Treatment of urinary incontinence in women

Author
Emily S Lukacz, MD, MAS
Section Editors
Linda Brubaker, MD, FACS, FACOG
Kenneth E Schmader, MD
Deputy Editors
Lee Park, MD, MPH
Kristen Eckler, MD, FACOG
Contributor disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Mar 2016. | This topic last updated: Mar 11, 2016.

INTRODUCTION Urinary incontinence, the involuntary leakage of urine, is often treated

inadequately [1]. In one survey, only 60 percent of patients seeking care for leakage (at least once
weekly) recalled receiving any treatment for their incontinence [2]. Additionally, nearly 50 percent of
those who did receive treatment reported moderate-to-great frustration with ongoing incontinence.

This topic will discuss the treatment of urinary incontinence in nonpregnant women, focusing on the
initial management of stress and urgency incontinence. Overactive bladder (OAB) is a syndrome
characterized by urinary urgency, frequency, and nocturia with or without incontinence, and is
treated in a similar manner to urgency incontinence.

The evaluation of urinary incontinence in women and urinary incontinence in men are discussed
separately. Urinary incontinence in pregnancy is also discussed separately. (See "Urinary
incontinence in men" and "Evaluation of women with urinary incontinence" and "Urinary
incontinence and pelvic organ prolapse associated with pregnancy and childbirth".)

PRIOR TO INITIATING THERAPY

Identify indications for referral Indications for further evaluation or referral prior to initiating
treatment for urinary incontinence include the presence of associated abdominal/pelvic pain or
hematuria in the absence of urinary tract infection, new neurologic symptoms, suspected
vesicovaginal fistula or urethral diverticulum, advanced pelvic organ prolapse, uncertainly in
diagnosis, history of pelvic reconstructive surgery or pelvic irradiation, or persistently elevated
postvoid residual (after treatment of possible causes) (algorithm 1). (See "Evaluation of women with
urinary incontinence", section on 'Specialist referral'.)

Assess incontinence type and severity Determining the classification of urinary incontinence
type (stress, urgency, mixed) can help direct treatment (algorithm 1). While most women with
incontinence will have improved symptoms with therapy, they may not achieve full continence.
Treatment should proceed in a stepwise fashion with emphasis on improving quality of life. Risks
and side effects of therapy should be carefully balanced with benefits and aligned with patient goals
and expectations. (See "Evaluation of women with urinary incontinence", section on 'Evaluation'.)

A baseline assessment of symptom severity with a voiding diary and quality of life measures (eg,
International Consultation on Incontinence Questionnaire, The King's Health Questionnaire, Pelvic
Floor Distress Inventory, and Pelvic Floor Impact Questionnaire) can facilitate assessment and
focus treatment goals. These measures can also be helpful in assessing treatment efficacy. The
Patient Global Impression of Improvement (PGII) and Patient Global Impression of Severity (PGIS)
(table 1) are acceptable measures to assess improvement and satisfaction, respectively [3].
(See "Evaluation of women with urinary incontinence", section on 'History'.)

Pads and protective garments Most patients with incontinence use pads and protective
garments. Pads should be designed for incontinence. Those designed for menstrual use are usually
not sufficiently absorbent. While protective items are available at minimum to no cost in many
European countries, in the United States, these items are expensive and usually not covered by
insurance, except Medicaid.

Chronic exposure to urine-soaked pads can result in contact dermatitis and skin breakdown.
Ensuring regular changes is important, especially when used in a nursing home setting.
(See "Prevention of pressure ulcers", section on 'Minimize excess moisture'.)

Information on pad varieties and other urinary incontinence supplies is available from medical
supply companies and urinary incontinence patient advocacy groups, such as The Simon
Foundation and the National Association for Continence.

INITIAL TREATMENT Initial treatment includes lifestyle modifications and pelvic floor muscle
exercise for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder
training in women with urgency incontinence and for some women with stress incontinence
(algorithm 1) [4-8]. We typically treat with these conservative therapies for six weeks before
considering subsequent therapies. It is also reasonable to treat with conservative therapies for up to
12 weeks, particularly in women who would like to lose weight.

Modifying contributory factors Before starting any treatment for urinary incontinence,
contributory factors such as medical conditions and medications should be addressed, particularly
in older patients (table 2) [9]. (See "Evaluation of women with urinary incontinence", section on
'Other contributing factors/conditions'.)

Lifestyle modification We suggest weight loss to improve symptoms of urinary incontinence in

obese women. Other lifestyle modifications generally focus on other dietary changes. These have
been less studied but are often helpful to alleviate symptoms.

Weight loss Obesity is a known risk factor for urinary incontinence, and weight loss in
obese women appears to improve symptoms of urinary incontinence [10-14]. Studies show
greater benefits for stress incontinence than urgency incontinence. For example, one
randomized trial of 338 overweight and obese women (mean body mass index
36 kg/m2) found that weekly incontinence episodes decreased in patients assigned to an
intensive six-month weight loss program compared with a control group (47 versus 28
percent) [10]. Mean weight loss was 7.8 kg in the intervention group and 1.5 kg in the control
group. While the difference in the groups was driven by a decrease in stress, but not urgency
incontinence, more women in the intervention group had a 70 percent reduction in the
frequency of all incontinence episodes. (See "Obesity in adults: Overview of management".)
Dietary changes Some beverages may exacerbate symptoms of urinary incontinence. We
ask patients to reduce consumption of alcoholic, caffeinated, and carbonated beverages
[15,16]. Women who are drinking excess amounts of liquids (>64 ounces of liquids) should
normalize their fluid intake. We do not restrict fluid consumption below this level as this can
lead to dehydration. We also ask women who complain of nocturia to decrease the amount of
 liquid consumed before bedtime. (See "Nocturia: Clinical presentation, diagnosis, and
treatment", section on 'Initial measures'.)
Constipation Constipation can exacerbate urinary incontinence and increase the risks of
urinary retention [17]. Constipation should be managed and avoided when possible.
(See "Management of chronic constipation in adults".)
Smoking cessation Smoking has been associated with an increased risk for urinary
incontinence [16,18]. However, no studies have evaluated whether smoking cessation
decreases urinary incontinence.

Pelvic floor muscle exercises (Kegel exercises) We suggest pelvic floor muscle exercises for
all women with urinary incontinence. In women who are able to isolate their pelvic floor muscles to
stop urine flow, verbal instruction on timing and frequency of exercise is usually sufficient. For those
with difficulty identifying the proper muscles, supplemental modalities can help women to perform
these exercises properly.

Initial instruction Pelvic muscle (Kegel) exercises strengthen the pelvic floor musculature to
provide a backboard for the urethra to compress on and to reflexively inhibit detrusor contractions.
As such, these can be effective for both stress and urgency incontinence [5,19]. Systematic reviews
of randomized trials have found that compared with no treatment, women treated with pelvic muscle
exercises were more likely to report improvement or cure [5,20,21]. (See "Evaluation of women with
urinary incontinence", section on 'Stress incontinence' and "Evaluation of women with urinary
incontinence", section on 'Urgency incontinence'.)

The basic regimen consists of three sets of 8 to 12 contractions sustained for 8 to 10 seconds each,
performed three times a day. Patients should try to do this every day and continue for at least 15 to
20 weeks [22]. Adequacy of pelvic floor muscle contraction can be assessed during the pelvic
examination. The examiner places one or two fingers within the vagina and asks the patient to
contract her pelvic floor using the same muscles she would use to stop urine flow or gas [23].
(See "Patient information: Pelvic floor muscle exercises (Beyond the Basics)".)

Patients have better outcomes with regular exercise and proper technique. For women who are
able to isolate pelvic floor musculature, supplemental therapy may not be necessary. However,
other patients may have difficulty because of poor muscle isolation, low motivation, or inability to
properly contract the pelvic floor. For these patients, we use supplemental therapies such as
supervised pelvic floor therapy, vaginal weighted cones, or biofeedback (based on patient
preference, access, and availability).

Supplemental modalities

Supervised pelvic floor therapy Women who are having difficulty performing the
exercises or have no improvement may benefit from referral to a pelvic floor physical therapist
where available. Pelvic muscle exercises are most effective with specific instruction by health
professionals and regular performance by motivated patients. It is not clear how much
healthcare supervision is optimal [24,25].
Vaginal weighted cones Pelvic muscle exercises can be supplemented by the use of
weighted vaginal cones. These may be preferable for women who have insufficient time or
resources to dedicate to supervised physical therapy or biofeedback. The woman inserts the
cone in her vagina and uses pelvic muscle contractions to hold it in place during activity. A
 2013 systematic review and meta-analysis of 23 small randomized trials found some evidence
that cones have increased efficacy over no active treatment, but inconclusive evidence that
they provide increased efficacy over standard pelvic floor muscle exercises [26]. Vaginal
weighted cones are available without a prescription and typically ordered online or from a
medical supply store.
Biofeedback Biofeedback as a supplement to pelvic muscle exercises is particularly useful
in women who are unable to properly isolate the pelvic floor or use accessory muscles during
pelvic floor contractions. This modality involves placement of a vaginal pressure sensor within
the vagina that measures pressure and provides an audible or visual feedback of strength of
pelvic floor contraction. Augmented versions also use abdominal and perineal
electromyography (EMG) recordings to demonstrate improper contraction of abdominal and
gluteal muscles. In the United States, biofeedback is covered by Medicare for patients who fail
an initial four-week trial of behavioral therapy.
A 2011 systematic review and meta-analysis of 17 randomized or quasi-randomized trials
found that compared with women who received pelvic floor muscle exercises alone, those that
also received biofeedback were more likely to report improvement or cure of urinary
incontinence (relative risk [RR] 0.75, 95% CI 0.66-0.86) [27].
Biofeedback can also be done using electrical stimulation. The device is placed in the vagina
or anus and provides a small electrical current that stimulates the pelvic floor muscles to
contract, aiding the patient in identification and isolation of the proper muscles. A 2012 review
of nine studies found that compared with sham stimulation, intravaginal electrical stimulation
improved continence rates for women with urgency, stress, or mixed incontinence [21].

Bladder training Bladder training is most effective for women with urgency incontinence [21].
Some women who have stress incontinence only at higher bladder volumes may also benefit from
the timed voiding component to keep bladder volumes below that where stress incontinence occurs.
Bladder training and pelvic muscle exercises are often used in combination.

Bladder training starts with timed voiding. Patients should keep a voiding diary to identify their
shortest voiding interval. They are then instructed to void by the clock at regular intervals using the
shortest interval between voids identified on their voiding diary as the initial voiding interval.
Urgency between voiding is controlled with either distraction or relaxation techniques (eg,
performing mental math, deep breathing, or by quick contractions of the pelvic floor muscles "quick
flicks") [4]. When the patient can go two days without leakage, the time between scheduled voids is
increased. The intervals are gradually increased until the patient is voiding every three to four hours
without urinary incontinence or frequent urgency. A sample patient bladder training instruction sheet
is shown (table 3). Successful bladder training can take up to six weeks. Patients often need
reassurance to proceed despite initial lack of response.

Patients should be encouraged to void regularly even when outside of the home. Websites that give
the locations of public restrooms are available for many major cities. Many such United States cities
can be found at: www.americanrestroom.org/locate/index.htm.

Topical vaginal estrogen We suggest a trial of vaginal estrogen therapy for peri- or
postmenopausal women with either stress or urgency incontinence and vaginal atrophy. Vaginal
atrophy can lead to symptoms of urinary frequency and dysuria and can contribute to incontinence.
Available preparations include creams, rings, and tablets as shown in the table (table 4). We use
Premarin or Estrace cream 0.5 mg twice weekly, Vagifem 10 mcg twice weekly, or the Estring. The
product choice is determined by patient preference and ease of use. (See "Treatment of vaginal
atrophy".)

It may take up to three months for patients to notice benefits from treatment.

Systemic absorption is low with the recommended doses. The use of vaginal estrogen in women
with a history of breast cancer is discussed separately. (See "Treatment of vaginal atrophy", section
on 'Systemic absorption' and "Treatment of vaginal atrophy", section on 'Treatment of women with
breast cancer'.)

A 2012 systematic review and meta-analysis of four randomized trials of postmenopausal women
found that vaginal estrogen was associated with improved incontinence (RR 0.74, 95% CI 0.64-
0.86) [28]. Three of the four trials were restricted to patients with stress incontinence, and statistical
heterogeneity between trials limit the confidence in the meta-analysis' conclusion.

We do not recommend systemic (oral hormone replacement therapy) estrogen therapy for urinary
incontinence. Evidence suggests that systematic hormone therapy may worsen urinary
incontinence [21,28,29]. (See "Menopausal hormone therapy: Benefits and risks", section on
'Urinary incontinence'.)

STRESS INCONTINENCE If initial treatments described above are not sufficient for patients with
stress incontinence, pessaries may be effective as a next step (algorithm 1). Patients without
adequate relief should be referred for additional treatment options.

Pessaries Continence pessaries may be used for women with stress incontinence as an
adjunct or substitute for pelvic muscle exercises. Overall success rates are approximately 50
percent [30]. We find them most useful for patients who have stress incontinence associated
with specific activities or situations (eg, exercise or transient cough in the setting of upper
respiratory infection). This treatment is discussed in detail separately. (See "Vaginal pessary
treatment of prolapse and incontinence", section on 'Treatment of urinary incontinence trials'.)
Pharmacologic therapy Multiple medications have been evaluated for stress incontinence
in women [31]. In the United States, no pharmacologic therapies have been approved by the
US Food and Drug Administration (FDA) for treatment of stress incontinence.
Duloxetine Duloxetine is a serotonin and norepinephrine reuptake inhibitor and may
be effective for incontinence. We do not routinely use duloxetine as treatment for stress
incontinence. However, if patients are already being treated for depression, it is
reasonable to discuss the option of duloxetine a primary treatment for depression given
this potential beneficial side effect.
Some studies have shown decreases in incontinence episode frequency compared with
placebo, and it is used in Europe for treatment of stress incontinence [32]. However, a
2012 systematic review of 24 studies (including six randomized trials) found
that duloxetine was not more effective than placebo for stress incontinence [21].
Other medications Alpha-adrenergic agonists (eg, phenylpropanolamine), which
stimulate urethral smooth muscle contraction, had been used previously for the
treatment of stress incontinence. They are no longer recommended because they are
only mildly efficacious compared with placebo and have a high rate of adverse effects
 [31,33]. There is insufficient evidence for the efficacy of imipramine in stress and mixed
incontinence and side effects are significant [33].
Mechanical devices Several devices have been developed over the years. They are
placed within the urethra or vagina to prevent urinary leakage. Their use is limited by their high
rates of urinary tract infections and lack of evidence regarding long-term safety and efficacy
[34].
Surgery Women without sufficient improvement with initial treatment and/or pessaries
should be evaluated for surgical therapy. Surgery offers high cure rates for stress urinary
incontinence (SUI), even in older women. A randomized trial comparing pelvic floor muscle
training with surgery found improved overall outcomes with surgery, with nearly 50 percent of
women assigned to conservative therapy crossing over to surgery [35]. (See"Surgical
management of stress urinary incontinence in women: Choosing a primary surgical
procedure", section on 'Women who decline or have persistent symptoms following
conservative therapy'.)
Other treatments Transurethral radiofrequency collagen denaturation has been proposed
as a minimally invasive device-based intervention to treat urinary incontinence. A systematic
review and meta-analysis was able to find only one trial of 173 women that assessed this
technology, and concluded that it was not known if radiofrequency denaturation improved
urinary incontinence symptoms because that outcome was not assessed [36]. In addition, the
meta-analysis concluded that there was insufficient evidence to determine if the procedure
improved disease-specific quality of life. An intravesical balloon device for the treatment of SUI
has shown efficacy and safety, and has been associated with improved quality of life and
satisfaction compared with a sham procedure [37]. Urethral bulking agent (UBA) therapy, also
known as periurethral injection therapy, is rarely used as a primary treatment for SUI, but
remains an option for women with persistent/recurrent SUI or women who are unable to
tolerate surgical procedure. (See "Stress urinary incontinence in women: Persistent/recurrent
symptoms after surgical treatment", section on 'Periurethral injection therapy'.)

URGENCY INCONTINENCE/OVERACTIVE BLADDER If initial treatment of urgency, urgency-

predominant mixed urinary incontinence, or overactive bladder (OAB) with incontinence is
ineffective, then we suggest a trial of pharmacologic therapy. Women who fail initial and
pharmacologic therapy should be referred to a specialist to consider other options (algorithm 1)
[38].

Pharmacologic therapy Antimuscarinics are appropriate for women with urgency incontinence
symptoms who do not experience enough improvement with initial treatments. For women who
cannot tolerate or do not have sufficient improvement on antimuscarinics, beta-adrenergic therapy
(mirabegron) may be an option. The combination of medication with behavioral therapy is more
effective than either alone, but must be balanced against costs and side effects [39]. We counsel
our patients to continue pelvic floor exercise and other behavioral therapies while initiating medical
treatment.

Antimuscarinics For women with urgency symptoms who have not had sufficient improvement
in their symptoms with initial treatment, we suggest a trial of antimuscarinics [17]. They are thought
to act primarily by increasing bladder capacity and decreasing urgency by blocking basal release of
acetylcholine during bladder filling [40].
Efficacy and administration Systematic reviews of randomized trials have found that
antimuscarinics have a modest benefit over placebo in reducing urgency incontinence, and rarely
resolve all symptoms [21,41,42]. There are six antimuscarinic agents available in different doses
and formulations: darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium (table
5). A seventh, propiverine, is used primarily in Asia. The efficacy of all the antimuscarinic agents is
thought to be similar [43]. The quick onset of action of the immediate-release preparations makes
them useful when continence is desired at specific times.

In our practice we attempt to tailor therapy with the risks and side effect profiles of each medication.
We start with the lowest dose and titrate up as needed after two weeks if the patient has insufficient
response and minimal side effects (table 5). We have patients follow up after four to six weeks to
assess response and determine if a change in medication is necessary. Improvement in symptoms
may take up to 4 weeks and it may take up to 12 weeks for medications to have full efficacy.
Clinicians should avoid prematurely declaring treatment failure. Efficacy across the various
formulations is similar and thus selection of the appropriate drug for an individual patient is primarily
dictated by side effect profile, tolerability, medical comorbidities, or more commonly by insurance
coverage. For most women, we are required to begin with generic therapies such
as oxybutynin immediate-release. (See 'Adverse drug effects' below.)

For patients who do not experience sufficient improvement in symptoms after an adequate trial with
a specific antimuscarinic, we assess for adherence to medication. Women with appropriate
compliance without sufficient improvement or who are unable to tolerate medications because of
side effects may benefit from a different antimuscarinic or change in class of medication
(eg, mirabegron) [38]. Patients may respond to one antimuscarinic and not another and side effect
profiles differ between antimuscarinics (table 5). The oxybutynin patch tends to have the fewest
side effects of dry mouth and constipation. (See 'Mirabegron' below.)

A postvoid residual should be checked in women at higher risk for urinary retention who are taking
an antimuscarinic. These include women who develop difficulty urinating or worsening urinary
incontinence symptoms while taking an antimuscarinic, who have advanced pelvic organ prolapse,
or who are taking other medications with anticholinergic effects. (See "Evaluation of women with
urinary incontinence", section on 'Clinical tests'.)

A 2012 systematic review including 72 randomized trials found that antimuscarinic medications
were more effective in improving urinary incontinence compared with placebo, but with low
magnitude of effect (table 6) [41]. Understanding of the comparative effectiveness and safety of the
antimuscarinic agents is limited by the lack of head-to-head trials between specific agents. Head-to-
head comparison trials consistently show that extended-release agents have lower rates of adverse
effects than immediate-release agents.

Adverse drug effects All antimuscarinics exert peripheral anticholinergic effects, which may
limit drug tolerability and dose escalation [41,44]. Anticholinergic effects include dry mouth,
constipation, blurred vision for near objects, tachycardia, drowsiness, and decreased cognitive
function. Antimuscarinics are contraindicated in patients with gastric retention and angle-closure
glaucoma. They have also been associated with dementia. (See"Angle-closure
glaucoma" and "Risk factors for cognitive decline and dementia", section on 'Toxin exposure'.)
In clinical trials, discontinuation of all antimuscarinics due to adverse effects was higher compared
with placebo [21,41]. Dry mouth was the most common reason for discontinuation [45]. Constipation
and compensatory fluid intake for dry mouth may exacerbate urinary incontinence.

Extended-release formulations may have fewer side effects and have lower rates of discontinuation
compared with immediate-release formulations [41].

Mirabegron Mirabegron is a beta3-adrenoceptor agonist that is available for treatment of OAB.

Mirabegron is an option for patients who do not tolerate antimuscarinic medications or have
contraindications to antimuscarinic medications (eg, narrow angle-closure glaucoma or taking
cholinesterase inhibitors). We also add it to antimuscarinics for combination therapy in patients with
persistent symptoms who cannot increase the antimuscarinic dose secondary to side effects or
dose limits.

Mirabegron is started at 25 mg daily with increases to 50 mg daily after two to four weeks if patients
are tolerating the drug, but have inadequate symptom control. In patients who are taking
mirabegron with an antimuscarinic, we monitor for urinary retention by measuring postvoid residual
at their follow-up visit in four to six weeks, or if new symptoms suggesting incomplete bladder
emptying arise (urinary hesitancy, incomplete emptying, worsening urinary incontinence, or
frequency).

Patients with severe or uncontrolled hypertension should not be prescribed mirabegron. While
clinical trials have not demonstrated significant increases in blood pressure compared with placebo,
patients can develop hypertension, and blood pressure should be monitored. In a pooled analysis of
668 persons aged 65 and older, treatment-emergent hypertension developed in 8.4 percent on
placebo, 13.6 percent on mirabegron 25 mg, and 10 percent on mirabegron 50 mg [46]. A meta-
analysis including 3511 patients of all ages across a range of doses found no other significant
treatment-emergent adverse effects, although there was a trend toward increased adverse events
secondary to cardiac arrhythmia (odds ratio [OR] 1.67, 95% CI 0.95-2.92) [47].

Pooled results and meta-analysis from phase III trials show that compared with
placebo, mirabegron decreases incontinence and urgency episodes [43,47,48]. Compared with
placebo, mirabegron decreased the mean number of incontinence episodes per 24-hour period by -
0.44 (95% CI -0.59 to -0.29) [47]. A systematic review by the British National Institute for Health and
Care Excellence concluded that the clinical effectiveness of mirabegron is similar to that of the
antimuscarinics, but has a different side effect profile, specifically less dry mouth and constipation
[49].

Third-line therapies Patients with persistent urgency incontinence symptoms despite an

adequate trial of initial treatments and pharmacotherapies, or an inability to tolerate pharmacologic
therapy, can be referred to a specialist to discuss further options for treatment. In general, we try at
least one or two pharmacotherapies prior to third-line therapies.

Third-line therapies include acupuncture, botulinum toxin injection, percutaneous tibial nerve
stimulation, and sacral neuromodulation (SNM) [38]. The decision of which third-line therapy to
pursue should be based on a detailed discussion with the patient regarding safety, efficacy, time
commitment, and insurance coverage for the various approaches.
 Acupuncture Acupuncture is used as an alternative therapy for patients who prefer a
complementary medicine approach to treatment of urinary incontinence, but there is
insufficient evidence to support general use of this therapy [50,51]. For urgency and mixed
incontinence, initial pilot studies of using acupuncture have shown some positive short-term
improvements in quality of life measures and reduction in urinary frequency [52,53].
Botulinum toxin For women with urgency or urgency-predominant mixed incontinence
who do not respond to or cannot tolerate pharmacotherapy, injection of botulinum toxin into
the detrusor muscle is an option. A randomized trial in 247 women comparing oral
antimuscarinic therapy withonabotulinumtoxinA injection found similar reductions in the
frequency of daily episodes of urgency incontinence [54]. The onabotulinumtoxinA group was
less likely to have dry mouth and more likely to have complete resolution of incontinence but
had higher rates of transient urinary retention and urinary tract infection. (See "Use of
botulinum toxin for treatment of non-neurogenic lower urinary tract conditions".)
Percutaneous tibial nerve stimulation Percutaneous stimulation of the tibial nerve
(PTNS) may have some benefit for women with detrusor overactivity [38,55]. Methods include
placement of an acupuncture needle medially behind the ankle with electrical stimulation
administered for 30 minutes. These sessions occur once a week for 12 weeks followed by
maintenance therapy of approximately once a month if the patient desires.
A 2015 review of nine studies evaluating PTNS concluded that there was evidence of benefit,
though the available studies were small (60 patients) and most studies reported short-term
outcomes at 12 weeks [38]. In the single randomized trial, PTNS was compared to a sham
procedure in 35 women who did not respond to antimuscarinic therapy [55]. While no women
in the sham procedure group improved, 71 percent of women in the PTNS group improved.
Sacral neuromodulation SNM is a minimally invasive option for treatment for OAB
symptoms, following failure of initial interventions and pharmacotherapy [38,56]. SNM involves
placement of a wire lead into the S3 foramen that is connected to a stimulation device.
The procedure includes a test phase and a second implantation phase. The test phase can be
done with a percutaneous trial where a temporary lead is placed usually bilaterally. However,
due to high rates of migration of the percutaneous wires and failed test phases with this
technique, we prefer a staged approach in which a permanent lead wire is placed into one (or,
rarely, both) S3 foramina and tunneled under the skin to connect to a temporary stimulation
device. For the test phase, patients are asked to maintain voiding diaries to document their
urinary urgency, frequency, and leakage severity at baseline for three days and then daily
during the trial. If a greater than a 50 percent improvement in any of these parameters is
confirmed over a two-week trial, the patient can elect to undergo a permanent implantation
with a pacemaker-like stimulator placed under the skin of the upper buttock. If the test phase
is unsuccessful, then the lead is removed.
A 2015 review of 16 studies concluded that there was evidence of benefit for SNM in some
patients but noted that patients had frequent adverse events, including need for subsequent
surgeries [38]. In one randomized trial of 147 patients (93 percent female) with OAB, patients
who had SNM were more likely to have improved or greatly improved urinary symptoms at six
months than those who had standard medical therapy (86 percent versus 44 percent) [57].

Surgery Patients who fail other therapies should be evaluated by a urologic specialist to discuss
surgical options. These may include augmentation cystoplasty, urinary diversion, or placement of a
suprapubic catheter. (See "Stress urinary incontinence in women: Persistent/recurrent symptoms
after surgical treatment", section on 'Urinary diversion'.)

MIXED INCONTINENCE For women with mixed urinary incontinence, we start with lifestyle
modifications, pelvic floor muscle exercises, and bladder training [58]. A systematic review of five
randomized trials found that a combination of pelvic floor exercises and bladder training improves
symptoms [21]. (See 'Initial treatment' above.)

If initial treatments above are not effective, women are then treated based on their predominant
symptoms (stress or urgency). While there are little data evaluating antimuscarinics in patients with
mixed incontinence, those with urgency-predominant symptoms are treated similarly as those with
pure urgency incontinence [59]. (See 'Urgency incontinence/overactive bladder' above.)

For women with SUI-predominant symptoms, we offer surgical treatment, typically with a mid-
urethral sling. SUI surgery can result in improvement in overactive bladder symptoms in some
women, but may also worsen them. Thus, careful counseling regarding expectations of treatment is
imperative. We counsel women that surgical success rates are slightly lower in women with mixed
incontinence compared with women with pure SUI. As there is no data-proven optimum treatment
order or combination, the patient and clinician weigh the risks of the various therapies, including the
time and cost of behavioral therapy, the need for long-term use and possible side effects of
medication, and risks of surgery. (See "Surgical management of stress urinary incontinence in
women: Choosing a primary surgical procedure", section on 'Mixed incontinence'.)

OVERFLOW INCONTINENCE Overflow incontinence can present with a variety of symptoms

including involuntary, intermittent, or continuous urinary leakage with no warning or sensation
dribbling, and incomplete bladder emptying. Treatment of urinary incontinence associated with
impaired bladder emptying depends upon the etiology.

Bladder outlet obstruction Women with bladder outlet obstruction from previous vaginal
or urethral surgery are referred to a surgical specialist for further evaluation. Obstruction from
a large cystocele or uterine prolapse can be treated with a pessary or surgically. (See "Pelvic
organ prolapse in women: An overview of the epidemiology, risk factors, clinical
manifestations, and management", section on 'Approach to management' and "Vaginal
pessary treatment of prolapse and incontinence".)
Detrusor underactivity Specific treatment for patients with detrusor underactivity is
limited. Potentially-reversible causes of impaired emptying should be addressed, such as
stopping medications that impair detrusor contractility (table 2) or increasing urethral tone and
treating constipation.
Sacral nerve stimulation may be beneficial for patients with idiopathic or neurogenic
underactivity. In the United States, it is approved for the treatment of nonobstructive urinary
retention. Success rates in general are not as promising as for urgency urinary incontinence
and overactive bladder (OAB), but it is reasonable to try prior to more invasive and permanent
solutions [60,61]. (See 'Third-line therapies' above.)
Clean intermittent catheterization may be used to manage overflow incontinence due to
detrusor underactivity. (See "Placement and management of urinary bladder catheters",
section on 'Clean intermittent catheterization'.)
Chronic urinary retention When there is chronic partial urinary retention (eg, from prior
spinal cord injury), clean intermittent catheterization may be used alone or in conjunction with
 the above approaches. (See "Chronic complications of spinal cord injury and disease", section
on 'Bladder dysfunction' and "Placement and management of urinary bladder catheters",
section on 'Clean intermittent catheterization'.)

Patients who fail other therapies should be evaluated by a urologic specialist to discuss surgical
options. These may include augmentation cystoplasty, urinary diversion, or placement of a
suprapubic catheter. (See "Stress urinary incontinence in women: Persistent/recurrent symptoms
after surgical treatment", section on 'Urinary diversion'.)

SPECIAL POPULATIONS When beginning initial treatment for urinary incontinence, special
consideration needs to be given to pregnant women or those with cognitive impairment or
neurologic disease.

Pregnant women The management of pregnant women with urinary incontinence is discussed
in detail elsewhere. (See "Urinary incontinence and pelvic organ prolapse associated with
pregnancy and childbirth", section on 'Symptom management during pregnancy'.)

Cognitive impairment When managing incontinence in adults with cognitive impairment, it

should not be assumed that the cognitive impairment is the only cause of incontinence. Other
factors (eg, functional impairment, comorbid conditions, and medications) should also be
investigated and treated. Goals of care and treatment preference discussions should include the
needs and wishes of the caregivers who will oversee or implement treatment [62].
Nonpharmacological approaches (eg, prompted voiding, scheduling toileting) are preferred in
persons with dementia because these individuals are particularly vulnerable to adverse effects of
antimuscarinic agents. Pharmacotherapies should be used with caution as these women may
experience more side effects [38]. (See "Evaluation of women with urinary incontinence", section on
'Evaluation' and "Medical care in skilled nursing facilities (SNFs) in the United States", section on
'Incontinence'.)

Neurologic disease Adults with specific neurologic diseases (eg, multiple sclerosis, spinal cord
injury, Parkinson's disease) often have associated bladder or sphincter impairment. The treatment
of urinary incontinence in adults with neurologic disease is discussed separately. (See "Symptom
management of multiple sclerosis in adults", section on 'Sphincter dysfunction' and "Chronic
complications of spinal cord injury and disease", section on 'Urinary complications'.)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The
Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language,
at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)
 Basics topics (see "Patient information: Urinary incontinence (The Basics)" and "Patient
information: Pelvic muscle (Kegel) exercises (The Basics)"and "Patient information:
Neurogenic bladder in adults (The Basics)" and "Patient information: Surgery to treat stress
urinary incontinence in women (The Basics)" and "Patient information: Treatments for urgency
incontinence in women (The Basics)")
Beyond the Basics topics (see "Patient information: Urinary incontinence in women (Beyond
the Basics)" and "Patient information: Urinary incontinence treatments for women (Beyond the
Basics)" and "Patient information: Pelvic floor muscle exercises (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Patients with concerning symptoms on presentation (eg, sudden onset of incontinence or

associated abdominal/pelvic pain or hematuria in the absence of infection) should be
evaluated and/or referred for evaluation of underlying systemic conditions (algorithm 1).
(See 'Identify indications for referral' above.)
Determining the classification of urinary incontinence type (stress, urgency, mixed) can help
direct treatment (algorithm 1). Having a baseline assessment of symptoms (eg, voiding diary,
quality of life measures) can facilitate assessment of treatment efficacy. (See "Evaluation of
women with urinary incontinence", section on 'History'.)
Before starting any treatment for urinary incontinence, contributory factors such as medical
conditions and medications (table 2) should be addressed. (See 'Modifying contributory
factors' above.)
Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all
patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in
women with urgency incontinence. (See 'Initial treatment' above.)
We suggest that women be instructed to perform pelvic muscle (Kegel) exercises
(Grade 2A). (See 'Pelvic floor muscle exercises (Kegel exercises)' above.)
Bladder training is most effective for women with urgency incontinence. Some women
who have stress incontinence only at higher bladder volumes may also benefit from the
timed voiding component to keep bladder volumes below that where stress incontinence
occurs. (See'Bladder training' above.)
We typically treat initially for six weeks before considering subsequent therapies.
(See 'Initial treatment' above.)
In peri- or postmenopausal women with vaginal atrophy and either stress or urgency
incontinence, we suggest topical vaginal estrogen (table 4) (Grade 2C).
For women with stress incontinence with incomplete efficacy with lifestyle modification and
pelvic floor muscle training, pessaries are offered, particularly to patients who have
incontinence with particular activities. Patients without adequate relief should be referred to
consider other options. (See 'Stress incontinence' above.)
If initial treatment of urgency, urgency-predominant mixed urinary incontinence, or overactive
bladder (OAB) with incontinence is ineffective, then we suggest a trial of pharmacologic
therapy with an antimuscarinic (table 5) (Grade 2B). (See 'Antimuscarinics' above.)
For women with an insufficient response to or who cannot tolerate antimuscarinic therapy, we
consider mirabegron as an option.
 Women who fail initial and pharmacologic therapy require referral to a specialist to consider
third-line options. (See 'Pharmacologic therapy' above and 'Third-line therapies' above
and 'Surgery' above.)
Treatment of mixed urinary incontinence should begin with lifestyle modification and pelvic
floor muscle training. Subsequent therapy should be focused first on alleviation of symptoms
causing most degree of bother. While surgical treatment of stress symptoms may improve
urgency symptoms, surgery should not be considered as a primary treatment for refractory
urge incontinence.
Treatment of overflow incontinence is specific to the etiology. (See 'Overflow
incontinence' above.)
When beginning initial treatment for urinary incontinence, special consideration needs to be
given to pregnant women, those with cognitive impairment, or neurologic disease.
(See 'Special populations' above.)

ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge Catherine E

DuBeau, MD, who contributed to an earlier version of this topic review.