What are the treatment options for urinary incontinence in adults?

Treatment Options for 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 reduce incontinence episodes by more than 50% and must be attempted before any pharmacologic or surgical treatment. 1, 2

Classification and Initial Assessment

Determine the specific type of incontinence through focused questioning about leakage patterns:

• Stress urinary incontinence: Leakage with coughing, sneezing, laughing, or physical exertion due to increased intra-abdominal pressure 1
• Urgency urinary incontinence: Involuntary loss with sudden compelling urge to void 1
• Mixed urinary incontinence: Combination of both stress and urgency symptoms 1

Essential initial evaluation components include: 1

• Focused history assessing symptom onset, patterns, frequency, and impact on quality of life 2
• Pelvic examination 1, 2
• Objective demonstration of stress incontinence with comfortably full bladder 1
• Post-void residual urine measurement 1
• Urinalysis to rule out infection or hematuria 1, 3

First-Line Conservative Management by Type

For Stress Urinary Incontinence

Supervised pelvic floor muscle training taught by a healthcare professional is more than 5 times as effective as no treatment (NNT = 2). 2, 4

• PFMT involves repeated voluntary pelvic floor muscle contractions (Kegel exercises) 1
• Supervision by a trained healthcare professional significantly improves outcomes compared to unsupervised training 1
• Continue for minimum 3 months before considering escalation to other treatments 3
• Do NOT use systemic pharmacologic therapy for stress incontinence—it is ineffective 1, 3

For Urgency Urinary Incontinence

Bladder training is the primary initial treatment, involving scheduled voiding with progressively longer intervals between bathroom trips (NNT = 2). 1, 2, 4

• Behavioral therapy extends time between voiding episodes 1
• Adding PFMT to bladder training does not improve outcomes for pure urgency incontinence 4

For Mixed Urinary Incontinence

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

• Weight loss benefits the stress component more than urgency component in obese women 3, 4

Lifestyle Modifications for All Types

Weight loss and exercise for obese women with any type of incontinence (NNT = 4 for improvement). 1

• Decrease caffeine intake 5
• Avoid excessive fluid consumption 5, 6
• Smoking cessation 6
• No harms identified with behavioral interventions 2, 4

Second-Line Pharmacologic Treatment (Urgency Incontinence ONLY)

If bladder training fails for urgency incontinence, initiate anticholinergic or beta-3 agonist medications, selecting based on tolerability, adverse effects, ease of use, and cost rather than efficacy. 1, 2

Medication options with similar effectiveness: 4

• Oxybutynin
• Tolterodine
• Darifenacin
• Solifenacin
• Fesoterodine
• Trospium
• Mirabegron (beta-3 agonist) 7, 6

Common anticholinergic adverse effects causing discontinuation: 4

• Dry mouth
• Constipation
• Cognitive impairment (especially in elderly)
• Urinary retention

Mirabegron dosing for adults with OAB: 7

• Starting dose: 25 mg orally once daily
• Maximum dose: 50 mg orally once daily after 4-8 weeks if needed
• Adjust for renal impairment: maximum 25 mg daily if eGFR 15-29 mL/min/1.73 m²
• Adjust for hepatic impairment: maximum 25 mg daily for Child-Pugh Class B

Third-Line Surgical Interventions (After Conservative Measures Fail)

For Stress Urinary Incontinence

Synthetic midurethral mesh slings are the most common primary surgical treatment (48-90% symptom improvement, <5% mesh complications). 1, 2

Alternative surgical options: 1

• Retropubic suspension (colposuspension)
• Autologous fascial slings
• Urethral bulking agents
• Artificial urinary sphincters (for severe/complicated cases)

Surgical complications to counsel patients about: 4

• Direct injury to lower urinary tract
• Hemorrhage
• Infection
• Bowel injury
• Wound complications
• Mesh-specific complications (erosion, exposure, pain)

For Urgency Urinary Incontinence (Refractory to Medications)

Advanced procedural options: 5, 6

• OnabotulinumtoxinA bladder injections
• Percutaneous tibial nerve stimulation
• Sacral neuromodulation

Critical Pitfalls to Avoid

Never skip behavioral interventions—always attempt PFMT and/or bladder training first before medications or surgery. 2, 3

Never use systemic pharmacologic therapy for stress incontinence—it is completely ineffective. 1, 3

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

Avoid transobturator midurethral slings in patients with fixed/immobile urethras. 2

Avoid synthetic mesh in patients with poor tissue quality, significant scarring, radiation history, or concomitant urethral procedures. 2

Counsel patients upfront about anticholinergic side effects to improve adherence and set realistic expectations. 4

Special Populations

Older Adults with Diabetes

Screen annually for urinary incontinence symptoms, as women with diabetes are at higher risk. 1

Evaluate for diabetes-specific reversible causes: 1

• Polyuria from glycosuria
• Neurogenic bladder from autonomic insufficiency
• Urinary tract infection
• Candida vaginitis
• Fecal impaction

Post-Prostate Treatment Incontinence (Men)

Initiate PFMT immediately upon catheter removal to improve time-to-achieving continence. 3

Consider early surgical intervention if no improvement after 6 months. 3

Definition of Treatment Success

Clinically successful treatment reduces urinary incontinence episode frequency by at least 50%. 1, 2, 3, 4