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Mixed Urinary Incontinence

Mixed urinary incontinence (MUI) is involuntary urine loss associated with both urgency and exertion, effort, sneezing, or coughing.[1][2] It is the coexistence of stress urinary incontinence or male sphincteric leakage with urgency urinary incontinence / OAB. The central question is which component is driving bother, risk, and treatment failure.

Classification​

The useful clinical classification is symptom predominance:[1]

SubtypeDominant complaintUsual first target
Stress-predominant MUILeakage with cough, lifting, exercise, standing, or position change is more frequent or more bothersomePelvic floor muscle training (PFMT); consider anti-incontinence surgery if persistent
Urgency-predominant MUIUrgency, frequency, nocturia, and UUI episodes are more frequent or more bothersomeBladder training, OAB medication, or OAB procedures
Equal-predominance MUIBoth components are similarly bothersome or difficult to separateCombined behavioral therapy; staged escalation based on diary and patient goals

Predominance is not fixed. A patient may begin as urgency-predominant, improve with OAB therapy, and then become most bothered by residual stress leakage; another may have sling surgery and later reveal persistent urgency that was masked by severe SUI.

Epidemiology and Impact​

MUI is common and becomes more prevalent with age.[3][4] In NHANES 2017–2018, stress UI was the most common reported subtype, followed by urgency UI and MUI; the survey estimated MUI in 18.1% of all adult US women, rising to 31.4% among women aged 60 years or older.[4] National estimates from the Urologic Diseases in America Project similarly show a large population burden of female UI, with mixed symptoms representing a clinically important subset.[5]

In a cross-sectional survey of 346 women aged 30–64 attending primary care in Tacna, Peru, slight or moderate quality-of-life impact was reported by 63/169 with MUI, 17/86 with isolated SUI, and 3/25 with isolated UUI.[6] Patients may need to manage both urgency-associated and exertional leakage.[1][6]

Pathophysiology​

MUI combines urethral failure and bladder storage failure.

Stress component​

  • Urethral hypermobility. Loss of vaginal, fascial, and pelvic-floor support prevents pressure transmission to the urethra during exertion
  • Intrinsic sphincter deficiency. Poor urethral coaptation; common after prior urethral surgery, radiation, severe obstetric injury, or complex reconstructive history
  • High abdominal pressure states. Obesity, chronic cough, constipation, and high-impact exertion amplify the pressure gradient across the urethra

Urgency component​

  • Detrusor overactivity or afferent hypersensitivity during bladder filling
  • Outlet-associated bladder remodeling from obstruction or dysfunctional voiding
  • Neurogenic disinhibition from stroke, Parkinson disease, multiple sclerosis, spinal disease, or dementia syndromes
  • Local bladder / urethral irritants including UTI, stone, foreign body, mesh erosion, radiation cystitis, and painful bladder syndrome

In one two-center Chinese comparison, stress-predominant MUI showed lower maximal urethral closure pressure on urodynamics and greater bladder-neck descent on perineal ultrasound than controls; urgency-predominant MUI showed more detrusor overactivity and smaller bladder volume on urodynamics, and thicker detrusor wall on ultrasound, than controls.[7]

Diagnosis and Evaluation​

Initial workup​

The initial evaluation should document the patient’s report of both stress- and urgency-associated leakage, identify which component is more bothersome, and decide which component to treat first:[1][2]

  • History. Onset, triggers, urgency warning time, stress triggers, nocturia, pad use, prior pelvic surgery, childbirth history, radiation, neurologic disease, constipation, medications, UTIs
  • Predominance assessment. Ask which leakage type is most frequent, most bothersome, and most important to fix
  • Validated questionnaires. ICIQ-UI-SF, UDI-6, IIQ-7, King's Health Questionnaire, OAB-q; use IPSS in men
  • 3-day bladder diary. Voided volumes, urgency grade, leakage timing, fluid and caffeine intake, nocturnal urine volume, pad use
  • Urinalysis with or without culture. Rule out infection, glycosuria, pyuria, and hematuria
  • Post-void residual. Especially before antimuscarinics, botulinum toxin, sling surgery, or outlet surgery
  • Physical examination. Pelvic exam in women; prolapse, atrophy or GSM, urethral mobility, pelvic-floor tone, cough stress test; DRE and focused neurologic exam when relevant
  • Pad test. Useful when baseline severity or surgical response needs objective quantification

When to use specialized testing​

Urodynamics are not required for every patient with uncomplicated incontinence, but MUI is a common reason to escalate when symptoms are complex, surgery is being planned, or initial treatment fails. The AUA/SUFU OAB guideline notes that urodynamics with a voiding diary can help when no predominant incontinence type can be defined, and also when poor compliance is suspected.[8][9][16] The EAU 2026 guideline goes further for MUI and recommends a bladder diary and urodynamics as part of the multimodal assessment , characterizing the case as stress- or urgency-predominant where possible ; it also notes that evidence has not shown that urodynamics changes MUI treatment outcomes.[18] In FUTURE, 1,099 women with refractory OAB or urgency-predominant MUI being considered for invasive treatment were randomized to urodynamics plus comprehensive clinical assessment or assessment alone; at 15 months, 117/496 (23.6%) versus 114/503 (22.7%) reported being much or very much improved (adjusted OR 1.12, 95% CI 0.73–1.74).[24]

TestBest use in MUI
Multichannel urodynamicsDiscordant symptoms/exam, prior failed surgery, elevated PVR, voiding dysfunction, significant prolapse, neurogenic concern, or preoperative planning when the dominant mechanism is unclear
CystoscopyHematuria, recurrent UTI, prior mesh/sling, radiation, suspected foreign body, fistula, stone, stricture, or bladder-neck pathology
Pelvic / perineal ultrasoundSelected centers use it to evaluate bladder-neck mobility, urethral support, and pelvic-floor morphology.[7]

Red flags for referral: hematuria, recurrent UTIs, obstructive symptoms, elevated PVR, suspected fistula, prior continence surgery with pain or voiding dysfunction, significant prolapse, neurologic disease, or refractory symptoms after appropriate conservative therapy.

Management Principles​

See the Female SUI treatment database for stress-component procedures and the OAB & UUI treatment database for urgency-component procedures.

Start with goals, not labels​

The 2024 IUGA committee opinion emphasizes individualized management of the SUI and UUI components rather than a one-size sequence.[1] In practice:

  • Treat the most bothersome component first .[18]
  • Use combined behavioral therapy when both components matter.
  • Counsel that treating one component can unmask the other.
  • Reassess after each step with the same diary or questionnaire metrics used at baseline.

First-line: behavioral and pelvic-floor therapy​

For women with MUI, EAU 2026 recommends supervised intensive PFMT for at least three months and bladder training as first-line therapy .[18] The ACP guideline strongly recommends PFMT plus bladder training for MUI (moderate-quality evidence), and systematic reviews support behavioral therapy as a high-value, low-harm intervention.[10][11][12]

Core elements:

  • PFMT. Strengthens periurethral and perivaginal support for the stress component
  • Bladder training. Scheduled voiding, progressive intervals, urgency suppression, and delayed voiding for the urgency component
  • Lifestyle modification. Weight loss when appropriate, constipation treatment, smoking cessation, exercise, fluid timing, caffeine or alcohol reduction
  • Pelvic-floor physical therapy. Especially when pelvic-floor overactivity, poor coordination, or pain coexists
  • Biofeedback or electrical stimulation. A 2025 Cochrane review of 33 PFMT-plus-biofeedback comparisons (3,031 women, mostly with SUI) found little or no difference in UI-specific quality of life or patient-reported cure or improvement versus PFMT alone; a matched-intensity trial with 61.3% MUI also found no added biofeedback benefit.[25][1][18] Electrical stimulation may improve OAB symptoms in some women and may be considered for SUI or to teach pelvic-floor contraction when it cannot be isolated .[18]

Pharmacotherapy​

Antimuscarinics and β3 agonists treat the urgency component.[1][13]

Medication strategyUse
AntimuscarinicsUrgency-predominant MUI or persistent urgency after PFMT/bladder training; discuss dementia/cognitive risk with every patient prescribed one, use long-term therapy cautiously in cognitively vulnerable older adults, and use extreme caution with narrow-angle glaucoma, impaired gastric emptying, or prior urinary retention.[16][18]
β3 agonistsUrgency-predominant MUI, older patients, constipation-prone patients, or antimuscarinic intolerance; monitor blood pressure with mirabegron. Mirabegron is not recommended for severe uncontrolled hypertension (systolic ≥180 or diastolic ≥110 mm Hg); use caution and monitor for retention with clinically significant bladder outlet obstruction or concomitant antimuscarinic therapy.[23]
Vaginal estrogenPostmenopausal GSM with urinary symptoms or recurrent UTI risk; local therapy only
Systemic estrogenNot a treatment for UI; oral conjugated equine estrogen can worsen incontinence, so review alternative HRT if leakage develops or worsens[18]

For women with urgency UI, the ACP guideline recommends medication after unsuccessful bladder training (Strong; high-quality evidence), with drug selection guided by tolerability, adverse effects, ease of use, and cost.[10] EAU 2026 recommends anticholinergics or β3 agonists for urgency-predominant MUI and offers duloxetine, where licensed, only to selected women with stress-predominant MUI who have not responded to conservative care and wish to avoid surgery , with careful counseling about adverse events.[18] In its SUI pharmacotherapy section, EAU also recommends dose titration when starting and withdrawing duloxetine .[18] In a 588-woman placebo-controlled trial of women with MUI (duloxetine 40 mg twice daily versus placebo), incontinence-episode frequency fell more with duloxetine for both components: the median reduction in stress-incontinence episodes was 59% versus 43% (P = 0.001) and in urgency-incontinence episodes was 58% versus 40% (P < 0.001).[19] For the urgency component, the newer AUA/SUFU framework allows selection among behavioral, drug and procedural therapies through shared decision-making rather than requiring failure of every preceding category.[16]

Surgery for stress-predominant MUI​

Stress-predominant MUI can be treated surgically after conservative therapy and shared decision-making, but counseling must be explicit: surgery addresses the stress component and may not cure urgency. EAU 2026 advises warning women that surgery for MUI is less likely to succeed than surgery for SUI alone .[1][14][18]

OptionRole
Midurethral slingStandard surgical option for stress-predominant female MUI when objective SUI is present
Autologous fascial sling / Burch colposuspensionMesh-avoidant or specific anatomic/surgical-context options
Bulking agentLower-risk, lower-durability option for selected patients prioritizing minimal invasiveness

The ESTEEM randomized trial tested perioperative behavioral and PFMT plus midurethral sling versus sling alone in women with MUI. At 12 months, the between-group Urogenital Distress Inventory difference favored combined treatment by 13.4 points (95% CI 1.0–25.9), but did not meet the prespecified 35-point threshold for clinical importance.[14] Additional urinary treatment was less frequent with combined therapy.[14]

Urgency symptoms often change after stress surgery. A secondary analysis of three multicenter Urinary Incontinence Treatment Network trials in women with stress-predominant MUI (Burch colposuspension, autologous fascial sling, and retropubic or transobturator midurethral sling) found that 56.6–70.9% across surgical groups met a study-defined threshold of at least a 70% reduction in the composite UDI-I irritative symptom score at 1 year. Improvement was similar after retropubic and transobturator slings (65.5% versus 70.7%) and more frequent after Burch than after fascial sling (67.9% versus 56.6%); the initial improvement diminished over up to 5 years of follow-up. Obesity blunted improvement, and preoperative anticholinergic use and urodynamic parameters did not predict the change.[20]

The 2025 MUSA superiority trial randomized 150 women with MUI who had failed conservative therapy and oral medication; 137 treated women with postbaseline data entered the primary six-month analysis of onabotulinumtoxinA 100 U versus midurethral sling. Both improved the UDI total score at 6 months with no significant difference between groups (mean difference 18.1 points, 95% CI −4.6 to 40.7). The sling gave greater improvement in the stress subscore, and the irritative subscores did not differ. By 12 months, 20/66 (30.3%) in the sling group had received onabotulinumtoxinA, 11/71 (15.5%) in the onabotulinumtoxinA group had received a sling, and 20/71 (28.2%) in the onabotulinumtoxinA group had received a second injection. Additional treatment for either component was common. At 12 months, after crossover and other treatments were permitted from month 6, the exploratory UDI total-score difference favored sling over onabotulinumtoxinA by 24.4 points (95% CI 1.1–47.7; scores from 60 sling and 61 onabotulinumtoxinA recipients); the point estimate was below the trial's 26.1-point minimal clinically important difference.[17] See the MUSA evidence summary.[17]

Advanced therapy for urgency-predominant or refractory MUI​

When urgency remains the main problem, discuss OAB or UUI procedures after inadequate response or intolerance to conservative or drug treatment, or earlier when appropriate through shared decision-making. The AUA/SUFU guideline does not require prior behavioral or medication trials before every minimally invasive treatment; product labeling, catheterization ability and coverage criteria still apply.[16]

Evidence specific to true MUI is thinner than evidence for isolated OAB or isolated SUI.[1][13]

Special Populations​

Older women​

MUI prevalence rises with age; review cumulative anticholinergic burden, constipation, and cognitive risk when choosing OAB treatment in older women.[4][16][18] The AUA/SUFU guideline advises discussing dementia and cognitive risk with patients with OAB who take or are prescribed an antimuscarinic and cites a SUFU white paper that prefers a trial of a β3 agonist first.[16] Favor low-risk behavioral therapy, β3 agonists when medication is needed and blood pressure permits, constipation treatment, fall-risk reduction, and caregiver-aware timed voiding.

Men​

In men, MUI requires reported stress- and urgency-associated urine loss.[22] The following clinical settings may coexist with or mimic that symptom pair:

  • Post-prostate-treatment incontinence. Sphincteric stress leakage may coexist with urgency urinary incontinence after radical prostatectomy, radiation, TURP or HoLEP, or bladder-neck stenosis treatment; detrusor overactivity may be present on urodynamics
  • BPH and OAB. Outlet obstruction with storage symptoms
  • Neurogenic or frailty-associated UI. Urgency, functional leakage, impaired emptying, and mobility and cognition overlap

The AUA/GURS/SUFU guideline recommends cystourethroscopy before surgery for stress incontinence after prostate treatment to assess urethral and bladder pathology that may affect outcomes .[21] Before male sling, AUS, outlet surgery, or botulinum toxin, clarify PVR, obstruction, sphincteric leakage, detrusor overactivity, and the patient's ability to operate devices or perform catheterization.[15][16]

Follow-Up and Failure Patterns​

Track:

  • Patient-prioritized component: stress, urgency, or both
  • 3-day diary episodes and voided volumes
  • Pad count / pad weight
  • Cough stress test response when treating SUI
  • PVR and voiding symptoms when using OAB medications, botulinum toxin, or outlet procedures
  • Adverse effects: constipation, dry mouth, cognitive symptoms, retention, UTI

Common failure patterns:

  • Sling cured stress leakage but urgency persists. Treat residual OAB; check for obstruction if new urgency or retention develops.
  • OAB medication improved urgency but leakage persists with exertion. Reassess objective SUI and discuss stress-directed therapy.
  • Both components persist. Revisit diagnosis: fistula, recurrent UTI, obstruction, pain syndrome, neurologic disease, severe prolapse, or poor adherence to behavioral therapy.

See Also​

Videos​

Urodynamic Interpretation of Mixed Incontinence
Laborie webinar series (2016)

References​

1. Jha S, Jeppson PC, Dokmeci F, et al. "Management of Mixed Urinary Incontinence: IUGA Committee Opinion." Int Urogynecol J. 2024;35(2):291-301. doi:10.1007/s00192-023-05694-z

2. Haylen BT, de Ridder D, Freeman RM, et al. "An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction." Neurourol Urodyn. 2010;29(1):4-20. doi:10.1002/nau.20798

3. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. "Urinary Incontinence in Women: A Review." JAMA. 2017;318(16):1592-1604. doi:10.1001/jama.2017.12137

4. Abufaraj M, Xu T, Cao C, et al. "Prevalence and Trends in Urinary Incontinence Among Women in the United States, 2005-2018." Am J Obstet Gynecol. 2021;225(2):166.e1-166.e12. doi:10.1016/j.ajog.2021.03.016

5. Lee UJ, Feinstein L, Ward JB, et al. "Prevalence of Urinary Incontinence Among a Nationally Representative Sample of Women, 2005-2016: Findings From the Urologic Diseases in America Project." J Urol. 2021;205(6):1718-1724. doi:10.1097/JU.0000000000001634

6. Sologuren-Garcia G, Linares CL, Flores JR, et al. "Associated Factors and Quality of Life in Women With Urinary Incontinence in Southern Peru, 2023." Front Public Health. 2024;12:1487330. doi:10.3389/fpubh.2024.1487330

7. Hu Y, Lou Y, Liao L, et al. "Comparison of Urodynamics and Perineal Ultrasonography for the Diagnosis of Mixed Urinary Incontinence in Women." J Ultrasound Med. 2018;37(11):2647-2656. doi:10.1002/jum.14626

8. Glazener CMA, Lapitan MCM. "Urodynamic Investigations for Management of Urinary Incontinence in Adults." Cochrane Database Syst Rev. 2002;(3):CD003195. doi:10.1002/14651858.CD003195

9. Rosier PFWM, Kuo HC, De Gennaro M, et al. "International Consultation on Incontinence 2016; Executive Summary: Urodynamic Testing." Neurourol Urodyn. 2019;38(2):545-552. doi:10.1002/nau.23903

10. Qaseem A, Dallas P, Forciea MA, et al. "Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians." Ann Intern Med. 2014;161(6):429-440. doi:10.7326/M13-2410

11. Todhunter-Brown A, Hazelton C, Campbell P, et al. "Conservative Interventions for Treating Urinary Incontinence in Women: An Overview of Cochrane Systematic Reviews." Cochrane Database Syst Rev. 2022;9:CD012337. doi:10.1002/14651858.CD012337.pub2

12. Balk EM, Rofeberg VN, Adam GP, et al. "Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes." Ann Intern Med. 2019;170(7):465-479. doi:10.7326/M18-3227

13. Game X, Dmochowski R, Robinson D. "Mixed Urinary Incontinence: Are There Effective Treatments?" Neurourol Urodyn. 2023;42(2):401-408. doi:10.1002/nau.25065

14. 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;322(11):1066-1076. doi:10.1001/jama.2019.12467

15. Breyer BN, Kim SK, Kirkby E, Marianes A, Vanni AJ, Westney OL. "Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024)." J Urol. 2024;212(4):531-538. doi:10.1097/JU.0000000000004088

16. Cameron AP, Chung DE, Dielubanza EJ, et al. "The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder." J Urol. 2024;212(1):11-20. doi:10.1097/JU.0000000000003985

17. Harvie HS, Menefee SA, Richter HE, et al. "Midurethral Sling vs OnabotulinumtoxinA in Females With Urinary Incontinence: The MUSA Randomized Clinical Trial." JAMA. 2025;333(21):1887–1896. doi:10.1001/jama.2025.4682

18. European Association of Urology. EAU Guidelines on Management of Non-Neurogenic Female Lower Urinary Tract Symptoms (LUTS) (Limited Update March 2026). Guideline.

19. Bent AE, Gousse AE, Hendrix SL, et al. "Duloxetine compared with placebo for the treatment of women with mixed urinary incontinence." Neurourol Urodyn. 2008;27(3):212-221. doi:10.1002/nau.20471

20. Zyczynski HM, Albo ME, Goldman HB, Wai CY, Sirls LT, Brubaker L, et al. Change in overactive bladder symptoms after surgery for stress urinary incontinence in women. Obstet Gynecol. 2015;126(2):423-430. doi:10.1097/AOG.0000000000000929

21. American Urological Association. Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2019; amended 2024). Guideline.

22. D’Ancona C, Haylen B, Oelke M, et al. "The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction." Neurourol Urodyn. 2019;38(2):433-477. doi:10.1002/nau.23897

23. Qilu Pharmaceutical Co., Ltd. Mirabegron extended-release tablets, for oral use: full prescribing information. Updated October 21, 2025. DailyMed.

24. Abdel-Fattah M, Chapple C, Cooper D, et al. "Invasive urodynamic investigations in the management of women with refractory overactive bladder symptoms (FUTURE) in the UK: a multicentre, superiority, parallel, open-label, randomised controlled trial." Lancet. 2025;405(10484):1057-1068. doi:10.1016/S0140-6736(24)01886-5

25. Fernandes ACNL, Jorge CH, Weatherall M, Ribeiro IV, Wallace SA, Hay-Smith EJC. "Pelvic floor muscle training with feedback or biofeedback for urinary incontinence in women." Cochrane Database Syst Rev. 2025;3(3):CD009252. doi:10.1002/14651858.CD009252.pub2