Mixed Urinary Incontinence

Stress vs urge leaks

In mixed incontinence, both mechanisms are present, though one usually bothers the person more. See stress incontinence and urge incontinence for each type in detail.

Causes and risk factors

• pregnancy and vaginal childbirth, which stretch and weaken the pelvic floor
• menopause, with thinning of the urethra and bladder tissues
• aging
• obesity, which increases pressure on the bladder
• chronic cough, constipation and heavy lifting
• pelvic organ prolapse
• neurological conditions such as multiple sclerosis or stroke
• prostate surgery in men
• bladder irritants: caffeine, alcohol, fizzy drinks and artificial sweeteners

Diagnosis

• history: which leaks are more frequent and bothersome, fluid intake, medicines, pregnancies and surgeries
• bladder diary for 3 days: fluids, urination times and leaks
• urine test to rule out infection and blood
• pelvic examination with a cough test, and assessment for prolapse and vaginal atrophy
• post-void residual measurement by ultrasound to check emptying
• validated questionnaires to measure how much each type bothers you
• urodynamic testing before surgery or when the diagnosis is unclear

Treatment

Start with conservative treatments, which help both types.

Pelvic floor muscle training

Squeeze the muscles you use to stop urine and wind, hold for up to 10 seconds, relax fully, and repeat 10 times, 3 times a day, for at least 3 months. Quick squeezes help with urges and before coughing. A pelvic floor physical therapist can check technique and may use biofeedback.

Bladder training

Urinate on a schedule and gradually increase the time between trips. When an urge strikes, stop, squeeze the pelvic floor several times, breathe and wait for the urge to pass before walking calmly to the toilet.

Lifestyle

• lose weight if overweight. Even 5% to 10% weight loss reduces leaks
• limit caffeine, alcohol and fizzy drinks
• drink enough fluids, but avoid large volumes at once and in the evening
• treat constipation and chronic cough
• stop smoking

Medicines and devices

• beta-3 agonists (mirabegron, vibegron) or anticholinergics for urge symptoms. Anticholinergics may affect memory in older adults
• vaginal estrogen for women after menopause
• pessaries or urethral inserts to support the urethra during activity

Procedures

• Botox injections into the bladder muscle for urge symptoms not controlled by medicines
• nerve stimulation: tibial nerve stimulation or sacral neuromodulation
• midurethral sling surgery or other procedures for stress leaks. In mixed incontinence, surgery cures the stress component well, and urge symptoms improve in many but not all people

Outlook

Most people improve significantly with combined treatments. Regular pelvic floor exercise maintains benefits. Continence products such as pads and protective underwear can help in the meantime.

Frequently asked questions

What is mixed incontinence?

Mixed incontinence is bladder leakage with features of both stress incontinence, leaking during coughing, sneezing or exercise, and urge incontinence, leaking after a sudden strong need to urinate. It is especially common in women after childbirth and menopause.

What causes mixed urinary incontinence?

It results from a weak pelvic floor and urethral support, which causes stress leaks, combined with an overactive bladder muscle, which causes urge leaks. Childbirth, menopause, aging, obesity, chronic cough, constipation and some neurological conditions contribute.

How is mixed incontinence treated?

Treatment usually starts with pelvic floor muscle training, bladder training and lifestyle changes. Bladder medicines treat urge symptoms, and vaginal estrogen helps after menopause. Pessaries, Botox, nerve stimulation and sling surgery are options when needed.

Which type of incontinence should be treated first?

Doctors usually treat the type that bothers you most. Pelvic floor exercises help both types and are tried first. If stress leaks are worse and you consider surgery, urge symptoms are often treated first, because surgery mainly fixes the stress component.

Can mixed incontinence be cured?

Many people become dry or nearly dry with treatment, especially when combining pelvic floor training, bladder training and targeted medicines or procedures. Symptoms may return without ongoing exercise, so maintenance matters.