What are the treatment approaches for stress versus urge incontinence?

Treatment Approaches for Stress versus Urge Incontinence

For stress urinary incontinence, initiate supervised pelvic floor muscle training as first-line therapy for at least 3 months, with surgical intervention (midurethral slings) reserved for refractory cases; for urge incontinence, begin with bladder training and escalate to antimuscarinic medications (solifenacin or fesoterodine) if behavioral therapy fails. 1

Stress Urinary Incontinence Management

First-Line Conservative Treatment

• Pelvic floor muscle training (PFMT) is the cornerstone of stress incontinence management, demonstrating up to 70% symptom improvement when properly supervised by a healthcare professional 1, 2
• PFMT should consist of repeated voluntary pelvic floor muscle contractions taught and supervised by a trained clinician or physiotherapist for optimal results 1
• Treatment duration must be at least 3 months to achieve meaningful clinical benefit 1, 2
• Supervised programs significantly outperform unsupervised or leaflet-based approaches 2

Common pitfall: Patients often perform PFMT incorrectly without proper instruction. Ensure patients receive hands-on teaching from qualified personnel rather than written instructions alone 2.

Adjunctive Conservative Measures

• Weight loss specifically benefits stress incontinence more than urge incontinence in obese women, with randomized trials showing significant symptom improvement 1
• Behavioral interventions carry no identified harms, making them ideal initial therapy 1

Pharmacologic Therapy

• Systemic pharmacologic therapy should NOT be used for stress incontinence as standard medications have not demonstrated effectiveness 1
• Vaginal estrogen formulations may improve stress incontinence symptoms, though transdermal preparations worsen incontinence 1

Surgical Intervention

• Reserve surgery for patients whose symptoms remain bothersome despite 3+ months of conservative therapy 1
• Synthetic midurethral slings represent the most common primary surgical treatment for stress incontinence 1
• Alternative surgical options include urethral bulking agents, retropubic colposuspension, and autologous fascial slings 1
• Important caveat: Mesh-related complications have created patient hesitancy; counsel patients thoroughly about the escalation in invasiveness and complication rates when transitioning to surgical management 1

Urge Urinary Incontinence Management

First-Line Behavioral Therapy

• Bladder training is the initial treatment for urgency incontinence, involving behavioral therapy that extends time between voiding 1
• Bladder training alone (without PFMT) is sufficient for pure urgency incontinence 1

Pharmacologic Escalation

• Initiate antimuscarinic medications only after bladder training has failed 1
• Effective agents include: oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium 1
• Solifenacin and fesoterodine demonstrate dose-response effects, making them preferred choices 1
• Mirabegron (beta-3 agonist) is FDA-approved for overactive bladder with urge incontinence, urgency, and frequency 3

Critical limitation: Medications show modest efficacy with absolute risk difference <20% compared to placebo 1

Medication Selection Strategy

Base drug selection on:

• Tolerability profile (dry mouth, constipation, heartburn, urinary retention are common) 1
• Discontinuation rates are high due to adverse effects 1
• Tolterodine causes fewer harms than oxybutynin while maintaining equal efficacy 1
• Cost and ease of use 1

Important consideration: Long-term safety data for these medications remain unavailable 1

Mixed Urinary Incontinence Management

• Combine PFMT with bladder training for mixed incontinence, as this combination improves both continence and quality of life 1
• This dual approach addresses both the urethral sphincter dysfunction (stress component) and detrusor overactivity (urge component) 1

Quality of Life Considerations

• Both PFMT and bladder training improve patient satisfaction and quality of life measures beyond just symptom reduction 1
• Even modest symptom improvements may have important effects on women's daily functioning 1
• Treatment adherence remains challenging, particularly with pharmacologic therapy where adverse effects frequently lead to discontinuation 1

Surgical Complications to Counsel Patients About

When discussing surgical options for refractory stress incontinence:

• Direct injury to lower urinary tract 1
• Hemorrhage, infection, bowel injury, wound complications 1
• Mesh-specific complications have led to decreased utilization 1