Treatment Plan for Urinary Incontinence
The treatment of urinary incontinence should be tailored to the specific type of incontinence, with pelvic floor muscle training recommended as first-line therapy for all types of urinary incontinence in women. 1, 2
Types of Urinary Incontinence
- Stress urinary incontinence (SUI): Involuntary loss of urine associated with intra-abdominal pressure, such as coughing, sneezing, or physical exertion 2
- Urgency urinary incontinence (UUI): Involuntary loss of urine associated with a sudden compelling urge to void 2
- Mixed urinary incontinence (MUI): A combination of stress and urgency incontinence 2
- Overactive bladder: A constellation of symptoms including urinary urgency, frequency, and nocturia 2
First-Line Treatment Options
For Stress Urinary Incontinence:
- Pelvic floor muscle training (PFMT) supervised by healthcare professionals is the first-line treatment, with high-quality evidence showing it is more than 5 times as effective as no treatment 1, 2
- PFMT should involve repeated voluntary pelvic floor muscle contractions taught and supervised by a healthcare professional for optimal results 2, 3
- Systemic pharmacologic therapy is NOT recommended for stress UI due to lack of efficacy 1, 2
For Urgency Urinary Incontinence:
- Bladder training is the first-line behavioral therapy, which includes extending time between voiding 1, 4
- If bladder training is unsuccessful, pharmacologic treatment should be initiated 1, 5
- Medication selection should be based on tolerability, adverse effect profile, ease of use, and cost 1
- FDA-approved medications include antimuscarinic agents like tolterodine (indicated for overactive bladder with symptoms of urge urinary incontinence) 5, 6
For Mixed Urinary Incontinence:
- Combined approach of pelvic floor muscle training with bladder training is recommended 1, 4
- Treatment should initially focus on the most bothersome component (stress or urgency) 4
Lifestyle Modifications
- Weight loss and exercise are strongly recommended for obese women with UI 1, 7
- Adequate but not excessive fluid intake is recommended 2, 4
- Smoking cessation can help reduce chronic cough that exacerbates stress incontinence 4
- Regular voiding intervals can help reduce urgency incontinence episodes 8
Second-Line Treatment Options
For Persistent Urgency Urinary Incontinence:
- If first-line treatments fail, more invasive options include:
For Persistent Stress Urinary Incontinence:
- Surgical options should be considered when conservative measures fail:
Important Considerations and Caveats
- Clinically successful treatment is defined as reducing the frequency of UI episodes by at least 50% 2
- Supervised PFMT shows significantly better outcomes than unsupervised training 2, 3
- No harms have been identified in studies of behavioral interventions like PFMT or weight loss programs 2
- For complex cases of UI with scarred proximal urethra, synthetic mid-urethral slings should be avoided due to higher risk of erosion and treatment failure 9
- Only about 25% of women with UI seek or receive treatment despite the availability of effective options 8
- Infection and hematuria should be ruled out before initiating treatment for UI 8
Treatment Algorithm
- Identify the type of urinary incontinence (stress, urgency, or mixed)
- Start with appropriate conservative measures:
- For SUI: Supervised PFMT
- For UUI: Bladder training
- For MUI: Combined PFMT and bladder training
- Implement lifestyle modifications (weight loss, fluid management)
- If symptoms persist after 3 months of conservative therapy:
- For SUI: Consider surgical options
- For UUI: Initiate pharmacologic therapy
- For MUI: Address the predominant symptom first
- For refractory cases, consider referral to a specialist for advanced treatment options