Treatment of Urinary Incontinence

Introduction to Treatment Options

The American College of Physicians and the American Urological Association recommend a range of treatments for urinary incontinence, including pharmacologic and non-pharmacologic therapies, as well as surgical options 1, 2, 3, 4

Pelvic floor muscle training (PFMT) is recommended as a first-line treatment for urinary incontinence, with a protocol of 3 sets of 8-12 contractions daily, holding each contraction for 6-8 seconds, as a strong recommendation with high-quality evidence, by the American College of Physicians 1
Bladder training is recommended as a first-line non-pharmacologic therapy, involving scheduled voiding and gradually extending time between voids, with strong recommendation and moderate-quality evidence, as suggested by the American College of Physicians 1
Fluid management with a 25% reduction in fluid intake is also recommended as a first-line non-pharmacologic therapy, as suggested by the American Urological Association 3
Weight loss and exercise are recommended for obese patients with urinary incontinence, with a strong recommendation and moderate-quality evidence, by the American College of Physicians 1

Tolterodine reduces micturition frequency by 22% and urge incontinence episodes by 71-76% 1
The American College of Physicians recommends tolterodine or solifenacin as preferred options due to better tolerability 1
Solifenacin is recommended as an alternative with the lowest risk for discontinuation due to adverse effects among antimuscarinics, with a number needed to benefit (NNTB) of 9 for achieving continence, regardless of age, as stated by the American College of Physicians 1
Fesoterodine is more effective than tolterodine but with a higher risk of dry mouth, as reported by the European Association of Urology 5
Mirabegron is recommended as a first-choice pharmacologic therapy for urge incontinence, due to its superior side effect profile and comparable efficacy to antimuscarinic medications, with strong recommendation and high-quality evidence, as suggested by the American College of Physicians and the American Urological Association 1, 2
Combination therapy with α-blockers and antimuscarinics is more effective than monotherapy for men with both storage and voiding symptoms, as reported by the European Association of Urology 5

The following side effect profiles are associated with antimuscarinic medications:

Medication	Side Effects
Oxybutynin	Dry mouth (71.4%), constipation (15.1%), blurred vision (9.6%), dizziness (16.6%), somnolence/drowsiness (14%), headache (7.5%) [3]
Fesoterodine	Higher rates of adverse effects than tolterodine, with dry mouth and constipation as common side effects [1]
Tolterodine	Better side effect profile than oxybutynin, with lower discontinuation rates due to adverse effects [6, 1]
Trospium	Lower incidence of constipation compared to other antimuscarinics [1]
Darifenacin	Risk for discontinuation due to adverse effects similar to placebo, which may reduce systemic side effects [1]
Solifenacin	Lowest risk for discontinuation due to adverse effects among antimuscarinics, and better tolerated than immediate-release oxybutynin [1, 1]

Urethral bulking agents are recommended as a less invasive surgical option for patients with urinary incontinence, by the American Urological Association 4
Male sling or artificial urinary sphincter is suggested as a surgical option for men with urinary incontinence, by the American Urological Association 4
Midurethral slings, single-incision slings, and urethral bulking agents should be considered only after failure of conservative measures, according to the American Urological Association 1
Sacral neuromodulation (SNS) is recommended for patients with severe refractory symptoms who are willing to undergo a surgical procedure, with moderate-strength evidence, as suggested by the American Urological Association 2
Peripheral tibial nerve stimulation (PTNS) can be offered as an alternative third-line treatment, with low-strength evidence, as suggested by the American Urological Association 2
OnabotulinumtoxinA injections may be considered for patients with severe refractory symptoms, with patient counseling about the potential need for self-catheterization, with moderate-strength evidence, as suggested by the American Urological Association 2

Follow-up should be scheduled at 4-6 weeks to assess technique and compliance, and treatment response should be evaluated at 8-12 weeks, according to the American Urological Association 1
Allow 4-8 weeks for medications and 8-12 weeks for behavioral therapies to determine efficacy, as suggested by the European Urology guidelines, with a strength of evidence rated as high, as suggested by the European Association of Urology 2
Inadequate trial of conservative therapy can lead to premature advancement to other options, and allowing sufficient time (8-12 weeks) for PFMT to show benefit is essential, according to the American Urological Association 1