What medications are used to treat urine urgency and incontinence?

Medications for Urine Urgency and Incontinence

For urgency urinary incontinence, start with tolterodine or darifenacin as first-line antimuscarinic therapy due to their placebo-level discontinuation rates, or use mirabegron (a beta-3 agonist) to avoid anticholinergic side effects entirely. 1

First-Line Pharmacologic Options

Preferred Antimuscarinics

• Tolterodine has no statistically significant difference in treatment discontinuation rates compared to placebo, making it an optimal first-line choice 1
• Darifenacin offers comparable tolerability with discontinuation rates similar to placebo and effectively improves urinary incontinence and quality of life 1
• Both agents avoid the high adverse effect burden seen with older antimuscarinics 1

Beta-3 Agonist Alternative

• Mirabegron (starting dose 25 mg daily, may increase to 50 mg after 4-8 weeks) avoids anticholinergic side effects entirely, including dry mouth, constipation, and cognitive impairment 2, 3
• Mirabegron's most common adverse effects are nasopharyngitis and gastrointestinal disorders, which are generally better tolerated than antimuscarinic side effects 2
• This agent is particularly valuable in elderly patients, those with polypharmacy, or cardiac patients where anticholinergic burden is problematic 2

Second-Line Options

When First-Line Agents Provide Partial Response

• Solifenacin has the lowest risk for discontinuation due to adverse effects among antimuscarinics (NNTH 78) 2, 1
• Combination therapy with solifenacin 5 mg plus mirabegron 50 mg provides greater reductions in incontinence episodes than either agent alone when monotherapy is inadequate 4

Medications to Avoid

Oxybutynin

• Oxybutynin should be avoided as first-line therapy due to its highest discontinuation rate (NNTH 16) and significant risk of cognitive impairment in elderly patients 1
• This agent has the highest incidence of dry mouth, constipation, and cognitive side effects among all antimuscarinics 1
• If oxybutynin must be used due to cost constraints, start at lower doses (2.5 mg BID-TID) in frail elderly patients 1

Fesoterodine

• Fesoterodine has poor tolerability with an NNTH for adverse effects of only 7, the worst among antimuscarinics 1

Treatment Algorithm

Step 1: Initial Assessment

• Determine incontinence type (urgency vs stress vs mixed) 1
• Assess polypharmacy status (count total medications) 1
• Screen for contraindications: narrow-angle glaucoma, urinary retention, severe uncontrolled hypertension 4, 3

Step 2: First-Line Pharmacotherapy Selection

• If taking <7 medications: Start tolterodine or darifenacin 1
• If taking ≥7 medications: Prefer mirabegron to avoid adding anticholinergic burden 1
• In elderly cardiac patients or those with cognitive concerns: Use mirabegron monotherapy 2

Step 3: If First-Line Therapy Inadequate

• Switch to solifenacin monotherapy (lowest antimuscarinic discontinuation risk) 2
• Or add solifenacin 5 mg to mirabegron 50 mg for combination therapy 4

Step 4: If Combination Not Tolerated

• Substitute with tolterodine 2 mg twice daily plus mirabegron 50 mg 2
• If combination therapy fails completely, consider darifenacin monotherapy (placebo-level discontinuation rates) 2

Critical Safety Considerations

Blood Pressure Monitoring

• Mirabegron can increase blood pressure and requires periodic monitoring, especially in hypertensive patients 3
• Mirabegron is not recommended in patients with severe uncontrolled hypertension 3

Urinary Retention Risk

• Administer all antimuscarinics with caution in patients with bladder outlet obstruction due to risk of urinary retention 3
• Extreme caution is needed in patients with diabetes, prior abdominal surgery, or narcotic use 4

Cognitive Effects

• Antimuscarinics are associated with increased risk of dementia in a cumulative, dose-dependent manner, making this a critical counseling point 4
• This risk is particularly concerning in elderly patients who may not notice cognitive decline 1

Drug Interactions

• Mirabegron is a CYP2D6 inhibitor, requiring dose adjustment monitoring when used with narrow therapeutic index drugs metabolized by this pathway 3

Common Pitfalls to Avoid

• Never start with oxybutynin in elderly patients despite its historical use as "gold standard" - newer agents have superior tolerability 1
• Do not overlook polypharmacy status when selecting agents, as patients on ≥7 medications have increased adverse effect risk 1
• Avoid prescribing antimuscarinics without screening for cognitive impairment or discussing dementia risk 4
• Do not use systemic pharmacologic therapy for pure stress incontinence - pelvic floor muscle training is the evidence-based approach 1