Management of Urinary Incontinence
Begin with pelvic floor muscle training (PFMT) for stress incontinence, bladder training for urgency incontinence, or both combined for mixed incontinence—these behavioral interventions must be attempted before any pharmacologic or surgical options. 1, 2
Initial Assessment and Classification
Proactively screen all patients for urinary incontinence during routine visits, as most do not voluntarily report symptoms. 2 Classification into stress, urgency, or mixed incontinence is essential for guiding treatment. 2
Key diagnostic elements to identify:
- Stress urinary incontinence (SUI): Leakage with coughing, sneezing, laughing, or physical exertion due to increased intra-abdominal pressure 1, 2
- Urgency urinary incontinence: Involuntary loss associated with sudden compelling desire to void 1, 2
- Mixed incontinence: Combination of both stress and urgency symptoms 1, 2
Perform focused physical examination including neurologic assessment. 2 For post-prostate treatment patients, assess severity using pads per day: social continence (≤1 pad/day), mild (1-2 pads), moderate (2-4 pads), severe (5+ pads). 3
First-Line Treatment: Conservative Management
For Stress Urinary Incontinence
Supervised PFMT taught by a healthcare professional is more than 5 times as effective as no treatment, with 50-70% symptom improvement (NNT=2). 1, 2 This applies to both general female populations and post-prostate treatment patients. 3
Additional first-line options for women include vaginal mechanical devices (pessaries, cones, urethral plugs) and electroacupuncture. 4 Biofeedback and electrical muscle stimulation serve as adjunctive therapy. 4, 5
For Urgency Urinary Incontinence
Bladder training is the primary initial treatment (NNT=2), involving scheduled voiding with progressively longer intervals between bathroom trips. 1, 2 For post-stroke patients, implement a behavioral bladder-training program offering the commode every 2 hours while awake and every 4 hours at night, limiting fluids in early evening. 3
For Mixed Incontinence
Combine supervised PFMT plus bladder training together (NNT=3 for improvement, NNT=6 for continence). 1, 2
Lifestyle Modifications
Weight loss for obese women has NNT=4 for improvement. 1 Fluid management benefits urgency symptoms. 1
Common pitfall: Never skip behavioral interventions—always attempt PFMT and/or bladder training for minimum 3 months before escalating to medications or surgery. 2
Second-Line Treatment: Pharmacologic Therapy
For Urgency Incontinence ONLY
If behavioral interventions fail, initiate anticholinergic or beta-3 agonist medications. 1, 2 Select based on tolerability, adverse effects, ease of use, and cost rather than efficacy, as all show similar effectiveness. 1, 2
Medication options include:
- Anticholinergics: oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium 1, 6
- Beta-3 agonist: mirabegron (25-50mg daily for adults; dose-adjusted for renal/hepatic impairment) 6, 4
Beta-3 agonists have fewer anticholinergic side effects compared with antimuscarinics. 4 Adverse medication effects often lead to discontinuation due to poor tolerability. 4
Critical pitfall: Do NOT use systemic pharmacologic therapy for stress incontinence—it is completely ineffective and represents wrong treatment. 1
For Overflow Incontinence from BPH
Alpha-1-blockers are first-line for moderate to severe overflow incontinence. 4 5-alpha reductase inhibitors serve as adjunct in refractory cases with PSA ≥1.5 mg/dL. 4
Third-Line Treatment: Surgical and Advanced Interventions
For Refractory Stress Incontinence
Synthetic midurethral mesh slings are the most common and effective primary surgical treatment (48-90% symptom improvement, <5% mesh complications). 1, 2 Alternative options include retropubic suspension, autologous fascial slings, and urethral bulking agents with varying success rates. 1, 2
For patients with fixed/immobile urethra:
- Pubovaginal sling (PVS), retropubic midurethral sling (RMUS), or urethral bulking agents are preferred 7
- Artificial urinary sphincter (AUS) or autologous fascial sling for significant scarring and complete immobility 7
- Avoid transobturator midurethral slings—they require additional tension, increasing complication risks 7, 2
Contraindications for synthetic mesh:
- Poor tissue quality, significant scarring, or radiation therapy history 7, 2
- Inadvertent urethral injury during procedure 7
- Concomitant urethral diverticulectomy, urethrovaginal fistula repair, or urethral mesh excision 7
For Post-Prostate Treatment Incontinence
Treat symptomatic vesicourethral anastomotic stenosis or bladder neck contracture BEFORE surgery for incontinence. 3 For persistent incontinence after male sling, artificial urinary sphincter is recommended. 3 In patients unable to obtain long-term quality of life after multiple device failures, urinary diversion ±cystectomy may be considered. 3
For Refractory Urgency Incontinence
Third-line therapies include neuromodulation, neurotoxin injections, vaginal laser therapy, and acupuncture, though these lack high-grade evidence. 4
Special Populations
Post-Stroke Patients
Bladder dysfunction affects 25-50% of stroke survivors. 3 Implement prompted voiding for urinary incontinence. 3 For persistent constipation or bowel incontinence, implement a bowel management program ensuring adequate fluid, bulk, and fiber intake with regular toileting schedule. 3
Post-Prostate Treatment Patients
Counsel regarding sexual arousal incontinence and climacturia following localized prostate cancer treatment. 3 For bothersome climacturia, conservative management includes emptying bladder prior to sex, wearing condoms, using penile variable tension loop, and implementing PFME. 3
Neurogenic Bladder
Clean intermittent catheterization is first-line therapy but increases risk of catheter-associated urinary tract infection. 4
Treatment Success Definition
Clinically successful treatment reduces urinary incontinence episode frequency by at least 50%. 2 No harms have been identified with behavioral interventions like PFMT or weight loss programs. 1, 2