Medications for Stress Incontinence
Direct Recommendation
Pharmacologic therapy is NOT recommended for stress urinary incontinence—the American College of Physicians provides a strong recommendation against systemic pharmacologic treatment based on low-quality evidence showing lack of efficacy. 1
Treatment Algorithm for Stress Incontinence
First-Line: Non-Pharmacologic Therapy
- Pelvic floor muscle training (PFMT) is the only recommended treatment for stress incontinence, with strong evidence demonstrating increased continence rates and improved quality of life 1, 2
- PFMT is more cost-effective than medications, has no adverse effects, and should always be prioritized 1
Why Medications Fail in Stress Incontinence
Standard pharmacologic therapies used for urgency incontinence (antimuscarinics) have not been shown effective for stress incontinence 1
The evidence specifically examined duloxetine, which showed:
- Limited efficacy with a number needed to benefit (NNTB) of 13—meaning 13 patients must be treated for one to benefit 2
- Did NOT achieve statistically significant improvement compared to placebo 2
- Failed to improve quality of life in women with severe stress incontinence 2
- High discontinuation rates due to adverse effects, particularly nausea, which was the primary reason patients stopped treatment 3, 4
- One study lasting 36 weeks showed duloxetine was no more effective than placebo 5
Limited Exception: Postmenopausal Women Only
For postmenopausal women specifically, vaginal estrogen tablets or ovules may be considered as they demonstrated improvement with an NNTB of 5 2
Critical caveat: Transdermal estrogen patches actually worsened urinary incontinence and should be avoided 1
Common Pitfalls to Avoid
- Do not prescribe antimuscarinics (oxybutynin, tolterodine, solifenacin, etc.) for stress incontinence—these are only effective for urgency incontinence 1, 2
- Do not use duloxetine as first-line therapy—approximately 25% of patients discontinued treatment within 3 months due to adverse effects in clinical trials 5
- Do not confuse stress incontinence with urgency incontinence—the pharmacologic approach differs completely between these two conditions 1
Management of Mixed Incontinence
If a patient has both stress and urgency components:
- Combined PFMT with bladder training is first-line treatment 1, 2
- If pharmacotherapy becomes necessary, it should target only the urgency component 6
- The stress component should continue to be managed with PFMT alone 1
Adjunctive Interventions
For obese women with stress incontinence, weight loss and exercise are strongly recommended with moderate-quality evidence showing symptom reduction 1, 2