What are the treatment options for female urinary incontinence?

Treatment of Female Urinary Incontinence

The treatment approach for female urinary incontinence depends critically on the type of incontinence: pelvic floor muscle training (PFMT) is first-line for stress incontinence, bladder training is first-line for urgency incontinence, and both PFMT plus bladder training are recommended for mixed incontinence. 1

Initial Assessment and Classification

Before initiating treatment, determine the specific type of urinary incontinence:

• Stress urinary incontinence (SUI): Urine loss with coughing, sneezing, laughing, or physical exertion due to urethral sphincter failure 1
• Urgency urinary incontinence (UUI): Involuntary urine loss associated with a sudden compelling urge to void 1
• Mixed urinary incontinence (MUI): Combination of both stress and urgency symptoms 1

Rule out urinary tract infection and hematuria before proceeding with treatment 2

Treatment Algorithm by Type

Stress Urinary Incontinence

First-Line Treatment:

• Initiate supervised pelvic floor muscle training (PFMT) as the primary intervention - this is supported by high-quality evidence showing PFMT is more than 5 times as effective as no treatment and can reduce incontinence episodes by more than 50% 1, 3
• PFMT should involve repeated voluntary pelvic floor muscle contractions (Kegel exercises) taught and supervised by a healthcare professional, not unsupervised home exercises 3
• More intensive PFMT with greater individual supervision is more effective than less-intensive programs 4
• Consider adding biofeedback using vaginal EMG to provide visual feedback on proper pelvic floor muscle contraction 1
• Vaginal cones can be used as an alternative to PFMT, with moderate to high certainty evidence of benefit 4

Adjunctive Interventions:

• For obese women, recommend weight loss and exercise - this has moderate-quality evidence showing significant symptom improvement 1, 3
• Vaginal pessaries or urethral inserts can be considered, particularly when combined with PFMT 3, 5
• Continence pessary plus PFMT is more beneficial than pessary alone 4

Critical Pitfall to Avoid:

• Do NOT use systemic pharmacologic therapy for stress incontinence - the American College of Physicians strongly recommends against this based on lack of efficacy 1, 3

Surgical Options (if conservative measures fail):

• Synthetic midurethral mesh slings are the most common surgical treatment, with symptom improvement in 48% to 90% of women and low mesh complication rates (<5%) 2
• Other options include retropubic suspension and fascial slings 3

Urgency Urinary Incontinence

First-Line Treatment:

• Begin with bladder training - this behavioral therapy involves scheduled voiding with progressively longer intervals between bathroom trips 1, 3
• This is supported by strong recommendation with moderate-quality evidence 1
• PFMT plus biofeedback is also effective for urgency incontinence 4
• Electrical stimulation has moderate to high certainty evidence of benefit 4

Second-Line Pharmacologic Treatment (if bladder training unsuccessful):

• Initiate anticholinergic medications or beta-3 agonists - all agents show similar effectiveness, so base selection on tolerability, adverse effect profile, ease of use, and cost rather than efficacy 1, 3
• Effective anticholinergic options include: oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium - all increase continence rates with moderate magnitude of benefit 3
• Mirabegron (beta-3 agonist) at 50 mg daily reduces incontinence episodes by 0.34-0.42 episodes per 24 hours compared to placebo and reduces micturitions by 0.42-0.61 per 24 hours 6
• Beta-3 agonists have fewer anticholinergic side effects compared to antimuscarinics 7

Critical Counseling Points:

• Warn patients upfront about anticholinergic adverse effects including dry mouth, constipation, heartburn, urinary retention, and potential cognitive impairment - these are major reasons for treatment discontinuation 3, 5
• Poor adherence to pharmacologic treatments is common due to side effects 3
• Not all patients require pharmacotherapy if symptoms are mild and behavioral measures provide adequate relief 3

Third-Line Interventions (if conservative and pharmacologic therapies fail):

• OnabotulinumtoxinA (Botox) injections 2, 5
• Percutaneous tibial nerve stimulation 2, 5
• Sacral nerve stimulators (surgically implanted) 5

Mixed Urinary Incontinence

First-Line Treatment:

• Combine pelvic floor muscle training with bladder training - this has strong recommendation with moderate-quality evidence 1
• PFMT plus bladder training is more beneficial than bladder training alone for both cure/improvement and quality of life 4
• For obese women, prioritize weight loss - this benefits the stress component more than the urgency component 3

Second-Line Pharmacologic Treatment:

• Solifenacin and fesoterodine are preferred choices as they demonstrate dose-response effects on symptom improvement, with modest benefit of less than 20% absolute risk difference versus placebo 3
• Counsel about anticholinergic adverse effects including dry mouth, constipation, heartburn, and urinary retention 3

Surgical Intervention (if conservative measures fail):

• Synthetic midurethral mesh slings can cure both stress and urge components in 40-50% of cases 3
• Counsel about surgical complications including direct injury to lower urinary tract, hemorrhage, infection, bowel injury, wound complications, and mesh-specific complications 3

Universal Lifestyle Modifications

Regardless of incontinence type, recommend:

• Adequate but not excessive fluid intake 3, 2
• Regular voiding intervals to reduce urgency episodes 2
• Avoidance of bladder irritants (caffeine, alcohol) 2
• Treatment of chronic cough and constipation 1

Key Clinical Principles

• Behavioral interventions (PFMT, bladder training) have no identified harms in studies, making them ideal first-line treatments 3
• Clinically successful treatment is defined as reducing incontinence episodes by at least 50% 1, 3
• Only 25% of women with incontinence seek or receive treatment despite many effective options available 2
• Supervised PFMT is significantly more effective than unsupervised home exercises 3, 4
• More intensive, frequent PFMT with individual supervision improves effectiveness 4