What are the treatment options for urinary incontinence (UI)?

Treatment Options for Urinary Incontinence

First-line treatment for urinary incontinence should be non-pharmacological, with specific approaches tailored to the type of incontinence (stress, urgency, or mixed). 1, 2

Types of Urinary Incontinence

Urinary incontinence (UI) can be categorized into three main types:

• Stress UI: Involuntary leakage during physical activity, coughing, sneezing, or laughing
• Urgency UI: Involuntary leakage associated with a sudden compelling urge to void
• Mixed UI: Combination of both stress and urgency components

Treatment Algorithm by UI Type

For Stress Urinary Incontinence:

1. Pelvic Floor Muscle Training (PFMT)

   • Should be offered as first-line treatment 1, 2
   • High-quality evidence shows women with SUI who perform PFMT are 8 times more likely to report cure (56% versus 6%) 3
   • Most effective when supervised by specialists for at least 3 months 4
   • Include proper technique instruction and regular follow-up 2

2. Lifestyle Modifications

   • Weight loss and exercise for obese women (strong recommendation, moderate-quality evidence) 1, 2
   • Smoking cessation 5
   • Regular voiding intervals 6

3. Adjunctive Options

   • Continence pessaries or vaginal inserts can be offered alongside PFMT 2
   • Biofeedback using vaginal EMG for visual feedback may improve results 2

4. Avoid Pharmacological Treatment

   • Systemic pharmacologic therapy is NOT recommended for stress UI (strong recommendation) 1, 2

5. Surgical Options (if conservative measures fail after adequate trial)

   • Midurethral synthetic slings (success rates 51-88%) 2
   • Urethral bulking agents (less invasive but lower success rates) 2
   • Autologous fascia pubovaginal sling (85-92% success rate with 3-15 years follow-up) 2
   • Burch colposuspension (especially if undergoing concomitant abdominal surgery) 2

For Urgency Urinary Incontinence:

1. Bladder Training

   • First-line treatment (strong recommendation, moderate-quality evidence) 1, 2
   • Involves extending time between voiding 1

2. Lifestyle Modifications

   • Avoid bladder stimulants (caffeine, alcohol) 5
   • Weight loss for obese patients 1
   • Adequate but not excessive hydration 6

3. Pharmacological Treatment (if bladder training unsuccessful)

   • Anticholinergics (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium) 1, 7, 8
   • Base choice on tolerability, adverse effect profile, ease of use, and cost 1
   • Tolterodine may cause fewer adverse effects than oxybutynin 1

4. Advanced Options

   • Botulinum toxin A injections 5
   • Sacral nerve stimulation 5
   • Percutaneous nerve stimulation 6

For Mixed Urinary Incontinence:

1. Combined Approach

   • PFMT with bladder training (strong recommendation, moderate-quality evidence) 1, 2

2. Target Predominant Symptom

   • Control overactive bladder symptoms before addressing stress component 5
   • Then follow appropriate algorithm for predominant symptom 5

Important Considerations

• Underreporting: At least half of women with UI do not report symptoms to healthcare providers 1
• Quality of Life Impact: Treatment decisions should be guided by degree of bother and impact on quality of life 2
• Treatment Adherence: Supervised PFMT programs show better outcomes than unsupervised or leaflet-based care 4
• Medication Discontinuation: Many patients stop pharmacologic treatment due to adverse effects 1
• Surgical Risks: While more effective than non-surgical approaches, surgical procedures have higher complication rates 9

Common Pitfalls to Avoid

1. Rushing to surgical intervention without adequate trial of conservative management (minimum 3 months of supervised PFMT) 2

2. Overlooking vaginal atrophy in postmenopausal women, which may require local estrogen therapy before other treatments 2

3. Using systemic pharmacologic therapy for stress UI, which is not effective and not recommended 1

4. Failing to address modifiable factors like obesity, smoking, and fluid intake patterns 5, 6

5. Inadequate PFMT instruction - proper technique and supervision significantly improve outcomes 4

By following this evidence-based approach to urinary incontinence treatment, clinicians can significantly improve patient outcomes and quality of life while minimizing unnecessary interventions and adverse effects.