What medications can be used to treat urinary incontinence in women?

Medications for Treatment of Urinary Incontinence in Women

Pharmacologic treatment for urinary incontinence in women should be based on the type of incontinence, with antimuscarinic medications recommended only for urgency urinary incontinence after bladder training has failed, while pharmacologic therapy is not recommended for stress urinary incontinence. 1

Types of Urinary Incontinence and First-Line Treatments

Before considering medication, it's important to identify the type of urinary incontinence:

1. Stress Urinary Incontinence (SUI)

   • First-line: Pelvic floor muscle training (PFMT) 1
   • Pharmacologic therapy is NOT recommended 1

2. Urgency Urinary Incontinence (UUI)

   • First-line: Bladder training 1
   • Second-line: Pharmacologic therapy (if bladder training fails) 1

3. Mixed Urinary Incontinence

   • First-line: PFMT combined with bladder training 1

Pharmacologic Options for Urgency Urinary Incontinence

When bladder training fails for urgency UI, medications should be considered. The following options are available:

1. Antimuscarinic Medications

These are the most commonly used medications with high-quality evidence supporting their efficacy 1:

• Solifenacin: Associated with lowest risk of discontinuation due to adverse effects 1
• Darifenacin: Risk of discontinuation similar to placebo 1
• Tolterodine: Risk of discontinuation similar to placebo 1
• Fesoterodine: Shows dose-response effects on symptom improvement 1
• Oxybutynin: Highest risk of discontinuation due to adverse effects 1
• Trospium: Moderate risk of discontinuation 1
• Propiverine: Moderate risk of discontinuation 1

2. Beta-3 Adrenoceptor Agonists

• Mirabegron: FDA-approved for overactive bladder 2
  • Different mechanism of action than antimuscarinics
  • Common side effects include nasopharyngitis and gastrointestinal disorders 1

Medication Selection Algorithm for Urgency UI

1. First attempt: Bladder training for 4-8 weeks

2. If bladder training fails, select medication based on:

   • Patient tolerability
   • Adverse effect profile
   • Ease of use
   • Medication cost

3. Initial medication choices:

   • For patients concerned about dry mouth/constipation: Consider mirabegron
   • For most patients: Consider solifenacin or tolterodine (better tolerability)
   • For patients with cost concerns: Consider generic options first

4. If first medication fails:

   • Try a different class (switch from antimuscarinic to beta-3 agonist or vice versa)
   • Consider combination therapy in refractory cases

Common Adverse Effects

Antimuscarinic Medications

• Dry mouth (most common)
• Constipation
• Blurred vision
• Heartburn
• Urinary retention 1

Beta-3 Adrenoceptor Agonists (Mirabegron)

• Nasopharyngitis
• Gastrointestinal disorders
• Increased blood pressure (monitor in hypertensive patients) 2

Important Considerations and Pitfalls

1. Avoid pharmacologic therapy for stress incontinence: Medications are ineffective for this type 1

2. Medication discontinuation is common: Up to 20% of patients discontinue due to side effects 1

3. Efficacy is modest: Absolute risk difference <20% for all medications compared to placebo 1

4. Long-term safety data is limited: Information on long-term safety of medications is generally unavailable 1

5. Special populations:

   • Elderly patients: May be more sensitive to anticholinergic side effects
   • Patients with cognitive impairment: Avoid anticholinergics due to risk of worsening cognition
   • Patients with glaucoma: Use antimuscarinics with caution

6. Estrogen considerations: Vaginal estrogen formulations may improve continence in postmenopausal women with stress UI, but transdermal estrogen patches may worsen UI 1

7. Monitor for urinary retention: Especially in patients with bladder outlet obstruction or those taking multiple anticholinergic medications 1

By following this evidence-based approach to medication selection for urinary incontinence in women, clinicians can optimize treatment outcomes while minimizing adverse effects.