Management of Urinary Incontinence in Young Adults

First-Line Treatment Recommendations

Behavioral therapies, including bladder training, pelvic floor muscle training (PFMT), fluid management, and weight loss if the patient is obese, should be the first-line treatment for all patients with urinary incontinence, according to the American College of Physicians 1
For stress urinary incontinence, PFMT is strongly recommended as first-line treatment (strong recommendation, high-quality evidence) 2
For urgency urinary incontinence, bladder training is strongly recommended as first-line treatment (strong recommendation, moderate-quality evidence) 2
For mixed urinary incontinence, PFMT with bladder training is strongly recommended (strong recommendation, moderate-quality evidence) 2

Antimuscarinic medications like oxybutynin should only be used as second-line therapy after behavioral interventions have failed, as recommended by the American College of Physicians 1
Oxybutynin has been associated with the highest risk for discontinuation due to adverse effects among antimuscarinic medications (high-quality evidence; NNTH, 16 [CI, 8 to 86]) 3, 4

Darifenacin and tolterodine have risks for discontinuation due to adverse effects similar to placebo 4, 2
Solifenacin was associated with the lowest risk for discontinuation due to adverse effects among antimuscarinic medications, according to the American College of Physicians 1
Dry mouth and insomnia were more frequently reported for oxybutynin than for tolterodine 4

Oxybutynin should not be used in patients with narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention, as recommended by the American College of Physicians 1

Consider post-void residual assessment in patients at higher risk of urinary retention before starting antimuscarinic therapy, according to the American College of Physicians 1
If inadequate response or intolerable side effects occur, consider switching to an alternative antimuscarinic with a better tolerability profile, as recommended by the American College of Physicians 1
Treatment should be periodically reassessed to determine if continued therapy is necessary, especially given the high rate of adverse effects 3, 4

The American Urological Association (AUA) and Society of Urodynamics, Female Urology (SUFU) guideline advises clinicians to stop oral antimuscarinic therapy, including oxybutynin, in patients with overactive bladder who achieve an adequate response to minimally invasive procedures such as botulinum toxin injection, sacral neuromodulation, or peripheral tibial nerve stimulation. 5
When a patient experiences symptom recurrence after medication cessation, the guideline recommends promptly restarting the antimuscarinic agent. 5
In individuals who demonstrate a good therapeutic response to a minimally invasive modality, continuation of oxybutynin provides no additional benefit and should therefore be discontinued. 5

After stopping oxybutynin, clinicians should monitor for the return of overactive bladder symptoms (e.g., urinary frequency, urgency, incontinence episodes). 5
If OAB symptoms reappear following discontinuation that was initiated after successful minimally invasive therapy, pharmacologic treatment should be reinstated. 5

The guideline cautions against maintaining oxybutynin therapy after successful minimally invasive treatment, as it offers no clinical advantage and exposes patients to the drug’s notable adverse‑effect profile. 5