Initial Management of Intermittent Urinary Incontinence in Females
Begin with pelvic floor muscle training (PFMT) as first-line treatment for all types of urinary incontinence in women, supervised by a healthcare professional for at least 3 months before considering other interventions. 1, 2, 3
Immediate First Steps
Determine Incontinence Type Through Focused History
- Stress incontinence: Leakage with coughing, sneezing, laughing, or physical exertion due to increased intra-abdominal pressure 1, 2
- Urgency incontinence: Involuntary loss with sudden compelling urge to void, often with frequency and nocturia 1, 2
- Mixed incontinence: Combination of both stress and urgency symptoms 1, 2
Rule Out Red Flags
- Screen for urinary tract infection and hematuria before initiating treatment 4
- Assess for serious underlying pathology including cancer or neurologic disease 4
- Evaluate for high-grade pelvic organ prolapse, which may require specialist referral 5
First-Line Conservative Management (Start Here for All Types)
Pelvic Floor Muscle Training (PFMT)
- Supervised PFMT is more than 5 times as effective as no treatment for stress incontinence (NNT = 2) 1, 3
- Must involve repeated voluntary pelvic floor muscle contractions taught and supervised by a healthcare professional—unsupervised training is significantly less effective 1, 2, 5
- Continue for minimum 3 months before escalating to other treatments 5
- For stress incontinence: PFMT alone reduces episodes by more than 50% 2, 3
- For mixed incontinence: Combine PFMT with bladder training (NNT = 3 for improvement, NNT = 6 for continence) 1, 3
Bladder Training (Primarily for Urgency Component)
- Scheduled voiding with progressively longer intervals between bathroom trips 1, 2
- For pure urgency incontinence: NNT = 2 for improvement 1, 3
- Do not add PFMT to bladder training for pure urgency incontinence—it provides no additional benefit 2
Lifestyle Modifications
- Weight loss for obese patients: NNT = 4 for improvement, particularly benefits stress component 1
- Adequate but not excessive fluid intake 4
- Regular voiding intervals to reduce urgency episodes 4
Second-Line Treatment: When to Escalate
For Urgency Incontinence Only (After 3 Months of Behavioral Therapy)
- Pharmacologic therapy is appropriate only for urgency incontinence—it is completely ineffective for stress incontinence and should never be used 2, 3
- Select medication based on tolerability, adverse effects, ease of use, and cost rather than efficacy, as all agents show similar effectiveness 1
Anticholinergic options (all with moderate benefit, absolute risk difference <20% vs placebo):
- Oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium 1, 2
- Common adverse effects: dry mouth, constipation, heartburn, urinary retention 1
- Avoid in older adults due to cognitive impairment risk 6
Beta-3 agonist alternative:
- Mirabegron: NNT = 12 for continence, NNT = 9 for improvement 1, 7
- Effective within 4-8 weeks for symptom reduction 7
For Mixed Incontinence (After Conservative Measures)
- Solifenacin and fesoterodine are preferred as they demonstrate dose-response effects 1, 2
- Weight loss benefits stress component more than urgency component 2
Common Pitfalls to Avoid
- Never skip behavioral interventions—always attempt PFMT and/or bladder training first before medications or surgery 3
- Never use pharmacologic therapy for stress incontinence—no medications are FDA-approved or effective for this indication 2, 6
- Never proceed to surgery without adequate trial of conservative management—minimum 3 months of supervised PFMT required 3, 5
- Counsel patients upfront about anticholinergic side effects (dry mouth, constipation, cognitive effects) to improve adherence and set realistic expectations 2
- Do not ignore coexisting conditions such as high-grade prolapse or incomplete bladder emptying, which affect treatment selection 5