What are the treatment options for urge incontinence?

Treatment Options for Urge Incontinence

Bladder training should be the first-line treatment for women with urge urinary incontinence, followed by pharmacologic therapy if bladder training is unsuccessful. 1

First-Line Treatment: Behavioral Therapies

• Bladder training is the initial recommended treatment for urge incontinence and has shown significant improvement in urinary symptoms and quality of life 1
• Bladder training involves behavioral therapy that includes gradually extending the time between voiding episodes 1
• For women with mixed urinary incontinence (combination of stress and urge), pelvic floor muscle training (PFMT) combined with bladder training is recommended 1
• Weight loss and exercise are strongly recommended for obese women with urinary incontinence 1, 2

Second-Line Treatment: Pharmacologic Options

• If bladder training is unsuccessful, pharmacologic therapy should be initiated 1
• Antimuscarinic medications are effective for treating urge incontinence and include:
  • Tolterodine (FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency) 3
  • Oxybutynin, darifenacin, solifenacin, fesoterodine, and trospium 1, 2
• Beta-3 adrenoceptor agonists:
  • Mirabegron is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 4

Medication Selection Considerations

• When choosing between medications, consider the following factors 1:

  • Tolerability
  • Adverse effect profile
  • Ease of use
  • Cost of medication

• Comparative medication profiles:

  • Solifenacin has the lowest risk for discontinuation due to adverse effects 1
  • Darifenacin and tolterodine have risks for discontinuation due to adverse effects similar to placebo 1
  • Oxybutynin is associated with the highest risk for discontinuation due to adverse effects 1
  • Common antimuscarinic side effects include dry mouth, constipation, and blurred vision 1
  • Mirabegron's common side effects include nasopharyngitis and gastrointestinal disorders 1

Advanced Treatment Options

• For refractory urge incontinence that doesn't respond to behavioral and pharmacologic therapy, consider 5, 6:
  • Neuromodulation devices (posterior tibial nerve stimulators)
  • OnabotulinumtoxinA injections
  • Sacral nerve stimulators (surgically implanted)

Treatment Algorithm

1. Start with bladder training for all patients with urge incontinence 1
2. Add weight loss and exercise for obese patients 1, 2
3. If bladder training is unsuccessful after 8-12 weeks, initiate pharmacologic therapy 1
4. Choose medication based on side effect profile, cost, and patient factors:
   • Consider tolterodine or solifenacin as first choices due to better side effect profiles 1
   • Consider mirabegron for patients who cannot tolerate antimuscarinic side effects 4, 7
5. For treatment-resistant cases, refer to specialist for advanced therapies 5, 6

Common Pitfalls to Avoid

• Failing to try behavioral therapy before initiating pharmacologic treatment 1, 8
• Not considering medication side effects, particularly in older adults where anticholinergic burden can affect cognition 5, 7
• Overlooking the possibility of mixed incontinence, which requires a combined approach of PFMT and bladder training 1
• Underdiagnosing urinary issues, as many women do not report incontinence to their physicians 6
• Not addressing modifiable factors such as excessive fluid intake, caffeine, and alcohol consumption that can worsen urge symptoms 5, 7