Treatment of Urinary Incontinence
The treatment of urinary incontinence must be tailored to the specific type: start with pelvic floor muscle training (PFMT) for stress incontinence, bladder training for urgency incontinence, and combined PFMT with bladder training for mixed incontinence—all before considering medications. 1
Treatment Algorithm by Incontinence Type
Stress Urinary Incontinence (SUI)
First-line treatment is pelvic floor muscle training (Kegel exercises), which has high-quality evidence showing improved continence rates and quality of life. 1 This involves voluntary contraction of pelvic floor muscles, ideally with instruction from a trained provider.
- PFMT can be enhanced with biofeedback using vaginal EMG probes to provide visual feedback on proper muscle contraction 1
- Do NOT use systemic pharmacologic therapy for stress incontinence—it is ineffective 1
- Vaginal estrogen formulations may improve stress UI, but transdermal estrogen patches worsen incontinence 1
If conservative measures fail after adequate trial (typically 8-12 weeks), surgical options include mid-urethral slings, which have become the standard surgical approach 2, 3.
Urgency Urinary Incontinence (Overactive Bladder)
Start with bladder training, which involves behavioral therapy to extend the time between voiding. 1 This has moderate-to-high quality evidence for effectiveness.
If bladder training fails, add pharmacologic therapy. 1 When selecting medications:
- All antimuscarinics are equally effective for achieving continence, so choose based on side effect profile, cost, and ease of use 1
- Solifenacin has the lowest discontinuation rate due to adverse effects 1
- Oxybutynin has the highest discontinuation rate (NNTH = 16) due to adverse effects including dry mouth, constipation, and blurred vision 1
- Darifenacin and tolterodine have discontinuation rates similar to placebo 1
- Mirabegron (β-3 agonist) is an alternative with different side effect profile (nasopharyngitis, GI disorders rather than anticholinergic effects) 1, 4
Mixed Urinary Incontinence
Combine PFMT with bladder training as first-line treatment. 1 This combination improves both continence and quality of life in women with mixed symptoms.
If conservative measures fail, treat the predominant symptom type, but control urgency symptoms before considering surgical intervention for stress component 5.
Special Populations
Obese Women
Weight loss combined with exercise is strongly recommended (moderate-quality evidence) as it improves continence across all incontinence types 1. This should be initiated alongside other conservative measures.
Elderly Women (>65 years)
This vulnerable population has higher prevalence (75%) but lower reporting rates 1. Before initiating treatment:
- Identify and manage reversible causes: UTIs, metabolic disorders, excess fluid intake, delirium, medications that worsen UI 1
- Anticholinergics should be used cautiously due to cognitive side effects and increased fall risk
- Consider mirabegron as alternative to antimuscarinics 4
Critical Clinical Pitfalls
At least half of women with UI do not report symptoms to physicians 1—you must specifically ask about incontinence during history-taking, including onset, symptom pattern, and frequency.
Many patients discontinue pharmacologic therapy due to adverse effects 1. Set realistic expectations: medications provide moderate benefit (not cure) and require balancing efficacy against tolerability. The NNTH for discontinuation ranges from 16 (oxybutynin) to 78 (solifenacin) 1.
Do not skip conservative therapy. Nonpharmacologic treatments are effective, have minimal adverse effects, and are more cost-effective than medications 1. They should be attempted for adequate duration (typically 8-12 weeks) before escalating to pharmacologic or surgical options.
Avoid systemic pharmacologic therapy for pure stress incontinence—it doesn't work 1. This is a strong recommendation despite being counterintuitive to some clinicians.
Third-Line Options for Refractory Cases
When first and second-line therapies fail: