Treatments for Urge Incontinence
First-line treatment for urge incontinence should be behavioral therapies, particularly bladder training and pelvic floor muscle training (PFMT), which can reduce incontinence episodes by up to 70% with minimal side effects. 1
First-Line Treatments: Behavioral Therapies
Bladder Training
- Bladder training alone can significantly improve urge incontinence with a relative risk of 3.22 and absolute risk difference of 0.43 compared to no treatment 2
- Involves scheduled voiding, gradual extension of voiding intervals, and positive reinforcement
- Can reduce incontinence episodes by 57-86% 3
Pelvic Floor Muscle Training (PFMT)
- Should be performed daily with proper technique
- Supervised PFMT for 8-12 weeks shows superior outcomes compared to unsupervised training 1
- For optimal results:
- Proper instruction on technique is essential
- Daily performance recommended
- 8-12 week supervised program yields best results
Combination Therapy
- PFMT combined with bladder training is particularly effective for mixed incontinence (RR 3.8) 2
- This combination approach shows high-quality evidence of effectiveness 2
Lifestyle Modifications
- Weight loss for overweight/obese patients (moderate-quality evidence) 1
- Fluid management strategies:
- 25% reduction in fluid intake if excessive
- Reducing caffeine consumption
- Avoiding excessive fluids at night 1
Second-Line Treatments: Pharmacologic Options
When behavioral therapies are insufficient, pharmacologic options include:
Antimuscarinic Medications
- Darifenacin: Improves UI with RR 1.3 (95% CI 1.2-1.5) 2
- Fesoterodine: Improves continence with RR 1.5 (95% CI 1.1-1.9) 2
- Tolterodine: FDA-approved for overactive bladder with symptoms of urge urinary incontinence 4
- Other options: Oxybutynin, solifenacin, trospium
Common side effects: Dry mouth, constipation, headache, dizziness 2, 5
Beta-3 Adrenergic Agonists
- Mirabegron: FDA-approved for overactive bladder with symptoms of urge urinary incontinence 6
- Offers fewer anticholinergic side effects compared to antimuscarinics 1
Treatment Algorithm
Initial assessment:
- Determine type of incontinence (urge, stress, mixed)
- Evaluate impact on quality of life using validated questionnaires
- Consider 24-72 hour voiding diary
- Rule out UTI with urinalysis
Start with behavioral therapies:
- Bladder training
- Supervised PFMT for 8-12 weeks
- Implement lifestyle modifications
If insufficient improvement after 8-12 weeks:
- Add pharmacologic therapy
- Choose between antimuscarinic medications or beta-3 agonist based on:
- Patient age (elderly patients have higher risk of side effects from antimuscarinics)
- Comorbidities
- Potential drug interactions
- Side effect profile
Monitor and reassess:
- Evaluate efficacy and tolerability after 4-6 weeks
- Consider switching medications if side effects are intolerable
- Discontinue medications that aren't providing benefit
Special Considerations
- Elderly patients: Start with lower doses of antimuscarinic medications due to increased risk of side effects 1
- Treatment success: Should be measured not only by clinical improvement but also by tolerability and quality of life improvement 5
- Persistence: Behavioral therapy benefits may continue to improve over time, with some studies showing continued improvement at 12 months 7
Pitfalls to Avoid
- Skipping behavioral therapy: Don't jump straight to medications; behavioral therapies have high success rates with minimal side effects
- Inadequate PFMT instruction: Proper technique is essential for effectiveness
- Overlooking medication side effects: Dry mouth and constipation can significantly impact quality of life and medication adherence
- Failing to reassess: Regular follow-up is needed to evaluate treatment effectiveness and make adjustments
Behavioral therapies remain the cornerstone of urge incontinence treatment due to their effectiveness, absence of side effects, and high patient satisfaction levels 3.