Treatment of Urge Incontinence in Females
Start with bladder training as first-line therapy for urge incontinence, and only add antimuscarinic medications if bladder training fails after an adequate trial. 1, 2
First-Line Treatment: Bladder Training
Bladder training is the cornerstone of initial management for urgency urinary incontinence, supported by strong recommendation with moderate-quality evidence from the American College of Physicians. 1 This behavioral intervention involves:
- Scheduled voiding with progressively longer intervals between bathroom trips 2
- Extending time between voiding episodes systematically 3
- Moderate magnitude of benefit for achieving continence 1
The evidence demonstrates that bladder training alone improves urinary incontinence outcomes without the adverse effects associated with pharmacologic therapy. 2 Importantly, adding pelvic floor muscle training (PFMT) to bladder training does not improve continence compared with bladder training alone for pure urgency incontinence. 2
Second-Line Treatment: Antimuscarinic Medications
If bladder training is unsuccessful after an adequate trial, proceed to pharmacologic therapy. 1, 2 The American College of Physicians provides strong recommendation with high-quality evidence for this approach. 1
Medication Selection Strategy
Base your choice on tolerability, adverse effect profile, ease of use, and cost—not efficacy, since all agents are similarly effective. 1, 2 All antimuscarinics (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium) increase continence rates with moderate magnitude of benefit. 1, 2
Preferred Agents Based on Tolerability:
- Solifenacin: Lowest risk for discontinuation due to adverse effects 1
- Darifenacin and tolterodine: Risks for discontinuation similar to placebo 1
- Avoid oxybutynin as first choice: Highest risk for discontinuation due to adverse effects 1
Alternative Agent:
- Mirabegron (beta-3 adrenoceptor agonist): FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 4
- Starting dose: 25 mg orally once daily, may increase to 50 mg after 4-8 weeks 4
- Different adverse effect profile: nasopharyngitis and gastrointestinal disorders rather than anticholinergic effects 1
Critical Counseling Points
Set realistic expectations about anticholinergic adverse effects upfront to improve adherence. 2 Common side effects include:
- Dry mouth 1
- Constipation 1
- Blurred vision 1
- Cognitive impairment (particularly concerning in elderly patients) 2
Poor adherence to pharmacologic treatments is common due to these side effects. 2 Many patients discontinue medication because of adverse effects despite clinical efficacy. 1
Common Pitfalls to Avoid
- Do not skip bladder training: It has strong evidence and should always be attempted first before medications 2
- Do not use systemic pharmacologic therapy for stress incontinence: This represents the wrong treatment for the wrong condition and is ineffective 2, 3
- Do not prescribe medications without adequate behavioral therapy trial: Combining drug therapy with behavioral training improves outcomes during active treatment 5
- Weigh symptom severity against medication adverse effects: Not all patients require pharmacotherapy if symptoms are mild and behavioral measures provide adequate relief 2
Additional Considerations
For obese women with urge incontinence, weight loss and exercise should be recommended as adjunctive therapy. 1 The American College of Physicians provides strong recommendation with moderate-quality evidence for this intervention. 1
Identify and manage reversible causes that may worsen urge incontinence, including: