Treatment Options for Urinary Incontinence
Pelvic floor muscle training (PFMT) is the first-line treatment for all types of urinary incontinence, particularly for stress urinary incontinence where it can reduce episodes by more than 50%. 1
Initial Assessment and Classification
- Urinary incontinence should be categorized by type and severity through history, physical examination, and appropriate diagnostic modalities to determine the most effective treatment approach 2
- The main types include stress urinary incontinence (leakage with physical exertion), urgency urinary incontinence (leakage with sudden urge to void), and mixed urinary incontinence (combination of both) 1
- Assessment should focus on characterizing the incontinence, its severity, progression or resolution over time, and degree of bother 2
First-Line Conservative Management
- Supervised PFMT should be offered as initial treatment for all types of urinary incontinence and continued for at least 3 months before considering other options 1, 3
- PFMT involves repeated voluntary pelvic floor muscle contractions taught and supervised by a healthcare professional, showing significantly better outcomes than unsupervised training 1
- Weight loss programs should be recommended for patients who are obese, as this has been shown to improve incontinence symptoms 2, 3
- Bladder training, including extending time between voiding, is recommended as a behavioral therapy 1
- Lifestyle modifications should include adequate but not excessive fluid intake and timed voiding 1, 3
Pharmacologic Treatment
- For urgency or urgency-predominant mixed urinary incontinence, medications such as tolterodine may be prescribed 2, 4
- Tolterodine is FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency 4
- Common side effects of medications include dry mouth, constipation, heartburn, and urinary retention 2
- No pharmacologic therapy has been shown effective for stress urinary incontinence 1
Surgical Treatment Options
- Surgical interventions should be considered when conservative measures fail to adequately control symptoms 3
- Prior to surgical intervention for stress urinary incontinence, the condition should be confirmed by history, physical exam, or ancillary testing 2
- Synthetic midurethral mesh slings are the most common primary surgical treatment for stress incontinence 2, 1
- For severe stress incontinence, retropubic midurethral sling has better long-term outcomes 3
- Autologous fascia pubovaginal sling is an excellent alternative for patients concerned about mesh complications 3
- Cystourethroscopy should be performed before surgery to assess for urethral and bladder pathology that may affect outcomes 2
Treatment Algorithm Based on Incontinence Type
For Stress Urinary Incontinence:
- Start with supervised PFMT for at least 3 months 1, 3
- If obese, add weight loss program 2, 3
- If conservative management fails, consider surgical options like midurethral slings 2, 1
For Urgency Urinary Incontinence:
- Begin with bladder training and PFMT 1
- Add pharmacologic therapy such as tolterodine if needed 4, 2
- For refractory cases, consider specialized treatments like onabotulinumtoxinA or neuromodulators 5
For Mixed Urinary Incontinence:
- Start with PFMT and behavioral modifications 1
- Address the predominant component (stress or urgency) with appropriate targeted therapy 2
Special Considerations and Pitfalls
- Patients should be thoroughly counseled about potential complications specific to each treatment option 3
- Surgical complications can include direct injury to the lower urinary tract, hemorrhage, infection, and wound complications 2
- Success rates for surgical interventions range from 51-88%, and patients should be informed that symptoms may recur 3
- Avoid proceeding to surgery before an adequate trial of conservative management 3
- Treatment expectations should be realistic - one thin pad per day may be expected after treatment rather than complete dryness 2