditional MUS complications. The SIMS trial, which included 596 women, found SIS had similar success rates to MUSs at 36 months, with reduced postoperative pain. However, further research is needed to assess their long-term safety and efficacy. Future SUI treatment will focus on personalised care, considering patient preferences, risk factors, and evolving technologies. Advancements in conservative and surgical treatments, alongside improved access to effective interventions, will shape the next phase of SUI management.
Prevalence, diagnosis, and management of SUI in women
Reviewed by Asif H Ansari
Prevalence, diagnosis, and management of stress urinary incontinence in women: a collaborative review.
