Treatment of Urinary Incontinence
Pelvic floor muscle training (PFMT) is the first-line treatment for all types of urinary incontinence in women, reducing episodes by more than 50%, and should be supervised by a healthcare professional for optimal outcomes. 1
Initial Assessment and Classification
Before initiating treatment, classify the incontinence type through focused questioning about specific leakage patterns 2, 3:
- Stress urinary incontinence (SUI): Leakage with coughing, sneezing, or physical exertion due to increased intra-abdominal pressure 1
- Urgency urinary incontinence (UUI): Leakage preceded by sudden compelling urge to void 1
- Mixed incontinence: Combination of both stress and urgency symptoms 1
Perform a focused physical examination including neurologic assessment, and rule out urinary tract infection and hematuria 2, 3
Treatment Algorithm by Incontinence Type
Stress Urinary Incontinence
First-Line: Conservative Management (Always Start Here)
Supervised pelvic floor muscle training is more than 5 times as effective as no treatment (NNT = 2) and must be taught by a healthcare professional, not self-directed. 2, 1
- PFMT involves repeated voluntary pelvic floor muscle contractions with proper technique instruction 2
- Supervision significantly improves outcomes compared to unsupervised training 1
- Continue for minimum 3 months before considering escalation 3, 4
- Add biofeedback using vaginal electromyography probe for enhanced benefit (NNT = 3) 2
Lifestyle modifications for all patients:
- Weight loss for obese women (NNT = 4 for improvement) 2, 1
- Adequate but not excessive fluid intake 1
- Avoid caffeine 5
Second-Line: Mechanical Devices
- Vaginal pessaries or intravaginal devices can be offered, though evidence is limited 2, 6
- Urethral plugs may be considered 6
Third-Line: Surgical Intervention
Synthetic midurethral mesh slings are the most common and effective primary surgical treatment, with 48-90% symptom improvement and less than 5% mesh complications. 1, 7
- Reserve surgery only after failed conservative therapy (minimum 3 months supervised PFMT) 3
- Alternative surgical options include retropubic suspension and autologous fascial slings 1
- Urethral bulking agents available for patients unable to tolerate more invasive surgery 4
Critical Pitfall: Never use systemic pharmacologic therapy for stress incontinence—it is completely ineffective and represents wrong treatment for the condition 2, 1, 3
Urgency Urinary Incontinence (Overactive Bladder)
First-Line: Behavioral Therapy
Bladder training is the primary initial treatment, involving scheduled voiding with progressively longer intervals between bathroom trips (NNT = 2). 2, 1
- Implement timed voiding schedule, gradually extending intervals 1, 5
- PFMT alone does not improve pure urgency incontinence as effectively as bladder training 1
- Lifestyle modifications: weight loss, fluid management, caffeine avoidance 1, 5
Second-Line: Pharmacologic Therapy
All anticholinergic medications (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium) show similar effectiveness; select based on tolerability, adverse effects, ease of use, and cost rather than efficacy. 1
- Beta-3 adrenergic agonists (mirabegron) have fewer anticholinergic side effects and are increasingly preferred 6, 5
- Common anticholinergic adverse effects include dry mouth, constipation, cognitive impairment—major reasons for discontinuation 1, 8
- Counsel patients upfront about side effects to improve adherence 1
- Oxybutynin exhibits direct antispasmodic effect on bladder smooth muscle, increasing bladder capacity and diminishing uninhibited detrusor contractions 8
Drug Interactions to Avoid:
- CYP3A4 inhibitors (ketoconazole, itraconazole, erythromycin, clarithromycin) increase oxybutynin levels 3-4 fold 8
- Anticholinergics antagonize prokinetic agents like metoclopramide 8
Third-Line: Advanced Interventions
For refractory symptoms after failed behavioral and pharmacologic therapy 5, 7:
- OnabotulinumtoxinA bladder injections 5, 7
- Percutaneous tibial nerve stimulation 5, 7
- Sacral neuromodulation 5, 7
Mixed Urinary Incontinence
First-Line: Combined Conservative Approach
PFMT combined with bladder training achieves continence (NNT = 6) and improves incontinence (NNT = 3) compared to no treatment. 2, 1
- Weight loss benefits the stress component more than urgency component in obese women 1
- Implement both supervised PFMT and scheduled voiding protocols simultaneously 2, 3
Second-Line: Pharmacologic Therapy
Solifenacin and fesoterodine are preferred choices as they demonstrate dose-response effects, with modest benefit of less than 20% absolute risk difference versus placebo. 1
- Target the urgency component with anticholinergics or beta-3 agonists 1
- Counsel about anticholinergic adverse effects: dry mouth, constipation, heartburn, urinary retention 1
Third-Line: Surgical Management
- Synthetic midurethral mesh slings can cure both stress and urge components in 40-50% of cases 1
- Counsel about surgical complications: lower urinary tract injury, hemorrhage, infection, bowel injury, wound complications, mesh-specific complications 1
Special Populations
Post-Prostate Treatment Incontinence (Men)
PFMT should be offered immediately upon catheter removal, as it improves time-to-achieving continence compared to control groups, with recovery occurring as early as 3-6 months. 2
- Evaluate with history, physical exam, and diagnostic modalities to categorize type and severity 2
- For urgency incontinence post-prostate treatment, follow overactive bladder treatment guidelines 2
- Patients showing no improvement after 6 months are candidates for early surgical intervention 2
Surgical options for persistent stress incontinence:
- Artificial urinary sphincter (AUS) is first-line for severe incontinence or history of radiation 2
- Male slings can be offered for moderate incontinence with appropriate counseling 2
- Perform cystourethroscopy before surgery to assess for urethral/bladder pathology 2
Pediatric Patients (Age 5-15)
- Oxybutynin is safe and effective in children aged 5 years and older with neurogenic bladder 8
- Dosing ranges from 5-15 mg total daily dose, associated with improved clinical and urodynamic parameters 8
- Not recommended for children under age 5 due to insufficient clinical data 8
Geriatric Patients
- Start with lower initial dose of oxybutynin (2.5 mg given 2-3 times daily) due to prolonged elimination half-life (5 hours vs. 2-3 hours in younger patients) 8
- Exercise caution due to greater frequency of decreased hepatic, renal, or cardiac function 8
Definition of Treatment Success
Clinically successful treatment reduces urinary incontinence episode frequency by at least 50%. 1, 3
Critical Pitfalls to Avoid
- Never skip behavioral interventions—always attempt PFMT and/or bladder training first before medications or surgery 3
- Never use systemic pharmacologic therapy for stress incontinence—it is ineffective 2, 1, 3
- Never proceed to surgery without adequate trial of conservative measures—minimum 3 months supervised PFMT required 3, 4
- Avoid synthetic mesh in scarred urethras, poor tissue quality, radiation history, or concomitant urethral procedures—use autologous fascial sling instead 4
- Do not use transobturator midurethral slings in patients with fixed/immobile urethras 3
- Set realistic expectations—counsel patients that one thin pad per day is expected outcome even after successful surgery 2