What are the treatment options for urge incontinence vs overflow incontinence?

Treatment Options for Urge Incontinence vs. Overflow Incontinence

The treatment of urinary incontinence differs significantly based on type, with bladder training being first-line for urge incontinence and addressing the underlying cause being essential for overflow incontinence.

Urge Incontinence Treatment

First-Line: Non-Pharmacologic Approaches

• Bladder training is strongly recommended as first-line treatment for urge incontinence, showing significant improvement in urinary symptoms 1
• Pelvic floor muscle training (PFMT) can be combined with bladder training, particularly effective for mixed incontinence 1
• Lifestyle modifications including weight loss for obese patients, avoiding bladder irritants (caffeine, alcohol), and proper fluid intake management 2, 3

Second-Line: Pharmacologic Options

• If bladder training is unsuccessful, antimuscarinic medications are recommended 1, 4
• Options include:
  • Tolterodine - causes fewer adverse effects than oxybutynin with similar efficacy 4, 5
  • Solifenacin, darifenacin, fesoterodine, and trospium - all effective for urgency UI 1, 4
  • Mirabegron (β-3 agonist) - indicated for OAB with symptoms of urge incontinence with fewer anticholinergic side effects 6, 3
• Common side effects include dry mouth, constipation, and blurred vision, which often lead to discontinuation 2, 7

Third-Line Options

• Neuromodulation devices (posterior tibial nerve stimulators) for refractory urge incontinence 8
• OnabotulinumtoxinA injections for persistent symptoms 8
• Sacral nerve stimulation for cases not responding to other treatments 8

Overflow Incontinence Treatment

First-Line Approaches

• Address underlying cause (e.g., bladder outlet obstruction, neurogenic bladder) 9, 10
• Clean intermittent catheterization is first-line therapy for neurogenic bladder causes, though it carries risk of urinary tract infection 3
• For BPH-related overflow incontinence, α-1-blockers are recommended as first-line pharmacologic treatment 9, 3

Second-Line Options

• 5-α reductase inhibitors can be added for refractory overflow incontinence symptoms with PSA ≥ 1.5 mg/dL 3
• Combination therapy with α-blockers and 5-α reductase inhibitors for BPH-related overflow incontinence 9

Surgical Options

• Transurethral resection of the prostate (TURP) for BPH-related overflow incontinence that doesn't respond to medical therapy 9
• Other minimally invasive procedures may be considered before major surgery 9

Key Differences in Management Approach

• Urge incontinence: Focus on bladder retraining and suppressing detrusor overactivity 1
• Overflow incontinence: Focus on relieving obstruction or improving bladder contractility 9, 10
• Medication selection: Antimuscarinics/β-3 agonists for urge vs. α-blockers for overflow 4, 9
• Catheterization: Rarely needed for urge incontinence but often necessary for overflow 3

Common Pitfalls to Avoid

• Failing to properly diagnose the type of incontinence before initiating treatment 4
• Using anticholinergic medications in older adults without considering cognitive side effects 8
• Overlooking potential drug interactions with incontinence medications 7
• Not addressing underlying causes of overflow incontinence before symptomatic treatment 10