How to manage urinary incontinence?

Management of Urinary Incontinence

Pelvic floor muscle training should be the first-line treatment for stress urinary incontinence, bladder training for urgency incontinence, and a combination of both for mixed incontinence. 1

Diagnosis and Classification

Before initiating treatment, proper classification of urinary incontinence is essential:

• Stress UI: Involuntary leakage with physical exertion, coughing, sneezing, or laughing
• Urgency UI: Involuntary leakage associated with a sudden compelling urge to void
• Mixed UI: Combination of both stress and urgency UI
• Overactive bladder: Urgency with or without UI, usually with frequency and nocturia

Treatment Algorithm Based on UI Type

Stress Urinary Incontinence

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

   • Involves voluntary contraction of pelvic floor muscles
   • 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. For obese women: Weight loss and exercise program 1

   • Strong recommendation with moderate-quality evidence
   • Significant improvement in continence with weight reduction

3. Avoid pharmacologic therapy for stress UI 1

   • Strong recommendation against systemic medications
   • Low-quality evidence for effectiveness

4. If conservative measures fail: Consider surgical options

   • Midurethral slings
   • Urethral bulking agents
   • Autologous fascial slings

Urgency Urinary Incontinence

1. First-line: Bladder training 1

   • Strong recommendation with moderate-quality evidence
   • Involves behavioral therapy to extend time between voiding

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

   • Antimuscarinic medications (e.g., oxybutynin, tolterodine, solifenacin)
   • Base choice on tolerability, adverse effect profile, ease of use, and cost
   • Common side effects include dry mouth, constipation, and blurred vision 1
   • Caution in elderly patients due to anticholinergic side effects 2

3. For refractory cases: Consider neuromodulation or botulinum toxin 3

   • Posterior tibial nerve stimulation
   • Sacral nerve stimulation
   • OnabotulinumtoxinA injections

Mixed Urinary Incontinence

1. First-line: Combination of PFMT with bladder training 1

   • Strong recommendation with moderate-quality evidence

2. Second-line: Address predominant symptom (stress or urgency) with appropriate second-line therapies

Lifestyle Modifications for All UI Types

• Fluid management: Moderate fluid intake, avoid bladder irritants (caffeine, alcohol)
• Scheduled voiding: Timed bathroom visits to prevent accidents
• Weight loss for obese patients 1
• Absorbent products as needed for management 4

Special Considerations

Elderly Patients

• Start with lower doses of medications if pharmacologic therapy is needed 2
• Anticholinergic medications should be used with caution due to increased risk of cognitive side effects
• Consider functional limitations that may affect toileting ability

Treatment Failures

• Reassess diagnosis and compliance with initial therapy
• Consider urodynamic testing if not previously performed
• Evaluate for comorbidities that may contribute to UI (diabetes, neurological conditions)
• Consider referral to specialist for advanced therapies

Common Pitfalls to Avoid

1. Skipping first-line conservative therapies: Many providers jump to medications before adequate trials of PFMT or bladder training
2. Inadequate PFMT instruction: Patients need proper education on correct technique and sufficient duration (at least 3 months)
3. Overlooking medication side effects: Particularly anticholinergic burden in elderly patients
4. Failure to address obesity: Weight loss should be prioritized in obese patients with UI
5. Not recognizing mixed incontinence: Requires combination therapy approach

By following this evidence-based approach to urinary incontinence management, clinicians can significantly improve continence rates and quality of life for affected women.