Behavioral therapies relieve stress, urgency, and mixed urinary incontinence (UI) more effectively than drug monotherapies in nonpregnant women.

In a new systematic review and network meta-analysis (NMA) of 84 randomized trials published in the Annals of Internal Medicine, most interventions including combination therapies improved or resolved women’s symptoms better than no treatment, whether sham or watchful waiting, Ethan Balk, MD, MPH, of Brown University in Providence, Rhode Island, and colleagues reported. Hormones and periurethral bulking agents appeared less than effective, however.

Women with stress UI improved more with behavioral therapy (alone or with hormones) than with alpha-agonists or hormones alone. Alpha-agonists typically outperformed hormone therapy. Neuromodulation appeared better than no treatment for improving or resolving symptoms or increasing patient satisfaction.

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Among urgency UI treatments, behavioral therapy more often led to improvement or cure than anticholinergics. Both neuromodulation and onabotulinum toxin A were more effective than no treatment. Onabotulinum toxin A outperformed neuromodulation for symptom resolution.

Investigators considered each intervention or combination according to whether it was first-, second-, or third-line therapy. Adverse events varied according to the intervention, and they included dry mouth, nausea, and fatigue following drug therapy.

“Our findings are consistent with previously published systematic reviews regarding nonsurgical treatment of UI in women but are more complete, because we evaluated additional medication classes and interventions, and conducted NMAs to combine direct evidence from head-to-head comparisons with indirect evidence,” Dr Balk and his peers stated.


Balk EM, Rofeberg VN, Adam GP, Kimmel HJ, Trikalinos TA, and Jeppson PC. Pharmacologic and nonpharmacologic treatments for urinary incontinence in women: A systematic review and network meta-analysis of clinical outcomes. Ann Intern Med. DOI:10.7326/M18-3227