Treatment for Urinary Incontinence
Start with pelvic floor muscle training (PFMT) for stress incontinence, bladder training for urgency incontinence, and combine both for mixed incontinence—these nonpharmacologic approaches are first-line therapy with high-quality evidence showing effectiveness, minimal adverse effects, and superior cost-effectiveness compared to medications. 1
Treatment Algorithm by Incontinence Type
For Stress Urinary Incontinence
First-line: Pelvic floor muscle training (PFMT)
- PFMT alone is strongly recommended based on high-quality evidence showing increased continence rates and improved quality of life 1
- Consists of voluntary contraction of pelvic floor muscles (Kegel exercises) 1
- Can be enhanced with biofeedback using vaginal EMG to provide visual feedback on proper muscle contraction 1
- Do NOT use systemic pharmacologic therapy for stress incontinence (strong recommendation against) 1
- Vaginal estrogen formulations may improve stress incontinence, but transdermal estrogen patches worsen it 1
For obese women: Add weight loss and exercise programs (strong recommendation, moderate-quality evidence) 1
For Urgency Urinary Incontinence
First-line: Bladder training
- Behavioral therapy involving extending time between voiding 1
- Strong recommendation with moderate-quality evidence 1
- Adding PFMT to bladder training does NOT improve outcomes compared to bladder training alone for pure urgency incontinence 1
Second-line: Pharmacologic therapy (only if bladder training fails)
- All antimuscarinic agents are equally efficacious but differ significantly in adverse effects 1
- Base drug selection on tolerability and adverse effect profile, NOT efficacy 1
Antimuscarinic options ranked by discontinuation rates:
- Best tolerated: Darifenacin and tolterodine (discontinuation rates similar to placebo) 1
- Intermediate: Solifenacin (lowest discontinuation risk among active drugs; NNTH 78) 1
- Moderate: Fesoterodine (NNTH 33), Trospium (NNTH 56) 1
- Worst tolerated: Oxybutynin (highest discontinuation risk; NNTH 16) 1
Common adverse effects: Dry mouth, constipation, blurred vision for antimuscarinics; nasopharyngitis and GI disorders for mirabegron 1
Alternative: β3-adrenergic agonist (mirabegron) offers different adverse effect profile 1
For Mixed Urinary Incontinence
Combine PFMT with bladder training (strong recommendation, moderate-quality evidence) 1
Critical Clinical Considerations
Identify reversible causes before initiating treatment:
- Urinary tract infections
- Metabolic disorders
- Excess fluid intake
- Delirium or impaired mental status
- Medications that cause or worsen incontinence 1
High-risk populations requiring proactive screening:
- Women aged >65 years
- Nursing home residents
- Women receiving Medicare home care services
- At least 50% of incontinent women do NOT report symptoms to physicians 1
Common Pitfalls to Avoid
Do NOT prescribe systemic pharmacologic therapy for stress incontinence—it is ineffective 1
Do NOT add PFMT to bladder training for pure urgency incontinence—bladder training alone is sufficient 1
Do NOT select antimuscarinic drugs based on efficacy—they are all equally effective; choose based on adverse effect profile and cost 1
Do NOT use transdermal estrogen patches—they worsen incontinence 1
Expect high discontinuation rates with pharmacotherapy—many patients stop medications due to adverse effects, particularly with oxybutynin 1
Treatment Success Definition
Clinically successful treatment reduces incontinence episodes by ≥50% 1
When Conservative Management Fails
Surgical interventions become appropriate for women with persistent stress incontinence after adequate conservative therapy trials 2, 3. Options include mid-urethral slings, colposuspension, and autologous fascial slings, though surgical management is beyond the scope of initial primary care treatment 2.