Pharmacologic Treatment for Stress Urinary Incontinence
Systemic pharmacologic therapy should NOT be used for stress urinary incontinence in postmenopausal women, as standard medications have not been shown to be effective for this condition. 1, 2
Why Medications Don't Work for Stress Incontinence
The American College of Physicians issues a strong recommendation against systemic pharmacologic therapy for stress urinary incontinence based on evidence showing lack of efficacy. 1, 2
Standard antimuscarinic medications used for urgency incontinence (oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, trospium) have no proven benefit for stress incontinence and should not be prescribed for this indication. 1, 2
Duloxetine showed minimal efficacy with a number needed to benefit of 13 and failed to improve quality of life in women with severe stress incontinence. 2, 3
The Only Exception: Vaginal Estrogen
Vaginal estrogen formulations (tablets or ovules) may be considered in postmenopausal women, as they demonstrated improvement with a number needed to benefit of 5. 1, 2
Avoid transdermal estrogen patches as they actually worsened urinary incontinence. 1, 2
What Actually Works: Non-Pharmacologic Treatment
Pelvic floor muscle training (PFMT) is the only recommended first-line treatment for stress incontinence, with strong evidence showing increased continence rates, improved quality of life, and up to 70% symptom improvement. 1, 2, 4, 5
PFMT is more cost-effective than medications, has no adverse effects, and should always be prioritized before considering any other intervention. 1, 2, 4
Supervised PFMT programs (by specialist physiotherapists or continence nurses) for at least three months produce better outcomes than unsupervised or leaflet-based approaches. 4
Additional Supportive Measures
Weight loss and exercise are strongly recommended for obese postmenopausal women with stress incontinence. 2
Vaginal devices and urethral inserts may reduce stress incontinence symptoms. 6
Bulking agents can reduce leakage but effectiveness typically decreases after 1-2 years. 6
Critical Pitfalls to Avoid
Do not prescribe antimuscarinics for stress incontinence - they only work for urgency incontinence and will not address the urethral sphincter weakness causing stress leakage. 1, 2
Do not skip PFMT and jump to medications - there are no effective systemic medications for this condition, and PFMT has the strongest evidence base. 1, 2
Do not use systemic estrogen replacement therapy - only vaginal formulations have shown benefit, while transdermal patches worsen symptoms. 1, 2
Special Consideration for Mixed Incontinence
If the patient has both stress and urgency components (mixed incontinence), use PFMT combined with bladder training as first-line treatment. 1, 2
If pharmacotherapy becomes necessary for persistent urgency symptoms despite behavioral interventions, antimuscarinic medications can target only the urgency component while PFMT continues to address the stress component. 2