What are the treatment options for urinary incontinence?

Treatment Options for Urinary Incontinence

Initial Assessment and Type Identification

Begin with pelvic floor muscle training (PFMT) as first-line treatment for all types of urinary incontinence in women, particularly stress incontinence where it reduces episodes by more than 50%. 1

The approach differs fundamentally based on incontinence type:

• Stress urinary incontinence (SUI): Involuntary urine loss with coughing, sneezing, or physical exertion 1
• Urgency urinary incontinence (UUI): Involuntary loss with sudden compelling urge to void 1
• Mixed incontinence: Combination of both stress and urgency symptoms 1

Treatment Algorithm for Stress Urinary Incontinence

First-Line: Conservative Management

• Supervised PFMT is more than 5 times as effective as no treatment and shows significantly better outcomes than unsupervised training. 1
• PFMT must involve repeated voluntary pelvic floor muscle contractions taught and supervised by a healthcare professional for at least 3 months before considering other options 1, 2
• Supervised programs demonstrate up to 70% improvement in symptoms when properly performed 2
• Weight loss programs should be implemented for obese patients, as this improves stress incontinence symptoms 1, 2
• Lifestyle modifications include adequate but not excessive fluid intake 1

Critical Pitfall to Avoid

• No pharmacologic therapy has been shown effective for stress urinary incontinence and is not recommended. 1, 3 This represents wrong treatment for the wrong condition.

Second-Line: Surgical Options (When Conservative Measures Fail)

• Synthetic midurethral mesh slings are the most common primary surgical treatment, with symptom improvement in 48-90% of women and low mesh complication rates (<5%) 1, 4
• Retropubic midurethral sling has better long-term outcomes for severe stress incontinence 2
• Autologous fascia pubovaginal sling is an excellent alternative for patients concerned about mesh complications, with 85-92% success rates at 3-15 years follow-up 2
• Retropubic suspension and fascial slings are additional surgical options 1

Special Consideration: Scarred Open Proximal Urethra

• Autologous Fascial Sling (AFS) is the first-line surgical option for complex SUI with scarred proximal urethra, providing robust support for damaged urethra 3
• Artificial Urinary Sphincter (AUS) is an alternative for severe cases with significant intrinsic sphincter deficiency 3
• Avoid synthetic mid-urethral slings in patients with scarred urethras due to higher risk of erosion, extrusion, and treatment failure. 3

Treatment Algorithm for Urgency Urinary Incontinence

First-Line: Behavioral Management

• Bladder training is the primary initial treatment for urgency incontinence, involving scheduled voiding with progressively longer intervals between bathroom trips 1
• Bladder training improved urinary incontinence outcomes with moderate-quality evidence 1
• Adding PFMT to bladder training does not improve continence compared with bladder training alone for pure urgency incontinence. 1

Second-Line: Pharmacologic Treatment

When behavioral measures provide inadequate relief, consider medications:

• All anticholinergic agents (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium) increase continence rates with similar effectiveness. 1
• Base medication selection on tolerability, adverse effect profile, ease of use, and cost rather than efficacy, as all agents show similar effectiveness 1
• Mirabegron (beta-3 agonist) is FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 5
• Mirabegron starting dose is 25 mg orally once daily, with maximum dose of 50 mg once daily after 4-8 weeks if needed 5
• Mirabegron was effective in treating OAB symptoms within 4-8 weeks and maintained efficacy through 12-week treatment period 5

Critical Counseling Points

• Counsel patients about anticholinergic side effects upfront (dry mouth, constipation, cognitive impairment) to improve adherence, as these are major reasons for treatment discontinuation 1
• Poor adherence to pharmacologic treatments is common due to side effects 1
• Mirabegron requires dose adjustment in renal impairment (maximum 25 mg daily for eGFR 15-29 mL/min/1.73 m²) and moderate hepatic impairment 5

Third-Line: Specialist Treatments

• OnabotulinumtoxinA injections for refractory urgency incontinence 4
• Percutaneous or implanted neuromodulators 4

Common Pitfalls to Avoid Across All Types

• Do not skip behavioral interventions - bladder training and PFMT have strong evidence and should always be attempted first 1
• Do not proceed to surgery before an adequate trial of conservative management (minimum 3 months of supervised PFMT) 2
• Weigh symptom severity against medication adverse effects - not all patients require pharmacotherapy if symptoms are mild and behavioral measures provide adequate relief 1
• Do not ignore coexisting conditions such as high-grade prolapse, urgency-predominant mixed incontinence, or incomplete bladder emptying, as these affect treatment selection and outcomes 2

Success Metrics and Expectations

• Clinically successful treatment is defined as reducing the frequency of UI episodes by at least 50% 1
• No harms were identified in studies of behavioral interventions like PFMT or weight loss programs 1
• Surgical success rates range from 51-88%, and patients should be informed that symptoms may recur and require additional treatment 2
• Surgical complications can include direct injury to lower urinary tract, hemorrhage, infection, bowel injury, and wound complications 1