Understanding Mixed Urinary Incontinence in Women
Mixed urinary incontinence is common, and it’s harder to sort out than either type of leakage alone. Below are the causes, the symptoms, and how we decide what to treat first.
What is Mixed Urinary Incontinence?
Mixed urinary incontinence (MUI) means you have symptoms of both stress urinary incontinence (SUI) and urge urinary incontinence (UUI). You leak urine in two different situations:
- When something puts pressure on the bladder (coughing, sneezing, laughing, or exercise)
- When you feel a sudden, strong urge to urinate that’s difficult to control
How Common is Mixed Urinary Incontinence?
Mixed incontinence is common:
- Affects approximately 30-40% of women with incontinence
- Prevalence increases with age
- Often underreported due to embarrassment or misconceptions about it being a normal part of aging
Mixed incontinence is common, but it is not a normal part of aging or an unavoidable result of childbirth. It’s a medical condition, and it can be managed effectively with treatment.
Causes and Risk Factors
The causes of mixed incontinence are a combination of factors that contribute to both stress and urge incontinence:
- Weakened pelvic floor muscles: Often due to pregnancy, childbirth, or menopause
- Neurological issues: Affecting nerve signals between the brain, the bladder, and the pelvic floor muscles
- Hormonal changes: Particularly during menopause
- Obesity: Excess weight puts additional pressure on the pelvic floor
- Chronic conditions: Such as diabetes or multiple sclerosis
- Previous pelvic surgeries: Including hysterectomy
- Lifestyle factors: Including smoking, excessive caffeine or alcohol consumption
Symptoms of Mixed Urinary Incontinence
The symptoms of mixed incontinence combine those of stress and urge incontinence:
- Leaking urine when coughing, sneezing, laughing, or during physical activity
- Sudden, strong urges to urinate that are difficult to control
- Leaking large amounts of urine before reaching the bathroom
Mixed incontinence also often travels with other symptoms:
- Frequent urination (more than 8 times in 24 hours)
- Nocturia (waking up to urinate at night)
Diagnosis
If you have symptoms of mixed incontinence, see a healthcare provider. Diagnosis typically involves:
- Medical history: Your doctor will ask about your symptoms, medical background, and lifestyle
- Physical examination: To check for any physical abnormalities or pelvic organ prolapse
- Urinalysis: To rule out urinary tract infections or other issues
- Bladder diary: You may be asked to keep a log of your fluid intake, urination frequency, and incontinence episodes
- Urodynamic testing: In some cases, to measure bladder pressure and urine flow
- Cystoscopy: A small camera may be used to examine the inside of your bladder and urethra
Treatment Approach
The two types of incontinence often need different treatments, so the usual strategy is to:
- Identify which type of incontinence (stress or urge) is more bothersome
- Treat the most bothersome type first
- Address the other type of incontinence if symptoms persist
Important Note
In most cases, the urge component is treated first because it often involves large volume leaks and can be more disruptive to daily life.
If you’re not sure which type bothers you more, keep a detailed bladder diary. It shows how often each kind of leak happens and how bad it is.
Treatment Options
Treatment often combines several of these:
Conservative Treatments
- Pelvic floor exercises (Kegels): Strengthen the muscles that support your bladder
- Bladder training: Techniques to increase the time between feeling the urge to urinate and passing urine
- Biofeedback: Helps you identify and control your pelvic floor muscles
- Pelvic floor physical therapy: Therapy with a pelvic floor physical therapist that combines exercises, manual therapy, and education to improve pelvic floor function and bladder control
Lifestyle Changes
- Weight loss: If overweight, losing excess pounds can reduce pressure on the bladder
- Fluid management: Avoiding bladder irritants like caffeine and alcohol
- Scheduled toilet trips: Going to the bathroom at set times, rather than waiting for the urge
Medications
- Anticholinergics or beta-3 agonists: For urge symptoms
- Topical estrogen: For postmenopausal women, may help improve urethral and vaginal tissue health and decrease bladder irritation
Devices and Products
- Vaginal pessaries: Support devices inserted into the vagina to reduce stress incontinence
- Disposable vaginal inserts: Small tampon-like devices inserted into the vagina before activities
- Absorbent products: Pads or protective underwear for managing leaks
Advanced Therapies
- BOTOX injections: Can help relax the bladder muscle for urge symptoms
- Percutaneous or implanted tibial nerve stimulation: A form of neuromodulation that may improve bladder control in patients with urge symptoms
- Sacral neuromodulation: Implanted device that stimulates the nerves controlling the bladder; it can help with urge urinary incontinence (and fecal incontinence)
- Bulking agents: Substances injected around the urethra to help close the sphincter and improve stress incontinence
Surgical Options
- Sling procedures: For stress incontinence symptoms
- Colposuspension: Another option for stress incontinence
A note on surgery and urge symptoms
Surgery for the stress component does not always relieve urgency, and persistent urge symptoms are the most common reason women need further treatment after a sling. Adding pelvic floor muscle therapy around the time of sling surgery can reduce urgency symptoms and lower the chance of needing more treatment later.
Remember
Treatment plans differ from one woman to the next. Your provider will work with you to find the approach that fits your situation.
Living with Mixed Urinary Incontinence
While you’re getting treatment, these steps can make daily life easier:
- Use absorbent products for peace of mind
- Wear easily removable clothing for quick bathroom access
- Locate bathrooms before you need them when out in public
- Practice both pelvic floor exercises and relaxation techniques
- Stay hydrated, but limit fluids before bedtime and activities
What to Do Next
If you’re experiencing symptoms of mixed urinary incontinence:
- Don’t be embarrassed. It’s a common, treatable medical condition
- Keep a detailed bladder diary to share with your healthcare provider
- Schedule an appointment with a urogynecologist or pelvic health specialist
- Be open about your symptoms and how they affect your quality of life
3-day diary
Download and print three copies of the bladder diary to bring to your first visit with Dr. Stewart. This will help us better understand your symptoms and develop a treatment plan that works for you.
References
- Sung VW, Borello-France D, Newman DK, 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. JAMA. 2019. doi:10.1001/jama.2019.12467
- Sung VW, Richter HE, Moalli P, et al. Characteristics Associated With Treatment Failure 1 Year After Midurethral Sling in Women With Mixed Urinary Incontinence. Obstetrics & Gynecology. 2021. doi:10.1097/AOG.0000000000004444
- Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Current Opinion in Obstetrics and Gynecology. 2019. doi:10.1097/GCO.0000000000000584