What are the medical treatment options for incontinence in women?

Medical Treatment Options for Urinary Incontinence in Women

For women with urinary incontinence, pelvic floor muscle training (PFMT) should be offered as first-line treatment for stress incontinence, bladder training for urgency incontinence, and a combination of both for mixed incontinence, with pharmacologic options reserved as second-line therapy for those who fail conservative management. 1

Types of Urinary Incontinence

Urinary incontinence affects approximately 25% of young women, 44-57% of middle-aged women, and up to 75% of elderly women 2, 1. The main types include:

• Stress incontinence: Urine leakage with increased abdominal pressure (coughing, sneezing, physical activity)
• Urgency incontinence: Involuntary loss of urine associated with a sudden compelling urge to void
• Mixed incontinence: Combination of stress and urgency symptoms
• Overflow incontinence: Leakage due to bladder overdistention

First-Line Non-Pharmacologic Treatments

For Stress Incontinence

• Pelvic floor muscle training (PFMT): Strong recommendation with high-quality evidence 1
  • Can result in up to 70% improvement in symptoms 3
  • Should be supervised by healthcare professionals
  • Effectiveness should be evaluated after 8-12 weeks
  • PFMT with biofeedback using vaginal EMG shows superior results compared to PFMT alone 1

For Urgency Incontinence

• Bladder training: Strong recommendation with moderate-quality evidence 1
  • Includes extending time between voiding
  • Implementing a scheduled bathroom regimen (every 2 hours during day, every 4 hours at night)

For Mixed Incontinence

• Combination of PFMT and bladder training: Strong recommendation with moderate-quality evidence 1

Additional Lifestyle Modifications

• Weight loss: Strongly recommended for obese women (number needed to benefit: 4) 1
• Fluid management:
  • Reduce fluid intake at night to decrease nocturnal incontinence
  • Avoid excessive fluid consumption
  • Decrease caffeine intake 4
• Adequate hygiene and skin care to protect from irritation 1

Second-Line Pharmacologic Treatments

For Urgency Incontinence

• Anticholinergic medications: Strong recommendation with high-quality evidence when bladder training is unsuccessful 1

  • Options include oxybutynin, tolterodine, solifenacin, darifenacin, fesoterodine
  • Oxybutynin works by:
    • Exerting direct antispasmodic effect on smooth muscle
    • Inhibiting muscarinic action of acetylcholine
    • Increasing bladder capacity
    • Diminishing frequency of uninhibited contractions 5
  • Caution: Higher risk of side effects in elderly patients, including dry mouth, constipation, and cognitive effects 1, 5
  • Lower starting dose (2.5mg 2-3 times daily) recommended for frail elderly due to prolonged elimination half-life 5

• Beta-3 adrenergic agonists (mirabegron): Effective alternative for patients with inadequate response to anticholinergics 1

  • Effective within 4-8 weeks at doses of 25-50mg
  • May have fewer anticholinergic side effects 4

For Stress Incontinence

• Limited pharmacologic options:
  • No FDA-approved medications specifically for stress incontinence
  • Off-label agents sometimes used include tricyclic antidepressants (imipramine) and alpha/beta-adrenergic agonists, though results are unpredictable 6

Treatment Algorithm

1. Initial assessment:

   • Determine type of incontinence (stress, urgency, mixed)
   • Assess impact on quality of life
   • Rule out urinary tract infection and hematuria 7

2. First-line approach:

   • Stress incontinence → PFMT (supervised if possible)
   • Urgency incontinence → Bladder training
   • Mixed incontinence → Combination of PFMT and bladder training
   • All types → Appropriate lifestyle modifications

3. If inadequate response after 8-12 weeks:

   • Stress incontinence → Consider referral for surgical evaluation
   • Urgency incontinence → Add anticholinergic medication or mirabegron
   • Mixed incontinence → Add medication for predominant component

4. Treatment goal: Reduce incontinence episodes by at least 50%, which is considered clinically successful treatment 2, 1

Important Considerations

• Anticholinergic medications should be used with caution in elderly patients due to increased risk of side effects 1, 5
• Medications like ketoconazole can increase oxybutynin concentrations 3-4 fold; use caution with concomitant CYP3A4 inhibitors 5
• Supervised PFMT programs show better outcomes than unsupervised or leaflet-based care 3
• For patients who fail conservative and pharmacologic therapy, referral for specialist treatments may be warranted 7

Remember that despite the high prevalence of urinary incontinence, only about 25% of affected women seek treatment 7. Proactively asking about symptoms during routine visits is essential for identifying and addressing this condition.