What are the treatment options for urge incontinence?

Treatment Options for Urge Incontinence

Start with bladder training as first-line therapy for urge incontinence, and add antimuscarinic medications or mirabegron only if behavioral therapy fails after an adequate trial. 1

First-Line Treatment: Bladder Training

• Bladder training is the primary recommended treatment for urgency urinary incontinence, with strong evidence supporting its effectiveness and essentially no adverse effects. 1
• This behavioral therapy involves systematically extending the time intervals between voiding episodes to retrain bladder function. 1
• The magnitude of benefit is substantial, with low risk for adverse effects compared to pharmacologic options. 1
• Bladder training should be attempted for at least 10 weeks before considering it unsuccessful. 2

Adjunctive Conservative Measures

• Weight loss and exercise are strongly recommended for obese women with urge incontinence, as these interventions improve continence rates and quality of life. 1
• Lifestyle modifications include adequate (but not excessive) fluid intake, avoidance of bladder irritants like caffeine, and establishing regular voiding intervals. 3
• These conservative measures should be initiated immediately and continued throughout treatment. 4

Second-Line Treatment: Pharmacologic Therapy

If bladder training is unsuccessful after an adequate trial, add antimuscarinic medications or beta-3 adrenergic agonists. 1

Medication Selection Strategy

• Base medication choice on tolerability, adverse effect profile, ease of use, and cost rather than efficacy, as all approved agents show similar effectiveness. 1
• Solifenacin has the lowest discontinuation rate due to adverse effects among antimuscarinics, making it a preferred initial choice when tolerability is a concern. 1, 4
• Tolterodine and darifenacin have discontinuation rates similar to placebo, representing another reasonable first-line pharmacologic option. 1
• Avoid oxybutynin as initial therapy due to the highest discontinuation rate from adverse effects (NNTH = 16). 1
• Mirabegron (beta-3 agonist) is FDA-approved for overactive bladder with urge incontinence and represents an alternative mechanism of action. 5

Common Antimuscarinic Adverse Effects

• Dry mouth, constipation, and blurred vision are the most frequently reported adverse effects with antimuscarinics. 1
• Cognitive effects including confusion and hallucinations can occur, particularly with oxybutynin and tolterodine in older adults. 1
• Mirabegron causes nasopharyngitis and gastrointestinal disorders more frequently than placebo. 1
• Many patients discontinue pharmacologic therapy due to adverse effects, so close monitoring and follow-up are essential. 1

Third-Line and Specialist Treatments

When conservative and pharmacologic therapies fail:

• OnabotulinumtoxinA (Botox) injections into the bladder wall can be considered for refractory urgency incontinence. 3, 6
• Neuromodulation devices including posterior tibial nerve stimulators or surgically implanted sacral nerve stimulators improve symptoms in medication-refractory cases. 7, 6
• These interventions require referral to urology or urogynecology specialists. 8

Critical Pitfalls to Avoid

• Never use systemic pharmacologic therapy for stress urinary incontinence—it is ineffective and not recommended. 1, 4
• Do not skip behavioral interventions and jump directly to medications, as bladder training has large benefits with no adverse effects. 1, 4
• Do not continue ineffective antimuscarinic therapy indefinitely—reassess symptoms regularly and adjust treatment or refer to specialists. 3
• Ensure urinary tract infection and hematuria are ruled out before initiating treatment. 3
• Identify medications that may worsen urinary incontinence (diuretics, sedatives, anticholinergics for other conditions). 1

Treatment Algorithm

1. Initiate bladder training immediately for all patients with urge incontinence 1
2. Add lifestyle modifications (weight loss if obese, fluid management, regular voiding) 1
3. Trial for 10-12 weeks before declaring behavioral therapy unsuccessful 1, 2
4. If inadequate response, add antimuscarinic medication (prefer solifenacin, tolterodine, or darifenacin based on tolerability profile) 1
5. Continue bladder training while on medication—combination therapy improves outcomes during active treatment 2
6. Reassess at 8-12 weeks of pharmacologic therapy 1
7. If still inadequate, refer to specialist for consideration of botulinum toxin or neuromodulation 3, 6