What are the treatment options for urinary incontinence due to bladder leaking?

Treatment Options for Urinary Incontinence (Bladder Leaking)

Start with pelvic floor muscle training (Kegel exercises) as first-line therapy for stress incontinence and bladder training for urgency incontinence—these conservative approaches should be attempted for 2-4 weeks before escalating to medications or procedures. 1

Initial Diagnostic Steps

Before initiating treatment, you must determine the type of incontinence through specific assessments:

• Characterize symptoms to distinguish stress incontinence (leaking with coughing, sneezing, exercise) from urgency incontinence (leaking with sudden compelling urge to void) 1, 2
• Perform a cough stress test with a comfortably full bladder to objectively demonstrate stress incontinence 1
• Measure post-void residual using portable ultrasound to rule out overflow incontinence 1, 3
• Obtain urinalysis to exclude infection or hematuria before proceeding with treatment 1, 4
• Conduct pelvic examination to evaluate for pelvic organ prolapse that may require different management 1
• Use voiding diaries to objectively document frequency and incontinence episodes 1

Treatment Algorithm by Incontinence Type

For Stress Urinary Incontinence (leaking with physical activity)

First-line conservative therapy (try for 2-4 weeks):

• Pelvic floor muscle training is the strongest recommendation with high-quality evidence 1
• Weight loss if obese (strong recommendation, moderate-quality evidence) 3
• Vaginal estrogen for postmenopausal women 3
• Avoid excessive fluid intake and caffeine 4

Second-line options if conservative measures fail:

• Midurethral sling surgery is the most effective surgical treatment with 48-90% symptom improvement and less than 5% mesh complications 1, 5
• Colposuspension (Burch procedure) or autologous fascial slings are alternative surgical options 1
• Urethral bulking agents have low efficacy and cure is rare—only consider in patients who cannot tolerate surgery 6

For Urgency Urinary Incontinence (leaking with sudden urge)

First-line conservative therapy (try for 2-4 weeks):

• Bladder training (behavioral therapy extending time between voiding) is recommended with moderate-quality evidence 1, 3
• Pelvic floor muscle training with biofeedback using vaginal EMG 3
• Timed or prompted voiding 4

Second-line pharmacotherapy if bladder training unsuccessful:

• Antimuscarinic medications (oxybutynin 7, tolterodine 8) are recommended with high-quality evidence 1
• Beta-3 adrenergic agonists (mirabegron) are increasingly preferred due to fewer adverse effects than anticholinergics 3, 4
• Monitor closely for anticholinergic side effects including cognitive changes, constipation, dry mouth, and blurred vision 1, 7

Third-line procedural interventions if medications fail:

• OnabotulinumtoxinA bladder injections 4, 5
• Percutaneous tibial nerve stimulation 4, 5
• Sacral neuromodulation (implanted device) 5

For Mixed Incontinence (both stress and urgency symptoms)

• Combine pelvic floor muscle training with bladder training as initial therapy (moderate-quality evidence) 1
• Treat the most bothersome symptom first based on patient preference 2

For Overflow Incontinence (incomplete bladder emptying)

• Intermittent catheterization is the primary treatment 4
• Address underlying obstruction or detrusor hypoactivity 4

Special Populations

Diabetic Women

• Urge incontinence is the predominant type in diabetic women, not stress incontinence—this is a critical diagnostic pitfall to avoid 3
• Treat recurrent urinary tract infections which are more common in this population 3
• Address peripheral neuropathy affecting bladder function 3
• Consider combination therapy with lactobacillus-containing probiotics for stress incontinence 3

Elderly/Frail Patients

• Start oxybutynin at lower dose of 2.5 mg given 2-3 times daily due to prolonged elimination half-life (5 hours vs 2-3 hours in younger patients) 7

Critical Reassessment Timeline

• Reassess treatment response after 2-4 weeks of behavioral interventions 1
• Use voiding diaries to objectively document improvement in frequency and incontinence episodes 1
• If initial conservative measures fail after this timeframe, escalate to next treatment tier 1

Common Pitfalls to Avoid

• Do not assume all incontinence in diabetic women is stress-related—urge incontinence is actually more prevalent 3
• Do not skip urinalysis—infection must be ruled out before attributing symptoms to primary incontinence 1, 4
• Do not prescribe estrogen systemically for stress incontinence—it is not indicated and ineffective 9
• Do not offer urethral bulking agents as primary surgical treatment—efficacy is low and cure is rare 6