What is the first line of treatment for urge incontinence?

First-Line Treatment for Urge Incontinence

Bladder training is the first-line treatment for urge incontinence in women, with pharmacologic therapy reserved only after bladder training has failed. 1

Treatment Algorithm

Step 1: Bladder Training (First-Line)

• Initiate bladder training as the primary intervention for all women with urgency urinary incontinence, supported by strong recommendation and moderate-quality evidence from the American College of Physicians 1
• Bladder training alone improved urinary incontinence without the adverse effects associated with medications 1
• Adding pelvic floor muscle training (PFMT) to bladder training for pure urge incontinence does not improve outcomes compared to bladder training alone 1

Step 2: Address Modifiable Factors

• Implement weight loss and exercise if the patient is obese, as this effectively reduces urinary incontinence symptoms 2, 3
• Reduce caffeine intake and optimize fluid management 2
• Identify and treat reversible causes: urinary tract infections, metabolic disorders, excess fluid intake, delirium, and medications that worsen incontinence 1

Step 3: Pharmacologic Therapy (Second-Line Only)

Only proceed to medications if bladder training has been unsuccessful 1, 3

Preferred First-Line Medications (Best Tolerability):

• Tolterodine or darifenacin are the optimal first choices due to discontinuation rates similar to placebo 2, 3
• Solifenacin has the lowest risk for discontinuation due to adverse effects among all antimuscarinics (NNTB 9) 2, 3

Alternative Option:

• Mirabegron (β-3 agonist) offers significantly lower anticholinergic side effects and lower risk of cognitive effects, particularly important in patients over 60 years 2, 4
• Starting dose: 25 mg orally once daily, may increase to 50 mg after 4-8 weeks 4

Medications to Avoid:

• Oxybutynin should be avoided as first-line therapy due to the highest discontinuation rate from adverse effects (NNTH 16) and significant cognitive impairment risk in elderly patients 1, 2, 3
• Fesoterodine has poor tolerability with NNTH of only 7 2

Critical Considerations

Medication Selection Criteria:

When pharmacotherapy is necessary, base selection on: 1

• Tolerability and adverse effect profile (most important, as all drugs are similarly efficacious)
• Ease of use
• Cost
• Polypharmacy status (if taking ≥7 medications, avoid trospium and prefer tolterodine, darifenacin, or mirabegron) 2

Common Pitfalls to Avoid:

• Do not skip behavioral interventions and proceed directly to medications—bladder training has large magnitude of benefit with no adverse effects 1, 5
• Do not use systemic pharmacologic therapy for stress incontinence—it is ineffective 1, 3
• Recognize that adherence to pharmacologic treatments is poor, with adverse effects being the major reason for discontinuation 1
• At least half of women with urinary incontinence do not report symptoms to physicians, so active screening is essential 1

Expected Outcomes:

• Pharmacologic therapies have moderate magnitude of benefit for achieving continence but are associated with adverse effects including dry mouth, constipation, and blurred vision 1, 3
• Behavioral therapy is more cost-effective with fewer adverse effects than pharmacologic therapy 1, 3
• Many patients discontinue medication due to adverse effects despite achieving some improvement 1