Urinary Incontinence in Adults

Clinical Snapshot

Urinary incontinence (UI) is the complaint of involuntary leakage of urine — a symptom, not a single diagnosis.^[1] The four principal mechanisms are stress incontinence (urethral sphincter incompetence overwhelmed by increased intra-abdominal pressure), urgency incontinence (detrusor overactivity, usually as part of overactive bladder syndrome), overflow incontinence (chronic urinary retention from a noncontractile bladder or bladder outlet obstruction, with dribbling and leakage from an overdistended bladder), and functional incontinence (a normal lower urinary tract, but leakage from an inability to reach or use the toilet in time because of mobility, cognitive, or environmental barriers). Mixed incontinence combines stress and urgency features. Correctly identifying which mechanism (or combination) is driving a given patient's leakage is the single most important step in management, because the treatments are not interchangeable — an antimuscarinic that helps urgency incontinence can actively worsen overflow incontinence, and pelvic floor muscle training that is first-line for stress incontinence does little for urgency incontinence. Never start empiric drug therapy for incontinence without first establishing which type is present.

Recognize the Condition

Urinary incontinence is diagnosed by taking a focused history — no single physical finding or lab test "makes" the diagnosis. A validated screening tool such as the 3-question incontinence questionnaire (3IQ) efficiently distinguishes stress-predominant, urgency-predominant, and mixed incontinence in a primary care or pharmacy setting: (1) has the patient leaked urine in the last 3 months; (2) did leakage occur with physical activity, with urgency, with neither, or with both about equally; (3) which pattern occurs most often.^[1] The presentation of each type is distinct enough to guide an initial working diagnosis before any testing is done.

The 5 mechanisms of urinary incontinence

Stress incontinence

Leakage of typically small volumes triggered by increased intra-abdominal pressure — coughing, sneezing, laughing, lifting, or exercise. Results from urethral sphincter incompetence, most often from weakened pelvic floor muscles causing urethral and bladder-neck mobility. The most common type overall, and the type most clearly amenable to first-line non-pharmacologic treatment.

Urgency incontinence (overactive bladder)

Leakage of moderate-to-large volumes associated with a sudden, compelling urge to void that cannot be deferred long enough to reach a toilet. Caused by detrusor overactivity or instability, often as part of overactive bladder (OAB) syndrome; some patients with OAB have urgency without incontinence. CNS disorders (parkinsonism, stroke, spinal cord injury, multiple sclerosis) are recognized causes.

Mixed incontinence

Features of both stress and urgency incontinence in the same patient. Treat the predominant (more bothersome) symptom first rather than trying to address both mechanisms simultaneously from the outset.

Overflow incontinence

Frequent dribbling, hesitancy, and poor urine flow from a chronically overdistended bladder (chronic urinary retention). Caused by detrusor underactivity (an "underactive bladder," including neurogenic bladder from diabetes or stroke) or bladder outlet obstruction (most often benign prostatic hyperplasia in men). Most common in men. Anticholinergic/antimuscarinic and other bladder-relaxing medications can precipitate or worsen overflow incontinence and must not be used to treat it — see Red Flags and Choose Initial Treatment.

Functional incontinence

Leakage caused by an inability to reach or use the toilet in time, with a normal lower urinary tract. Drivers include restricted mobility, dexterity limitations (difficulty removing clothing), cognitive impairment (dementia, delirium), depression, and environmental barriers (toilet access, lighting, positioning). Management targets the underlying functional, cognitive, or environmental barrier rather than the bladder itself.

Risk Factors

Caffeine intake.
Fluid intake — both inadequate and excessive matter; a total daily intake of roughly 1.5-2 L/day is generally appropriate.
Limited physical activity.
Restricted mobility or environmental challenges, including dexterity in removing clothing and accessibility of toilets.
Smoking.
Benign prostatic hyperplasia.
Bowel problems — constipation or fecal impaction.
Poorly controlled diabetes mellitus.
Lower urinary tract conditions — urinary tract infection, urogenital atrophy.
Obesity, particularly abdominal obesity.
Obstructive sleep apnea.
Cognitive impairment or delirium (contributes to functional incontinence specifically).
Prior pelvic surgery, pelvic radiation, or an obstetric injury (particularly with forceps use, a prolonged second stage, or delivery of a larger infant) — risk factors for stress incontinence via sphincter or pelvic floor injury.

Medications that can cause or worsen incontinence

A focused medication review is one of the highest-yield steps in assessing any patient with new or worsening incontinence — reversing a contributing drug is often more effective, and always safer, than starting a new one.

Drug class (examples)	Type of incontinence worsened	Mechanism / note
Alpha-adrenergic antagonists (e.g., terazosin and other alpha-blockers)	Stress	Relax the urethral sphincter/bladder neck.
Diuretics, including loop diuretics and SGLT2 inhibitors	Stress (and can unmask urgency or overflow through increased urine volume/frequency)	Increase bladder filling rate and volume.
Corticosteroids (e.g., prednisone)	Stress	Fluid retention and tissue effects.
Sympatholytics (e.g., clonidine)	Stress	Reduce urethral sphincter tone.
Acetylcholinesterase inhibitors (e.g., donepezil)	Urgency	Increase detrusor contractility.
Bladder irritants (e.g., ketamine; caffeine as a non-prescription example)	Urgency	Direct bladder irritation.
Alpha-adrenergic agonists (e.g., decongestants such as phenylephrine or pseudoephedrine)	Overflow	Increase urethral sphincter/bladder outlet resistance, impairing bladder emptying.
Anticholinergics/antimuscarinics (e.g., dimenhydrinate, first-generation antihistamines, other bladder antimuscarinics)	Overflow	Impair detrusor contractility — the same mechanism used therapeutically for urgency incontinence becomes harmful when retention is already present.
Some calcium channel blockers (e.g., diltiazem)	Overflow	Relax detrusor smooth muscle.
Sedative-hypnotics and other CNS depressants	Functional	Impair arousal, alertness, and mobility needed to reach the toilet in time, particularly overnight.
Opioids	Overflow and functional	Can impair detrusor contractility and reduce mobility/alertness.

Red Flags & Refer

Most urinary incontinence is a chronic, non-emergent symptom appropriately managed in primary care or by a pharmacist working within a collaborative practice — but escalate immediately for any of the following:

New incontinence accompanied by saddle anesthesia, bilateral leg weakness or numbness, or new bowel incontinence — this pattern suggests cauda equina syndrome or spinal cord compression, a surgical emergency requiring immediate emergency assessment and imaging, not routine incontinence workup.
Gross (visible) hematuria — requires urologic investigation to rule out malignancy or another structural cause before any incontinence-specific treatment is started.
Signs of urinary retention or overflow incontinence — a palpably distended bladder, inability to void, or a markedly elevated post-void residual — requires catheterization and urologic assessment, not a trial of antimuscarinic or beta-3 agonist therapy, which can worsen retention.
Recurrent urinary tract infections occurring alongside incontinence — suggests an anatomic or functional cause (incomplete emptying, fistula, calculus, or structural abnormality) that needs urologic workup rather than repeated antibiotic courses alone.
A pelvic mass or significant pelvic organ prolapse found on examination.
New-onset incontinence after recent pelvic surgery, radiation, or an obstetric injury, suggesting a fistula.
Incontinence together with significant, undifferentiated pelvic pain or fever.

Assessment & Diagnosis

Differentiating the mechanisms of incontinence

Feature	Stress	Urgency (OAB)	Overflow	Functional
Leakage trigger	Cough, sneeze, laugh, lift, exercise	Sudden urge, often with little warning	Continuous dribbling; no clear trigger	Normal urge, but cannot reach/use the toilet in time
Volume leaked	Small	Moderate to large	Small, frequent dribbling	Variable, often a full-volume void
Cough test	Immediate leakage	Delayed leakage, if any	Not typically diagnostic	Not typically diagnostic
Post-void residual	Normal	Normal	Elevated	Normal
Key associated findings	Urethral/bladder-neck hypermobility on exam; history of vaginal delivery or pelvic surgery	Urinary frequency, nocturia; may coexist with detrusor overactivity from a CNS cause	Hesitancy, weak stream, sensation of incomplete emptying; palpably distended bladder; BPH or neurogenic bladder history	Impaired mobility, dexterity, or cognition; otherwise normal urinary tract
Initial treatment approach	Pelvic floor muscle training	Bladder training	Treat the underlying cause; catheterize if needed	Optimize mobility/cognition/environment

Mixed incontinence combines stress and urgency features and is managed by treating the predominant (more bothersome) symptom.

History

Characterize the leakage: onset, frequency, severity, triggers, and volume; use a validated tool such as the 3IQ to help classify stress-predominant, urgency-predominant, or mixed patterns.
Degree of bother and impact on daily function and emotional well-being — this shapes how aggressively to treat, not just whether incontinence is present.
Previous treatments tried (pelvic floor therapy, pessary, surgery, containment products) and the current number of pads/products used per day.
A 3-day bladder diary (fluid intake, voiding frequency, timing, volume, and leakage episodes) is useful for decision-making; longer diaries add patient burden without meaningfully more information.
Obstetric history (vaginal versus Cesarean delivery, forceps use), menopausal status, and bowel habits (constipation is both a risk factor and a modifiable contributor).
Medical history for conditions associated with incontinence: diabetes, depression, mobility or cognitive impairment, prior bladder or pelvic surgery, and neurologic conditions (multiple sclerosis, stroke, spinal cord injury).
Full medication history, including nonprescription products and natural health products, and any recent medication changes — see Risk Factors for the specific drug classes to review.

Physical examination

Neurologic exam — mental status/cognition, and evidence of central or peripheral neurologic disease.
Pelvic examination — assess pelvic floor tone, rule out a pelvic mass or organ prolapse, and check for latent stress incontinence and urogenital atrophy.
Rectal examination — tone, masses, and fecal impaction.
Functional assessment — dexterity, mobility, and vision, since impairment in any of these can drive functional incontinence independent of the lower urinary tract.

Investigations

Cough test — immediate leakage on coughing suggests stress incontinence; delayed leakage suggests urgency incontinence.
Urinalysis — to rule out infection, glucosuria, or hematuria.
Post-void residual (PVR) — under 50 mL is normal; consider intervention (further workup, catheterization) once PVR reaches roughly 100-150 mL or more.
Renal function testing (urea, creatinine, glucose, calcium) when renal dysfunction is suspected or polyuria is present.
Urodynamic testing — accessed through specialist referral (urology, geriatrics) to measure detrusor compliance and contractility, PVR, and bladder capacity; not needed for straightforward, typical presentations.

Treatment Targets

Relieve urinary symptoms and reduce leakage episodes.
Prevent complications — skin breakdown, falls (particularly from nocturia and rushing to the toilet in older adults), recurrent urinary tract infection, and social withdrawal or low mood related to incontinence.
Improve quality of life and restore confidence in daily activities.
Correctly identify and treat the type-specific mechanism driving leakage, rather than pursuing generic symptomatic control.
Avoid treatment-related harm — particularly anticholinergic burden in older adults and inadvertent worsening of overflow incontinence.
Improve bladder function and, where relevant, restore functional continence by addressing mobility, cognitive, or environmental barriers.

Choose Initial Treatment

Direct treatment rule

Stress incontinence, 1st line pelvic floor muscle training (PFMT) after ruling out or treating secondary causes; reserve pharmacologic therapy (duloxetine, off-label) for patients who cannot or do not want surgery and have an inadequate response to PFMT.^[2]

Urgency incontinence / overactive bladder, 1st line bladder training (timed voiding) plus pelvic floor muscle exercise; add pharmacotherapy — a beta-3 agonist (mirabegron) or an antimuscarinic — only if behavioural therapy alone gives inadequate relief after an adequate trial.^[3]

Urgency incontinence, pharmacologic 2nd line mirabegron and the antimuscarinics are both reasonable 2nd-line choices with no strong preference between them in a healthy adult — but prefer mirabegron, or the more selective antimuscarinics (solifenacin, darifenacin, trospium), over oxybutynin specifically in frail, older, or cognitively impaired patients, given oxybutynin's comparatively high anticholinergic burden.^[4]

Urgency incontinence, refractory intradetrusor onabotulinumtoxinA injection is a specialist-administered option once behavioural therapy has been adequately tried and at least one pharmacologic class has failed or is not tolerated.

Mixed incontinence identify and treat the predominant (more bothersome) component first, using the stress or urgency pathway above, rather than treating both mechanisms simultaneously from the outset.

Overflow incontinence, 1st line identify and correct the underlying cause — review and stop or substitute contributing medications, and manage bladder outlet obstruction (e.g., BPH) or catheterize for chronic urinary retention due to detrusor underactivity.

Do not treat overflow incontinence with an antimuscarinic or a beta-3 agonist — both classes are used to relax or reduce detrusor contractility for urgency incontinence, and using either in a patient with overflow incontinence can worsen retention and precipitate acute urinary retention. Confirm the mechanism, including post-void residual, before starting any drug that affects bladder contractility.

Functional incontinence optimize the underlying mobility, cognitive, or environmental barrier (scheduled toileting, assistive devices, clothing modification, improved toilet access/lighting) — this is not a lower urinary tract problem and does not respond to bladder-directed pharmacotherapy.

Non-Pharmacologic Treatment

Stress incontinence

Pelvic floor muscle exercise (PFME) — a self-guided program of 12-20 muscle contractions, 3-5 times per day, holding each contraction toward a goal of 10 seconds; benefit may take 6-8 weeks to appear.
Pelvic floor muscle training (PFMT), also called pelvic floor physical therapy — a professional-led version of the same principle, delivered by a physiotherapist specializing in pelvic floor disorders; in males, evidence-based guidelines recommend PFME/PFMT before prostate resection and in the immediate postoperative period.
Biofeedback and/or electrical stimulation therapy to help the patient isolate and control the pelvic floor muscles.
Weight loss in patients who are overweight or obese.
Vaginal devices — a pessary for patients with vaginal prolapse; single-use tampon-like inserts; weighted vaginal cones (less evidence, but a reasonable option with results similar to PFME).
Surgical options depend on etiology: a midurethral mesh sling (retropubic or transobturator; single-incision slings are a less-effective variant) is the most common intervention in females and may also be used in males after prostatectomy once non-invasive options have been tried; periurethral bulking agents (e.g., collagen or synthetic gel) are less effective, with benefit that can decline substantially within 6 months; retropubic suspension is a last-line surgical option.^[2]

Urgency incontinence / overactive bladder

Bladder training (timed voiding) — a voiding schedule gradually lengthened toward a reasonable interval with minimal incontinence, for example starting at 1-hour intervals and increasing weekly toward voiding every 2-3 hours; more effective than antimuscarinic therapy in comparative studies and should be tried first.
Pelvic floor muscle exercise, using the same technique described for stress incontinence.
Weight loss in overweight or obese patients — reduces nocturia, urgency, and stress incontinence, though sustaining weight loss long-term is a genuine challenge.
Smoking cessation.
Caffeine reduction (not necessarily complete cessation).
Moderate fluid intake — a modest reduction in daytime fluid can reduce daytime frequency, urgency, and nocturia in some patients, but avoid aggressive fluid restriction, since concentrated urine can itself irritate the bladder and worsen constipation.
Biofeedback training and electrical stimulation, including protocols using tibial neurostimulation.
Sacral or tibial neuromodulation is an accepted 3rd-line option for refractory urgency incontinence, alongside onabotulinumtoxinA.^[3]

Overflow incontinence

Address the underlying cause directly: stop or substitute medications that impair bladder emptying (anticholinergics, calcium channel blockers, sympathomimetics/decongestants, opioids).
Catheterization (intermittent, indwelling, or suprapubic) for chronic retention due to detrusor underactivity — intermittent catheterization is generally preferred when feasible.
For overflow incontinence from bladder outlet obstruction (e.g., benign prostatic hyperplasia), manage the obstruction directly — medical or surgical therapy as appropriate; see Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia for detailed management of BPH itself.

Functional incontinence

Scheduled or prompted toileting at regular intervals.
Improve toilet access — proximity, lighting, grab bars, raised toilet seats, and clothing that is easy to remove quickly.
Address the underlying mobility, cognitive, or mood disorder driving the functional barrier wherever possible.
Containment products designed specifically for incontinence (not menstrual products) — correct absorbency, placement of the absorbent core, and odour control differ from menstrual products, and using the wrong type of product for the patient's anatomy or type of incontinence undermines management.

General counselling, all types

Set realistic expectations: nonpharmacologic interventions generally need 6-12 weeks to show benefit; pharmacologic interventions take several weeks to reach maximum effect and are not curative.
Treat secondary/contributing causes (UTI, constipation, poor mobility, contributing medications) before or alongside definitive incontinence-specific therapy.
Document baseline frequency, urgency, and other symptoms so that improvement (or lack of it) can be objectively assessed at follow-up.
Assess baseline cognition in older adults before starting an antimuscarinic, to allow later monitoring for treatment-associated cognitive change.
Anticipate and address adherence challenges — both nonpharmacologic and pharmacologic treatments have real persistence problems in practice.

Pharmacologic Treatment Options

Drug / intervention	Role	Dose / use	Important adverse effects	Teaching points
Oxybutynin, immediate-release Alternative	Antimuscarinic — urgency incontinence/OAB, when a low-cost option is needed	2.5-5 mg PO once daily to four times daily; in older adults start at the lowest dose and titrate slowly	Dry mouth, constipation, blurred vision, cognitive impairment/delirium, urinary retention	Highest anticholinergic burden of this class — avoid where possible, or use the lowest dose, in frail or cognitively impaired older adults.
Solifenacin Alternative	More selective antimuscarinic, preferred over oxybutynin when an antimuscarinic is chosen in an older adult	5 mg PO once daily; may increase to 10 mg once daily if tolerated; do not exceed 5 mg daily with severe hepatic or renal impairment	Dry mouth, constipation, blurred vision	Comparatively lower anticholinergic burden than oxybutynin, but still counsel on cognitive effects in older adults.
Trospium Alternative	More selective antimuscarinic alternative	20 mg PO twice daily on an empty stomach; in older adults or severe renal impairment do not exceed 20 mg once daily at bedtime	Dry mouth, constipation, blurred vision	Minimal blood-brain-barrier penetration gives a theoretical CNS/cognitive advantage over oxybutynin, though this has not been confirmed head-to-head.
Mirabegron Preferred	Beta-3 agonist — 1st pharmacologic choice for urgency incontinence/OAB, especially in frail or cognitively impaired older adults	25 mg PO once daily; may increase to 50 mg once daily; do not exceed 25 mg daily with severe renal or moderate hepatic impairment	Hypertension, headache, nasopharyngitis, urinary tract infection	No meaningful anticholinergic burden — preferred over an antimuscarinic when minimizing cognitive risk matters. Check blood pressure before starting and periodically during treatment.
Duloxetine Special situation	Off-label SNRI adjunct for stress incontinence when surgery is not appropriate or not wanted	30 mg PO once daily for 1-2 weeks, then 60 mg PO once daily	Nausea, dry mouth, insomnia, increased blood pressure, palpitations	Not approved for this indication in Canada. Counsel on adverse effects before starting — benefit is modest and discontinuation due to side effects is common; taper rather than stop abruptly.
OnabotulinumtoxinA Special situation	Intradetrusor injection for refractory urgency incontinence/OAB	100 units by intradetrusor injection via cystoscopy, administered by a specialist	Urinary tract infection, dysuria, urinary retention	Specialist-administered (urology). Confirm the patient is willing and able to self-catheterize if retention occurs before proceeding.
Vaginal estrogen (conjugated estrogens cream or estradiol ring/tablet) Special situation	Adjunct for postmenopausal urgency, stress, or mixed incontinence with coexisting vaginal atrophy	See Drug Tables for full product-specific dosing	Local irritation, discharge, spotting	Evidence for incontinence itself is weak — benefit is mainly for coexisting genitourinary syndrome of menopause. See the Menopause chapter for full estrogen-therapy guidance.

Confirm the type of incontinence, including post-void residual, before selecting any drug from this table — an antimuscarinic or beta-3 agonist given for unrecognized overflow incontinence can worsen retention.

Special Populations

Pregnancy

Urinary incontinence before pregnancy is uncommon; the peripartum period is when many patients experience it for the first time, with stress incontinence the most common pattern and urgency/frequency increasing through pregnancy. The mechanism combines hormonal change, weight gain, and increased pressure on the bladder and pelvic floor. Risk factors for postpartum incontinence include an assisted vaginal delivery (forceps), oxytocin exposure in labour, and delivery of a larger infant. Management in pregnancy and the immediate postpartum period is preventative and non-pharmacologic — pelvic floor muscle training started during pregnancy and continued postpartum is effective and is the primary intervention; most patients experience resolution of symptoms after delivery, though the risk of long-term stress incontinence and nocturia is increased, especially after more than one delivery.

Breastfeeding

Incontinence itself does not affect the nursing infant. Avoid recommending fluid restriction as a treatment strategy during breastfeeding — reducing fluid intake can reduce milk production, and fluid restriction for incontinence has not been studied in this population.

Older adults and frail patients

Anticholinergic burden is a central safety issue in this population. Cumulative anticholinergic exposure — including from bladder antimuscarinics — is associated with an increased risk of dementia, and this risk does not appear to fully reverse on stopping the drug.^[5] The 2023 AGS Beers Criteria identify bladder antimuscarinics as potentially inappropriate in older adults, particularly with concurrent use of other anticholinergic medications or in patients with, or at risk of, cognitive impairment, falls, or urinary retention.^[4] Assess baseline cognition before starting an antimuscarinic, prefer mirabegron or a more selective antimuscarinic over oxybutynin, start at the lowest dose, and reassess regularly for cognitive change, constipation, and falls risk.

Renal impairment

Fesoterodine: do not exceed 4 mg once daily if creatinine clearance is under 30 mL/min.
Solifenacin: do not exceed 5 mg once daily in severe renal impairment (creatinine clearance under 30 mL/min).
Trospium: do not exceed 20 mg once daily (at bedtime) in severe renal impairment.
Mirabegron: do not exceed 25 mg once daily in severe renal impairment; not recommended in end-stage renal disease or dialysis.
Propiverine: do not exceed 30 mg once daily (the 45 mg strength should not be used) if creatinine clearance is under 30 mL/min.

Hepatic impairment

Darifenacin and fesoterodine: avoid in severe hepatic impairment.
Solifenacin: do not exceed 5 mg once daily in severe hepatic insufficiency.
Mirabegron: do not exceed 25 mg once daily in moderate hepatic impairment; not recommended in severe hepatic impairment.
Propiverine: not recommended in moderate or severe hepatic impairment.

Male patients

Overflow incontinence in men is most often related to bladder outlet obstruction from benign prostatic hyperplasia — manage the obstruction directly (see Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia). Stress incontinence in men occurs mainly after prostate surgery; pelvic floor muscle training before and immediately after prostatectomy is recommended, with a sling procedure an option for persistent post-prostatectomy stress incontinence once non-invasive measures have been tried.

Postmenopausal patients

Topical vaginal estrogen may be considered as an adjunct for postmenopausal urgency, stress, or mixed incontinence when vaginal atrophy is also present, though the evidence for benefit on incontinence itself is weak — the rationale is treating coexisting genitourinary syndrome of menopause rather than the incontinence directly. Systemic estrogen therapy (oral or transdermal) is not effective for incontinence and may worsen it — do not substitute a systemic product for a topical one. See the Menopause chapter for full estrogen-therapy dosing, safety, and counselling guidance.

Monitoring & Follow-Up

Reassess symptom frequency/severity against the documented baseline at each follow-up, using the same bladder diary or symptom count used initially so improvement (or lack of it) is objectively comparable. For antimuscarinic or beta-3 agonist therapy, continue for at least 4-8 weeks before judging benefit, and reassess adherence and tolerability at that point — early discontinuation from side effects is common and should prompt a switch rather than simply stopping therapy without follow-up. In patients started on an antimuscarinic, monitor for constipation, cognitive change, and urinary retention (repeat PVR if retention is suspected), particularly in older adults; reassess cognition periodically against the pre-treatment baseline. Recheck blood pressure periodically in patients on mirabegron. For patients using a pessary or other vaginal device, arrange periodic device checks and vaginal examination. For stress incontinence managed with pelvic floor muscle training, reassess at 6-8 weeks, since this is the typical time to first benefit; continued improvement can occur for several months with adherence. Reinforce that pharmacologic therapy for incontinence is not curative and requires ongoing use to maintain benefit.

Treatment Failure / Next Step

Confirm the diagnosis: reconfirm which type of incontinence is present, and specifically rule out overflow incontinence (check PVR) before continuing or escalating antimuscarinic/beta-3 agonist therapy.
Confirm and treat secondary/contributing causes that may not yet have been addressed — urinary tract infection, constipation, poorly controlled diabetes, and contributing medications.
Confirm adherence to nonpharmacologic therapy specifically — PFMT/bladder training needs a genuine 6-8 week trial with correct technique before being judged ineffective; consider a pelvic floor physiotherapy referral if self-directed exercise has not helped.
For urgency incontinence on pharmacotherapy without adequate benefit at 8 weeks: switch to a different agent, or switch class (from an antimuscarinic to mirabegron, or vice versa), rather than simply increasing the dose of a poorly tolerated agent.
Combine nonpharmacologic and pharmacologic therapy if either alone gives only partial benefit.
For stress incontinence refractory to an adequate PFMT trial: reassess for a vaginal device (pessary), or discuss duloxetine versus surgical referral based on patient preference and suitability for surgery.
For urgency incontinence refractory to an adequate trial of behavioural therapy plus at least one pharmacologic class: refer for onabotulinumtoxinA, sacral or tibial neuromodulation, or specialist urodynamic assessment.
For overflow incontinence not resolving with reversible-cause management: refer to urology for further evaluation of detrusor underactivity or bladder outlet obstruction, and ensure catheterization (intermittent preferred where feasible) is in place in the interim.

Common Errors to Avoid

Starting an antimuscarinic or beta-3 agonist for suspected overactive bladder without first ruling out overflow incontinence (elevated PVR) — this can precipitate urinary retention.
Treating urgency incontinence with drug therapy before an adequate trial of bladder training — behavioural therapy is more effective than antimuscarinic therapy alone and should come first.
Defaulting to oxybutynin in a frail or cognitively impaired older adult instead of a more selective antimuscarinic or mirabegron.
Continuing an antimuscarinic or beta-3 agonist indefinitely without reassessing benefit at 4-8 weeks, or stopping therapy after a single side effect without trying dose reduction or a class switch.
Missing a medication-induced or medication-aggravated cause (diuretics, alpha-blockers, sedative-hypnotics, opioids, anticholinergic medications used for other indications) before starting incontinence-specific drug therapy.
Prescribing systemic estrogen therapy for incontinence — it is not effective and may worsen urgency incontinence; only topical/vaginal estrogen has a role, and only as an adjunct when vaginal atrophy coexists.
Recommending aggressive fluid restriction — this can worsen constipation (itself a risk factor for incontinence) and, in a breastfeeding patient, reduce milk supply; a modest daytime reduction is reasonable, but complete restriction is not.
Substituting a menstrual pad for a purpose-designed incontinence containment product, or using the wrong containment product for the patient's anatomy or type of incontinence.
Not assessing baseline cognition before starting an antimuscarinic in an older adult, making later treatment-related cognitive change difficult to recognize.
Attributing all incontinence in a frail older adult to "old age" without screening for the functional (mobility/cognitive/environmental) contributors that are often the most modifiable part of the problem.

Clinical Decision Algorithm

Algorithm A — Initial assessment and classification

New or worsening involuntary urine leakage — screen with the 3IQ or a similar validated tool

Assess for red flags: neurologic deficit/saddle anesthesia, gross hematuria, signs of retention, recurrent UTI, pelvic mass

Red flag present

Escalate/refer urgently — do not proceed with routine incontinence workup

No red flags

Review medications; treat reversible causes (UTI, constipation, poorly controlled diabetes, mobility/environmental barriers)

Obtain post-void residual (PVR) and urinalysis; classify by history, cough test, and PVR

Stress-predominant: immediate leakage on cough, normal PVR

Proceed to Algorithm B — Stress incontinence

Urgency-predominant or mixed: delayed/no leakage on cough, normal PVR

Proceed to Algorithm C — Urgency incontinence; if mixed, treat the predominant symptom first

Elevated PVR, or dribbling/poor stream

Proceed to Algorithm D — Overflow incontinence; do not start an antimuscarinic or beta-3 agonist

Algorithm B — Stress incontinence

Stress incontinence confirmed

1st line: pelvic floor muscle training (PFMT) — 12-20 contractions, 3-5 times daily, 10-second hold; trial at least 6-8 weeks^[2]

Inadequate response after an adequate PFMT trial

Consider a vaginal device (pessary) if prolapse/hypermobility is present, or discuss duloxetine (off-label) if surgery is not wanted or appropriate

Refractory to conservative and pharmacologic measures, or patient prefers definitive treatment

Refer for surgical evaluation — midurethral sling preferred; bulking agents or retropubic suspension are alternatives

Algorithm C — Urgency incontinence / overactive bladder

Urgency incontinence / overactive bladder confirmed

1st line: bladder training (timed voiding) plus pelvic floor muscle exercise; address caffeine intake and fluid habits^[3]

Inadequate response after an adequate behavioural trial

Add mirabegron, or an antimuscarinic — prefer a more selective agent or mirabegron in frail/older/cognitively impaired patients

Benefit at 4-8 weeks

Continue; reassess periodically for anticholinergic side effects/cognition if on an antimuscarinic

No benefit, or not tolerated, at 8 weeks

Switch to a different agent, or switch class (antimuscarinic to mirabegron, or vice versa)

Refractory after adequate trials of behavioural therapy and at least one pharmacologic class

Refer for onabotulinumtoxinA (intradetrusor injection) or sacral/tibial neuromodulation

Algorithm D — Overflow incontinence

Overflow incontinence suspected — dribbling, hesitancy, poor stream, elevated PVR

Do not start an antimuscarinic or beta-3 agonist — both can worsen retention

Review and stop or substitute reversible causes: anticholinergics, calcium channel blockers, sympathomimetics/decongestants, opioids

Bladder outlet obstruction suspected (e.g., BPH)

Evaluate and manage the obstruction directly — see Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia

Detrusor underactivity / noncontractile bladder

Catheterize — intermittent preferred where feasible; indwelling or suprapubic if intermittent is not feasible

Refer to urology; pharmacologic options for detrusor underactivity have limited evidence and poor tolerability

Drug Tables

How to use this table: Doses are adult doses and require patient-specific confirmation, including renal/hepatic adjustment. Confirm the type of incontinence before selecting any drug — antimuscarinics and beta-3 agonists are not appropriate for overflow incontinence. Select any drug name to open its complete Pharmasist Drug Database page.

Antimuscarinics (anticholinergics)

Considered 2nd line for urgency incontinence, after an adequate trial of bladder training. Do not use for overflow incontinence — every agent in this class can worsen urinary retention. Continue for at least 4-8 weeks before judging benefit; discontinue or switch if there is no benefit, or if side effects are not tolerable, at that point.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Oxybutynin, immediate-release	Standard adult dosing: 2.5-5 mg PO once daily to four times daily Older adults: Start at the lowest dose and titrate slowly	Dry mouth, constipation, blurred vision, increased intraocular pressure/worsening glaucoma, cognitive impairment/delirium, tachycardia	Additive effects with other anticholinergic medications	Highest anticholinergic burden of the class; avoid where possible, or use the lowest dose, in frail/older adults per Beers Criteria.
Darifenacin, extended-release	Initial: 7.5 mg PO once daily Titration: May increase to 15 mg once daily after 2 weeks if needed	Dry mouth, constipation, delirium, increased intraocular pressure/worsening glaucoma, dry eyes, tachycardia	Do not exceed 7.5 mg daily with a potent CYP3A4 inhibitor; caution with other narrow-therapeutic-index CYP2D6 substrates	Avoid in severe hepatic impairment. More selective for the M3 receptor.
Fesoterodine, extended-release	Initial: 4 mg PO once daily Titration: May increase to 8 mg once daily if needed Renal impairment: Do not exceed 4 mg daily if creatinine clearance is under 30 mL/min	Back pain, constipation, cough, dry eyes, dry mouth	Do not exceed 4 mg daily with a potent CYP3A4 inhibitor; concomitant use with a potent CYP3A4 inducer is not recommended	Do not crush or chew. Avoid in severe hepatic impairment.
Solifenacin	Initial: 5 mg PO once daily Titration: May increase to 10 mg once daily if tolerated Severe renal or hepatic impairment: Do not exceed 5 mg once daily	Dry mouth, constipation, blurred vision, delirium, increased intraocular pressure/worsening glaucoma	Do not exceed 5 mg daily with a potent CYP3A4 inhibitor	Avoid in severe hepatic insufficiency. Comparatively favourable tolerability among antimuscarinics.
Tolterodine	Immediate-release: 1-2 mg PO twice daily Extended-release: 2-4 mg PO once daily With a potent CYP3A4 inhibitor: Maximum 2 mg once daily, either formulation	Dry mouth, constipation, blurred vision, delirium, increased intraocular pressure/worsening glaucoma, tachycardia	CYP3A4 metabolism becomes clinically significant in CYP2D6 poor metabolizers; an antacid taken with the extended-release capsule can cause dose-dumping; proton pump inhibitor use may also affect the extended-release formulation	Use the lowest recommended starting dose in older adults and in severe renal impairment.
Trospium	Standard adult dosing: 20 mg PO twice daily on an empty stomach Older adults or severe renal impairment: Do not exceed 20 mg once daily at bedtime	Dry mouth, constipation, blurred vision, urinary retention	Additive effects with other anticholinergic medications	Quaternary amine with minimal blood-brain-barrier penetration — a theoretical CNS/cognitive advantage not confirmed head-to-head.
Propiverine, modified-release	Initial: 30 mg PO once daily Titration: May increase to 45 mg once daily if tolerated but not fully effective Severe renal impairment: Do not exceed 30 mg once daily	Dry mouth, constipation, blurred vision, tachycardia	Additive effects with other anticholinergic medications	Swallow the modified-release capsule whole. Not recommended in moderate or severe hepatic impairment.

Beta-3 adrenergic agonists

Comparable efficacy to antimuscarinic therapy with essentially no anticholinergic burden — a reasonable 1st pharmacologic choice, and generally preferred over an antimuscarinic in frail or cognitively impaired older adults.^[3]

Drug	Dosage	Adverse effects	Drug interactions	Comments
Mirabegron, extended-release	Initial: 25 mg PO once daily Titration: May increase to 50 mg once daily Severe renal or moderate hepatic impairment: Do not exceed 25 mg once daily	Hypertension (including worsening of existing hypertension), nasopharyngitis, urinary tract infection, headache, tachycardia, rare QT prolongation	Moderate CYP2D6 inhibitor and weak P-glycoprotein inhibitor — can raise levels of CYP2D6 substrates (e.g., metoprolol, desipramine) and digoxin; caution with other drugs that raise heart rate/blood pressure or prolong the QT interval; may increase urinary retention risk if combined with an antimuscarinic	Contraindicated in severe uncontrolled hypertension. Check blood pressure before starting and periodically during treatment. Do not crush or chew.

Vibegron is a newer beta-3 agonist with comparable efficacy and tolerability to mirabegron, including similarly minimal anticholinergic burden. It is approved and marketed in the United States and parts of Europe, but is not currently approved or marketed in Canada, so mirabegron remains the beta-3 agonist available in Canadian practice.

Botulinum toxin

Reserved for urgency incontinence/OAB refractory to behavioural therapy and at least one pharmacologic class. Administered by a specialist via cystoscopy — not a community pharmacy dispensing decision, but pharmacists should recognize it as the next step and counsel appropriately.

Drug	Dosage	Adverse effects	Drug interactions	Comments
OnabotulinumtoxinA	Adults: 100 units by intradetrusor injection via cystoscopy, administered by a specialist	Urinary tract infection (most common), dysuria, urinary retention	None specific to this indication at the doses used	Confirm the patient is willing and able to perform self-catheterization if retention occurs before proceeding; benefit has been shown to be sustained with repeat treatment over several years.

Serotonin-norepinephrine reuptake inhibitor (stress incontinence, off-label)

Duloxetine is approved in Canada for depression, anxiety, and pain — not for stress incontinence. Evidence shows a reduction in incontinence episodes and improved quality of life, but benefit is modest and discontinuation due to side effects is common.^[6]

Drug	Dosage	Adverse effects	Drug interactions	Comments
Duloxetine	Initial: 30 mg PO once daily for 1-2 weeks (may also be used from the outset for tolerability) Target: 60 mg PO once daily	Nausea, dry mouth, constipation, tachycardia, increased blood pressure, palpitations, flushing, erectile dysfunction	CYP1A2/CYP2D6 substrate and CYP2D6 inhibitor; contraindicated with MAO inhibitors (serotonin syndrome risk); CYP1A2/CYP2D6 inhibitors can raise duloxetine levels, inducers can lower them	Not approved for this indication in Canada. Counsel on adverse effects, including a possible increased suicidality signal seen in depressed patients (unclear whether this applies without depression), before starting. Not recommended in end-stage renal disease/dialysis or severe renal impairment.

Vaginal estrogen (adjunct for coexisting atrophy)

Evidence for benefit on incontinence itself is weak; use is justified mainly by treating coexisting genitourinary syndrome of menopause in a patient with urgency, stress, or mixed incontinence. See the Menopause chapter for complete estrogen-therapy dosing, safety, and counselling guidance not specific to incontinence.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Conjugated estrogens, vaginal cream	Induction: 0.5 g intravaginally once daily for the first 14 days Maintenance: 0.5 g intravaginally 2-3 times weekly	Local burning, irritation, or itching; vaginal discharge; breast tenderness (uncommon)	Systemic absorption is low; no clinically significant interactions reported at recommended doses	No progestogen is needed alongside vaginal estrogen; concomitant progestogen or endometrial surveillance is not recommended in an asymptomatic (non-bleeding) patient.
Estradiol, vaginal ring or tablet	Ring (e.g., Estring): 1 ring inserted vaginally, left in place continuously, replaced every 3 months Tablet/insert (e.g., Vagifem): 1 tablet inserted vaginally once daily for the first 2 weeks, then twice weekly for maintenance	Local burning, irritation, or itching; vaginal discharge; spotting	Systemic absorption is low; no clinically significant interactions reported at recommended doses	Two distinct products/regimens — confirm which formulation is prescribed.

Evidence note: Drug inventory, dosing, adverse effects, and comments reflect standard Canadian product labelling, cross-checked against the AUA/SUFU and CUA guidelines cited throughout this chapter.^[7]

References

The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society — Neurourology and Urodynamics (Abrams P, Cardozo L, Fall M, et al.). Neurourol Urodyn 2002;21(2):167-178
Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023) — Journal of Urology, American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (Kobashi KC, Vasavada S, Bloschichak A, et al.). J Urol 2023;209(6):1091-1098
The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder — Journal of Urology, American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (Cameron AP, Chung DE, Dielubanza EJ, et al.). J Urol 2024;212(1):11-20
American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults — Journal of the American Geriatrics Society (American Geriatrics Society Beers Criteria Update Expert Panel). J Am Geriatr Soc 2023;71(7):2052-2081
Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study — JAMA Internal Medicine (Coupland CAC, Hill T, Dening T, et al.). JAMA Intern Med 2019;179(8):1084-1093
Considering benefits and harms of duloxetine for treatment of stress urinary incontinence: a meta-analysis of clinical study reports — CMAJ (Maund E, Guski LS, Gøtzsche PC). CMAJ 2017;189(5):E194-E203
2024 Canadian Urological Association guideline: Female stress urinary incontinence — Canadian Urological Association Journal (Carlson K, Andrews M, Bascom A, et al.). Can Urol Assoc J 2024;18(4):83-102

Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.