What are the treatment options for urinary incontinence in adults?

Treatment of Urinary Incontinence in Adults

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

First, proactively screen all patients for urinary incontinence during routine visits, as at least half of incontinent women do not voluntarily report symptoms to their physicians. 1, 3 Classify the type of incontinence to guide treatment:

• Stress incontinence: Involuntary urine loss with coughing, sneezing, laughing, or physical exertion due to increased intra-abdominal pressure 1, 2
• Urgency incontinence: Involuntary loss associated with a sudden compelling urge to void 1, 2
• Mixed incontinence: Combination of both stress and urgency symptoms 1, 2

Rule out urinary tract infection, hematuria, and reversible causes including urine retention, fecal impaction, restricted mobility, and certain medications. 1, 4 In older adults with diabetes, also evaluate for polyuria from glycosuria, neurogenic bladder, and candida vaginitis. 1

First-Line Treatment: Behavioral Interventions (ALL Patients)

For Stress Incontinence

Supervised pelvic floor muscle training (PFMT) is the primary treatment, with effectiveness more than 5 times greater than no treatment. 1, 2, 3 PFMT involves repeated voluntary pelvic floor muscle contractions (Kegel exercises) taught and supervised by a healthcare professional—unsupervised training shows significantly inferior outcomes. 2, 5 Success rates exceed 50-70% symptom improvement with a number needed to treat of 2. 2, 3

For Urgency Incontinence

Bladder training is the primary initial treatment, involving scheduled voiding with progressively longer intervals between bathroom trips. 1, 2, 5 This has a number needed to treat of 2 for clinically meaningful improvement. 2 Adding PFMT to bladder training does not improve continence compared with bladder training alone for pure urgency incontinence. 5

For Mixed Incontinence

Combine supervised PFMT plus bladder training together to address both components simultaneously. 1, 2, 5 This combination has a number needed to treat of 3 for improvement and 6 for continence. 3

Lifestyle Modifications (All Types)

For obese women (BMI ≥30), recommend weight loss and exercise, which has a number needed to treat of 4 for improvement. 1, 2 Weight loss benefits the stress component more than the urgency component. 5 Also recommend adequate but not excessive fluid intake and regular voiding intervals. 4, 6

Second-Line Treatment: Pharmacologic Therapy

Critical Pitfall to Avoid

Never use systemic pharmacologic therapy for stress incontinence—it is completely ineffective and represents wrong treatment for the wrong condition. 1, 2, 5

For Urgency Incontinence Only

Initiate anticholinergic medications only after behavioral interventions have been attempted for at least 3 months. 5, 3 All anticholinergic agents show similar effectiveness, so base selection on tolerability, adverse effect profile, ease of use, and cost rather than efficacy. 1, 2

Medication options include:

• Oxybutynin 7, 8
• Tolterodine 7
• Darifenacin 2, 5
• Solifenacin 2, 5
• Fesoterodine 2, 5
• Trospium 2, 5

Solifenacin and fesoterodine are preferred choices due to their dose-response effects and lower discontinuation rates. 5 Counsel patients upfront about anticholinergic adverse effects including dry mouth, constipation, heartburn, urinary retention, and potential cognitive impairment—these are the major reasons for treatment discontinuation. 5, 8 In frail elderly patients, start with lower doses due to prolonged elimination half-life (5 hours vs 2-3 hours in younger patients). 8

For Mixed Incontinence

Target the urgency component first with antimuscarinic medications after adequate trial of combined PFMT plus bladder training. 5 Solifenacin and fesoterodine demonstrate modest benefit of less than 20% absolute risk difference versus placebo. 5

Third-Line Treatment: Surgical Intervention

Reserve surgery only for women whose symptoms don't improve with conservative therapies after minimum 3 months of supervised behavioral interventions. 5, 3

For Stress and Mixed 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, 4 These can address both stress and urge components in 40-50% of mixed incontinence cases. 5 Alternative surgical options include retropubic colposuspension and autologous fascial slings. 5, 3

Counsel patients about surgical complications including direct injury to the lower urinary tract, hemorrhage, infection, bowel injury, wound complications, and mesh-specific complications. 5 Avoid synthetic mesh in patients with poor tissue quality, significant scarring, radiation history, or concomitant urethral procedures. 3

For Refractory Urgency Incontinence

Specialist treatments include onabotulinumtoxinA intravesical injection and percutaneous or implanted neuromodulators. 4, 6

Definition of Treatment Success

Clinically successful treatment reduces urinary incontinence episode frequency by at least 50%. 1, 5, 3 No harms have been identified with behavioral interventions like PFMT or weight loss programs. 2, 3

Special Considerations for Older Adults

Urinary incontinence affects 44-57% of middle-aged and postmenopausal women aged 40-60 years and 75% of women aged 75+ years. 1, 2 In older adults with diabetes, annual screening is recommended due to higher risk from polyuria, neurogenic bladder, autonomic insufficiency, and recurrent infections. 1 Incontinence is associated with social isolation, depression, falls, fractures, and nursing home admissions. 1, 6