What medications are used to treat urge incontinence?

Medications for Urge Incontinence

For urge urinary incontinence, antimuscarinic medications (tolterodine, darifenacin, solifenacin, fesoterodine, trospium) and beta-3 adrenergic agonists (mirabegron) are recommended as pharmacologic therapy, but only after bladder training has been unsuccessful. 1, 2

Treatment Algorithm for Urge Incontinence

First-Line Treatment (Non-Pharmacologic)

• Bladder training is the recommended first-line treatment for urgency urinary incontinence with strong recommendation and moderate-quality evidence 3, 2
• Pharmacologic therapy should only be initiated if bladder training has been unsuccessful 3, 1

Second-Line Treatment (Pharmacologic)

• When bladder training fails, antimuscarinic agents and beta-3 adrenergic agonists are the recommended pharmacologic options 1, 2
• The choice of agent should be based on tolerability, adverse effect profile, ease of use, and cost 3, 2

Specific Medication Options

Antimuscarinic Agents

• Tolterodine: Indicated for overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency 4

  • Has fewer adverse effects than oxybutynin 3, 2
  • Discontinuation rates similar to placebo 1

• Darifenacin: Recommended as a first-line pharmacologic option with favorable tolerability profile 1, 2

  • Discontinuation rates similar to placebo 1

• Solifenacin: Has the lowest risk for discontinuation due to adverse effects 1

  • No significant difference in discontinuation rates compared to tolterodine 2

• Fesoterodine: Higher discontinuation rates than tolterodine 2

• Trospium: Increases continence rates and improves urinary incontinence 3

• Oxybutynin: Has the highest risk for discontinuation due to adverse effects 1, 5

  • Starting with a lower dose (2.5 mg three times daily) may improve tolerability while maintaining efficacy 5
  • Controlled-release formulations may enhance treatment compliance by allowing once-daily dosing 6

Beta-3 Adrenergic Agonists

• Mirabegron: Indicated for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 7
  • Common side effects include nasopharyngitis and gastrointestinal disorders 1
  • Starting dose is 25 mg once daily, which may be increased to 50 mg after 4-8 weeks 7

Common Side Effects and Considerations

Antimuscarinic Side Effects

• Dry mouth, constipation, and blurred vision are common side effects 1
• Adverse effects are a major reason for treatment discontinuation 3
• Adherence to pharmacologic treatments for urge incontinence is generally poor 2

Special Populations

• For obese women, weight loss and exercise are strongly recommended 1, 2
• For elderly patients, consider lower starting doses due to increased risk of side effects 1
• In patients with renal or hepatic impairment, dose adjustments may be necessary 7

Important Clinical Considerations

• Monitor blood pressure, especially in hypertensive patients, as medications like mirabegron can increase blood pressure 7
• Use caution in patients with bladder outlet obstruction or those taking muscarinic antagonist drugs due to risk of urinary retention 7
• Pharmacologic therapy is not recommended for stress urinary incontinence 3, 2
• All pharmacologic therapies are equally efficacious at managing urgency UI, with moderate benefit in achieving continence rates 2