What are the treatment options for urinary incontinence?

Treatment of Urinary Incontinence

Start with supervised pelvic floor muscle training (PFMT) as first-line therapy for all types of urinary incontinence, as it is more than 5 times as effective as no treatment and can reduce incontinence episodes by over 50%. 1, 2

Initial Assessment and Categorization

Before initiating treatment, determine the specific type of incontinence through focused questioning and examination: 1

• Stress incontinence: Leakage with coughing, sneezing, or physical exertion due to sphincteric insufficiency 1, 2
• Urgency incontinence: Leakage with sudden compelling urge to void, often part of overactive bladder syndrome 1, 2
• Mixed incontinence: Combination of both stress and urgency symptoms 1, 2
• Overflow incontinence (in men post-prostate treatment): Leakage from incomplete bladder emptying 1

Perform urinalysis to rule out infection and hematuria, and assess severity, frequency, and impact on quality of life. 1, 3

Treatment Algorithm by Type

For Stress Urinary Incontinence

First-line (initiate immediately):

• Supervised PFMT with a trained healthcare professional or physiotherapist for at least 3 months—this achieves continence in 1 out of every 3 women treated 1, 2, 4
• Weight loss for obese women (reduces episodes significantly, with 1 in 4 obese women achieving meaningful improvement) 1, 4
• Lifestyle modifications: adequate but not excessive fluid intake, avoid caffeine 2, 4

Critical caveat: Unsupervised PFMT is significantly less effective than supervised training. 2, 4

Second-line (if conservative measures fail after 3-6 months):

• Vaginal estrogen formulations for postmenopausal women (improves continence) 5, 4
• Do NOT use systemic pharmacologic therapy—it has not been shown effective for stress incontinence 2, 4

Third-line (surgical, for refractory cases):

• Synthetic midurethral slings are the most common primary surgical option (48-90% symptom improvement) 2, 4, 3
• Alternative options: retropubic suspension or autologous fascial slings 2, 5
• Counsel patients about surgical risks: urinary tract injury, hemorrhage, infection, bowel injury, wound complications, and mesh-specific complications (<5% rate) 2, 4

For Urgency Urinary Incontinence (Overactive Bladder)

First-line:

• Bladder training—behavioral therapy extending time between voiding (1 in 2 women improve) 1, 4
• Lifestyle modifications: weight loss, fluid management 1

Second-line (only after bladder training fails):

• Antimuscarinic medications: 4, 6
  • Preferred agents with dose-response effects: solifenacin or fesoterodine 4
  • Alternative agents: oxybutynin, tolterodine, darifenacin, trospium 4, 6, 7
  • Tolterodine 2 mg twice daily is FDA-approved and demonstrated statistically significant reduction in incontinence episodes and micturition frequency in clinical trials 6

Third-line (specialist treatments for refractory cases):

• OnabotulinumtoxinA bladder injections 4, 3
• Percutaneous tibial nerve stimulation 4, 3
• Sacral neuromodulation 4, 3

For Mixed Urinary Incontinence

Combine PFMT with bladder training—this combination achieves continence in 1 out of 6 women and improves symptoms in 1 out of 3 women. 1, 4

• Add weight loss and physical activity for obese women (1 in 4 achieve improvement) 1
• If urgency symptoms predominate, follow the urgency incontinence treatment pathway above 1
• If stress symptoms predominate, prioritize PFMT and consider surgical options if conservative measures fail 1, 2

For Incontinence After Prostate Treatment (Men)

Immediate post-catheter removal:

• Offer PFMT/pelvic floor muscle therapy immediately upon catheter removal—this improves time-to-continence recovery (typically 3-6 months) 1

At 6 months post-treatment:

• If no significant improvement, offer early surgical intervention 1
• Assess whether incontinence is stress-type (sphincteric insufficiency) or urgency-type (bladder dysfunction) 1
• For urgency symptoms: follow the AUA Overactive Bladder guideline recommendations 1

Surgical options for persistent stress incontinence:

• Severe incontinence or history of radiation: Artificial urinary sphincter (AUS) is first-line, though male slings can be offered with appropriate counseling 1
• Moderate incontinence: Discuss risks and benefits of both AUS and male slings 1
• Perform cystourethroscopy before surgery to assess for urethral stricture, bladder neck contracture, or other pathology that may affect outcomes 1
• Set realistic expectations: one thin pad per day is the expected outcome 1

Common Pitfalls to Avoid

• Never skip supervised PFMT: Unsupervised exercises are far less effective than professionally supervised training 1, 2, 4
• Don't start medications for urgency incontinence without trying bladder training first 1, 4
• Avoid systemic pharmacologic therapy for stress incontinence—it doesn't work 2, 4
• Don't use transdermal estrogen for incontinence—it worsens symptoms (only vaginal formulations may help) 4
• For post-prostate treatment incontinence, don't wait beyond 6 months to offer surgical options if no improvement occurs 1
• Avoid synthetic midurethral slings in patients with scarred urethras—higher risk of erosion and failure 5

Defining Treatment Success

Clinically meaningful improvement is defined as reducing incontinence episode frequency by at least 50%. 2 Even modest improvements can significantly impact daily functioning and quality of life. 4