What are the treatment options for urinary incontinence?

Treatment of Urinary Incontinence

Start with supervised pelvic floor muscle training (PFMT) as first-line treatment for all types of urinary incontinence in women, as it is more than 5 times as effective as no active treatment and shows success rates of 85-92% in long-term studies. 1, 2

Classification and Initial Assessment

Before initiating treatment, identify the specific incontinence subtype through focused questioning about leakage patterns: 3

• Stress urinary incontinence: Leakage with coughing, sneezing, or physical exertion due to increased intra-abdominal pressure 3
• Urgency urinary incontinence: Involuntary loss of urine with sudden compelling urge to void 1
• Mixed urinary incontinence: Combination of both stress and urgency symptoms 1

Rule out urinary tract infection and hematuria through urinalysis before proceeding with treatment. 3

Treatment Algorithm by Incontinence Type

Stress Urinary Incontinence

First-Line Conservative Management:

• Supervised PFMT is mandatory as initial therapy, involving repeated voluntary pelvic floor muscle contractions taught by a healthcare professional, continued for minimum 3 months before considering escalation 1, 3, 2
• PFMT supervised by healthcare professionals is significantly more effective than unsupervised training, reducing episodes by more than 50% 1
• Weight loss for obese patients (BMI ≥30) has a number needed to treat of 4 for improvement 3, 2
• Adequate but not excessive fluid intake is recommended 1

Critical Pitfall: Never use systemic pharmacologic therapy for stress incontinence—it is completely ineffective and wastes time and resources. 1, 3, 2

Surgical Options (only after 3 months of supervised conservative therapy fails):

• Synthetic midurethral mesh slings are the most common primary surgical treatment, with 48-90% symptom improvement rates 2, 4
• Autologous fascia pubovaginal sling shows 85-92% success with 3-15 years follow-up 2
• Alternative options include retropubic suspension and fascial slings 1

Urgency Urinary Incontinence

First-Line Behavioral Management:

• Bladder training is the primary initial treatment, involving scheduled voiding with progressively longer intervals between bathroom trips 1, 3, 2
• Adding PFMT to bladder training does not improve continence compared with bladder training alone for pure urgency incontinence 1
• Weight loss and fluid management benefit urgency symptoms 3

Second-Line Pharmacologic Treatment (only after behavioral interventions attempted):

• Anticholinergic agents (oxybutynin 5, 6, tolterodine 5, darifenacin, solifenacin, fesoterodine, trospium) all increase continence rates with moderate magnitude of benefit 1
• Select medications based on tolerability, adverse effect profile, ease of use, and cost rather than efficacy, as all agents show similar effectiveness 1
• Medications show modest benefit with absolute risk difference <20% compared to placebo 2
• Anticholinergic adverse effects (dry mouth, constipation, cognitive impairment) are major reasons for treatment discontinuation—counsel patients upfront about these effects 1
• Beta-3 adrenergic receptor agonists (mirabegron) offer an alternative pharmacological option 7

Third-Line Specialized Treatments (for refractory cases):

• OnabotulinumtoxinA injections 8, 4
• Percutaneous tibial nerve stimulation 8, 4
• Sacral neuromodulation 8, 4

Mixed Urinary Incontinence

First-Line Conservative Management:

• Combined supervised PFMT plus bladder training addresses both stress and urgency components simultaneously 1, 3
• Weight loss benefits the stress component more than the urgency component in obese women 1, 3

Second-Line Pharmacologic Treatment:

• Target the urgency component first with antimuscarinic medications, initiated only after behavioral interventions have been attempted for at least 3 months 1
• Solifenacin and fesoterodine are preferred choices due to dose-response effects and lower discontinuation rates, with modest benefit of less than 20% absolute risk difference versus placebo 1
• Counsel patients about anticholinergic adverse effects including dry mouth, constipation, heartburn, and urinary retention 1

Third-Line Surgical Intervention:

• Synthetic midurethral mesh slings can cure both stress and urge components in 40-50% of cases 1
• Consider only after minimum 3 months of supervised PFMT plus bladder training 1
• Alternative options include retropubic colposuspension and urethral bulking agents 1

Universal Interventions Across All Types

Weight loss and exercise are strongly recommended for obese women with any type of incontinence, showing particular benefit for stress incontinence with moderate-quality evidence. 2

Definition of Treatment Success

Clinically successful treatment is defined as reducing urinary incontinence episode frequency by at least 50%. 1, 3

Critical Pitfalls to Avoid

• Never skip behavioral interventions—always attempt PFMT and/or bladder training first before medications or surgery 3, 2
• Never start medications before attempting behavioral interventions for at least 3 months, as this violates evidence-based stepped-care approach 1, 2
• Never proceed to surgery without minimum 3 months of supervised conservative therapy 1, 3
• Ensure proper PFMT technique with professional supervision to avoid treatment failure 2
• Address modifiable risk factors (obesity, constipation, excessive fluid intake) to ensure effective treatment outcomes 2
• Set realistic expectations about medication side effects upfront to improve adherence 1
• Weigh symptom severity against medication adverse effects—not all patients require pharmacotherapy if symptoms are mild and behavioral measures provide adequate relief 1