How to manage urinary incontinence?

Management of Urinary Incontinence

Urinary incontinence should be treated with non-pharmacologic therapies as first-line management, including pelvic floor muscle training for stress incontinence, bladder training for urgency incontinence, and a combination of both for mixed incontinence. 1

Types of Urinary Incontinence

Urinary incontinence can be classified into three main types:

• Stress urinary incontinence: Involuntary leakage with physical exertion, coughing, or sneezing
• Urgency urinary incontinence: Involuntary leakage associated with a sudden compelling urge to void
• Mixed urinary incontinence: Combination of both stress and urgency symptoms

Diagnostic Approach

Clinicians should proactively ask female patients about bothersome UI symptoms, as at least half of incontinent women do not report the issue to their physicians 1. Key assessment elements include:

• Time of onset, symptoms, and frequency of incontinence episodes
• Focused physical examination including neurological assessment
• Specific questioning such as: "Do you have a problem with urinary incontinence that is bothersome enough that you would like to know more about how it could be treated?"

Treatment Algorithm Based on UI Type

1. Stress Urinary Incontinence

1. First-line: Pelvic floor muscle training (PFMT) 1

   • High-quality evidence shows PFMT is more than 5 times as effective as no treatment
   • Number needed to treat for benefit: 3 (95% CI, 2 to 5)

2. Avoid pharmacologic therapy for stress UI 1

   • Standard medications used for urgency UI are not effective for stress UI

3. For obese women: Weight loss and exercise 1

   • Strong recommendation based on moderate-quality evidence

2. Urgency Urinary Incontinence

1. First-line: Bladder training 1

   • Behavioral therapy that includes extending time between voiding

2. Second-line: Pharmacologic treatment if bladder training unsuccessful 1

   • Anticholinergic medications (e.g., oxybutynin, tolterodine, darifenacin, solifenacin)
   • Base medication choice on tolerability, adverse effect profile, ease of use, and cost
   • Note: Anticholinergics not recommended in older adults due to adverse effects 2

3. Medication considerations:

   • Oxybutynin increases bladder capacity and decreases urgency 3
   • Caution with anticholinergics in elderly patients - consider starting at lower doses 3
   • Monitor for common side effects: dry mouth, constipation, blurred vision 3

3. Mixed Urinary Incontinence

1. First-line: Combination of PFMT with bladder training 1
   • Strong recommendation based on moderate-quality evidence

Special Considerations

For Elderly Patients

• Lower initial starting dose of anticholinergic medications (e.g., 2.5 mg of oxybutynin 2-3 times daily for frail elderly) 3
• Consider prolonged elimination half-life (from 2-3 hours to 5 hours in elderly) 3

For Obese Patients

• Weight loss and exercise programs should be implemented 1
• Strong recommendation based on moderate-quality evidence

For Patients with Scarred Open Urethra

• Referral for surgical intervention may be necessary 4
• Non-pharmacologic management alone will likely be insufficient 4

Common Pitfalls to Avoid

1. Failure to identify UI type: Different types require different treatment approaches
2. Underreporting: Proactively ask about UI symptoms as many patients don't report them
3. Overreliance on medications: Non-pharmacologic therapies should be first-line for all types
4. Medication side effects: Anticholinergics have significant side effects, especially in elderly
5. Inadequate follow-up: Treatment effectiveness should be monitored over time

Measuring Treatment Success

Clinically successful treatment is defined as reducing the frequency of UI episodes by at least 50% 1. Complete continence and improved quality of life are also important outcome measures.

When to Refer

Consider referral to a specialist when:

• Initial treatments fail
• Complex cases (previous incontinence surgery or radiation) 5
• Consideration of surgical options for stress incontinence that hasn't responded to conservative management 2

By following this evidence-based approach to managing urinary incontinence, clinicians can significantly improve patients' quality of life and reduce the burden of this common condition.