Release: Surgery may benefit women with two types of urinary incontinence

NIH-funded study contrasts with current treatment guidelines

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Surgery for stress urinary incontinence (leaking that occurs with a cough or sneeze) improves symptoms of another form of incontinence, called urgency urinary incontinence, in women who have both types, according to a study supported by the National Institutes of Health. The findings challenge current treatment guidelines, which suggest that the surgery may worsen urgency urinary incontinence in women with both forms, also called mixed urinary incontinence. The study appears in the Journal of the American Medical Association. Funding was provided by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and Office of Research on Women’s Health.

“Women with mixed urinary incontinence may have more bothersome symptoms than women with either stress or urgency urinary incontinence alone,” said Donna Mazloomdoost, M.D., study author and program director of the NICHD Pelvic Floor Disorders Network. “The findings show promise in treating a condition that can be hard to manage under existing practices.”

Roughly one-third to one-half of all women with urinary incontinence have mixed urinary incontinence. Urgency urinary incontinence results from the spontaneous contraction of bladder muscles, leading to a strong and sudden need to urinate. Stress urinary incontinence occurs when urine leaks out after abdominal pressure increases following a sneeze, cough, laugh or movement, which squeezes the bladder.

Standard treatment guidelines for mixed urinary incontinence often involve treating the two forms of incontinence independently. Urgency urinary incontinence often is first treated with behavioral techniques, such as trying to delay urinating for a brief period after feeling the urge, reducing liquid consumption, exercises to strengthen muscles around the bladder (involving pelvic floor physical therapy) and with medication. Surgery is not usually recommended early on. Stress incontinence also can be treated with exercises, and many women experience symptom improvement. However, in women who do not improve or opt out of the exercises, surgery may be offered.

The Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) study is a randomized clinical trial that recruited 480 women with mixed urinary incontinence at centers across the United States. All participants underwent mid-urethral sling surgery, a well-established method that places a thin strip of mesh under the urethra; this helps prevent urine from leaking out during an exertion, such as a sneeze or cough. Participants were randomized to surgery alone or surgery with behavioral and pelvic floor muscle therapy, which included six visits with a trained health professional. They were followed for one year.

The women responded to a questionnaire, the urogenital distress inventory (UDI), which inquired about urinary symptoms. Symptoms are ranked from 0-300 points, depending on severity. They also responded to surveys on quality of life and perceptions of surgical success.

The study team found that both groups had significant improvements in their incontinence symptoms after surgery. The average UDI score for the surgery alone group was 176.8 before surgery and 40.3 a year after surgery; for the surgery and therapy combined group, the UDI score dropped from 178.0 to 33.8. According to the researchers, because the post-treatment UDI scores between the two groups did not differ greatly, adding behavioral and pelvic floor muscle therapy to the treatment may not result in better clinical outcomes.

However, the study team did find differences in other self-reported outcomes. The combined surgery and physical therapy group had fewer instances of incontinence a year after surgery and were less likely to receive additional treatment for urinary tract symptoms, suggesting they had more quality of life improvement than the surgery alone group.

“Current practice guidelines may be unnecessarily delaying surgery for women with mixed urinary incontinence,” said Vivian W. Sung, M.D., M.P.H., the study’s lead author and a professor at the Alpert Medical School of Brown University. “We hope these findings will improve how patients are counseled and treated.”

The researchers called for additional research to identify which patients with mixed urinary incontinence are at risk for continued symptoms after surgery and to identify effective treatments for them.


Sung VW et al., Effect of behavioral and pelvic floor muscle therapy combined with surgery vs. surgery alone on incontinence symptoms among women with mixed urinary incontinence: the ESTEEM randomized clinical trial. Journal of the American Medical Association DOI: 10.1001/jama.2019.12467 (2019)


About the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): NICHD leads research and training to understand human development, improve reproductive health, enhance the lives of children and adolescents, and optimize abilities for all. For more information, visit

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit

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