What are the treatment options for urinary incontinence in adults?

Treatment of Urinary Incontinence in Adults

Begin with pelvic floor muscle training (PFMT) as first-line therapy for stress urinary incontinence and bladder training for urgency incontinence—these conservative interventions are more than 5 times as effective as no treatment and should always be attempted before escalating to medications or surgery. 1, 2

Initial Assessment and Classification

Screen all patients proactively during routine visits, as most women do not voluntarily report symptoms despite prevalence rates of 44-57% in middle-aged women and 75% in elderly women. 1, 2

Essential Initial Evaluation Components:

• Focused history including time of onset, specific symptom patterns (leakage with coughing/sneezing vs. sudden urge), frequency of episodes, and impact on quality of life 2
• Pelvic examination to assess for pelvic organ prolapse, pelvic floor muscle strength, and urethral mobility 1, 2
• Urinalysis to rule out infection or hematuria 1, 3
• Post-void residual measurement (any method) to exclude overflow incontinence 1
• Objective demonstration of stress incontinence with comfortably full bladder using cough stress test 1

Classification by Type:

• Stress incontinence: Leakage with increased abdominal pressure (coughing, sneezing, physical exertion) due to urethral sphincter failure 1
• Urgency incontinence: Leakage with sudden compelling urge to void, often with frequency and nocturia 1
• Mixed incontinence: Combination of both stress and urgency symptoms 1

First-Line Conservative Management (All Patients)

For Stress Urinary Incontinence:

Initiate supervised pelvic floor muscle training (Kegel exercises) taught by a healthcare professional—this is more than 5 times as effective as no treatment with a number needed to treat (NNT) of 2. 1, 2, 4

• PFMT involves repeated voluntary contraction of pelvic floor muscles 1
• Supervised training shows significantly better outcomes than unsupervised approaches 4
• Continue for minimum 3 months before considering escalation 2

For Urgency Urinary Incontinence:

Start with bladder training as primary initial treatment (NNT = 2), involving scheduled voiding with progressively longer intervals between bathroom trips. 1, 2, 4

• Extend time between voids systematically 1
• Do not add PFMT to bladder training for pure urgency incontinence, as it provides no additional benefit 4

For Mixed Urinary Incontinence:

Combine PFMT plus bladder training (NNT = 3 for improvement, NNT = 6 for continence). 1, 2

Universal Lifestyle Modifications:

• Weight loss and exercise for obese women (strong recommendation, moderate-quality evidence) 1
• Decrease caffeine intake 5
• Avoid excessive fluid consumption while maintaining adequate hydration 3, 6
• Smoking cessation 6

Second-Line Pharmacologic Therapy

For Stress Incontinence:

Do not use systemic pharmacologic therapy—no medications have been shown effective for stress incontinence. 1, 4

For Urgency Incontinence (After Failed Bladder Training):

Initiate anticholinergic or beta-3 agonist medications, selecting based on tolerability, adverse effect profile, ease of use, and cost rather than efficacy, as all agents show similar effectiveness. 1, 2

Medication Options (All with Moderate Benefit):

• Oxybutynin 4
• Tolterodine 4
• Darifenacin 4
• Solifenacin 4
• Fesoterodine 4
• Trospium 4
• Mirabegron (beta-3 agonist): 25 mg once daily, increase to 50 mg if needed after 4-8 weeks 7

Key Medication Considerations:

• Counsel patients upfront about anticholinergic adverse effects: dry mouth, constipation, cognitive impairment, heartburn, and urinary retention 4
• Poor adherence is common due to side effects 4
• Beta-3 agonists (mirabegron) are increasingly preferred over anticholinergics due to better tolerability profile 5, 6
• For mixed incontinence, solifenacin and fesoterodine are preferred as they demonstrate dose-response effects 4

Third-Line Advanced Interventions

For Refractory Urgency Incontinence:

• OnabotulinumtoxinA bladder injections 5, 3, 6
• Percutaneous tibial nerve stimulation 5, 3, 6
• Sacral neuromodulation 5, 3, 6

For Refractory Stress Incontinence:

Synthetic midurethral mesh slings are the most common and effective primary surgical treatment, with 48-90% symptom improvement and less than 5% mesh complications. 2, 3

Alternative Surgical Options:

• Retropubic suspension 2, 4
• Autologous fascial slings 2, 4
• Urethral bulking agents (lower success rates but fewer complications, may require repeat injections) 2, 8

Special Surgical Considerations:

• For fixed/immobile urethra: Use pubovaginal sling, retropubic midurethral sling, or urethral bulking agents—avoid transobturator slings 8
• Avoid synthetic mesh in patients with poor tissue quality, significant scarring, radiation history, or concomitant urethral procedures 8

Special Populations

Older Adults with Diabetes:

Screen annually for urinary incontinence, as diabetic women are at higher risk due to polyuria, neurogenic bladder, autonomic insufficiency, and recurrent infections. 1

• Evaluate for treatable causes: urinary tract infection, urine retention, fecal impaction, restricted mobility, medication effects 1
• Address diabetes-specific contributors: glycosuria, atrophic vaginitis, vaginal candidiasis 1

Critical Pitfalls to Avoid

1. Never skip behavioral interventions—always attempt PFMT and/or bladder training first before medications or surgery 2
2. Never use pharmacologic therapy for stress incontinence—it is ineffective 1, 4
3. Never proceed to surgery without adequate trial of conservative measures—minimum 3 months of supervised PFMT 2
4. Never use transobturator midurethral slings in patients with fixed/immobile urethras—they require additional tension and increase complication risks 8
5. Never place synthetic mesh in patients with urethral injury, poor wound healing risk, or concomitant urethral procedures 8

Definition of Treatment Success

Clinically successful treatment reduces urinary incontinence episode frequency by at least 50%. 1, 2