How to manage urinary incontinence?

Management of Urinary Incontinence in Women

First-line treatment for urinary incontinence should be non-pharmacological approaches 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 (UI) is classified into three main types:

• Stress UI: Involuntary leakage with physical exertion (coughing, sneezing, laughing)
• Urgency UI: Involuntary leakage associated with a sudden compelling urge to void
• Mixed UI: Combination of both stress and urgency symptoms

Initial Assessment

• Proactively ask female patients about bothersome UI symptoms, as at least half of incontinent women do not report it to physicians 1
• Ask specific questions about:
  • Time of onset
  • Type of symptoms (leakage with exertion vs. sudden urge)
  • Frequency of episodes
  • Impact on quality of life

Management Algorithm Based on UI Type

1. Stress Urinary Incontinence

First-line treatment:

• Pelvic floor muscle training (PFMT) - High-quality evidence shows PFMT is more than 5 times as effective as no treatment 1
• Instructions for proper Kegel exercises:
  • Identify correct muscles (those used to stop urination midstream)
  • Contract muscles for 5 seconds, then relax for 5 seconds
  • Perform 10-15 repetitions, 3 times daily

Second-line options:

• PFMT with biofeedback using vaginal EMG for proper muscle contraction feedback
• Vaginal inserts or pessaries for anatomical support

Avoid:

• Systemic pharmacologic therapy - strongly recommended against for stress UI 1

2. Urgency Urinary Incontinence

First-line treatment:

• Bladder training - Behavioral therapy that includes extending time between voiding 1
• Techniques include:
  • Scheduled voiding with gradually increasing intervals
  • Urge suppression techniques
  • Fluid management

Second-line treatment:

• Pharmacologic therapy if bladder training unsuccessful 1
• Medication selection based on:
  • Tolerability
  • Adverse effect profile
  • Ease of use
  • Cost

Medication options:

• Anticholinergics (oxybutynin, tolterodine, solifenacin, etc.)
  • Note: Oxybutynin has highest risk of discontinuation due to side effects 1
  • Caution in elderly due to anticholinergic side effects 2
• Mirabegron (β3-adrenoceptor agonist) - alternative with different side effect profile

3. Mixed Urinary Incontinence

First-line treatment:

• Combination of PFMT with bladder training 1
• Address both components simultaneously for best outcomes

Additional Interventions

For Obese Women with UI

• Weight loss and exercise - Strong recommendation with moderate-quality evidence 1
• Even modest weight reduction can significantly improve symptoms

For Elderly Patients

• Start with lower doses of medications if pharmacologic therapy is needed
• For frail elderly, consider starting oxybutynin at 2.5 mg 2-3 times daily due to prolonged elimination half-life 2
• Monitor closely for adverse effects, particularly cognitive effects with anticholinergics

Common Pitfalls to Avoid

1. Failure to identify UI type - Treatment differs significantly based on whether it's stress, urgency, or mixed incontinence
2. Jumping to pharmacologic therapy - Non-pharmacologic approaches should be first-line for all types
3. Inadequate trial of behavioral therapy - PFMT and bladder training require consistent practice over weeks to months
4. Overlooking medication side effects - Anticholinergics can cause dry mouth, constipation, blurred vision, and cognitive effects
5. Missing comorbid conditions - Address contributing factors like UTIs, constipation, or medication side effects

When to Consider Referral

• Failure to respond to initial conservative management
• Complex cases with prior incontinence surgery
• Suspected neurological causes
• Significant pelvic organ prolapse
• Recurrent urinary tract infections

By following this evidence-based approach to managing urinary incontinence, clinicians can significantly improve continence rates and quality of life for women with this common but underreported condition.