What is the treatment for urinary incontinence (leaking urine)?

Treatment of Urinary Incontinence (Leaking Urine)

Start with pelvic floor muscle training (PFMT) as first-line treatment for stress urinary incontinence, bladder training for urgency incontinence, and combine both approaches for mixed incontinence—these conservative interventions demonstrate significant symptom improvement with minimal risk and should be attempted for at least 3 months before considering medications or surgery. 1, 2

Initial Assessment to Guide Treatment

Before initiating any treatment, you must determine the type of incontinence through specific questions and examination:

• Ask about timing of leakage: Does urine leak with coughing, sneezing, exercise, or physical exertion? This indicates stress urinary incontinence (SUI). 1, 3
• Ask about urgency: Does leakage occur with a sudden, compelling urge to urinate that cannot be deferred? This indicates urgency urinary incontinence (UUI). 1, 3
• Perform a cough stress test: With a comfortably full bladder, observe for leakage during coughing to objectively confirm SUI. 3, 4
• Measure post-void residual: This is mandatory to rule out overflow incontinence (normal is <200-300 mL); if elevated, the entire treatment approach changes. 2, 3, 4
• Perform urinalysis: Exclude infection or hematuria before proceeding with incontinence treatment. 3
• Assess for pelvic organ prolapse: Perform a pelvic examination, as prolapse may contribute to symptoms. 3

Treatment Algorithm by Incontinence Type

For Stress Urinary Incontinence (Leaking with Physical Activity)

First-Line: Pelvic Floor Muscle Training

• PFMT is highly effective with a number needed to treat of 2-3 for symptom improvement, meaning most patients benefit. 1, 2
• Requires proper instruction and supervision—unsupervised exercises are less effective. 1, 4
• Continue for at least 3 months before declaring treatment failure. 1, 4
• Studies demonstrate up to 70% symptom improvement when properly supervised. 4

Important Adjunct for Obese Women

• Weight loss significantly improves SUI symptoms in obese women (NNT = 4), with greater benefit for stress than urge symptoms. 1, 2

PFMT with Biofeedback

• Adding vaginal electromyography biofeedback to PFMT improves outcomes (NNT = 3) compared to no treatment. 1

Do NOT Use Systemic Medications

• Standard pharmacologic therapy has not demonstrated effectiveness for pure stress incontinence. 4

Surgical Options After Conservative Failure

• Discuss midurethral slings if conservative management fails after 3 months, with cure rates of 48-90% and mesh complications <5%. 1, 2, 3, 4
• Alternative surgical options include colposuspension or autologous fascial slings. 1, 3
• Never proceed to surgery without objective confirmation of SUI via cough stress test. 2, 3

For Urgency Urinary Incontinence (Leaking with Sudden Urge)

First-Line: Bladder Training

• Bladder training improves UUI with NNT = 2-4, making it highly effective. 1, 2
• Includes scheduled voiding with progressive interval increases and techniques to defer urgency. 1
• Provide specific advice on appropriate fluid intake (avoid excessive or insufficient fluids). 1

Second-Line: Antimuscarinic Medications

• Add antimuscarinic drugs (tolterodine, oxybutynin) if bladder training provides insufficient improvement after 2-4 weeks. 2, 3
• Tolterodine is FDA-approved for urgency, frequency, and urge incontinence associated with overactive bladder. 5
• Oxybutynin is indicated for urgency, frequency, urinary leakage, and urge incontinence. 6
• Important caveat: Absolute benefit is modest (<20% absolute risk difference), so set realistic expectations. 2
• Monitor closely for side effects: Cognitive changes, constipation, dry mouth, and urinary retention are common. 2, 3

Contraindications to Antimuscarinics

• Do not use if unable to empty bladder (urinary retention), delayed gastric emptying, or uncontrolled narrow-angle glaucoma. 5

For Mixed Urinary Incontinence (Both Stress and Urgency Symptoms)

Combined Approach Targeting Most Bothersome Symptom

• Combine PFMT with bladder training as initial therapy (NNT = 3-6 for continence). 1, 2, 3
• Treat the most bothersome symptom component first—ask the patient which symptom affects quality of life more. 2, 3
• If urgency predominates and behavioral interventions are insufficient, add antimuscarinic medications. 2, 3

Monitoring and Follow-Up

Reassessment Timeline

• Reassess treatment response after 2-4 weeks of behavioral interventions. 2, 3
• Use voiding diaries to objectively document improvement in frequency and incontinence episodes—subjective reporting is unreliable. 2, 3

Medication Monitoring

• For patients on antimuscarinics, monitor closely for cognitive changes (especially in elderly), constipation, and urinary retention. 2, 3

Common Pitfalls to Avoid

• Never skip post-void residual measurement: Treating overflow incontinence as stress or urgency incontinence will worsen symptoms and potentially cause bladder damage. 2, 3, 4
• Do not proceed to surgery without objective confirmation: History alone is insufficient; perform cough stress test to confirm SUI before surgical referral. 2, 3
• Avoid premature medication use: Conservative measures (PFMT, bladder training) should be attempted first, as they have minimal side effects and significant efficacy. 1, 2
• Do not use systemic medications for pure stress incontinence: They are ineffective and expose patients to unnecessary side effects. 4
• Recognize that most women do not report incontinence: Proactively ask about bothersome urinary leakage during routine visits, as this increases appropriate care by 15%. 1