Näytönastekatsaukset

Anticholinergics for urinary incontinence in women

Näytönastekatsaukset

31.3.2026

Sanna Hallamies and Aleksi Raudasoja

Level of evidence: B

Anticholinergics likely decrease the number of daily urge incontinence episodes.

A systematic review and meta-analysis compared anticolinergics to placebo and other medications «Farag F, Sakalis VI, Arteaga SM, et al. What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence »1. Anticholinergics decreased urge incontinence episodes for -0.48 episodes per day (-0.71 to –0.24) compared to placebo, translating to about -32 % decrease in incontinence episodes.

Similarly, in a systematic review and meta-analysis of 7 RCT:s «Ananda IGYP, Surya RNH, Surya PA, et al. Efficacy and safety of solifenacin for overactive bladder: An updated systematic review and meta-analysis. Urol Ann 2025;17(1):2-8 »2 comparing solifenacin to placebo, anticholinergics decreased daily urinary incontinence episodes by 0.56 episodes per day (−0.80 to −0.32). A network meta-analysis on anticholinergics for urinary incontinence suggested similar impact from different anticholinergics with decrease in leakage episodes ranging between -0.32 and -0.58 «Herbison P, McKenzie JE. Which anticholinergic is best for people with overactive bladders? A network meta-analysis. Neurourol Urodyn 2019;38(2):525-534 »3.

A Cochrane review found 4 points improvement in health-related quality of life (scale 0-100), suggesting little to no improvement «Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 »4. However, the evidence was low quality due to high risk of bias (insufficient reporting and publication bias).

The Cochrane review found dry mouth is more common with anticholinergics compared to placebo, occurring in 23.9% vs. 6.3% of patients (RD 16%). Urinary retention occurred in 0.3% of patients using placebo, compared to 0.7-2.1% of patients on anticholinergics (RD 0.9 %)), and constipation in 6.3% vs. 3.3% of patients (RD 3.4 %).

The level of evidence was downgraded once.

Table 1. Description of the included studies.
Reference	Study type	Population	Intervention and comparison	Outcomes	Risk of bias
RCT=randomized controlled trial; SR=systematic review; MA=meta-analysis
«Farag F, Sakalis VI, Arteaga SM, et al. What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence »1	SR/MA	Women 18 yr with OAB symptoms as defined by trialists	Antimuscarinics versus placebo	Change in the number of urgency incontinence episodes OAB-q (quality of life TAEs	Moderate
«Ananda IGYP, Surya RNH, Surya PA, et al. Efficacy and safety of solifenacin for overactive bladder: An updated systematic review and meta-analysis. Urol Ann 2025;17(1):2-8 »2	SR/MA	Adult male and female OAB	Solifenacin vs. placebo	Change in urge and incontinence episodes, change in micturition frequency, change in nocturia episodes, change in urine volume, adverse events	Moderate
«Herbison P, McKenzie JE. Which anticholinergic is best for people with overactive bladders? A network meta-analysis. Neurourol Urodyn 2019;38(2):525-534 »3	Network MA	Men and women with OAB	Tolterodine, oxybutynin,trospium, propiverine, solifenacin, darifenacin, imidafenacin, and fesoterodine vs placebo	The number of leakage episodes; the number of voids per day;cure or improvement; and dry mouth	Moderate
«Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 »4	SR/MA	Women with overactive bladder syndrome	Monotherapy of darifenacin /fesoterodine/ imidafenacin/ oxybutynin/ propantheline/ propiverine/ solifenacin/ tolterodine/trospium OR placebo	Condition-specific quality of life, patient perception of cure or improvement, mean number of urgency episodes per 24 hours, TAEs	High

Table 2. Additional comments for included studies.
Reference	Comments
«Farag F, Sakalis VI, Arteaga SM, et al. What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence »1	104 studies. In total across the rest of the studies, 29,682 people were given an anticholinergic drug compared to 17,424 people who were given a placebo. One study investigated symptoms only in men, while nine looked at symptoms in women. The rest of the studies included both men and women. None of the included studies reported results for those with frequency and/or urgency alone (OAB-dry) separately to those with urgency urinary incontinence (OAB-wet). As such, it was not possible to assess by type of overactive bladder. Health-related quality of life was measured with 0-100 scales: King's Health Questionnaire, Incontinence Quality of Life, and Overactive Bladder Questionnaire. Risk of bias (according to Cochrane): high (mostly due to insufficient reporting)
«Ananda IGYP, Surya RNH, Surya PA, et al. Efficacy and safety of solifenacin for overactive bladder: An updated systematic review and meta-analysis. Urol Ann 2025;17(1):2-8 »2	8 RCTs. 4387 participants: 2390 patients allocated to the solifenacin group, 1997 to the placebo group. Inclusion criteria: studies involving only adult patients, with RCTs as the preferred study design, and articles written in English, focusing on the primary outcomes of interest related to OAB symptoms, including urgency, incontinence, and micturition frequency. Exclusion criteria: studies with a pediatric population and articles not written in English. Risk of bias: low. Some missing data.
«Herbison P, McKenzie JE. Which anticholinergic is best for people with overactive bladders? A network meta-analysis. Neurourol Urodyn 2019;38(2):525-534 »3	128 RCTs with 58 335 participants. Inclusion criteria: To be included a study had to be a parallel randomized trialcomparing an anticholinergic drug with placebo or anotheranticholinergic drug. The included anticholinergic drugs weretolterodine, oxybutynin, trospium, propiverine, solifenacin,darifenacin, imidafenacin, and fesoterodine. Participants had to be adults with overactive bladders. Pairwise comparisons of all treatments that were compared directly were carried out using random effects meta-analysis. All drugs, apart from oxybutynin ER and trospium, were more effective than placebo, and there were no statistically significant differences between the different drugs (in incontinence episodes), data available from 65 studies.
«Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 »4	45 RCTs. Exclusion criteria: past medical history of pelvic radiotherapy for pelvic organ malignancy, active urinary tract infection, urinary tract cancer, neuropathic bladder dysfunction, urinary tract stones; studies predominantly on women with mixed urinary incontinence, chronic interstitial cystitis/bladder pain syndrome. Risk of bias: moderate.

Results

Table 3. Outcome 1: Urge incontinence episodes per day, anticholinergics vs placebo.
Reference	Number of studies and number of patients (I/C)	Follow-up time	Mean (sd) I	Mean (sd) C	Mean difference (95% CI)
Level of evidence: moderate The quality of evidence is downgraded due to study limitations. I=intervention; C=comparison; CI=confidence interval *not calculated by the study authors
«Farag F, Sakalis VI, Arteaga SM, et al. What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence »1	6 RCTs, n = 4688	6-12 weeks		1.49*	-0.48 (-0.71 to -0.24) relative effect: -32% (-16% to -48%)

Table 4. Outcome 2: Incontinence episodes per day, solifenacin vs placebo.
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect (95% CI)
Level of evidence: moderate The quality of evidence is downgraded due to study limitations.
«Ananda IGYP, Surya RNH, Surya PA, et al. Efficacy and safety of solifenacin for overactive bladder: An updated systematic review and meta-analysis. Urol Ann 2025;17(1):2-8 »2	7 (2239/1937)				(MD = -0.56, 95% CI: -0.80 to -0.32)

Table 5. Outcome 3: Urge incontinence episodes per day, vs beta-agonists.
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect (95% CI)
Level of evidence: very low The quality of evidence is downgraded due to study limitations, imprecision.
«Ananda IGYP, Surya RNH, Surya PA, et al. Efficacy and safety of solifenacin for overactive bladder: An updated systematic review and meta-analysis. Urol Ann 2025;17(1):2-8 »2	3 RCTs, n= 238				No significant differences were found between antimuscarinics and beta-3

Table 6. Outcome 4: health-related quality of life, scale 0-100.
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect (95% CI)
Level of evidence: low The quality of evidence is downgraded due to study limitations (mostly due to insufficient reporting) and imprecision. The meta-analysis used fixed-effects model, which may result in too precise estimates.
«Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 »4	12 RCTs, n= 6804				MD -4.41 (-5.28 to -3.54)

Table 7. Outcome 5: Dry mouth, antimuscarinics versus placebo.
Reference	Number of studies and number of patients (I/C)	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect (95% CI)
Level of evidence: moderate The quality of evidence is downgraded due to study limitations.
«Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 »4	66 studies, I 24 523, C 13 845	5859 (23,9 %)	875 (6,3 %)	RR 3.50 (3.26 to 3.75) RD 16 %
«Ananda IGYP, Surya RNH, Surya PA, et al. Efficacy and safety of solifenacin for overactive bladder: An updated systematic review and meta-analysis. Urol Ann 2025;17(1):2-8 »2	11 179	not reported		RR 3.20, (1.54 to 6.67)

Table 8. Outcome 6: Urinary retention.
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect (95% CI)
Level of evidence: moderate The quality of evidence is downgraded due to study limitations.
«Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 »4	I 4614, C 3248		73 (1.6 %)	11 (0.3 %)	RR 3.52 (2.04 to 6.08) RD 0.9 %

Table 9. Outcome 7: Constipation.
Reference	Number of studies and number of patients (I/C)	Follow-up time	Absolute number of events (%) I	Absolute number of events (%) C	Relative effect (95% CI)
Level of evidence: moderate The quality of evidence is downgraded due to study limitations.
«Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 »4	24756/12561		1557 (6.3%)	410 (3.3%)	RR 2.03 (1.78 to 2.31)

References

Farag F, Sakalis VI, Arteaga SM, et al. What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence Under the Auspices of the European Association of Urology, Female Non-neurogenic Lower Urinary Tract Symptoms Guidelines Panel. Eur Urol 2023;84(3):302-312 «PMID: 37331921»PubMed
Ananda IGYP, Surya RNH, Surya PA, et al. Efficacy and safety of solifenacin for overactive bladder: An updated systematic review and meta-analysis. Urol Ann 2025;17(1):2-8 «PMID: 40051990»PubMed
Herbison P, McKenzie JE. Which anticholinergic is best for people with overactive bladders? A network meta-analysis. Neurourol Urodyn 2019;38(2):525-534 «PMID: 30575999»PubMed
Stoniute A, Madhuvrata P, Still M, et al. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023;5(5):CD003781 «PMID: 37160401»PubMed