Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

stress incontinence

1st line – behavioral approaches plus lifestyle changes

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ONGOING
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stress incontinence
1st line – 

behavioral approaches plus lifestyle changes

Behavioral techniques are offered to motivated patients who do not want surgery or do not want to become dependent on drugs and external devices. Lifestyle interventions, pelvic muscle exercises (Kegel exercises), vaginal devices, biofeedback, and functional electrical stimulation can be used.​[1][75][82]

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.[11]​​​[33]​​[75][76]​​[79]

Vaginal devices, such as pessaries and tampons, mechanically support the bladder neck without hindering pelvic floor function. However, data to support mechanical devices are inconclusive.​[87]

Pelvic muscle exercises strengthen the voluntary periurethral and paravaginal muscles.[85]

Adjuncts to pelvic muscle exercises include biofeedback and functional electrical stimulation.[75]​​

Consider – pharmacotherapy

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ONGOING
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stress incontinence
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with urethral sphincter insufficiency
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Pharmacotherapy is less effective than behavioral treatments in stress incontinence and not routinely recommended.[81][82]​​​

In stress incontinence caused by urethral sphincter insufficiency, treatment with an alpha-blocker (e.g., pseudoephedrine), may be considered if there are no contraindications.[92]​

Duloxetine, although not approved by the Food and Drug Administration (FDA) for stress incontinence therapy in the US, has been widely studied and used in other countries.[130]

Primary options

pseudoephedrine: 15-50 mg orally three times daily

Secondary options

duloxetine: 40 mg orally twice daily

Consider – vaginal estrogen

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ONGOING
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stress incontinence
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with urethral sphincter insufficiency
Consider – 

vaginal estrogen

Treatment recommended for SOME patients in selected patient group

Vaginal estrogen in the form of a cream, vaginal tablets, or a vaginal ring can be used to supply local estrogen to poorly estrogenized vaginal and urethral tissue in postmenopausal patients.[84][95]

Primary options

estrogens, conjugated vaginal: 0.625 mg/g cream) insert 0.5 to 2 g into the vagina once daily for 21 days, followed by no treatment for 7 days, then repeat; or insert 0.5 g into the vagina twice weekly

OR

estradiol vaginal: (intravaginal tablets) 10 micrograms (1 tablet) into the vagina once daily for 2 weeks, followed by 10 micrograms (1 tablet) twice weekly thereafter; (intravaginal ring) 1 ring (7.5 micrograms/24 hours or 50-100 micrograms/24 hours) inserted into the vagina and replaced every 3 months, dose depends on brand used; (0.01% or 100 micrograms/g cream) insert 2-4 g (200-400 micrograms) into the vagina once daily for 1-2 weeks, then taper dose gradually over 1-2 weeks to maintenance dose of 1 g (100 micrograms) once to three times weekly

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Consider – periurethral bulking injection

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ONGOING
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stress incontinence
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with urethral sphincter insufficiency
Consider – 

periurethral bulking injection

Treatment recommended for SOME patients in selected patient group

Periurethral bulking agents are used to treat a urethra with poor sphincteric support.

Indicated if conservative treatment fails, if the patient requests more definitive therapy, or in patients who are poor surgical candidates.[96]

Several materials are available, including silicon microparticles (Macroplastique), polyacrylamide hydrogel (Bulkamid), carbon-coated beads (Durasphere), or calcium hydroxyapatite in a gel medium (Coaptite).[132]​ The urethral bulking agents are injected transurethrally or periurethrally in periurethral tissue at the bladder neck and proximal urethra. 

Consider – surgery

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ONGOING
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stress incontinence
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with urethral hypermobility or displacement
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

If the primary defect is urethral hypermobility or displacement, then sling procedures, including retropubic, transobturator, or single-incision slings (also known as mini-slings), and retropubic suspension (e.g., Burch colposuspension) can be performed.​​​​

Retropubic colposuspension (Burch colposuspension) stabilizes the anterior vaginal wall, bladder neck, and proximal urethra in a retropubic position. This prevents their descent and allows for urethral compression against a stable suburethral layer.

In midurethral sling procedures, a thin strip of polypropylene mesh is placed at the mid urethra to compensate for inefficiency of the pubourethral ligaments.[99]

Various sling types are available, including retropubic and transobturator midurethral slings and the single-incision sling (mini-sling). At 12 months postoperatively, retropubic and transobturator midurethral slings appear equivalent in efficacy.[102] Transobturator slings, however, should be used cautiously in women with intrinsic sphincter deficiency.[133]

Slings were found to be more effective than colposuspension and bulking agents.[110]

Alternatives to polypropylene mesh include autograph and allograph fascial slings. The fascial sling can be used in patients with prior polypropylene mesh failures, mesh complications, or in patients who decline mesh products.[110] The fascial sling is seen as less favorable by some surgeons due to the associated morbidity.[110]​

Placement of midurethral slings in women with concomitant stress incontinence and prolapse is also of importance. These women have less symptomatic stress incontinence after prolapse repair when a concomitant midurethral sling is performed. For example, one study found that 17% of women who underwent prolapse repair needed an additional sling.[109]

urgency incontinence

1st line – behavioral approaches plus lifestyle changes

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ONGOING
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urgency incontinence
1st line – 

behavioral approaches plus lifestyle changes

Behavioral approaches suitable for women with urgency incontinence include bladder retraining and prompted voiding.[63][82]​ Pelvic muscle exercises can be combined with bladder training.[82][85]​​​ Bladder training (bladder drills/timed voiding) involves techniques to distend the bladder (e.g., by adjusting fluid intake) or delay voiding.[75]​ Prompted voiding teaches patients to initiate micturition themselves.​

Electrical stimulation can be used together with pelvic floor exercises.[75]​ This technique is performed twice daily and is delivered via a probe placed vaginally or rectally. Electrical stimulation may be as beneficial as pelvic floor therapy and some pharmacotherapies, and can be used in conjunction with other therapies.[90]

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.​​​[11][33][75][76][79]​​

2nd line – pharmacotherapy

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ONGOING
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urgency incontinence
2nd line – 

pharmacotherapy

Pharmacotherapy may improve detrusor overactivity by inhibiting the contractile activity of the bladder. Drugs used include anticholinergics and beta-3-adrenergic receptor agonists.

Anticholinergics are the most frequently prescribed drug for urgency incontinence. They act by blocking muscarinic receptors on the detrusor muscle, which are stimulated by acetylcholine. Mirabegron, a beta-3-adrenoceptor agonist, has shown significant reductions in incontinence and micturations compared with placebo, without anticholinergic adverse effects.[112]​ Further data suggest that mirabegron has better long-term adherence, up to 38% at one year, compared with anticholinergics.[113][114]​​​​​​ Vibegron, another beta-3-adrenoceptor agonist, has increased efficacy when compared to mirabegron.[115]​

For patients with overactive bladder (detrusor overactivity), a beta-3 agonist (e.g., mirabegron, vibegron) or an anticholinergic (e.g., oral oxybutynin, tolterodine, darifenacin, solifenacin, trospium, fesoterodine) is the primary treatment option.[7][60]​​[116]​​​​​​​​[115]​​​​​​ If these treatments are ineffective, transdermal oxybutynin may be used.[117][118]​​​​​​

Caution is recommended when using anticholinergics in older or frail patients, and use should be avoided in patients with dementia, cognitive impairment, or delirium.[119][120][121]​​​ Anticholinergics should also only be used with extreme caution in patients who have narrow angle glaucoma, impaired gastric emptying or a history of urinary retention.[60]​ Oxybutynin is of particular concern, as it has a higher incidence of adverse effects than other anticholinergics.[63] For these reasons, some experts have recommended a trial of a beta-3 agonist before using anticholinergics in patients with overactive bladder.[122]

Primary options

oxybutynin: 2.5 to 5 mg orally (immediate-release) twice to three times daily, increase according to response, maximum 20 mg/day; 5 mg orally (extended-release) once daily, increase according to response, maximum 30 mg/day

OR

tolterodine: 1-2 mg orally (immediate-release) twice daily; 2-4 mg orally (extended-release) once daily

OR

darifenacin: 7.5 to 15 mg orally (extended-release) once daily

OR

solifenacin: 5-10 mg orally once daily

OR

trospium: 20 mg orally (immediate-release) twice daily; 60 mg orally (extended-release) once daily

OR

fesoterodine: 4-8 mg orally (extended-release) once daily

OR

mirabegron: 25-50 mg orally once daily

OR

vibegron: 75 mg orally once daily

Secondary options

oxybutynin transdermal: apply 1 patch (3.9 mg/day) twice weekly

OR

oxybutynin topical: gel (3%): apply 3 pumps (84 mg) to skin once daily; gel (10%): apply 1 pack (100 mg) to skin once daily

Plus – behavioral approaches plus lifestyle changes

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ONGOING
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urgency incontinence
Plus – 

behavioral approaches plus lifestyle changes

Treatment recommended for ALL patients in selected patient group

When used in combination with drug therapy, behavioral therapy has been shown to improve results by decreasing the frequency of urgency-incontinence events.​[80][81]

Behavioral approaches suitable for women with urgency incontinence include bladder retraining and prompted voiding.[63][82]​ Pelvic muscle exercises can be combined with bladder training.[82][85]​​​ Bladder training (bladder drills/timed voiding) involves techniques to distend the bladder (e.g., by adjusting fluid intake) or delay voiding.[75]​​ Prompted voiding teaches patients to initiate micturition themselves.​

Electrical stimulation can be used together with pelvic floor exercises.[75]​ This technique is performed twice daily and is delivered via a probe placed vaginally or rectally. Electrical stimulation may be as beneficial as pelvic floor therapy and some pharmacotherapies, and can be used in conjunction with other therapies.[90]

Anticholinergic therapy in combination with electrical stimulation or bladder training can significantly reduce frequency of urination.[91]

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.​​​[11][33][75][76][79]​​

3rd line – neuromodulation

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ONGOING
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urgency incontinence
3rd line – 

neuromodulation

Neuromodulation is used in the management of overactive bladder (detrusor overactivity) refractory to pharmacotherapy.[60][123]​​​

It can be delivered percutaneously to target the afferent input of the posterior tibial nerve, or via the sacral nerve directly (e.g., sacral nerve modulation).[60]

A 56% to 71% improvement in symptoms (urgency, frequency, incontinence) has been maintained for 5 years following sacral nerve neuromodulation.[126]

Tibial nerve neuromodulation has been shown to be 71% successful in patients completing 12 weeks of treatment and 77% effective at 3 years.[124][125][134]

Plus – behavioral approaches plus lifestyle changes

Back
ONGOING
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urgency incontinence
Plus – 

behavioral approaches plus lifestyle changes

Treatment recommended for ALL patients in selected patient group

Neuromodulation combined with behavioral therapy was found to be more effective than no treatment according to one study.[81]

Behavioral approaches suitable for women with urgency incontinence include bladder retraining and prompted voiding.[63][82]​​ Pelvic muscle exercises can be combined with bladder training.​[82][85]​​​ Bladder training (bladder drills/timed voiding) involves techniques to distend the bladder (e.g., by adjusting fluid intake) or delay voiding.[75]​ Prompted voiding teaches patients to initiate micturition themselves.​

Electrical stimulation can be used together with pelvic floor exercises.[75]​ This technique is performed twice daily and is delivered via a probe placed vaginally or rectally. Electrical stimulation may be as beneficial as pelvic floor therapy and some pharmacotherapies, and can be used in conjunction with other therapies.[90]

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.​​​[11][33][75]​​[76]​​[79]

3rd line – onabotulinumtoxinA

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ONGOING
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urgency incontinence
3rd line – 

onabotulinumtoxinA

OnabotulinumtoxinA (botulinum toxin type A) may be considered as an alternative to neuromodulation if pharmacotherapy is unsuccessful.[60]

Injection of onabotulinumtoxinA into the bladder wall has been shown to be effective in the management of overactive bladder (detrusor overactivity) and significantly decreases the number of episodes of urge incontinence.[127]​ 

Patients who failed one or more anticholinergics have been successfully treated with onabotulinumtoxinA.[128] However, use of onabotulinumtoxinA has higher rates of urinary retention and urinary tract infection compared with anticholinergics.[135]

Compared with sacral neuromodulation, onabotulinumtoxinA had a statistical decrease in the number of incontinence episodes; however, the clinical significance of these results have yet to be determined.[129]

Primary options

onabotulinumtoxinA: consult specialist for guidance on dose

Plus – behavioral approaches plus lifestyle changes

Back
ONGOING
|
urgency incontinence
Plus – 

behavioral approaches plus lifestyle changes

Treatment recommended for ALL patients in selected patient group

Behavioral treatments approaches suitable for women with urgency incontinence include bladder retraining and prompted voiding.[63][82]​ Pelvic muscle exercises can be combined with bladder training.[82][85]​​​ Bladder training (bladder drills/timed voiding) involves techniques to distend the bladder (e.g., by adjusting fluid intake) or delay voiding.[75]​ Prompted voiding teaches patients to initiate micturition themselves.​

Electrical stimulation can be used together with pelvic floor exercises.[75]​ This technique is performed twice daily and is delivered via a probe placed vaginally or rectally. Electrical stimulation may be as beneficial as pelvic floor therapy and some pharmacotherapies, and can be used in conjunction with other therapies.[90]

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.​​​[11][33][75][76][79]​​​

mixed incontinence

1st line – behavioral approaches plus lifestyle changes

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ONGOING
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mixed incontinence
|
stress incontinence predominant
1st line – 

behavioral approaches plus lifestyle changes

Treatment for mixed urinary incontinence begins with conservative management directed toward the most bothersome component of the symptom spectrum and progresses to more invasive therapy if required.[77][78]​

Conservative approaches include lifestyle interventions, pelvic muscle exercises (Kegel exercises), vaginal devices, biofeedback, and functional electrical stimulation.[1]​​[75][82] [ Cochrane Clinical Answers logo ]

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.[11]​​​​[33][75][76][79]​​​

Vaginal devices, such as pessaries and tampons, mechanically support the bladder neck without hindering pelvic floor function.[86]​ However, data to support mechanical devices are inconclusive.​[87]

Pelvic muscle exercises strengthen the voluntary periurethral and paravaginal muscles.[85]

Adjuncts to pelvic muscle exercises include biofeedback and functional electrical stimulation.[75]​​

Consider – pharmacotherapy or surgical procedure

Back
ONGOING
|
mixed incontinence
|
stress incontinence predominant
Consider – 

pharmacotherapy or surgical procedure

Treatment recommended for SOME patients in selected patient group

If symptoms persist, women with stress-predominant incontinence may first consider less invasive options, such as medical therapy (including drugs for an overactive bladder) or a continence pessary, before proceeding to urethral bulking agents or surgery.[78]

1st line – behavioral approaches plus lifestyle changes

Back
ONGOING
|
mixed incontinence
|
urgency incontinence predominant
1st line – 

behavioral approaches plus lifestyle changes

Treatment for mixed urinary incontinence begins with conservative management directed toward the most bothersome component of the symptom spectrum and progresses to more invasive therapy if required.[77][78]​

Behavioral approaches suitable for women with urgency incontinence include bladder retraining and prompted voiding.[63][82]​ Pelvic muscle exercises can be combined with bladder training.[82][85]​​​ Bladder training (bladder drills/timed voiding) involves techniques to distend the bladder (e.g., by adjusting fluid intake) or delay voiding.[75]​ Prompted voiding teaches patients to initiate micturition themselves.​

Electrical stimulation can be used together with pelvic floor exercises.[75]​ This technique is performed twice daily and is delivered via a probe placed vaginally or rectally. Electrical stimulation may be as beneficial as pelvic floor therapy and some pharmacotherapies, and can be used in conjunction with other therapies.[90]

Lifestyle interventions include weight loss in women with a BMI over 25, caffeine reduction, fluid management, reduction of physical exertion (e.g., exercise), smoking cessation, and resolution of chronic constipation.[11]​​​​[33][75][76][79]​​​

Consider – pharmacotherapy or neuromodulation or onabotulinumtoxinA

Back
ONGOING
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mixed incontinence
|
urgency incontinence predominant
Consider – 

pharmacotherapy or neuromodulation or onabotulinumtoxinA

Treatment recommended for SOME patients in selected patient group

If symptoms persist, women with urgency-predominant incontinence (or equal urge and stress incontinence) should first try medical therapy, including drugs for overactive bladder and vaginal estrogen (if postmenopausal), and then consider more intrusive procedures such as neuromodulation, botulinum toxin, or both.[78]​ Surgery is only considered in carefully selected women with urgency predominated incontinence.[78]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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