Treatment of Urinary Incontinence

Introduction to Urinary Incontinence Treatment

The American Urological Association recommends pharmacologic therapy, including beta-3 agonists like mirabegron, only for overactive bladder (urgency urinary incontinence) after behavioral therapies have failed 1

Pelvic floor muscle training (PFMT) is the recommended first-line treatment for stress incontinence with strong evidence and high-quality data 1
Non-pharmacological approaches should always be prioritized over medications for stress incontinence 1
Pharmacologic therapy is NOT recommended for stress urinary incontinence based on strong evidence 1
Duloxetine has limited efficacy (NNTB of 13) and did not show statistically significant improvement compared to placebo for stress incontinence 1
For postmenopausal women with stress incontinence, vaginal estrogen tablets or ovules may be considered (NNTB of 5) 1

Bladder training is the recommended first-line treatment for overactive bladder with strong recommendation and moderate-quality evidence 1
Non-pharmacological approaches including behavioral modification and pelvic floor exercises should be attempted first for overactive bladder 2
Solifenacin has the lowest risk for discontinuation due to adverse effects for overactive bladder 1
Darifenacin and tolterodine have discontinuation rates similar to placebo for overactive bladder 1
Mirabegron (beta-3 agonist) improves urinary incontinence (NNTB of 9) and achieves continence (NNTB of 12) for overactive bladder 3
Oxybutynin should be avoided due to highest discontinuation rates for overactive bladder 1
Beta-3 agonists commonly cause nasopharyngitis and gastrointestinal disorders 1
Beta-3 agonists have fewer drug interactions than antimuscarinics and lower cognitive effects, particularly important for elderly patients with overactive bladder 3

Combined PFMT with bladder training is the first-line treatment for mixed incontinence with strong recommendation 1
If pharmacotherapy is needed for mixed incontinence, it should target the urgency component only 4

If a patient presents with both BOO (bladder outlet obstruction) and OAB symptoms, combination therapy with alpha-blocker and antimuscarinic may be considered with increasing evidence of safety and efficacy, though this applies primarily to male patients 2