Approach to Urinary Incontinence in Women
Initial Screening and Diagnosis
Proactively screen all female patients for urinary incontinence during routine visits, as most women do not voluntarily report symptoms. 1
- Ask directly: "Do you have a problem with urinary incontinence that is bothersome enough that you would like to know more about how it could be treated?" 1
- Obtain focused history including time of onset, specific symptom patterns (leakage with coughing/sneezing vs. sudden urge), frequency of episodes, and impact on quality of life 1
- Perform focused physical examination including neurologic assessment 1
- Rule out urinary tract infection and hematuria 2
- Classify incontinence type: stress (leakage with physical exertion/coughing), urgency (leakage with sudden compelling urge), or mixed 3
First-Line Treatment: Conservative Management for All Types
Begin with pelvic floor muscle training (PFMT) as first-line therapy for all types of urinary incontinence, as it reduces incontinence episodes by more than 50% with high-quality evidence. 1, 3
For Stress Urinary Incontinence:
- Initiate supervised PFMT (Kegel exercises) taught by a healthcare professional—this is more than 5 times as effective as no treatment (NNT = 2) 1, 3
- PFMT with biofeedback using vaginal electromyography probe improves outcomes (NNT = 3) 1
- Weight loss and physical activity for obese women (NNT = 4) 1
- Do not use pharmacologic therapy for stress incontinence—it is ineffective 3
For Urgency Urinary Incontinence:
- Start bladder training as primary initial treatment, involving scheduled voiding with progressively longer intervals between bathroom trips (NNT = 2) 1, 3
- Lifestyle modifications: adequate but not excessive fluid intake, weight loss if obese, avoid bladder irritants 3
- Adding PFMT to bladder training does not improve outcomes for pure urgency incontinence compared to bladder training alone 3
For Mixed Urinary Incontinence:
- Combine PFMT plus bladder training (NNT = 3 for improvement, NNT = 6 for continence) 1
- Weight loss and exercise for obese women 1
Second-Line Treatment: Pharmacologic Therapy (Urgency Incontinence Only)
If behavioral interventions fail for urgency incontinence, initiate anticholinergic or beta-3 agonist medications, selecting based on tolerability, adverse effects, ease of use, and cost rather than efficacy, as all agents show similar effectiveness. 3
Medication Options (all with moderate magnitude of benefit):
Critical Counseling Points:
- Warn patients upfront about anticholinergic side effects (dry mouth, constipation, cognitive impairment) to improve adherence 3
- Poor adherence is common due to side effects—set realistic expectations 3
- Reassess symptoms promptly after initiation 2
Third-Line Treatment: Advanced Interventions
For Refractory Urgency Incontinence:
- OnabotulinumtoxinA intravesical injections 6, 2
- Sacral neuromodulation 6
- Posterior tibial nerve stimulation 6
For Stress Incontinence Refractory to Conservative Management:
- Synthetic midurethral mesh slings are the most common and effective primary surgical treatment (48-90% symptom improvement, <5% mesh complications) 3, 2
- Retropubic suspension 3
- Autologous fascial slings 3, 7
- Urethral bulking agents (lower success rates but fewer complications) 7
Common Pitfalls to Avoid
- Never skip behavioral interventions—always attempt PFMT and/or bladder training first before escalating to medications or surgery 3
- Never use systemic pharmacologic therapy for stress incontinence—it represents wrong treatment for the wrong condition 3
- Never proceed to surgery without adequate trial of conservative measures (minimum 3 months of supervised PFMT) 8
- Do not use transobturator midurethral slings in patients with fixed/immobile urethras 9
- Avoid synthetic mesh in patients with poor tissue quality, significant scarring, radiation history, or concomitant urethral procedures 9