What are the types of urinary incontinence and their treatment options, including medication dosages?

Types of Urinary Incontinence and Treatment Options

For urinary incontinence treatment, pelvic floor muscle training is recommended for stress incontinence, bladder training for urgency incontinence, and a combination of both for mixed incontinence, with pharmacologic therapy reserved for urgency incontinence when behavioral therapies fail. 1

Types of Urinary Incontinence

1. Stress Urinary Incontinence (SUI)

   • Involuntary leakage with physical exertion, coughing, sneezing
   • Related to urethral sphincter failure associated with intra-abdominal pressure 1

2. Urgency Urinary Incontinence (UUI)

   • Involuntary leakage associated with a sudden compelling urge to void
   • Part of overactive bladder syndrome 1

3. Mixed Urinary Incontinence (MUI)

   • Combination of both stress and urgency incontinence 1, 2

4. Overflow Incontinence

   • Leakage due to bladder over-distention 3

First-Line Treatment: Behavioral and Lifestyle Interventions

For All Types of Incontinence

• Weight loss and exercise for obese women (strong recommendation, moderate-quality evidence) 1
• Fluid management: avoiding bladder irritants (caffeine, alcohol) 2

Type-Specific Behavioral Treatments

• Stress UI: Pelvic floor muscle training (PFMT) (strong recommendation, high-quality evidence) 1

  • Regimen: 3-5 second contractions followed by 3-5 seconds of relaxation
  • 10-15 repetitions per session, 3 times daily 2

• Urgency UI: Bladder training (strong recommendation, moderate-quality evidence) 1

  • Scheduled voiding with gradual extension of time between voids 2

• Mixed UI: PFMT combined with bladder training (strong recommendation, moderate-quality evidence) 1

Pharmacologic Treatment

For Urgency UI (when bladder training fails)

• Anticholinergics (strong recommendation, high-quality evidence) 1

  • Oxybutynin: Starting dose 2.5-5 mg 2-3 times daily

    • Lower starting dose (2.5 mg 2-3 times daily) recommended for frail elderly 4
    • Side effects: dry mouth, constipation, heartburn 2, 4
    • Caution with CYP3A4 inhibitors (ketoconazole, erythromycin) 4

  • Tolterodine: 2 mg twice daily

    • Demonstrated efficacy in reducing incontinence episodes and micturition frequency 5

• Beta-3 agonists (e.g., mirabegron) 2

  • Alternative when anticholinergics cause intolerable side effects

For Stress UI

• Pharmacologic therapy NOT recommended (strong recommendation, low-quality evidence) 1, 6
  • Off-label use of tricyclic antidepressants (imipramine) and adrenergic agonists has unpredictable results 6

Advanced Treatment Options for Refractory Cases

For Urgency UI

• Minimally invasive therapies for patients with inadequate response to or intolerable side effects from behavioral/pharmacologic therapy 1:
  • Sacral neuromodulation
  • Tibial nerve stimulation
  • Intradetrusor botulinum toxin injection
    • Requires post-void residual measurement before treatment
    • Risk of urinary retention requiring clean intermittent catheterization 1

For Stress UI

• Mechanical devices (urethral inserts)
• Urethral bulking agents
• Surgical options: midurethral slings, autologous fascial slings 7

Treatment Selection Considerations

• Base choice of pharmacologic agents on:

  • Tolerability
  • Adverse effect profile
  • Ease of use
  • Cost 1

• Consider patient goals and symptom severity 7

• For elderly patients:

  • Start at lower doses of medications
  • Consider altered pharmacokinetics (elimination half-life of oxybutynin increases from 2-3 hours to 5 hours) 4

Treatment Efficacy

• Behavioral treatment has shown superior efficacy (80.7% reduction in incontinence episodes) compared to drug treatment (68.5%) and placebo (39.4%) 8

• Patient satisfaction is higher with behavioral treatments (74.1% reporting "much better" vs. 50.9% for drug treatment) 8

Common Pitfalls to Avoid

• Treating stress incontinence with anticholinergics (not effective) 6
• Overlooking pelvic floor muscle hypertonicity (Kegel exercises contraindicated) 2
• Inadequate assessment before treatment escalation 2
• Failing to measure post-void residual before and after botulinum toxin therapy 1