What are the treatment options for urinary incontinence?

Treatment of Urinary Incontinence

Treatment Algorithm by Incontinence Type

For stress urinary incontinence, begin with supervised pelvic floor muscle training (PFMT) as first-line therapy, which reduces incontinence episodes by more than 50% and is more than 5 times as effective as no treatment. 1, 2

Stress Urinary Incontinence

First-Line Treatment:

• Supervised PFMT by a healthcare professional is mandatory—unsupervised training is significantly less effective 1
• PFMT involves repeated voluntary pelvic floor muscle contractions taught and supervised by a clinician, demonstrating 85-92% long-term success rates 2
• Professional supervision (by physiotherapists or continence nurses) produces superior outcomes compared to leaflet-based or unsupervised programs 3
• Treatment duration should be at least 3 months for optimal benefit 3

Adjunctive Conservative Measures:

• Weight loss and exercise for obese women show moderate-quality evidence of benefit, with greater improvement in stress versus urge incontinence 2
• Lifestyle modifications including adequate (not excessive) fluid intake 1

What NOT to Do:

• Never use systemic pharmacologic therapy for stress incontinence—it is ineffective and represents wrong treatment for the wrong condition 1, 2

Surgical Options (When Conservative Therapy Fails):

• Synthetic midurethral mesh slings are the most common primary surgical treatment, with 48-90% symptom improvement rates 2, 4
• Autologous fascia pubovaginal sling shows 85-92% success with 3-15 years follow-up 2
• Surgical complications include lower urinary tract injury, hemorrhage, infection, bowel injury, and wound complications, though mesh complications occur in <5% 1, 4

Urgency Urinary Incontinence

First-Line Treatment:

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

Second-Line Pharmacologic Treatment:

• Anticholinergic agents (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium) all increase continence rates with moderate magnitude of benefit 1
• Beta-3 agonists are an alternative option 2
• Base medication selection on tolerability, adverse effect profile, ease of use, and cost rather than efficacy, as all agents show similar effectiveness 1
• Medications show modest benefit with absolute risk difference <20% compared to placebo 2
• Oxybutynin works by exerting direct antispasmodic effect on bladder smooth muscle, increasing bladder capacity and diminishing frequency of uninhibited detrusor contractions 5
• Tolterodine is FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency 6

Critical Adverse Effects:

• Anticholinergic side effects (dry mouth, constipation, cognitive impairment) are the major reason for treatment discontinuation 1
• Poor adherence to pharmacologic treatments is common due to side effects 1
• Counsel patients about anticholinergic side effects upfront to set realistic expectations and improve adherence 1
• Anticholinergics can paradoxically cause urinary retention, particularly in elderly women 7

Specialist Treatments:

• OnabotulinumtoxinA injections 4
• Percutaneous or implanted neuromodulators 4

Mixed Urinary Incontinence

• Treat with combination of approaches for both stress and urgency components 1
• Begin with PFMT and bladder training before considering medications 1, 2

Universal Interventions Across All Types

• Weight loss and exercise for obese women with any type of incontinence show moderate-quality evidence of benefit 2
• Address modifiable risk factors including obesity, constipation, and excessive fluid intake 2
• Regular voiding intervals reduce urgency incontinence episodes 4

Critical Pitfalls to Avoid

• Never start medications before attempting behavioral interventions—this violates the evidence-based stepped-care approach 2
• Do not skip behavioral interventions, as bladder training and PFMT have strong evidence and should always be attempted first 1
• Proper PFMT technique with professional supervision is essential to avoid treatment failure 2
• Weigh symptom severity against medication adverse effects—not all patients require pharmacotherapy if symptoms are mild and behavioral measures provide adequate relief 1
• Rule out urinary tract infection and hematuria before initiating treatment 4

Treatment Success Definition

• Clinically successful treatment is defined as reducing the frequency of incontinence episodes by at least 50% 1
• No harms were identified in studies of behavioral interventions like PFMT or weight loss programs 1