How to manage urinary incontinence?

Management of Urinary Incontinence

First-line treatment for urinary incontinence should be non-pharmacological approaches including pelvic floor muscle training, bladder training, and lifestyle modifications, with pharmacotherapy reserved for specific types of incontinence that don't respond to conservative measures. 1

Types of Urinary Incontinence

Urinary incontinence (UI) is classified into several types:

• Stress UI: Involuntary loss of urine with increased intra-abdominal pressure (coughing, sneezing)
• Urgency UI: Involuntary loss of urine associated with a sudden compelling urge to void
• Mixed UI: Combination of stress and urgency UI
• Overflow UI: Leakage due to bladder overdistention

Assessment

Key elements in evaluation:

• Determine type of incontinence through symptom description
• Assess frequency, severity, and impact on quality of life
• Rule out urinary tract infection with urinalysis
• Consider voiding diary to document patterns
• Evaluate for pelvic organ prolapse in women
• Measure post-void residual if overflow suspected

Management Algorithm by Type of Incontinence

1. Stress Urinary Incontinence

First-line:

• Pelvic floor muscle training (PFMT) - Kegel exercises 1
  • High-quality evidence shows PFMT increases continence rates (NNT=3)
  • Should be continued for at least 3 months
• Weight loss for obese women 1
  • Strong recommendation with moderate-quality evidence

Avoid:

• Systemic pharmacologic therapy for stress UI 1
  • Strong recommendation against, based on low-quality evidence

For persistent symptoms:

• Consider referral for surgical options (not covered in this guideline) 1

2. Urgency Urinary Incontinence

First-line:

• Bladder training 1
  • Progressive voiding schedule
  • Urge suppression techniques
  • Moderate-quality evidence supports effectiveness

Second-line (if bladder training unsuccessful):

• Pharmacologic treatment 1
  • Antimuscarinic medications (e.g., oxybutynin) 2
  • β3-adrenoceptor agonists (e.g., mirabegron)
  • Choose based on tolerability, adverse effects, ease of use, and cost

Common side effects of antimuscarinics:

• Dry mouth, constipation, blurred vision 2
• Higher discontinuation rates with oxybutynin compared to other agents 1

3. Mixed Urinary Incontinence

First-line:

• Combination of PFMT with bladder training 1
  • Strong recommendation with moderate-quality evidence
  • Addresses both stress and urgency components

4. For All Types of Incontinence

Lifestyle modifications:

• Weight loss and exercise for obese women 1, 3
• Fluid management (avoid excessive intake) 4
• Caffeine reduction 4
• Management of constipation 1

Incontinence management strategies:

• Discuss containment options (pads, protective underwear) 1
• Barrier creams to protect skin 1

Combination Approaches

For patients with inadequate response to monotherapy, consider combining:

• Behavioral therapy
• Non-invasive approaches
• Pharmacotherapy (for urgency UI)
• Referral for minimally invasive therapies 1

Special Considerations

• Elderly patients: Higher prevalence (up to 75% in women aged ≥75 years) 1
• Obese patients: Weight loss should be prioritized 1, 3
• Medication side effects: Monitor closely, especially in older adults using antimuscarinics 2

Common Pitfalls to Avoid

1. Failing to identify and address the specific type of incontinence
2. Starting pharmacotherapy before adequate trial of behavioral approaches
3. Using antimuscarinic medications for stress UI (ineffective) 1
4. Not allowing sufficient time for PFMT to show benefits (needs 3+ months)
5. Overlooking the impact of medications that may worsen UI (diuretics, sedatives)
6. Not addressing modifiable risk factors like obesity and constipation

Remember that UI is underreported, with only about 25% of affected women seeking treatment despite effective options being available 5. Proactively ask about UI symptoms during routine care to improve detection and treatment.