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Stress-predominant mixed urinary incontinence — MSRA MCQ

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HardLUTSStress-predominant mixed urinary incontinenceMSRA

A 52-year-old woman has stress-predominant mixed urinary incontinence. Her urgency and frequency improved satisfactorily after an 8-week supervised bladder-training programme. She continues to leak several times daily when coughing, running or lifting; she has no leakage preceded by urgency. A 3-day bladder diary supports stress-predominant symptoms. Urine dipstick is negative. Pelvic examination shows no anterior or apical prolapse, and cough testing with a comfortably full bladder demonstrates stress leakage. She has no hesitancy, poor stream, incomplete emptying or recurrent UTI. She completed 4 months of supervised pelvic floor muscle training with confirmed correct contraction and good adherence, without worthwhile improvement in stress leakage. She has had no previous continence surgery, has completed her family and wishes to consider definitive surgical treatment. What is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Refer for local multidisciplinary-team review for primary stress-incontinence surgery without routinely arranging multichannel cystometry

This woman has stress-predominant mixed incontinence: urgency symptoms have responded to bladder training, while objectively demonstrated stress leakage remains troublesome despite an adequate supervised pelvic floor muscle training trial. She is therefore appropriate for referral to the local MDT/urogynaecology pathway to discuss primary surgical treatment. Routine multichannel cystometry is not indicated before primary surgery where stress or stress-predominant mixed incontinence is established by detailed history and stress leakage is demonstrated on examination. Cystometry would become appropriate if urge symptoms predominated, the diagnosis were unclear, there were voiding symptoms, anterior/apical prolapse or previous stress-incontinence surgery. Solifenacin targets overactive bladder symptoms; these are no longer troublesome and it would not treat her exertional leakage. Duloxetine can be considered second-line when a woman prefers pharmacological treatment to surgery or is unsuitable for surgery, neither of which applies here. Repeating pelvic floor muscle training is not the best next step because she has already completed a longer-than-recommended, supervised and adherent programme without meaningful benefit.

Reference: Urinary incontinence and pelvic organ prolapse in women: management (NICE NG123) (Updated February 2025) — https://www.nice.org.uk/guidance/ng123/resources/urinary-incontinence-and-pelvicorgan-prolapse-in-women-management-pdf-66141657205189 Urinary incontinence and pelvic organ prolapse in women: management – Recommendations (NICE NG123) (2019; minor update February 2025) — https://www.nice.org.uk/guidance/ng123/chapter/Recommendations Urinary incontinence in women – NICE quality standard QS77 (Updated December 2021) — https://www.nice.org.uk/guidance/qs77/chapter/Quality-statements