

The demographic pyramid is currently being reshaped by an aging population.1 Classically, the term "elderly" refers to the age group above 60 years old.2 However, when referring to urinary incontinence, most studies establish a cut-off value at 70 years old.3 Currently, the overall prevalence of urinary incontinence is estimated at 8.7%.4 Mixed urinary incontinence (MUI) on the other hand, defined as the presence of stress urinary incontinence and overactive bladder symptoms, is a common condition in women over 60 years old, with a prevalence of 31%.5 The presence of overactive bladder symptoms is higher in older women than in younger women, with a 10-fold increase with age.5 Therefore, we can expect a continuous increase in the number of consultations for this reason.
Today, there is still no consensus on the best therapeutic approach for MUI, whether initially treating the urgency component and reserving surgical management for later or vice versa. However, there is ample support in the literature for improvement in urgency symptoms with mid-urethral sling (MUS), with a potential 30-50% symptomatic relief of overactive bladder symptoms in patients with MUI.6 However, in this group of women, it is necessary to consider some relevant aspects regarding the results and complications of MUS:
Elderly patients may be more prone to overlook or disregard mesh exposure.9 The use of local estrogens has not been shown to have better results in this group.10 In any case, there are no high-quality studies focused on this outcome. Despite this, it is imperative that patients are adequately informed about these possible complications, especially in sexually active patients.
Currently, there is no consensus on which mid-urethral sling is better in elderly women with mixed urinary incontinence. However, given the low rate of surgical complications and scarce but growing evidence suggesting that the transobturator route is better in improving overactive bladder symptoms in women with MUI over the retropubic route,6 the transobturator route could be considered as the preferred route in this subgroup. This is undoubtedly an area that requires further studies to confirm or deny this recommendation.
In conclusion, regardless of the preferred midurethral sling type, or whether it is performed before or after medical management of the overactive bladder, the benefit of mid-urethral slings in elderly patients with mixed urinary incontinence is clear. However, these patients require a more thorough evaluation, which should include a multichannel urodynamic study, to minimize the number of voiding complications and provide adequate data to better inform our patients with regard to the overall success of the surgery.