275
PROFESSIONAL ARTICLE
Urinary incontinence treatment algorithm
1 Department of 
Gynaecology, Division 
of Gynaecology and 
Obstetrics, University 
Medical Centre Ljubljana, 
Ljubljana, Slovenia
2 Department of 
Gynaecology and 
Obstetrics, Faculty of 
Medicine, University of 
Ljubljana, Ljubljana, 
Slovenia
Correspondence/
Korespondenca:
David Lukanović, e: david.
lukanovic@mf.uni-lj.si
Key words:
pelvic floor dysfunction; 
uncontrolled urine 
leakage; urogynaecology; 
therapeutic approaches
Ključne besede:
disfunkcija medeničnega 
dna; nenadzorovano 
uhajanje urina; 
uroginekologija; 
terapevtske možnosti
Received: 17. 1. 2020
Accepted: 15. 3. 2020
eng slo element
en article-lang
10.6016/ZdravVestn.3028 doi
17.1.2020 date-received
15.3.2020 date-accepted
Obstetrics, gynaecology, andrology, reproduc-
tion, sexuality
Porodništvo, ginekologija, andrologija, reproduk-
cija, spolnost
discipline
Professional article Strokovni članek article-type
Urinary incontinence treatment algorithm Algoritem zdravljenja urinske inkontinence article-title
Urinary incontinence treatment algorithm Algoritem zdravljenja urinske inkontinence alt-title
pelvic floor dysfunction, uncontrolled urine 
leakage, urogynaecology, therapeutic ap-
proaches
disfunkcija medeničnega dna, nenadzorovano 
uhajanje urina, uroginekologija, terapevtske 
možnosti
kwd-group
The authors declare that there are no conflicts 
of interest present.
Avtorji so izjavili, da ne obstajajo nobeni 
konkurenčni interesi. conflict
year volume first month last month first page last page
2021 90 5 6 275 287
name surname aff email
David Lukanović 1 david.lukanovic@mf.uni-lj.si
name surname aff
Mija Blaganje 1
Matija Barbič 1,2
eng slo aff-id
Department of Gynaecology, 
Division of Gynaecology and 
Obstetrics, University Medical 
Centre Ljubljana, Ljubljana, 
Slovenia
Klinični oddelek za ginekologijo, 
Ginekološka klinika, Univerzitetni 
klinični center Ljubljana, 
Ljubljana, Slovenija
1
Department of Gynaecology and 
Obstetrics, Faculty of Medicine, 
University of Ljubljana, 
Ljubljana, Slovenia
Katedra za ginekologijo in 
porodništvo, Medicinska 
fakulteta, Univerza v Ljubljani, 
Ljubljana, Slovenija
2
Urinary incontinence treatment algorithm
Algoritem zdravljenja urinske inkontinence
David Lukanović,1 Mija Blaganje,1 Matija Barbič1,2
Abstract
Uncontrolled leakage of urine or urinary incontinence is a pelvic floor dysfunction and defined as 
any involuntary urination. The aetiology of incontinence is multifactorial, but with respect to the 
basic pathophysiological mechanisms that cause its onset, it can be roughly divided into stress, 
urge, mixed and overflow incontinence. The basic treatment for a patient is complex because the 
symptoms and signs of these disorders can result from gynaecological as well as internal, uro-
logical and neurological diseases. This article uses relevant literature and European guidelines to 
present a urinary incontinence treatment algorithm that emphasises the application of stepwise 
treatment and the importance of conservative treatment. Surgery is recommended only after all 
the conservative treatment options have been exhausted.
Izvleček
Nenadzorovano uhajanje urina ali urinska inkontinenca je disfunkcija medeničnega dna in se 
opredeljuje kot vsako nehoteno uhajanje urina. Na vzrok inkontinence vpliva več dejavnikov. Po 
osnovnih patofizioloških mehanizmih nastanka se v grobem deli na stresno, urgentno, mešano 
in t.i. »overflow« urinsko inkontinenco. Osnovna obravnava bolnice je kompleksna, saj lahko na 
simptome in znake teh motenj vplivajo ginekološke, internistične, urološke in nevrološke bolez-
ni. V članku na osnovi literature in evropskih smernic prikazujemo algoritem zdravljenja urinske 
inkontinence s poudarkom na stopenjskem zdravljenju in na pomenu konservativnega zdravlje-
nja. Šele po izčrpanih možnostih konservativnega zdravljenja svetujemo bolnici kirurški poseg.
Cite as/Citirajte kot: Lukanović D, Blaganje M, Barbič M. Urinary incontinence treatment algorithm. Zdrav 
Vestn. 2021;90(5–6):275–87.
DOI: https://doi.org/10.6016/ZdravVestn.3028
Copyright (c) 2021 Slovenian Medical Journal. This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
Slovenian
Medical
Journal
1 Introduction
Uncontrolled leakage of urine or uri-
nary incontinence (UI) is a pelvic floor 
dysfunction found in all age groups (1). 
UI as a term has been used since 2002 for 
any involuntary urination, as per the defi-
nition by the International Continence 
Society (ICS) (2). Patients have varied 
symptoms and signs and cite a wide range 
of problems, from mild to disabling (2,3). 
The aetiology of UI is multifactorial, 
as risk factors include age, pregnancy and 
childbirth (multiparous women), pelvic 
276
OBSTETRICS, GYNAECOLOGY, ANDROLOGY, REPRODUCTION, SEXUALITY
Zdrav Vestn | May – June 2021 | Volume 90 | https://doi.org/10.6016/ZdravVestn.3028
floor injury during vaginal delivery, pel-
vic surgery, menopause (due to decreased 
oestrogen secretion), hysterectomy, in-
creased body weight, lack of physical ac-
tivity, urinary tract infections, chronic 
cough, prolonged heavy lifting, congenital 
weakness of connective tissue and chronic 
constipation (2,4).
According to anatomical criteria, UI is 
divided into urethral and extra-urethral. 
Clinically, it is divided into absolute and 
relative UI. Absolute UI in women occurs 
because of congenital (epispadias, ecto-
pic ureter, bladder exstrophy) or acquired 
abnormalities (obstetric fistula, following 
surgery, due to malignancy or following 
radiation therapy). Several types of rela-
tive UI are known, and they are divided 
by basic pathophysiological mechanisms 
that cause their onset. They are roughly di-
vided into stress UI (urinary incontinence 
due to pressure or upon exertion), urge 
UI (urgent urinary incontinence), mixed 
UI (with characteristics of stress and urge 
UI) and overflow UI (involuntary release 
of urine due to an overfull bladder). In 
practice, however, the borders between 
different UI types are often blurred due to 
mixed aetiology (2,4,5).
Results of epidemiological studies on 
the prevalence of UI in women differ sig-
nificantly. The cause can most probably be 
found in different sample sizes, UI defini-
tions and methodology (6). The UI prob-
lem is becoming more common due to the 
rising elderly population and the trend of 
rising prevalence of UI with ageing. Based 
on available data, the prevalence of UI in 
young women (18–44 years) is 20–30%, 
in middle-aged women (45–59  years) 
30–40% and in older women (older than 
60 years) 30–50% (6,7). For example, the 
Norwegian EPINCONT longitudinal 
study (8,9), which was underway between 
1995–1997 and again between 2006–2008, 
showed a rise in UI prevalence of 16% 
between the two periods. The incidence 
increased by 18.7%, and remission was 
achieved in 34.1%. Stress incontinence is 
more common than urge or mixed incon-
tinence (8,10,11). The prevalence of stress 
incontinence reaches its peak in the 5th 
decade of life, but the prevalence of mixed 
and urge incontinence keeps increasing. 
Studies predict that the prevalence of UI 
and other pelvic floor disorders, such as 
pelvic organ prolapse (POP) and anal in-
continence, will keep increasing with the 
overall ageing of the world’s population 
(8,12).
1.1 Stress urinary incontinence
The ICS defines stress urinary inconti-
nence (SUI) as the complaint of any invol-
untary loss of urine on effort or physical 
exertion (e.g. sporting activities) or on 
sneezing or coughing (2). When leakage 
of urine through the urethra, concurrent 
with an increase in intra-abdominal pres-
sure (e.g. on coughing, sneezing or the 
Valsalva manoeuvre) in the absence of 
bladder contraction is found with urody-
namic investigations, we speak of urody-
namically diagnosed SUI (2,13).
The main theory explaining the mech-
anism of SUI proposes that urine begins 
to leak uncontrollably through the ure-
thra as intra-abdominal pressure (IAP) 
rises (5,14). The moment IAP rises, the 
pressure in the bladder rises and becomes 
higher than the pressure in the urethra, 
as the rise in IAP is unevenly distributed 
between the bladder and the urethra in 
favour of the former. In SUI, this occurs 
without contraction of the detrusor mus-
cle in the bladder (14,15).
The factors that affect the pathologic 
deviation in urethral pressure are numer-
ous. The most important are the changed 
position of the bladder neck due to weak-
ness and the loss of the supportive role of 
277
PROFESSIONAL ARTICLE
Urinary incontinence treatment algorithm
the vagina (upon which the urethra and 
the bladder neck lie), the pelvic floor mus-
cles (PFM) and the posterior puboure-
thral ligament. Contractility of the ure-
thral sphincter and urethral compliance 
also affect the pressure (14). Numerous 
studies have confirmed that pregnancy 
and/or childbirth increase the possibility 
of SUI occurrence, especially in younger 
women. In most, this is a temporary oc-
currence, which becomes chronic in some 
of them (11). The reason can be found in 
changes in the female body, which oc-
cur during pregnancy and after delivery, 
the most important among them being 
the weakening of the levator ani muscle, 
bladder neck descent and partial loss of 
pelvic muscles innervation due to inju-
ry of the pudendal nerve or its branches 
(14,16,17,18). Constant physical exertion 
and obesity are also important factors for 
SUI occurrence due to chronic elevations 
in IAP (5).
1.2 Urge urinary incontinence
The ICS defines urge urinary inconti-
nence (UUI) as the observation of invol-
untary leakage from the urethral orifice 
associated with the individual reporting 
the sensation of a sudden, compelling de-
sire to void (urgency) (2). It most often 
occurs on the way to the bathroom, when 
listening to running water or during con-
tact with cold water. It is caused by un-
controlled bladder contractions, causing 
urgency which can lead to UUI (19).
UUI is only a part of the syndrome 
known as overactive bladder (OAB). It is 
defined by the presence of urgency, often 
accompanied by frequent urination and 
nocturia (one-time or multiple interrup-
tions of sleep per night due to the need 
for urination) in the absence of urinary 
tract infection or other obvious pathol-
ogy (2). The dry type without urinary 
incontinence, but with urgency and fre-
quent urination, and wet type with UUI 
are known (19). Pathophysiologically, 
there are two types of OAB. If the cause of 
an overactive bladder is a proven disorder 
of the central nervous system, we talk of 
detrusor hyperreflexia. This type of OAB 
can be present in patients with multiple 
sclerosis, stroke or Parkinson’s disease. 
The other type of OAB with an unstable 
detrusor has no known cause. With this 
type, central disorders of micturition 
control due to delayed maturation of the 
central nervous system can be found, or it 
can occur due to peripheral causes, such 
as excessive cholinergic stimulation or de-
creased peripheral adrenergic inhibition 
(5,19).
Risk factors for the occurrence 
and worsening of UUI are numerous. 
Recurrent urinary tract infections are 
connected to UUI and are a curable cause 
of incontinence. A high body mass index 
(BMI), ageing and caffeine use (due to its 
diuretic effect and increasing the feeling 
of urgency) are also connected with UUI 
occurrence. Risk factors also include de-
mentia, loss of higher cognitive functions 
and depression (20).
2 Initial assessment of patients 
with urinary incontinence
The initial management of patients with 
disorders of the pelvic floor function con-
sists of a urogynaecological history with 
analysis of a bladder diary, urine analysis 
and clinical examination. The goal of the 
focused urogynaecological history is to 
identify the patient’s main symptoms and 
signs and their duration, characteristics 
and effect on their quality of life. The pa-
tient should be asked about the severity of 
these symptoms, their onset and trigger-
ing factors. The amount and the type of 
fluid consumed during the day should be 
278
OBSTETRICS, GYNAECOLOGY, ANDROLOGY, REPRODUCTION, SEXUALITY
Zdrav Vestn | May – June 2021 | Volume 90 | https://doi.org/10.6016/ZdravVestn.3028
established. Complete gynaecological his-
tory and information regarding concomi-
tant medical issues, previous surgery and 
any allergies should also be obtained. The 
bladder diary can also be analyzed, as it 
provides valuable information regarding 
the patient’s frequency, incontinence epi-
sodes, pad use, fluid intake, and degree of 
urgency and incontinence (21). By taking 
a history, we try to identify problems, en-
abling us to choose further diagnostic in-
vestigations. Standardized questionnaires 
are sometimes used, especially to quantify 
symptoms. One of them, the International 
Consultation on Incontinence Modular 
Questionnaire – Urinary Incontinence 
Short Form (ICIQ-UI SF), has been trans-
lated, modified and validated for the 
Slovenian language (22,23). History is 
followed by a clinical examination, which 
consists of a general physical examina-
tion, abdominal examination and vaginal 
examination with POP and PFM assess-
ment. We recommend using the Pelvic 
Organ Prolapse quantification score 
(POP-Q) for POP assessment, which is 
recognized and organized by the ICS (22). 
PFM strength is assessed by digital palpa-
tion, with contraction strength assessed 
either according to the six-level Oxford 
scale or four levels of PFM strength. 
Because of the high prevalence of urinary 
tract infections in women with lower uri-
nary tract symptoms, urine analysis, uri-
nary culture and post-void residual eval-
uation represent an indispensable part of 
the initial assessment of these patients. 
The algorithm of the initial assessment of 
patients with UI is shown in Figure 1.
Urodynamic measurements are an im-
portant part of the diagnostic process in 
patients with complicated UI. These en-
able us to see the functional capabilities 
of the lower urinary tract – evaluation of 
urethral sphincter power and bladder wall 
activity. We can measure urethral pressure 
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at rest and during physical activity and in-
travesical pressure during bladder filling 
with normal saline.
The ICS specifies standard and addi-
tional urodynamic measurements (24). 
Standard measurements include uro-
flowmetry, post-void residual evaluation, 
cystometry and pressure-flow study. An 
EMG can be added to urodynamic mea-
surements with certain indications, along 
with imaging and urethral pressure pro-
file. Cystometry can also be performed via 
the suprapubic catheter (13,21,22,23,24).
Deciding on conservative or surgical 
treatment approach depends predom-
inantly on the severity of UI and on co-
morbidities. Before surgery is recom-
mended, we need to be certain which type 
of UI the patient has and if surgery is even 
required. It is important to know whether 
UI is primary or secondary. Conservative 
treatment should be exhausted, and be-
fore surgery is proposed, certain factors 
must be taken into account – the patient’s 
age, general condition and health, prior 
surgeries, and especially the gynaecologi-
cal and lower urinary tract status (19).
2.1 Treatment of stress 
urinary incontinence
2.1.1 Conservative treatment
Indications for treatment include mild 
and moderate SUI, treatment before and 
after surgery, severe SUI with an absolute 
contraindication for surgery and mixed 
forms of UI. Conservative treatment in-
cludes lifestyle changes, PFM strengthen-
ing exercises, pharmacological treatment 
with alpha agonists and oestrogens, func-
tional electrostimulation, magnetic stim-
ulation and pessaries. We do not use the 
latter for treatment, only for symptomatic 
relief (2,13,19,26).
PFM strengthening exercises are the 
oldest form of treatment of UI in women. 
279
PROFESSIONAL ARTICLE
Urinary incontinence treatment algorithm
established. Complete gynaecological his-
tory and information regarding concomi-
tant medical issues, previous surgery and 
any allergies should also be obtained. The 
bladder diary can also be analyzed, as it 
provides valuable information regarding 
the patient’s frequency, incontinence epi-
sodes, pad use, fluid intake, and degree of 
urgency and incontinence (21). By taking 
a history, we try to identify problems, en-
abling us to choose further diagnostic in-
vestigations. Standardized questionnaires 
are sometimes used, especially to quantify 
symptoms. One of them, the International 
Consultation on Incontinence Modular 
Questionnaire – Urinary Incontinence 
Short Form (ICIQ-UI SF), has been trans-
lated, modified and validated for the 
Slovenian language (22,23). History is 
followed by a clinical examination, which 
consists of a general physical examina-
tion, abdominal examination and vaginal 
examination with POP and PFM assess-
ment. We recommend using the Pelvic 
Organ Prolapse quantification score 
(POP-Q) for POP assessment, which is 
recognized and organized by the ICS (22). 
PFM strength is assessed by digital palpa-
tion, with contraction strength assessed 
either according to the six-level Oxford 
scale or four levels of PFM strength. 
Because of the high prevalence of urinary 
tract infections in women with lower uri-
nary tract symptoms, urine analysis, uri-
nary culture and post-void residual eval-
uation represent an indispensable part of 
the initial assessment of these patients. 
The algorithm of the initial assessment of 
patients with UI is shown in Figure 1.
Urodynamic measurements are an im-
portant part of the diagnostic process in 
patients with complicated UI. These en-
able us to see the functional capabilities 
of the lower urinary tract – evaluation of 
urethral sphincter power and bladder wall 
activity. We can measure urethral pressure 
Fi
gu
re
 1
: I
ni
tia
l a
ss
es
sm
en
t o
f p
at
ie
nt
 w
ith
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rin
ar
y 
in
co
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in
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. S
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Zdrav Vestn | May – June 2021 | Volume 90 | https://doi.org/10.6016/ZdravVestn.3028
In 1948, the American gynaecologist 
Arnold Kegel published instructions on 
how to strengthen the detrusor muscle 
with PFM strengthening exercises. The 
idea was not novel, as similar exercises 
are found in several traditional and East 
Asian cultures. Kegel recommended the 
exercises for the prevention and treatment 
of SUI (after childbirth, in menopause). 
With the development of modern phys-
ical therapy, these exercises differ from 
the ones described by Kegel, although the 
term “Kegel exercises” is still in use for 
PFM strengthening exercises. They con-
sist of voluntary contraction and relax-
ation of PFM, including of the detrusor 
muscle. Active exercising increases their 
strength and endurance. In turn, this in-
creases the power of the urethral sphincter 
if the intra-abdominal pressure suddenly 
rises (13). Adequate PFM exercises pro-
vide good structural support to the pelvis. 
Despite detailed and exhaustive individu-
al instructions, a third of women do not 
perform the exercises correctly after their 
first appointment; therefore, before start-
ing the exercises, it should be confirmed 
that the patient knows how to perform 
them correctly. PFM exercises can be per-
formed independently or in combination 
with other methods and techniques (26).
2.1.2 Surgical treatment
When conservative treatment fails, we 
opt for surgical treatment. Indications are 
severe SUI, failure of conservative treat-
ment and MUI with a predominance of 
SUI signs. When choosing a surgical app-
roach, it should be noted that two thirds 
of patients with SUI have to a certain ex-
tent altered statics of the pelvic organs and 
pelvic floor. As quality of life is in ques-
tion, we decide on the surgical approach 
that will eliminate the most pronounced 
symptoms and signs to the greatest ex-
tent. Depending on the approach, we 
distinguish between vaginal, retropubic, 
combined (vaginal and abdominal app-
roach) and endoscopic (laparoscopic and 
needle suspension) surgery (5).
Tension-free vaginal tape (TVT) sur-
gery for treating SUI was first described 
by Ulmsten in 1996 (1). Since then, it has 
become a gold standard for the surgical 
treatment of SUI worldwide (4). The suc-
cess rate is 84–95%, but the procedure is 
connected with possible complications, 
such as damage to the bladder, urethra, 
intestine or large vessels. After the pro-
cedure, 8–17 % of patients experience 
temporary urinary retention and 5–15% 
(27%) urgency. To avoid complications 
connected with the retropubic approach, 
Delorme introduced the transobturator 
approach. By inserting the tape through 
the obturator muscle, we compensate for 
the weakness of the endopelvic fascia and 
at the same time avoid intrapelvic and ret-
ropubic blind punctures, thus reducing 
the risk of damage to the bladder, intes-
tine and large vessels (5,27).
In recent years, physicians, national 
supervisory institutions, the media and 
various internet pages with information 
for patients have been warning of com-
plications following the use of synthetic 
meshes used in the surgical treatment of 
SUI and POP. They warn of possible com-
plications that additionally worsen the 
patient’s quality of life – including mesh 
exposure, chronic pain, dyspareunia and 
infections. In March 2017, a report was 
published on the results of an indepen-
dent Scottish study on the use, safety and 
efficacy of surgical meshes in the trans-
vaginal treatment of SUI and POP, reveal-
ing that the use of tension-free vaginal 
tape is a suitable solution only for SUI 
treatment (28). Morlin et al. (29) conduct-
ed a cohort study in 16,000 women who 
underwent their first surgery to treat UI 
or POP with a mesh or colposuspension. 
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Urinary incontinence treatment algorithm
Surgical procedures involving a mesh 
had less risk for immediate postoperative 
complications (relative risk: 0.44) and also 
for subsequent surgery for the treatment 
of POP. Due to inconsistent reports that 
affect media opinion and the position of 
lawyers and patients, multiple national 
organizations have recommended that 
patients be thoroughly informed of all 
risks connected to these procedures and 
consistently informed of conservative 
treatment options and other available 
surgical approaches. They stressed that 
surgical approaches which use a mesh are 
successful if they are used in appropriate 
patients and with suitably qualified sur-
geons (28,29,30).
Despite this, due to numerous patient 
lawsuits due to complications, TVT sur-
gery for treatment of SUI and POP was 
banned in Great Britain, Australia and 
New Zealand. In these countries, laparo-
scopic Burch colposuspension is now the 
main form of surgical treatment. The sur-
gery was first described in the literature 
by John Christopher Burch (1900–1977) 
in 1961 and was the most common sur-
gical approach for the treatment of SUI 
until the 1990s due to its high success rate 
of up to 86%. Surgical correction of the 
position of the bladder neck achieved by 
Burch colposuspension returns the proxi-
mal urethra to its original position behind 
the symphysis. It is an indirect suspension 
of the bladder neck as the paravaginal fas-
cia is lifted, that is the part of the endopel-
vic fascia of the paraurethral part of the 
vagina, leaving the urethra free and mo-
bile (5,29).
According to the European Association 
of Urology (EAU), treatment of SUI with 
colposuspension (open or laparoscopic) 
is only recommended if TVT surgery is 
banned. The British National Institute for 
Health and Clinical Excellence (NICE) 
guidelines state that treatment of SUI 
with colposuspension, TVT or autologous 
fascial sling is the first choice among the 
surgical approaches, but that laparoscop-
ic colposuspension should only be per-
formed by an experienced laparoscopic 
surgeon working with a multidisciplinary 
team (28,29,31,32).
SUI can also be treated by injecting 
various substances under the proximal 
urethra mucosa or into the bladder neck. 
The bulking agent can be injected via 
the transurethral approach or under the 
paraurethral mucosa to lift it and thus 
achieve better regulation and higher ure-
thral closing pressure. The ideal bulking 
agent should be easy to inject, biologically 
compatible and not leak into its surround-
ings or cause local inflammation (28,33).
According to EUA guidelines, bulking 
agents should not be offered to patients 
who expect a long-term cure; as they only 
improve SUI symptoms for short periods, 
retreatments are necessary. NICE guide-
lines recommend treatment with bulking 
agents, but they warn of short-term treat-
ment success and the need for repeat in-
jections (28,31,32).
2.1.3 Other treatment approaches
Recently, laser treatment of SUI and 
its therapeutic role have been at the fore-
front of research. In 2019, the Canadian 
agency responsible for national health 
policy (Health Canada), as the first in the 
world to do so, confirmed the use of laser 
for SUI treatment, vulvovaginal atrophy 
and genitourinary syndrome of meno-
pause (34). Despite studies (35,36,37,38) 
that have confirmed subjective and ob-
jective improvement of the symptoms 
of patients with SUI, the International 
Urogynaecological Association (IUGA) 
warns against the use of this meth-
od in everyday clinical practice due 
to the lack of quality evidence in the 
form of multicentric, randomized and 
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placebo-controlled studies. The thera-
peutic advantages of laser photothermal 
non-ablative treatment in urogynaecol-
ogy should only be recommended when 
additional clinical studies show long-term 
success, safety and efficacy (39).
2.2 Treatment of urge 
urinary incontinence
2.2.1 Conservative treatment
While in many cases, treatment of SUI 
is surgical, the treatment of UUI is most-
ly conservative. Every woman with UI 
should first be educated about the nature 
of the disease, the possibilities of self-help 
and procedures to promote a healthy life-
style as part of conservative management. 
We can partially affect the pathogenesis 
and symptoms of UI with lifestyle chang-
es and advice on reducing body mass in-
dex, eliminating constipation, lowering 
intake of carbonated beverages and caf-
feine, and with advice on quitting smok-
ing, the correct position for micturition 
and defecation, the correct techniques 
for lifting heavy weights, and recreational 
and sports activities (1,3,19,20,22).
As an addition to conservative ap-
proaches, treatment with magnetic 
stimulation could be offered to patients. 
Current EUA recommendations advise 
against treating UI or OAB with magnetic 
stimulation (strength of recommendation 
– strong). Despite this, the recent me-
ta-analysis by Qing He et al. (40) conclud-
ed that magnetic treatment is an effective 
therapeutic method for patients with UI. 
Numerous studies (41,42,43,44,45) show 
improvement in UI symptoms and im-
provement in quality of life for individ-
ual patients. With this method, patients 
with UI who are perhaps not motivated 
to perform regular PFM strengthening 
exercises can be conservatively treat-
ed. Still, Qing He concludes that further 
large, randomized control studies are 
necessary to define consistent protocols 
and standardize outcome measurements 
to generate comparable data. Longer ob-
servation periods and cost-benefit analy-
sis are needed to confirm treatment effi-
cacy with magnetic stimulation (40).
2.2.2 Pharmacological treatment
Pharmacological treatment is usu-
ally combined with bladder train-
ing and functional electrostimulation. 
Medication doses can be determined 
based on treatment success and possible 
side effects. These drugs are characterized 
by affecting the entire nervous system, 
and, as such, they have numerous side 
effects, including negative ones (46,47). 
For symptomatic treatment of UUI and/
or OAB, antimuscarinic agents (solifena-
cin, oxybutynin and tolterodine) and mi-
rabegron are used. Antimuscarinic agents 
work as competitive and specific antago-
nists of cholinergic receptors, as the blad-
der is innervated by parasympathetic 
cholinergic nerves. Acetylcholine con-
tracts the detrusor muscle by activating 
the M3 muscarinic receptors, and anti-
muscarinic agents work as their compet-
itive inhibitors. Mirabegron relaxes the 
smooth muscle of the bladder, increases 
the concentration of cyclic adenosine 
monophosphate (cAMP) in the bladder 
tissue and relaxes the detrusor muscle. 
Mirabegron improves the storage of urine 
by stimulating the beta-3 adrenergic re-
ceptors in the bladder (47). We can also 
treat UUI pharmacologically with oes-
trogens (because of urethral and vaginal 
mucosa changes due to hypoestrogenae-
mia in menopause), prostaglandin inhib-
itors and tricyclic antidepressants (5,31).
283
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Urinary incontinence treatment algorithm
2.2.3 Percutaneous stimulation 
of the posterior tibial nerve
Percutaneous electrical stimulation of 
the posterior tibial nerve (PTNS) affects 
the inhibition of the parasympathetic 
nervous pathway and stimulation of the 
sympathetic pathway (48). This increases 
the bladder capacity at the first involun-
tary contraction of the detrusor muscle 
(49,50). The treatment protocol includes 
the percutaneous insertion of electrodes 
in the immediate vicinity of the nerve. 
Treatment consists of 30-minute weekly 
sessions for a total of 12 weeks. Despite 
promising results described in the liter-
ature, there are still insufficient clinical 
studies evaluating long-term treatment 
success. According to NICE and EUA 
guidelines, PTNS is used as one of the 
possibilities of invasive management of 
UUI in patients in whom conservative 
treatment has failed and who do not opt 
for treatment with botulinum toxin in-
jections or sacral neuromodulation or 
have contraindications to both treatment 
methods (28,31,32,50).
2.2.4 Botulinum toxin A injections
Injection of botulinum toxin A, a pow-
erful neurotoxin, into the bladder wall is 
currently recommended for patients with 
OAB with or without UUI and who have 
not responded well to conservative or 
pharmacological treatment. The toxin is 
injected into the detrusor muscle using a 
flexible or rigid cystoscope with local or 
general anaesthesia. The main side effects 
include urinary tract infections, incom-
plete bladder emptying and temporary 
urinary retention (28,51,52).
Due to the availability of high-quality 
data, most guidelines recommend the use 
of onabotulinum A toxin for the treat-
ment of resistant OAB symptoms. NICE 
guidelines recommend a starting dose 
of 200 units in patients with a proven 
overactive detrusor, while the EUA guide-
lines recommend a starting dose of 100 
units. Patients should be made aware that 
there is a 5% risk of urinary retention fol-
lowing the procedure that would require 
occasional clean self-catheterization and 
repeated injections every 6–9 months, 
and that there is an increased risk of uri-
nary tract infections (28,31,32).
2.2.5 Other forms of treatment
Surgery in patients with UUI is very 
rarely indicated when conservative treat-
ment is exhausted and the UUI is very se-
vere. Due to the intertwining of aetiologi-
cal-pathogenetic factors in the formation 
of UUI and the lack of efficacy of surgical 
treatment, other forms of treatment are 
being tested, such as sacral neuromodula-
tion and alternative methods of treatment 
(acupuncture, hypnotherapy, homeopa-
thy) (28).
NICE guidelines currently recom-
mend the use of sacral neuromodulation 
in patients who do not respond to con-
servative treatment, including pharmaco-
logical treatment, and are not capable of 
occasional clean self-catheterization (and 
are thus not suitable for botulinum A tox-
in injections). The EAU guidelines recom-
mend the use of sacral neuromodulation 
as an alternative equivalent to botulinum 
A toxin injections in patients with UUI 
who do not respond to pharmacological 
treatment (28,31,32).
3 Mixed urinary incontinence
MUI is defined as the complaint of in-
voluntary leakage of urine associated with 
urgency and exertion, effort, sneezing, or 
coughing. A different ratio of UUI and 
SUI is seen in every patient with MUI. We 
thus differentiate between urge-predom-
inant MUI and stress-predominant MUI 
(5,19).
284
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Zdrav Vestn | May – June 2021 | Volume 90 | https://doi.org/10.6016/ZdravVestn.3028
MUI is the second most common type 
of UI. As with other types of UI, the data 
on prevalence differ between studies. Its 
prevalence is estimated at 20–36%, and 
the trend is increased prevalence with age 
(8,9). Diagnostic investigations are similar 
to those for other types of UI. Treatment 
is adjusted according to the leading and 
most bothersome symptoms, either urge- 
or stress-related. In any case, treatment is 
conservative at first and surgical if the for-
mer fails (20,28,31,32).
4 Conclusion
Basic management of patients with 
pelvic floor dysfunction is complicated as 
various gynaecological, medical, urolog-
ical and neurological diseases affect the 
symptoms and signs of these disorders. 
A detailed urogynaecological history 
together with a clinical examination is the 
cornerstone of our diagnostic procedure. 
Due to the high prevalence of these dis-
orders in the general female population, it 
is crucial that all gynaecologists learn the 
basics of urogynaecological management 
during their training. Treatment should 
start with simple general advice –“healthy 
habits for a healthy bladder”. Only after 
conservative treatment has been exhaust-
ed do we offer the patient surgery. The 
goal of treatment is to improve quality 
of life. Therefore, when choosing treat-
ment, especially surgical, the patient’s co-
operation is important, especially a good 
understanding of possible failure and 
complications. The physician’s duty is to 
explain the proposed treatment to the pa-
tient and explain to the patient what MUI 
means.
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