What are the treatment options for urge incontinence?

Treatment Options for Urge Incontinence

For urge incontinence, first-line treatment should be bladder training, followed by pharmacologic therapy with either anticholinergics or beta-3 adrenergic agonists if conservative measures fail. 1

First-Line Non-Pharmacological Approaches

Bladder Training

• Implement a structured bladder training program that includes:
  • Scheduled voiding every 2 hours during the day and every 4 hours at night 1
  • Progressive increase in voiding intervals to retrain the bladder
  • Urgency suppression techniques using relaxation and distraction 2

Pelvic Floor Muscle Training (PFMT)

• Supervised PFMT programs show significant improvement in symptoms
• Should include repeated voluntary pelvic floor muscle contractions
• Must be taught and supervised by a healthcare professional
• PFMT with biofeedback or vaginal electromyography probe shows superior results compared to PFMT alone 1
• Average reduction in incontinence frequency ranges from 57% to 86% with behavioral treatments 3

Lifestyle Modifications

• Weight loss for obese women (strong recommendation, moderate-quality evidence) 1
• Fluid management:
  • Reduce fluid intake at night
  • Avoid excessive fluid consumption
  • Manage timing of fluid intake 1
• Eliminate bladder irritants from diet 2
• Ensure regular bowel habits to prevent constipation 2
• Smoking cessation 4

Second-Line Pharmacological Treatment

When bladder training is unsuccessful, pharmacologic options should be considered:

Anticholinergic Medications

• Options include oxybutynin, tolterodine, solifenacin, darifenacin, and fesoterodine 1
• Tolterodine tartrate tablets are specifically indicated for overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency 5
• Clinical trials showed significant reduction in incontinence episodes, frequency of micturition, and increased voided volume compared to placebo 5
• Use with caution in elderly patients due to increased risk of side effects including dry mouth, constipation, and cognitive effects 1

Beta-3 Adrenergic Agonists

• Mirabegron is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 6
• Offers an effective alternative for patients with inadequate response to anticholinergics 1
• Has fewer anticholinergic side effects, making it potentially more suitable for elderly patients 1

Treatment Algorithm

1. Start with bladder training and lifestyle modifications

   • Implement scheduled voiding program
   • Address modifiable risk factors (weight, fluid intake, diet)
   • Add supervised PFMT with biofeedback if available

2. If insufficient improvement after 8-12 weeks, add pharmacotherapy:

   • For younger patients or those without contraindications: Anticholinergic medication (e.g., tolterodine)
   • For elderly patients or those with cognitive concerns: Mirabegron

3. If response remains inadequate:

   • Consider combination therapy (behavioral + pharmacological)
   • Refer for specialist evaluation for potential advanced interventions

Important Clinical Considerations

• Treatment goal is to reduce incontinence episodes by at least 50%, which is considered clinically successful 1
• Most patients achieve significant improvement with behavioral treatments but may not become completely dry 3
• Combining behavioral treatment with pharmacotherapy may have additive effects 3
• Annual screening for urinary incontinence is recommended for women of all ages 1
• Evaluate and treat urinary tract infections promptly as they can worsen symptoms 1
• The choice of pharmacologic treatment should be based on tolerability, adverse effect profile, ease of use, and cost 1