What are the initial treatment options for urinary incontinence?

Initial Treatment Options for Urinary Incontinence

Pelvic floor muscle training (PFMT) should be offered as first-line treatment for urinary incontinence, particularly for stress urinary incontinence, with supervised programs showing up to 70% improvement in symptoms. 1

Assessment and Classification

Before initiating treatment, it's essential to categorize the type of urinary incontinence:

• Stress urinary incontinence: Involuntary leakage with physical exertion, coughing, or sneezing
• Urgency urinary incontinence: Involuntary leakage accompanied by sudden, compelling urge to void
• Mixed urinary incontinence: Combination of stress and urgency symptoms
• Overactive bladder: Urgency with or without incontinence, usually with frequency and nocturia

Treatment Algorithm Based on Incontinence Type

For Stress Urinary Incontinence:

1. First-line: Supervised PFMT (Pelvic Floor Muscle Training)

   • Should include repeated voluntary pelvic floor muscle contractions
   • Taught and supervised by a healthcare professional
   • Continue for at least 8-12 weeks 1
   • More effective when supervised than unsupervised or leaflet-based care 2

2. Lifestyle modifications:

   • Weight loss for overweight/obese patients 1
   • Physical exercise 1

3. For postmenopausal women:

   • Local estrogen therapy for those with vaginal atrophy 1
   • Vaginal moisturizers and lubricants for symptoms of dryness 1

For Urgency Urinary Incontinence:

1. Behavioral interventions:

   • Bladder training/retraining - extending time between voiding 3
   • Fluid modification 4

2. Pharmacologic therapy (if behavioral approaches insufficient):

   • Antimuscarinic medications:
     • Tolterodine - for overactive bladder with symptoms of urge incontinence, urgency, and frequency 5
     • Oxybutynin - relaxes bladder smooth muscle, increases bladder capacity, and decreases frequency of uninhibited contractions 6

For Mixed Urinary Incontinence:

1. Start with treatment for the predominant symptom
   • For urgency-predominant: Follow urgency UI protocol 3
   • For stress-predominant: Begin with PFMT

Special Considerations

Post-Prostate Treatment Incontinence:

• Incontinence is expected short-term after prostate surgery but generally improves to near baseline by 12 months 3
• PFMT should be offered in the immediate post-operative period 3
• Surgical interventions may be considered as early as six months if incontinence is not improving despite conservative therapy 3

Evaluation of Treatment Effectiveness:

• Assess after 8-12 weeks of supervised PFMT 1
• Clinically successful treatment reduces frequency of UI episodes by at least 50% 3
• If inadequate improvement with conservative measures, consider referral for additional interventions 1

Advanced Techniques for PFMT

• PFMT with biofeedback: Uses EMG probe to give visual feedback on proper muscle contraction 3, 7
• Functional electrical stimulation (FES): Strengthens perineal awareness, increases tone and trophism of pelvic floor 8
• Vaginal cones: Used as adjunctive therapy to enhance PFMT effectiveness 8

When to Consider Surgical Options

• When conservative measures fail after adequate trial (typically 8-12 weeks)
• For stress UI: Midurethral sling is considered the gold standard with success rates between 51-88% 1
• For post-prostate treatment incontinence: Consider surgical intervention if no improvement after six months of conservative therapy 3

PFMT remains the cornerstone of initial treatment for urinary incontinence, with strong evidence supporting its effectiveness, particularly for stress urinary incontinence. When properly performed under supervision, it offers significant improvement with minimal risk of adverse effects.