What are the treatment options for urinary incontinence?

Treatment Options for Urinary Incontinence

Pelvic floor muscle training (PFMT) should be the first-line treatment for all types of urinary incontinence in women, particularly for stress urinary incontinence where it can reduce episodes by more than 50%. 1

Types of Urinary Incontinence

• Stress urinary incontinence: Involuntary loss of urine associated with intra-abdominal pressure (coughing, sneezing, physical exertion) 1
• Urgency urinary incontinence: Involuntary loss of urine associated with a sudden compelling urge to void 1
• Mixed urinary incontinence: Combination of stress and urgency incontinence 1
• Overactive bladder: Constellation of symptoms including urinary urgency (with or without UI), frequency, and nocturia 1

First-Line Conservative Management

• Pelvic floor muscle training (PFMT) - supervised by healthcare professionals shows significantly better outcomes than unsupervised training 1, 2

  • High-quality evidence shows PFMT is more than 5 times as effective as no active treatment for stress UI 1
  • PFMT should involve repeated voluntary pelvic floor muscle contractions taught and supervised by a healthcare professional 1
  • Treatment should continue for at least 3 months for optimal results 2

• Lifestyle modifications 1

  • Weight loss for obese patients - particularly effective for stress incontinence 1
  • Adequate but not excessive fluid intake 1
  • Bladder training - behavioral therapy that includes extending time between voiding 1

Pharmacologic Treatment

• For urgency urinary incontinence:

  • Mirabegron is FDA-approved for treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 3
  • Starting dose is 25 mg once daily, which can be increased to 50 mg once daily after 4-8 weeks if needed 3
  • Common side effects include dry mouth, constipation, heartburn, and urinary retention 1
  • Dose adjustments are required for patients with renal or hepatic impairment 3

• For stress urinary incontinence:

  • Pharmacologic therapy has not been shown to be effective and is not recommended 4

Specialized Treatment Options

• Urethral bulking agents for patients who cannot tolerate more invasive surgery 4

• For complex cases with fixed/immobile urethra:

  • Pubovaginal sling or autologous fascial sling is recommended for severe cases 4
  • Artificial urinary sphincter for severe cases with significant intrinsic sphincter deficiency 4

• Surgical options (when conservative measures fail):

  • Synthetic midurethral mesh slings are the most common primary surgical treatment for stress incontinence 1
  • Other surgical options include retropubic suspension and fascial slings 1
  • Surgical interventions should be reserved for women whose symptoms don't improve with conservative therapies 1

Important Considerations and Caveats

• Most women with UI do not report it to their physicians; clinicians should proactively ask about bothersome UI symptoms 1
• Clinically successful treatment is defined as reducing the frequency of UI episodes by at least 50% 1
• Avoid synthetic mesh slings in patients with poor tissue quality, significant scarring, or history of radiation therapy 4
• No harms were identified in studies of behavioral interventions like PFMT or weight loss programs 1
• Surgical complications can include direct injury to the lower urinary tract, hemorrhage, infection, bowel injury, and wound complications 1
• Treatment success rates for complex cases of UI (such as those with scarred urethras) are generally less favorable than for uncomplicated UI 4