What is the first line of treatment for a 30-year-old woman presenting with urgency incontinence?

First-Line Treatment for Urgency Incontinence in a 30-Year-Old Woman

Bladder training is the first-line treatment for urgency incontinence in this patient, as it is effective, has no adverse effects, and is less expensive than pharmacologic therapy. 1

Treatment Algorithm

Step 1: Initiate Bladder Training

• Bladder training involves scheduled voiding with progressively longer intervals between bathroom trips. 2
• This behavioral therapy teaches the patient to extend the time between voids, gradually increasing bladder capacity and reducing urgency episodes. 1
• The American College of Physicians gives this a strong recommendation based on moderate-quality evidence showing improvement in urgency incontinence outcomes. 1
• Bladder training alone is sufficient—adding pelvic floor muscle training (PFMT) does not improve continence compared with bladder training alone for pure urgency incontinence. 2

Step 2: Add Pharmacologic Therapy Only If Bladder Training Fails

• If bladder training is unsuccessful after an adequate trial (typically 3 months), initiate antimuscarinic medication. 1, 2
• All antimuscarinic agents show similar efficacy: oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium all increase continence rates with moderate magnitude of benefit. 1, 2
• Base medication selection on tolerability, adverse effect profile, ease of use, and cost—not efficacy, since all agents are equally effective. 1

Medication Selection Guidance

• Solifenacin is associated with the lowest risk for discontinuation due to adverse effects. 1
• Oxybutynin is associated with the highest risk for discontinuation due to adverse effects. 1
• Darifenacin and tolterodine have discontinuation rates similar to placebo. 1
• Tolterodine is FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. 3

Critical Pitfalls to Avoid

Do Not Skip Behavioral Interventions

• Never start with pharmacologic therapy—bladder training has strong evidence and must be attempted first. 2
• Nonpharmacologic therapies are effective, have few adverse effects, and are cheaper than medications. 1

Counsel About Anticholinergic Side Effects Upfront

• Common adverse effects include dry mouth, constipation, and blurred vision. 1
• Many patients discontinue pharmacologic treatment because of these adverse effects. 1
• Setting realistic expectations about side effects improves adherence. 2
• In elderly women, anticholinergics can paradoxically cause urinary retention and cognitive impairment. 4

Do Not Use Systemic Pharmacologic Therapy for Stress Incontinence

• If this patient has stress incontinence (not urgency), medications are ineffective and represent the wrong treatment. 1, 2
• Ensure accurate diagnosis by taking a detailed history about the timing of leakage (with cough/sneeze versus sudden urge). 1

Additional Considerations for This Young Patient

Weight Management

• If the patient is obese (BMI ≥30), recommend weight loss and exercise as an adjunct to bladder training. 1
• Weight loss has a number needed to treat of 4 for improvement in urinary incontinence. 2

Long-Term Management

• Clinically successful treatment is defined as reducing the frequency of incontinence episodes by at least 50%. 2
• If both behavioral and pharmacologic therapies fail, third-line options include neuromodulation devices (posterior tibial nerve stimulators, sacral nerve stimulators) or intravesical onabotulinumtoxinA injections. 5, 6, 7