Balancing Midurethral Sling vs OnabotulinumtoxinA for Mixed Urinary Incontinence

Mixed urinary incontinence presents a clinical conundrum. Patients with mixed urinary incontinence report symptoms of both stress incontinence (loss of urine with exertion) and urge incontinence (loss of urine with urgency). Mixed urinary incontinence is a combination of the two that affects 37% of women older than age 65 years. The personal and societal costs of incontinence are significant. In women with symptoms of severe urinary incontinence, the cost of supplies, laundry, and dry cleaning range from $900 to $4000 annually. By 80 years of age, 20% of women will undergo surgery for stress or mixed urinary incontinence. Physical and behavioral therapy improves both incontinence types, and medications are standard treatment for urgency urinary incontinence. When conservative therapies fail, conventional guidance has been to treat the urgency prior to the stress component of mixed incontinence, because anti-incontinence surgical procedures can worsen urgency incontinence, and many urgency treatments are medical rather than surgical. Another strategy has been to treat whichever symptom is dominant.