What medications are used to treat incontinence?

Medications for Urinary Incontinence

First-Line Pharmacologic Therapy

For urgency urinary incontinence requiring medication, tolterodine or darifenacin are the optimal first-line choices due to their superior tolerability profiles, with treatment discontinuation rates similar to placebo. 1, 2

Recommended First-Line Agents

• Tolterodine: High-quality evidence demonstrates no statistically significant difference in treatment discontinuation rates compared to placebo (NNTH 12 for adverse effects), while achieving continence (NNTB 12) and improving UI (NNTB 10) more effectively than placebo 1, 2

• Darifenacin: Discontinuation rates due to adverse effects are not significantly different from placebo, and it effectively improves UI and quality of life in older women 1, 2

Alternative Effective Agents

• Solifenacin: Associated with the lowest risk for discontinuation due to adverse effects among all antimuscarinics (NNTH 78), with high-quality evidence showing it achieves continence more than placebo (NNTB 9) 1, 3

• Fesoterodine: Superior efficacy compared to tolterodine (NNTB 36), but has significantly more adverse effects (NNTH 7) and higher discontinuation rates (NNTH 11 vs tolterodine) 1

• Trospium: Effective in reducing urgency UI episodes regardless of concomitant medications, but has a less favorable side effect profile with higher risk of dizziness (NNTH 8) 1, 2

Non-Antimuscarinic Option

• Mirabegron (β3-adrenoceptor agonist): FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency, offering lower anticholinergic side effects and reduced cognitive risk, particularly important in patients over 60 2, 4

Medications to Avoid

Oxybutynin should be avoided as first-line therapy due to the highest discontinuation rate among all antimuscarinics (NNTH 16 vs placebo; NNTH 14 vs tolterodine) and significant cognitive impairment risk in elderly patients. 1, 2

• Oxybutynin causes more frequent dry mouth, insomnia, and constipation compared to tolterodine 1
• If oxybutynin must be used due to cost or availability, start with low-dose 2.5 mg three times daily rather than standard 5 mg dosing to reduce side effects 2, 5

Clinical Algorithm for Medication Selection

Step 1: Determine Incontinence Type

• Stress incontinence: Do NOT use systemic pharmacologic therapy; initiate pelvic floor muscle training instead 2, 3
• Urgency incontinence: Proceed to pharmacologic options only after bladder training has been attempted 1, 3

Step 2: Assess Patient Factors

• Polypharmacy (≥7 medications): Avoid trospium due to increased adverse effects; prefer tolterodine, darifenacin, or mirabegron 1, 2
• Elderly patients: Tolterodine or darifenacin are optimal due to placebo-level discontinuation rates 2
• Cognitive concerns: Avoid oxybutynin; consider mirabegron for lowest anticholinergic burden 2
• Obesity: Implement weight loss and exercise concurrently, as this has strong evidence for symptom reduction 1, 2, 3

Step 3: Select Initial Agent

• First choice: Tolterodine or darifenacin 1, 2, 3
• Alternative if cost is concern: Solifenacin (best tolerability among alternatives) 1, 3
• If anticholinergic side effects are problematic: Mirabegron 2, 4

Common Adverse Effects

All antimuscarinics share similar adverse effects within the drug class, but frequency varies significantly 1:

• Most common: Dry mouth, constipation, blurred vision 1
• Tolterodine-specific: Associated with increased risk for hallucinations 1
• Mirabegron-specific: Nasopharyngitis and gastrointestinal disorders more frequent than placebo 1

Critical Pitfalls to Avoid

• Do not prescribe pharmacotherapy for stress incontinence - it is ineffective and exposes patients to unnecessary adverse effects 2, 3
• Do not start with oxybutynin unless tolterodine, darifenacin, and other alternatives are contraindicated, unavailable, or unaffordable 2
• Do not overlook non-pharmacologic interventions - bladder training should be first-line for urgency UI, and pelvic floor muscle training plus bladder training improves UI more than tolterodine alone 1, 3
• Age does not modify clinical outcomes with pharmacologic treatment, making tolerability the primary differentiating factor for drug selection 1, 2