What medications are used to treat stress incontinence?

Medications for Stress Urinary Incontinence

Pharmacologic therapy is not recommended as first-line treatment for stress urinary incontinence (SUI) in women, as high-quality evidence supports non-pharmacological approaches instead. 1

First-Line Treatment Approach

The American College of Physicians (ACP) strongly recommends against systemic pharmacologic therapy for stress urinary incontinence (Grade: strong recommendation, low-quality evidence). 1 Instead, the evidence-based treatment algorithm is:

1. Pelvic Floor Muscle Training (PFMT) - First-line treatment with strong evidence supporting its effectiveness 1
2. Weight loss and exercise for obese women with SUI (moderate-quality evidence) 1
3. Surgical interventions when conservative measures fail 1

Limited Role of Medications in SUI

Unlike urgency urinary incontinence, which responds well to pharmacologic treatment, medications have limited efficacy for stress incontinence:

Medications Sometimes Used (Despite Limited Evidence):

1. Duloxetine

   • Mechanism: Inhibits serotonin and norepinephrine reuptake, increasing urethral sphincter tone 2
   • Evidence: High-quality evidence showed duloxetine did not statistically significantly improve SUI compared with placebo 1
   • Potential use: May be considered in women who refuse or cannot undergo physical or surgical treatment 3
   • Main side effect: Nausea (most common reason for discontinuation) 2
   • Not FDA-approved in the US for SUI (though approved in Europe) 4

2. Topical Estrogen

   • Evidence is insufficient to determine effectiveness 1
   • Some benefit with vaginal estrogen tablets and ovules for improving SUI symptoms 1
   • Not recommended as primary treatment 5

3. Imipramine

   • Sometimes used off-label for mixed incontinence 6
   • Significant side effect profile including anticholinergic effects 6
   • Not specifically recommended in guidelines for SUI 1

4. Alpha-adrenergic agonists

   • Limited use due to cardiovascular side effects 5
   • Not recommended in current guidelines 1

Clinical Considerations and Pitfalls

• Common pitfall: Treating SUI with antimuscarinic medications (like oxybutynin, solifenacin, tolterodine) - these are effective for urgency incontinence but not for stress incontinence 1, 7

• Important distinction: Correctly differentiating between stress, urgency, and mixed incontinence is crucial for appropriate treatment selection 1

• Medication caution: When pharmacologic treatment is considered for mixed incontinence, be aware that many patients discontinue medication due to adverse effects 1

Special Populations

• Women awaiting surgery: In severe SUI cases where surgery is planned, duloxetine may reduce incontinence episodes and improve quality of life, with approximately 20% of women reconsidering surgery after treatment 8

• Elderly patients: Use caution with medications that have anticholinergic effects due to increased risk of cognitive impairment 7

Conclusion for Clinical Practice

For stress urinary incontinence, the evidence-based approach prioritizes non-pharmacological interventions, particularly pelvic floor muscle training, as first-line treatment. Medications play a very limited role in management and should not be considered primary therapy for SUI.