What are the treatment options for urinary incontinence?

Treatment for Urinary Incontinence

Treatment must be tailored to the specific type of incontinence: pelvic floor muscle training is first-line for stress incontinence, bladder training for urgency incontinence, and combined therapy for mixed incontinence, with behavioral interventions always preceding pharmacologic or surgical options. 1, 2

Initial Treatment Algorithm by Incontinence Type

Stress Urinary Incontinence (leakage with coughing, sneezing, physical exertion)

First-line treatment is supervised pelvic floor muscle training (PFMT), which involves repeated voluntary pelvic floor muscle contractions taught by a healthcare professional. 1 This approach has strong recommendation with high-quality evidence and demonstrates improved cure rates, symptom improvement, satisfaction, and quality of life compared to no treatment. 1

• PFMT shows 85-92% success rates in long-term studies. 1
• Avoid systemic pharmacologic therapy for stress incontinence as the American College of Physicians strongly recommends against it due to low-quality evidence of benefit. 1
• No adverse effects have been identified with behavioral interventions like PFMT. 1, 2

Urgency Urinary Incontinence (leakage with sudden compelling urge to void)

First-line treatment is bladder training, a behavioral therapy involving scheduled voiding with progressively extended intervals between voids. 1, 2

If bladder training fails, add pharmacologic treatment. 1 The choice between anticholinergic agents (tolterodine, oxybutynin) and beta-3 agonists should prioritize tolerability, adverse effect profile, ease of use, and cost. 1

• Medications show modest benefit with absolute risk difference <20% compared to placebo. 1
• Solifenacin and fesoterodine demonstrate dose-response effects on symptom improvement. 1
• Common adverse effects include dry mouth, constipation, heartburn, and urinary retention, leading to higher discontinuation rates than behavioral therapy. 1, 2
• Tolterodine is FDA-approved for overactive bladder with urge incontinence, urgency, and frequency. 3
• Oxybutynin exerts direct antispasmodic effects on bladder smooth muscle and increases bladder capacity. 4

Mixed Urinary Incontinence (combination of stress and urgency symptoms)

First-line treatment combines pelvic floor muscle training with bladder training. 1, 2 This dual approach addresses both mechanical and urgency components simultaneously with strong recommendation and moderate-quality evidence. 1

Universal Interventions Across All Types

Weight loss and exercise are strongly recommended for obese women with any type of incontinence, with moderate-quality evidence showing particular benefit for stress incontinence. 1, 2

• Weight loss improves symptoms more significantly in stress versus urge incontinence. 1
• No harms identified with weight loss programs or exercise interventions. 1, 2

Surgical Options (When Conservative Measures Fail)

For stress incontinence refractory to conservative therapy, surgical options include: 1

• Synthetic midurethral slings (MUS) - most common primary surgical treatment with 48-90% symptom improvement rates. 1, 5
• Autologous fascia pubovaginal sling - 85-92% success with 3-15 years follow-up, favored over Burch colposuspension (66% vs 49% effectiveness). 1
• Burch colposuspension - primarily for patients declining mesh or undergoing concurrent abdominal surgery. 1
• Bulking agents - viable but require re-treatment as the norm with limited long-term data. 1

Patients must be counseled on mesh-specific risks and FDA safety communications before selecting synthetic MUS procedures. 1

Surgical complications include urinary tract injury, hemorrhage, infection, bowel injury, wound complications, voiding dysfunction, and groin/suprapubic pain. 1

Critical Pitfalls to Avoid

• Never start medications before attempting behavioral interventions - this violates evidence-based stepped-care approach. 1, 2
• Ensure proper PFMT technique with professional supervision - inadequate instruction leads to treatment failure. 2
• Address modifiable risk factors (obesity, constipation, excessive fluid intake) as failure to do so undermines treatment outcomes. 2
• Recognize that intravaginal/intraurethral devices show limited effectiveness in methodologically sound trials. 1
• Long-term medication safety data is unavailable - factor this into shared decision-making. 1, 2

Treatment Success Definition

Clinically successful treatment reduces incontinence episodes by at least 50%. 2 Reassess symptoms regularly and advance to next treatment tier if conservative measures prove insufficient after adequate trial period.