What are the treatment options for urge incontinence (Urinary Incontinence due to a sudden, urgent need to urinate)?

Treatment Options for Urge Incontinence

For urge urinary incontinence, bladder training should be the first-line treatment, followed by pharmacologic therapy if behavioral approaches are unsuccessful. 1

First-Line Treatment: Behavioral Interventions

• Bladder training is strongly recommended as the initial treatment for patients with urgency urinary incontinence (strong recommendation, moderate-quality evidence) 1, 2
• Bladder training techniques include scheduled voiding, urge suppression strategies, and positive reinforcement to improve bladder control 2
• For patients with mixed urinary incontinence (both urge and stress components), pelvic floor muscle training (PFMT) combined with bladder training is recommended (strong recommendation, moderate-quality evidence) 1, 2
• Lifestyle modifications should be implemented, including weight loss for obese patients, avoiding bladder irritants (caffeine, alcohol), and treating constipation 2

Second-Line Treatment: Pharmacologic Options

• If bladder training is unsuccessful, pharmacologic treatment should be initiated (strong recommendation, high-quality evidence) 1, 2
• Antimuscarinic medications are effective for urgency urinary incontinence and include oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium 1, 2
• Solifenacin is FDA-approved for treating overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 3
• Mirabegron is another FDA-approved medication for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 4
• When selecting medications, consider that tolterodine causes fewer adverse effects than oxybutynin with similar efficacy 2
• Solifenacin has the lowest risk for discontinuation due to adverse effects, while oxybutynin has the highest risk 2, 5

Common Side Effects and Considerations

• Antimuscarinic medications can cause dry mouth, constipation, blurred vision, and cognitive effects 3
• Solifenacin may cause serious allergic reactions, urinary retention in patients with bladder outlet obstruction, and gastrointestinal issues 3
• These medications should be used with caution in older adults due to potential cognitive side effects 2, 6
• Patients should be warned that solifenacin may cause central nervous system effects or blurred vision that could impair driving or operating machinery 3

Advanced Treatment Options

• For urge incontinence that doesn't respond to behavioral and pharmacologic therapy, consider:
  • Neuromodulation devices such as posterior tibial nerve stimulation 6, 7
  • Sacral nerve stimulation (surgically implanted) 6, 8
  • Intravesical onabotulinumtoxinA injections 6, 7
  • Flat Magnetic Stimulation (FMS), a newer technology showing promise for treating refractory urge urinary incontinence 9

Important Caveats and Pitfalls

• Adherence to pharmacologic treatments for urinary incontinence is often poor due to side effects 1
• Clinicians should compare the risk of pharmacologic adverse effects with the severity of the patient's symptoms 1
• Underdiagnosis is common, with at least half of women with urinary incontinence not reporting the issue to their physicians 2
• Failure to identify medications that may cause or worsen urinary incontinence is a common pitfall 2
• Overlooking conditions that may cause urinary symptoms, such as urinary tract infections and metabolic disorders, should be avoided 2

Treatment Algorithm

1. Start with bladder training and lifestyle modifications for 8-12 weeks
2. If insufficient improvement, add pharmacologic therapy:
   • First choice: Solifenacin or tolterodine (fewer side effects)
   • Alternative: Mirabegron (different mechanism of action)
3. If inadequate response to medications after 4-8 weeks, consider:
   • Switching to another medication class
   • Referral for advanced therapies (neuromodulation, onabotulinumtoxinA)