What are the treatment options for urge urinary incontinence?

Treatment for Urge Urinary Incontinence

Start with bladder training as first-line therapy for urge incontinence, and if this fails after an adequate trial, add anticholinergic medications or mirabegron, selecting based on side effect profile and cost. 1

First-Line Behavioral Management

• Bladder training is the primary initial treatment for women with urgency urinary incontinence, involving scheduled voiding with progressively longer intervals between bathroom trips 1
• This behavioral approach improved urinary incontinence outcomes in moderate-quality evidence from the American College of Physicians 1
• Adding pelvic floor muscle training (PFMT) to bladder training does not improve continence compared with bladder training alone for pure urgency incontinence 1
• Lifestyle modifications including adequate (but not excessive) fluid intake and weight loss for obese patients should be implemented concurrently 2

Second-Line Pharmacologic Treatment

If bladder training is unsuccessful, proceed to pharmacologic therapy. 1

Medication Options (All Equally Efficacious):

• Oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium all increase continence rates with moderate magnitude of benefit 1
• Mirabegron (a beta-3 agonist) is FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency, starting at 25 mg daily and increasing to 50 mg if needed after 4-8 weeks 3
• Base medication selection on tolerability, adverse effect profile, ease of use, and cost rather than efficacy, as all agents show similar effectiveness 1

Critical Medication Considerations:

• Anticholinergic adverse effects (dry mouth, constipation, cognitive impairment) are a major reason for treatment discontinuation 1
• Poor adherence to pharmacologic treatments is common due to side effects 1
• Anticholinergics are not recommended in older adults due to adverse effects 4
• Mirabegron offers an alternative mechanism with different side effect profile for patients intolerant of anticholinergics 4, 5

Third-Line Advanced Therapies

For refractory urgency incontinence not responding to behavioral and pharmacologic interventions: 5, 6

• Intravesical onabotulinum toxin A (Botox) injections provide effective symptom control 4, 5, 7
• Sacral nerve stimulation (surgically implanted device) improves symptoms of urge incontinence 4, 6
• Posterior tibial nerve stimulation is a neuromodulation option for urge incontinence unresponsive to behavioral therapy 4, 6

Treatment Algorithm

1. Initiate bladder training immediately - scheduled voiding with progressive interval extension 1
2. Add lifestyle modifications - fluid management, weight loss if obese 2
3. If inadequate response after adequate trial (typically 4-8 weeks), add pharmacotherapy - select anticholinergic or mirabegron based on patient factors and cost 1, 3
4. If pharmacotherapy fails or is not tolerated, consider third-line therapies - Botox injections, sacral neuromodulation, or posterior tibial nerve stimulation 4, 5, 6

Common Pitfalls to Avoid

• Do not skip behavioral interventions - bladder training has strong evidence and should always be attempted first 1
• Do not use systemic pharmacologic therapy for stress incontinence - it is ineffective and represents the wrong treatment for the wrong condition 1
• Counsel patients about anticholinergic side effects upfront - set realistic expectations about dry mouth, constipation, and potential cognitive effects to improve adherence 1
• Weigh symptom severity against medication adverse effects - not all patients require pharmacotherapy if symptoms are mild and behavioral measures provide adequate relief 1