What are the first-line treatments for urinary incontinence, specifically urge incontinence?

First-Line Treatment for Urge Urinary Incontinence

Bladder training is the first-line treatment for urge urinary incontinence and should be implemented before any pharmacologic therapy. 1, 2

Initial Management Algorithm

Step 1: Non-Pharmacologic Therapy (First-Line)

• Bladder training alone is the primary treatment for urge incontinence, with strong recommendation and moderate-quality evidence from the American College of Physicians. 1
• Bladder training involves scheduled voiding with progressively increasing intervals between voids to improve bladder capacity and reduce urgency episodes. 2
• Pelvic floor muscle training (PFMT) should NOT be added to bladder training for pure urge incontinence, as the addition does not improve continence compared with bladder training alone. 1
• PFMT combined with bladder training is reserved specifically for mixed urinary incontinence (when both stress and urge components are present). 1, 3

Step 2: Lifestyle Modifications (Concurrent with Bladder Training)

• Weight loss and exercise for obese women should be implemented, with strong recommendation and moderate-quality evidence. 1, 3
• Avoid bladder irritants including caffeine and alcohol. 2
• Optimize fluid intake—adequate but not excessive. 2
• Rule out urinary tract infections through urinalysis and culture, as these can mimic or worsen urge incontinence symptoms. 1, 2
• Review and discontinue medications that may cause or worsen urinary incontinence. 1, 3

When Bladder Training Fails: Pharmacologic Therapy (Second-Line)

If bladder training is unsuccessful after 8-12 weeks, add antimuscarinic medications with strong recommendation and high-quality evidence. 1, 2

Preferred Antimuscarinic Agents (in order of tolerability):

1. Solifenacin has the lowest risk for discontinuation due to adverse effects and is FDA-approved for overactive bladder with urge urinary incontinence. 3, 4

2. Darifenacin has discontinuation rates similar to placebo and is FDA-approved for overactive bladder with urge urinary incontinence. 3, 5

3. Tolterodine has discontinuation rates similar to placebo and causes fewer harms than oxybutynin while providing equal efficacy. 1, 3

4. Fesoterodine and trospium are also effective options with moderate adverse effect profiles. 1

5. Oxybutynin should be avoided if possible due to the highest risk for discontinuation from adverse effects, despite equal efficacy to other agents. 1, 3

Alternative Pharmacologic Option:

• Mirabegron (β3-adrenoceptor agonist) is FDA-approved for adult overactive bladder with urge urinary incontinence and commonly causes nasopharyngitis and gastrointestinal disorders rather than antimuscarinic side effects. 3, 6

Key Clinical Considerations

Medication Selection Criteria:

Base the choice of pharmacologic agent on tolerability, adverse effect profile, ease of use, and cost—NOT on small efficacy differences, as all antimuscarinics are equally efficacious. 1, 3

Common Pitfalls to Avoid:

• Do NOT use systemic pharmacologic therapy for stress urinary incontinence—it is ineffective and has strong recommendation against use. 1, 3
• Antimuscarinic medications commonly cause dry mouth, constipation, and blurred vision. 3
• Adherence to pharmacologic treatments is poor, with many patients discontinuing due to adverse effects. 1
• Monitor post-void residual urine when initiating antimuscarinics to avoid precipitating urinary retention. 2

Expected Outcomes:

• Tolterodine demonstrates onset of action within 1 week of treatment, with 85% of patients preferring the 2 mg twice daily dose. 7
• The extended-release formulation of tolterodine (4 mg once daily) is 18% more effective than immediate-release formulation with 23% lower rate of dry mouth. 8
• Combining behavioral therapy with drug therapy improves incontinence reduction during active treatment (69% vs 58% achieving ≥70% reduction), though it does not improve ability to discontinue drugs long-term. 9

Follow-Up Strategy:

• Reassess at 8-12 weeks to determine if bladder training alone is sufficient before adding medications. 2
• Regular follow-up visits should monitor treatment efficacy and adverse effects. 2
• Refer to urology if symptoms persist despite optimal medical therapy for consideration of urodynamic testing or other interventions. 2