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, bladder training for urgency incontinence, and combined PFMT plus bladder training for mixed incontinence—all before considering 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 25% in young women, 44-57% in middle-aged women, and 75% in elderly women. 1, 2 For older adults with diabetes, annual screening is particularly important given their elevated risk. 1

Obtain a focused history documenting:

• Time of onset and specific symptom patterns (leakage with coughing/sneezing versus sudden urge to void) 2
• Frequency and severity of episodes 1
• Impact on quality of life and daily activities 2
• Risk factors including pregnancy, vaginal delivery, menopause, obesity, urinary tract infections, chronic cough, and constipation 1

Perform a focused physical examination including:

• Pelvic examination to assess for pelvic organ prolapse, cystoceles, and atrophic vaginitis 1, 2
• Neurologic assessment 2
• Objective demonstration of stress incontinence with comfortably full bladder (cough stress test) 1
• Assessment of post-void residual urine volume 1
• Urinalysis to rule out infection 1

Classify incontinence type:

• Stress incontinence: Leakage with physical exertion, coughing, sneezing due to urethral sphincter failure 1
• Urgency incontinence: Leakage with sudden compelling urge to void 1
• Mixed incontinence: Combination of both stress and urgency symptoms 1
• Overflow incontinence: Due to neurogenic bladder, retention, or obstruction 1

First-Line Conservative Management (All Patients)

For Stress Urinary Incontinence

Initiate supervised pelvic floor muscle training (PFMT) as the primary treatment, which is more than 5 times as effective as no treatment (NNT = 2). 1, 2, 3 PFMT involves repeated voluntary contraction of pelvic floor muscles (Kegel exercises) taught and supervised by a healthcare professional—unsupervised training shows significantly inferior outcomes. 2, 3

Add lifestyle modifications:

• Weight loss for obese patients (strong recommendation with moderate-quality evidence) 1
• Smoking cessation 4
• Appropriate fluid intake (avoid excessive consumption) 5, 4
• Decrease caffeine intake 6

Continue PFMT for minimum 3 months before escalating to other interventions, as clinically successful treatment is defined as reducing incontinence episodes by at least 50%. 1, 2

For Urgency Urinary Incontinence

Initiate bladder training as the primary treatment (NNT = 2), involving scheduled voiding with progressively longer intervals between bathroom trips. 1, 3 This behavioral therapy extends the time between voiding episodes. 1

Do not add PFMT to bladder training for pure urgency incontinence, as adding PFMT does not improve continence compared with bladder training alone. 3

Implement lifestyle modifications as described above for stress incontinence. 1

For Mixed Urinary Incontinence

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

Emphasize weight loss for obese patients, as this benefits the stress component more than the urgency component. 3

Second-Line Pharmacologic Treatment

For Stress Incontinence

Do not use systemic pharmacologic therapy for stress urinary incontinence—no medications have been shown effective and this represents strong recommendation with low-quality evidence. 1, 3

For Urgency Incontinence (After Failed Bladder Training)

Initiate anticholinergic or beta-3 agonist medications only after bladder training has been unsuccessful. 1

Select medication based on tolerability, adverse effects, ease of use, and cost rather than efficacy, as all agents show similar effectiveness with moderate magnitude of benefit (less than 20% absolute risk difference versus placebo). 1, 3

Medication options include:

• Oxybutynin 3
• Tolterodine 3
• Darifenacin 3
• Solifenacin (preferred for mixed incontinence due to dose-response effects) 3
• Fesoterodine (preferred for mixed incontinence due to dose-response effects) 3
• Trospium 3
• Mirabegron (beta-3 agonist): Starting dose 25 mg orally once daily, increase to maximum 50 mg once daily after 4-8 weeks if needed 7

Counsel patients upfront about anticholinergic adverse effects including dry mouth, constipation, heartburn, urinary retention, and potential cognitive impairment, as these are major reasons for treatment discontinuation. 3, 6

Adjust mirabegron dosing for renal impairment:

• eGFR 30-89 mL/min/1.73 m²: Starting dose 25 mg, maximum 50 mg 7
• eGFR 15-29 mL/min/1.73 m²: Starting dose 25 mg, maximum 25 mg 7
• eGFR <15 mL/min/1.73 m² or dialysis: Not recommended 7

Adjust mirabegron dosing for hepatic impairment:

• Child-Pugh Class A (mild): Starting dose 25 mg, maximum 50 mg 7
• Child-Pugh Class B (moderate): Starting dose 25 mg, maximum 25 mg 7
• Child-Pugh Class C (severe): Not recommended 7

Third-Line Surgical Interventions (After Failed Conservative Measures)

For Stress Incontinence

Refer for synthetic midurethral mesh sling placement as the most common and effective primary surgical treatment, with 48-90% symptom improvement and less than 5% mesh complications. 2, 3

Alternative surgical options include:

• Retropubic suspension 2, 3
• Autologous fascial slings 2, 3
• Urethral bulking agents (effective but with higher recurrence rates requiring repeat injections) 2, 8

For patients with fixed/immobile urethra, use pubovaginal sling, retropubic midurethral sling, or urethral bulking agents—avoid transobturator midurethral slings as they require additional tension and increase complication risks. 8

Avoid synthetic mesh slings in patients with:

• Poor tissue quality 8
• Significant scarring 8
• History of radiation therapy 8
• Concomitant urethral procedures (diverticulectomy, urethrovaginal fistula repair, urethral mesh excision) 8
• Inadvertent urethral injury during procedure 8

Counsel patients about surgical complications including direct injury to lower urinary tract, hemorrhage, infection, bowel injury, wound complications, and mesh-specific complications. 3

For Urgency Incontinence (Refractory to Medications)

Refer for advanced interventions:

• OnabotulinumtoxinA injections 6, 4
• Percutaneous tibial nerve stimulation 6, 4
• Sacral neuromodulation 4

For Mixed Incontinence

Synthetic midurethral mesh slings can cure both stress and urge components in 40-50% of cases. 3

Special Populations

Older Adults with Diabetes

Evaluate for reversible causes including urinary tract infection, urine retention, fecal impaction, restricted mobility, medication effects, polyuria from glycosuria, neurogenic bladder, prolapse, atrophic vaginitis, and vaginal candidiasis. 1

Obese Women

Prioritize weight loss and exercise as this has strong recommendation with moderate-quality evidence for improving incontinence across all subtypes. 1

Critical Pitfalls to Avoid

Never skip behavioral interventions—always attempt PFMT and/or bladder training first before escalating to medications or surgery. 2

Never use systemic pharmacologic therapy for stress incontinence—it is ineffective and represents wrong treatment for the condition. 1, 3

Never proceed to surgery without adequate trial of conservative measures—minimum 3 months of supervised PFMT is required. 2

Never place transobturator midurethral slings in patients with fixed/immobile urethras—this increases complication risks due to excessive tension requirements. 8

Never underestimate the impact of anticholinergic adverse effects—set realistic expectations upfront about dry mouth, constipation, and cognitive effects to improve adherence. 3

Never assume all patients require pharmacotherapy—if symptoms are mild and behavioral measures provide adequate relief, medication may not be necessary. 3