OBJECTIVE: To determine the efficacy and safety of treatments for nursing home residents with urinary incontinence (UI). PATIENTS AND METHODS: A systematic review was conducted of randomized controlled trials published from January 1985 through May 2008. Data sources were MEDLINE and Cochrane Library databases, proceedings of the 3rd International Consultation on Incontinence, and reference lists of retrieved clinical trials and review articles. Trials were eligible if they consisted of nursing home or long-term institutionalized residents with UI. Eligible trials compared interventions for improving UI with controls, including comparisons of UI outcomes and/or adverse events between randomized groups. RESULTS: Fourteen unique clinical trials, consisting of 1161 patients, met inclusion criteria. Treatments included antimuscarinic medications, oral estrogen plus progesterone, and behavioral interventions (eg, prompted voiding). Compared with usual care, prompted voiding alone or prompted voiding plus exercise reduced daytime incontinence and increased appropriate toileting. Efficacy outcomes indicated that neither prompted voiding plus exercise nor prompted voiding plus oral estrogen and progesterone was superior to prompted voiding alone for incontinence management. Prompted voiding plus oxybutynin slightly reduced incontinence compared with prompted voiding plus placebo. CONCLUSION: In nursing home residents with UI, prompted voiding alone and prompted voiding with exercise were associated with modest short-term improvement in daytime UI. Results do not clearly support an independent effect of exercise in improving UI. Oxybutynin may provide small additional benefit when used with prompted voiding. There appears to be no role for oral estrogen in UI treatment. Long-term clinical trials of prompted voiding alone, prompted voiding with exercise, and antimuscarinic medications should be conducted with targeted nursing home residents who have UI. These trials should include measures of UI, patient quality of life, and cost outcomes.