Mixed urinary incontinence (MUI) is defined as ‘the involuntary loss of urine associated with urgency and also with effort or physical exertion, or on sneezing or coughing’. It is highly prevalent, increases with age and affects women more than men. It has a significant negative impact on health-related quality of life (HRQL). Additionally, treatment of mixed urinary incontinence places a large financial burden on both individuals and the NHS. Optimal management of this common condition is contested – should we treat the urge urinary incontinence (UUI), stress urinary incontinence (SUI) or predominant symptom first? At the 2015 BAUS Section of Female, Neurological and Urodynamic Urology this subject was debated. Based on a common scenario, the authors of the debate present the arguments for treating the urge urinary incontinence component, stress urinary incontinence component or the predominant symptom of mixed urinary incontinence first, before making recommendations for current practice.
HaylenBTDe ridderDFreemanRM. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn2010; 29(1): 4–20.
2.
MyersDL.Female mixed urinary incontinence: a clinical review. JAMA2014; 311(19): 2007–14.3.
3.
HannestadYSRortveitGSandvikH. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of incontinence in the county of Nord-Trøndelag. J Clin Epidemiol2000; 53(11): 1150–1157.
4.
CoyneKSSextonCCThompsonCL. The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: results from the Epidemiology of LUTS (EpiLUTS) study. BJU Int2009; 104(3): 352–360.
5.
EbbesenMHHunskaarSRortveitG. Prevalence, incidence and remission of urinary incontinence in women: longitudinal data from the Norwegian HUNT study (EPINCONT). BMC Urol2013; 13: 27.
6.
MinassianVAStewartWFWoodGC.Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol2008; 111(2Pt 1): 324–331.
7.
CoyneKSZhouZThompsonC. The impact on health-related quality of life of stress, urge and mixed urinary incontinence. BJU Int2003; 92(7): 731–735.
8.
TurnerDAShawCMcgrotherCW. The cost of clinically significant urinary storage symptoms for community dwelling adults in the UK. BJU Int2004; 93(9): 1246–1252.
9.
BrubakerLMoalliPRichterHE. Challenges in designing a pragmatic clinical trial: the mixed incontinence – medical or surgical approach (MIMOSA) trial experience. Clin Trials2009; 6(4): 355–364.
National Institute for Clinical Excellence. Urinary incontinence in women: management. London: NICE, 2013; updated November2015.
12.
MinassianVADevoreEHaganK. Severity of urinary incontinence and effect on quality of life in women by incontinence type. Obstet Gynecol2013; 121(5): 1083–1090.
13.
AsogluMRSelcukSCamC. Effects of urinary incontinence subtypes on women’s quality of life (including sexual life) and psychosocial state. Eur J Obstet Gynecol Reprod Biol2014; 176: 187–190.
14.
WymanJFHarkinsSWChoiSC. Psychosocial impact of urinary incontinence in women. Obstet Gynecol1987; 70(3Pt 1): 378–381.
15.
LeeEWKobashiKC.Mixed incontinence: what takes precedence in its management?Curr Urol Rep2014; 15(12): 461.
16.
StaskinDRTeAE.Short- and long-term efficacy of solifenacin treatment in patients with symptoms of mixed urinary incontinence. BJU Int2006; 97(6): 1256–1261.
17.
KhullarVHillSLavalKU. Treatment of urge-predominant mixed urinary incontinence with tolterodine extended release: a randomized, placebo-controlled trial. Urology2004; 64(2): 269–274.
18.
DmochowskiRRDavilaGWZinnerNR. Efficacy and safety of transdermal oxybutynin in patients with urge and mixed urinary incontinence. J Urol2002; 168(2): 580–586.
19.
WuTDuanXCaoCX. The role of mirabegron in overactive bladder: a systematic review and meta-analysis. Urol Int2014; 93(3): 326–337.
20.
DowsonCKhanMSDasguptaP. Repeat botulinum toxin-A injections for treatment of adult detrusor overactivity. Nat Rev Urol2010; 7(12): 661–667.
21.
KarramMMBhatiaNN.Management of coexistent stress and urge urinary incontinence. Obstet Gynecol1989; 73(1): 4–7.
22.
GleasonJLPardenAMJaukV. Outcomes of midurethral sling procedures in women with mixed urinary incontinence. Int Urogynecol J2015; 26(5): 715–720.
23.
JainPJirscheleKBotrosSM. Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis. Int Urogynecol J2011; 22(8): 923–932.
24.
HolmgrenCNilssonSLannerL. Long-term results with tension-free vaginal tape on mixed and stress urinary incontinence. Obstet Gynecol2005; 106(1): 38–43
25.
Kulseng-HanssenSHusbyH. Follow-up of TVT operations in 1,113 women with mixed urinary incontinence at 7 and 38 months. Int Urogynecol J Pelvic Floor Dysfunct2008; 19(3): 391–396.
26.
BøK.Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work?Int Urogynecol J Pelvic Floor Dysfunct2004; 15(2): 76–84.
27.
International Conference on Incontinence, 2008. Paris.
28.
DumoulinCHay-smithEJMac habée-séguinG.Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014;5:CD005654.
29.
BentAEGousseAEHendrixSL. Duloxetine compared with placebo for the treatment of women with mixed urinary incontinence. Neurourol Urodyn2008; 27(3): 212–221.
NortonPBrubakerL.Urinary incontinence in women. Lancet2006; 367(9504): 57–67.
32.
ColomboMZanettaGVitobelloD. The Burch colposuspension for women with and without detrusor overactivity. Br J Obstet Gynaecol1996; 103(3): 255–260.
33.
ScottiRJAngellGFloraR. Antecedent history as a predictor of surgical cure of urgency symptoms in mixed incontinence. Obstet Gynecol1998; 91(1): 51–54.
34.
OsmanT.Stress incontinence surgery for patients presenting with mixed incontinence and a normal cystometrogram. BJU Int2003; 92(9): 964–968.
35.
FulfordSCFlynnRBarringtonJ. An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome. J Urol1999; 162(1): 135–137.
36.
SchrepfermanCGGrieblingTLNygaardIE. Resolution of urge symptoms following sling cystourethropexy. J Urol2000; 164(5): 1628–1631.
37.
ChouECFlisserAJPanagopoulosG. Effective treatment for mixed urinary incontinence with a pubovaginal sling. J Urol2003; 170(2Pt 1): 494–497.
38.
ChoeJHChooMSLeeKS.The impact of tension-free vaginal tape on overactive bladder symptoms in women with stress urinary incontinence: significance of detrusor overactivity. J Urol2008; 179(1): 214–219.
39.
Abdel-FattahMHopperLRMostafaA.Evaluation of transobturator tension-free vaginal tapes in the surgical management of mixed urinary incontinence: 3-year outcomes of a randomized controlled trial. J Urol2014; 191(1): 114–119.
40.
Toozs-HobsonPAl-SingaryWFynesM. Two-year follow-up of an open-label multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and stress-predominant mixed incontinence. Int Urogynecol J2012; 23(10): 1373–1378.
41.
JungSYFraserMOOzawaH. Urethral afferent nerve activity affects the micturition reflex; implication for the relationship between stress incontinence and detrusor instability. J Urol1999; 162(1): 204–212.
42.
BrubakerLStoddardARichterH. Mixed incontinence: comparing definitions in women having stress incontinence surgery. Neurourol Urodyn2009; 28(4): 268–173.
AlboMERichterHEBrubakerL. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med2007; 356(21): 2143–2155.
45.
BurgioKLKrausSRMenefeeS. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med2008; 149(3): 161–169.
46.
LewisJBNgAVO’connorRC. Are there differences between women with urge predominant and stress predominant mixed urinary incontinence?Neurourol Urodyn2007; 26(2): 204–207.
47.
StoffelJTSmithJJCrivellaroS. Mixed incontinence: does preoperative urodynamic detrusor overactivity affect postoperative quality of life after pubovaginal sling?Int Braz J Urol2008; 34(6): 765–771.
48.
DigesuGASalvatoreSFernandoR. Mixed urinary symptoms: what are the urodynamic findings?Neurourol Urodyn2008; 27(5): 372–375.
49.
ChouECBlaivasJGChouLW. Urodynamic characteristics of mixed urinary incontinence and idiopathic urge urinary incontinence. Neurourol Urodyn2008; 27(5): 376–378.
50.
MinassianVADevoreEHaganK. Severity of urinary incontinence and effect on quality of life in women by incontinence type. Obstet Gynecol2013; 121(5): 1083–1090.
51.
KimHMOhMMLeeJG.Does the incidence of urgency symptoms increase along with the severity of stress urinary incontinence?Korean J Urol2010; 51(11): 772–776.
