Water integrity refers to the ethical, professional, and transparent use of power and resources to ensure the sustainable and equitable provision of water services. The Integrity Management (IM) Toolbox is a tool that has been adopted to initiate IM reforms within water utilities. This paper reviews the application of the IM Toolbox application in 22 urban utilities across 7 countries from 2013 to 2018, focusing on integrity risks, selected tools, and the success and challenges faced by these utilities. Common integrity risks were identified in Operations and Consumer Relations, and corresponding tools were employed in Human Resources and Consumer Relations. Within 1 year, over two-thirds of the utilities implemented 70% or more of their action plans, indicating positive progress. However, obstacles such as staff rotation and reliance on internal champions provide obstacles to continued implementation. Despite challenges, certain utilities demonstrated notable medium-term improvements. To further advance water integrity, integrating the IM Toolbox with other utility-level efficiency processes is recommended. Additionally, supporting sectoral regulatory measures can contribute to overall integrity enhancement. By effectively addressing integrity risks and adopting comprehensive approaches, water utilities can enhance their ability to provide safe and sustainable water services, while promoting transparency and equity.