Therapy target
Restoration of urinary continence or improvement of quality of life.
Therapy recommendations
Therapy recommendations are based on the type of urinary incontinence:
- Overactive bladder (OAB), urge incontinence, urge symptoms:
- SS-3 mimetic: mirabegron (first-line therapy for OAB; level I evidence/recommendation grade A [guidelines: 3]).
- Anticholinergics/antimuscarinics, if appropriate.
- If necessary, also botulinum toxin (onabotulinum toxin A; dosage: 100 IU) as injection treatment (second-line therapy).
- In addition, if necessary, treatment with: Imipramine (tricyclic antidepressant).
- In postmenopause; treatment with estrogen-containing hormone replacement therapy (only local application!).
- Stress incontinence (formerly stress incontinence):
- Vaginal estrogen therapy may improve urinary incontinence in postmenopausal women [S3 guideline].
- For mild to moderate female stress incontinence, duloxetine (Selective Serotonin–Norepinephrine Reuptake Inhibitors, SSNRI) (see “Further guidance” below).
- Obstructive overflow incontinence: treatment with: Alpha-sympathomimetics
- Chronic urinary retention: cholinergics/parasympathomimetics.
- Overflow incontinence in detrusor hypotonia, detrusor atonia; treatment with: Cholinesterase inhibitor, parasympaticomimetic (direct).
- All forms of incontinence (in geriatric patients): desmopressin (DDAVP).
- See also under “Other therapy.”
Further notes
- According to the latest Cochrane review, local estrogen therapy may improve incontinence in women (risk ratio [RR] 0.74; 95% confidence interval [95%-CI] 0.64-0.86).
- Estrogens lead to improvement in the deteriorating physiologic processes at the urinary bladder (especially in overactive bladder); unlike stress incontinence, cure is possible.
- An improvement or cure of urinary incontinence by local estriol therapy has not yet been demonstrated.
- Patients should be informed before systemic estrogen therapy/estrogen-progestin therapy that it may lead to the occurrence or worsening of urinary incontinence [S3 guideline].
- According to a meta-analysis, the benefits of duloxetine for stress incontinence do not outweigh the harms. Furthermore, many patients would have unpleasant experiences under this medication, which could promote acts of violence or suicide.
- In dementia patients with overactive bladder, selective antimuscarinic agents (taking solifenacin in 95% of cases) showed 40% lower mortality compared with nonselective agents (oxybutynin; tolterodine).
Note: If symptom control is inadequate, consider combining an anticholinergic with mirabegron over invasive therapy [guidelines: 3].
