Stress Incontinence Medication in Women
Systemic pharmacologic therapy should NOT be used for stress urinary incontinence—the American College of Physicians strongly recommends against it based on lack of demonstrated effectiveness. 1, 2
First-Line Treatment: Non-Pharmacologic Approach
Supervised pelvic floor muscle training (PFMT) is the recommended first-line therapy for stress incontinence, demonstrating up to 70% symptom improvement when properly supervised by a trained clinician or physiotherapist. 1, 2
Treatment must continue for at least 3 months to achieve meaningful clinical benefit. 2
For obese women with stress incontinence, weight loss of 5-10% should be initiated immediately as it specifically benefits stress incontinence more than urge incontinence. 2
Why Medications Don't Work for Stress Incontinence
Standard pharmacologic therapies used for urgency incontinence (antimuscarinics like oxybutynin, tolterodine, solifenacin) have not been shown effective for stress incontinence. 1, 2
The pathophysiology differs: stress incontinence involves urethral sphincter weakness during physical stress, not bladder overactivity that responds to antimuscarinics. 1
Limited Pharmacologic Options
Vaginal Estrogen (Only Topical)
Vaginal estrogen formulations may improve stress incontinence symptoms, though evidence is limited. 1, 2
Critical caveat: Transdermal estrogen patches worsen incontinence and should be avoided. 1, 2
Duloxetine (Not FDA-Approved in US)
While duloxetine (a serotonin-norepinephrine reuptake inhibitor) has been studied for stress incontinence:
It works by increasing urethral sphincter tone through action at Onuf's nucleus in the sacral spinal cord. 3, 4
Clinical trials showed modest reductions in incontinence episodes (mean difference -13.56% versus placebo). 5
However, harms outweigh benefits: The number needed to harm is 7 for discontinuation due to adverse events (primarily nausea, insomnia, fatigue, activation events), while the number needed to treat is 8 for meaningful improvement. 5, 6
Discontinuation rates were 20.5% for duloxetine versus 3.9% for placebo, with 83% of discontinuations occurring within the first month. 6
Duloxetine is not FDA-approved for stress incontinence in the United States and should not be routinely used given the unfavorable benefit-to-harm ratio. 5
When Conservative Management Fails
If PFMT fails after 3 months, surgical options (synthetic midurethral slings) represent the most common definitive treatment for stress incontinence. 2
Patients should be counseled about surgical risks including lower urinary tract injury, hemorrhage, infection, and mesh-specific complications. 2
Common Clinical Pitfall
Do not prescribe antimuscarinics (oxybutynin, tolterodine, solifenacin, etc.) for pure stress incontinence—these medications only work for urgency incontinence and will expose patients to adverse effects (dry mouth, constipation, blurred vision) without benefit. 1