Urinary Incontinence

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also the separate articles Lower Urinary Tract Symptoms in Men and Lower Urinary Tract Symptoms in Women.

Urinary incontinence is common and it can have an impact on the physical, psychological and social well-being of sufferers, as well as their families and carers.[1] 

Urinary incontinence is the involuntary leakage of urine. The different types of urinary incontinence include:

  • Functional incontinence: the patient is unable to reach the toilet in time for such reasons as poor mobility or unfamiliar surroundings.
  • Stress incontinence: involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This is due to an incompetent sphincter. Stress incontinence may be associated with genitourinary prolapse.
  • Urge incontinence: involuntary urine leakage accompanied by, or immediately preceded by, urgency of micturition. This means a sudden and compelling desire to urinate that cannot be deferred. In urge incontinence there is detrusor instability or hyperreflexia leading to involuntary detrusor contraction. This may be idiopathic or secondary to neurological problems such as stroke, Parkinson's disease, multiple sclerosis, dementia or spinal cord injury.[2] It can sometimes be caused by local irritation due to infection or bladder stones.
  • Mixed incontinence: involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.
  • Overactive bladder syndrome (OAB): urgency that occurs with or without urge incontinence and usually with frequency and nocturia. It may be called 'OAB wet' or 'OAB dry', depending on whether or not the urgency is associated with incontinence. The usual cause of this problem is detrusor overactivity. See also the separate article Detrusor Instability and Irritable Bladder.
  • Overflow incontinence: usually due to chronic bladder outflow obstruction. It is often due to prostatic disease in men. It can lead to obstructive nephropathy due to back pressure; therefore, early assessment and intervention are required. See also the separate articles Acute Urinary Retention and Chronic Urinary Retention. Overflow incontinence may also be due to a neurogenic bladder.
  • True incontinence: may be due to a fistulous track between the vagina and the ureter, or bladder, or urethra. There is continuous leakage of urine.

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  • It is difficult to estimate the prevalence of urinary incontinence, due to differences in its definition and also the fact that it is thought that many people won't admit to having continence problems.[3]
  • Estimates suggest that approximately 3.5 million women suffer from urinary incontinence in the UK.[4] In general, urinary incontinence is two to three times as common in women as in men.[5] 
  • The prevalence increases with age. It is estimated that 46% of women and 34% of men aged over 80 years have urinary incontinence.[3] In a cohort study of individuals aged over 85 years, severe or profound urinary incontinence was reported by 21%.[6]
  • It is estimated that fewer than half of adults with moderate or severe urinary incontinence seek help from healthcare providers.[3]
  • The prevalence of urinary incontinence for adults living in institutions is as high as 50%.[7]
  • Women:
    • Risk factors in women include pregnancy and vaginal delivery (but become less important with age), diabetes mellitus, oral oestrogen therapy and high body mass index.[8][9] 
    • One study found that the perimenopause was associated with stress but not urge incontinence. Postmenopausal women had no higher prevalence of urinary incontinence (any type) than those who were pre-menopausal.[10] 
    • Hysterectomy is related to stress urinary incontinence, particularly vaginal hysterectomy.[11] 
    • Childbirth can cause anatomical or neuromuscular injury and can damage the pelvic floor muscles.[7] A vaginal delivery, the use of forceps and babies of a heavier birth weight are all risk factors.[12][13][14] Caesarean section does not necessarily confer protection against urinary incontinence. One study reported a 40% incidence of this complication, even in patients who had exclusively caesarean deliveries.[15] 
  • Parity is associated with stress but not urge incontinence.[16] 
  • Urinary incontinence occurs more frequently in women with urinary tract infections.[9] 
  • Risk factors in men include lower urinary tract symptoms (LUTS), infections, functional and cognitive impairment, neurological disorders and prostatectomy.[3][9] 
  • Neurological disease/organic brain damage can be a risk factor for incontinence in men and women - eg, stroke, dementia and Parkinson's disease.[2] 
  • Cognitive impairment increases the risk in both sexes. However, mild loss of cognitive function is not a risk factor for urinary incontinence but does increase the impact of urinary incontinence.[9] 
  • Obstruction, including enlarged prostate in men and pelvic tumours in women, can lead to incontinence.
  • Stool impaction may be implicated in elderly patients.[7]

See also the separate articles Gynaecological History and Examination, Genitourinary History and Examination (Female) and Genitourinary History and Examination (Male).

History

  • From the history, determine what type of urinary incontinence the patient has: stress, urge or mixed. If mixed, treatment should be directed towards the most prominent symptoms. Questions in the history can include:[3]
    • Stress incontinence: leakage of urine on sneezing, coughing, exercise, rising from sitting, or lifting.
    • Urge incontinence: urgency and failure to reach a toilet in time.
    • Frequency of urine during the day/at night.
    • Dribbling of urine after leaving the toilet.
    • Loss of bladder control.
    • Feeling of incomplete bladder emptying.
    • Dysuria: pain or burning sensation on passing urine.
    • Bladder spasms.
  • When assessing urinary incontinence in neurological disease, consider factors likely to affect management, such as mobility, hand co-ordination, cognitive function, social support and lifestyle.[2] 
  • A full obstetric history should be taken in women.
  • The patient should be asked during their initial assessment to complete a bladder diary for a minimum of three days. These should include both working days and days off. An example of a bladder diary can be found in Annex 2 of the Scottish Intercollegiate Guidelines Network (SIGN) guidelines.[3]
  • Enquire about sexual dysfunction and quality of life.
  • Assess functional status and access to toilet.
  • Establish whether any medication contributes to symptoms.
  • Enquire about bowel habit.
  • Enquire about desire for treatment.[9] 

Examination

  • Women:
    • Perform digital assessment of pelvic floor muscle contraction.
    • Perform a bimanual/vaginal examination to assess for the presence of prolapse. See the separate article Genitourinary Prolapse for more details about this examination.
    • Look for signs of vaginal atrophy.[9] 
    • Abdominal, pelvic and neurological examination should also be performed.[2][9] 
  • Men:
    • Perform digital rectal examination to assess prostate shape, size and consistency and to check for other rectal pathology.[3]
    • Digital anal assessment can be used to give an indication of pelvic floor muscle strength in men.[3]
    • Abdominal, pelvic and neurological examination should also be performed.[2][9] 

Investigations in primary care[1] 

The National Institute for Health and Care Excellence (NICE) suggests the following for women. It would be reasonable to follow the same guidelines in men.

  • Urinary dipstick testing:
    • Perform a urinary dipstick test to look for blood, glucose, protein, leukocytes and nitrites.
    • If a woman has symptoms of a UTI and dipstick testing shows leukocytes and nitrites, send an MSU for culture and sensitivities. Prescribe antibiotics whilst waiting for results.
    • Also send an MSU in other women with symptoms of UTI but negative urine dipstick testing. Consider antibiotics whilst waiting for results.
    • If a woman has no symptoms of UTI but positive dipstick testing for leukocytes and nitrites, send an MSU but don't start antibiotics until results are available.
    • If a woman has no symptoms and negative dipstick testing for nitrites and leukocytes, no MSU is needed.
    • Renal function tests may be indicated.
  • Assessment of residual urine:
    • Post-void residual volume should be measured in women who have symptoms suggesting voiding dysfunction or recurrent UTI. This is best performed using a bladder scan. Catheterisation may also be used.
    • Post-void residual volume should also be measured in men.[2][3] 
  • Urinary flow rates:
    • Assessment of urinary flow rates is disputed for most cases. They may be measured in men and in patients of either sex with neurological disease.[3]
  • Other investigations:
    • Urodynamic studies: urodynamic testing including multi-channel cystometry, ambulatory urodynamics or video urodynamics is not recommended before starting conservative treatment in women. However, these investigations may be carried out before surgery for urinary incontinence.
    • Multi-channel filling and voiding cystometry should not be performed in women in whom pure stress urinary incontinence is identified by history and examination.
    • Ambulatory urodynamics or videourodynamics should be considered if the diagnosis remains unclear after conventional urodynamics.
    • Cystoscopy is not recommended in the initial assessment of women with urinary incontinence alone.
    • No imaging techniques are recommended in the initial assessment in women, except for ultrasound assessment of residual volume. However, ultrasound of the kidneys is indicated in men and women with neurological disease where renal complications could occur (eg, spina bifida, spinal cord injury).[2] 

Women[1] 

An urgent two-week suspected cancer referral should be made for women who have any of the following:

  • Microscopic haematuria if aged ≥50.
  • Visible haematuria.
  • Recurrent or persisting UTI associated with haematuria if ≥40.
  • Suspected malignant mass arising from the urinary tract.

Refer women with:

  • A palpable bladder on bimanual/abdominal examination after voiding.
  • A prolapse visible at/below the introitus, with the patient symptomatic.

Consider referral to secondary care if:

  • There is persisting bladder or urethral pain.
  • There are clinically benign pelvic masses.
  • There is associated faecal incontinence.
  • There is suspected neurological disease.
  • There are symptoms of voiding difficulty.
  • Urogenital fistulae are suspected.
  • Previous continence surgery has taken place.
  • Previous pelvic cancer surgery has taken place.
  • Previous pelvic radiation therapy has taken place.

Men[3]

  • SIGN guidelines state that men with reduced urinary flow rates (<15 ml/second) or elevated post-void residual volumes (>100 mls) should be referred to secondary care. Local protocols may be in use.
  • If there are any criteria present that meet the two-week suspected cancer referral in men, appropriate referral should be made.
  • NICE recommends referral for men with LUTS complicated by recurrent or persistent UTI, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer.[17] 

Temporary containment products (eg, pads or collecting devices) to achieve social continence should be offered until there is a specific diagnosis and management plan. The permanent use of containment products should only be considered after assessment and exclusion of other methods of management.[1][17]

Urge incontinence and overactive bladder syndrome

See the separate article Detrusor Instability and Irritable Bladder.

Stress incontinence

NICE suggests the following management in women:

  • Pelvic floor muscle exercises:
    • A three-month trial of pelvic floor muscle exercises is the first-line treatment (subsequent to digital assessment of pelvic muscle contraction).
    • This should include eight contractions, three times a day.
    • Continue if successful.
    • Consider electrical stimulation and/or biofeedback in women who cannot actively contract pelvic floor muscles.
    • Provide the patient with a patient information leaflet about pelvic floor exercises.
  • Drug treatment:
    • Duloxetine should not be used as first-line treatment. It may be considered as second-line treatment in women who do not want surgery or who are unsuitable for surgery.
  • Surgical treatment:
    • If conservative measures fail, consider:
      • Retropubic mid-urethral tape procedures using a 'bottom-up' approach with synthetic tape.
      • Open colposuspension
      • Autologous rectal fascial sling.
    • Procedures and devices should be used which have a robust evidence base for effectiveness and safety and for which the surgeon is trained.
    • Synthetic tapes should be selected which are made from type 1 macroporous polypropylene material and are coloured for high-visibility colour.
    • Autologous slings should be used in preference to synthetic tape in patients with neurological disease due to the risk of urethral erosion.[2] 
    • If a transobturator foramen approach is used, women should be informed of the lack of long-term outcome data.
    • Synthetic slings using a retropubic 'top-down' should only be used as part of a clinical trial.
    • Patients should be offered a six-month follow-up appointment (including vaginal examination to exclude cervical erosion).
    • Intramural bulking agents (eg, glutaraldehyde cross-linked collagen, silicone) may be considered if conservative management has failed. However, their efficacy reduces with time, repeat injections may be needed and they are not as effective as retropubic suspension/sling procedures.
    • An artificial sphincter should generally only be considered if previous surgery has failed. However, it may be considered first-line in neurological disease if another procedure such as a sling is considered less likely to promote continence.[2] 
    • If laparoscopic colposuspension is used, the surgeon must be experienced and working in an experienced urogynaecological multidisciplinary team.
    • Anterior colporrhaphy, needle suspensions, paravaginal defect repair and the Marshall-Marchetti-Krantz procedure are not recommended by NICE for the treatment of stress incontinence.

Pelvic floor muscle exercises may be used in men with stress incontinence and in men who have undergone radical prostate surgery.[3] They are also useful for patients of both sexes with stress incontinence due to multiple sclerosis or stroke.[2] NICE supports the use of suburethral synthetic sling insertion for stress urinary incontinence in men.[18] The European Association of Urology guidelines also suggest the use of bulking agents and artificial urinary sphincter for the specialised management of stress incontinence in men.[9] 

Mixed incontinence

In mixed urinary incontinence, treatment should be directed towards the predominant symptom but may involve a combination of approaches.[6]

  • Pelvic floor exercises and bladder training, as above, are first-line treatment, both in men and in women.[3]
  • The antimuscarinic drug oxybutynin can be started if these are not effective (not recommended in frail, elderly women).
  • Newer antimuscarinic drugs such as darifenacin, solifenacin, tolterodine, and trospium are alternatives if oxybutynin is not well tolerated. Extended-release or transdermal oxybutynin are other possibilities.
  • Fesoterodine and propiverine are more recent antimuscarinics also licensed for this use.[19] 
  • Antimuscarinics are useful in the management of patients with neurological disease affecting the brain (eg, cerebral palsy) and overactive bladder syndrome and in those with bladder storage disorders. They should, however, be used with caution, as they can cause constipation, urinary retention and confusion.[2] 
  • Annual review should be undertaken of patients on long-term medication (six-monthly for women aged over 75).[1] 
  • In women with predominantly stress incontinence, NICE recommends discussing conservative options including drugs, before considering surgery.[1] 

Overflow incontinence

  • Overflow incontinence due to bladder outlet obstruction should be managed by relieving/treating the obstruction.
  • Intermittent self-catheterisation may be carried out.
  • If there is obstruction due to prostatic hypertrophy (benign or malignant), this should be managed appropriately. Please refer to the separate articles Benign Prostatic Hyperplasia and Prostatic Carcinoma for more details.

Catheterisation[1][17]

See also the separate article Catheterising Bladders. NICE suggests the following:

  • Intermittent catheterisation or indwelling urethral or suprapubic catheterisation may be needed for some patients - eg, if there is persistent urinary retention leading to incontinence, if there is renal impairment or if there are symptomatic infections.
  • Women with urinary retention may be taught to perform intermittent urethral self-catheterisation.
  • Indwelling catheters (either urethral or suprapubic) may be indicated if:
    • There is chronic urinary retention and the person cannot perform self-catheterisation.
    • Skin wounds, pressure sores or skin irritations are being contaminated by urine.
    • There is distress or disruption caused by changing clothes and the bed.
    • A woman would like this form of management.
  • Suprapubic catheters may have lower complication rates, including lower rates of symptomatic UTI and by-passing.

Other management points

  • If someone has cognitive impairment, they should follow a prompted and timed toileting programme.
  • Patients with neurological disease may also benefit from bladder retraining or habit retraining after assessment by a healthcare professional trained in such techniques. Carers/families should - with the patient's consent - be involved.[2] 
  • Botulinum toxin type A is sometimes used in some patients with neurological disease - eg, those with spinal cord disease and overactive bladder or impaired bladder storage.[2] 
  • Augmentation cystoplasty using an intestinal segment may be offered to patients with non-progressive neurological disease and impaired bladder storage.[2] 
  • Ileal conduit diversion (urostomy) with or without cystectomy may be considered for patients whose neurological disease causes intractable problems.[2] 
  • Desmopressin may be prescribed in women with troublesome nocturia. It should be used with caution in women with cystic fibrosis and is contra-indicated in those aged over 65 with cardiovascular disease or hypertension.[1] Its use in idiopathic urinary incontinence is outside its UK licence and women should be informed of this.
  • NICE does NOT recommend the following for the treatment of urinary incontinence:[1]
    • Propiverine, flavoxate, imipramine or propantheline.
    • Systemic hormone replacement therapy.
    • Complementary therapies.
  • Give patients the opportunity to return for review in the future to discuss investigations and management options, even if no treatment is wanted currently.
  • Offer all women pelvic floor muscle training in their first pregnancy.[1] 
  • Weight control may reduce the risk of developing incontinence.

Further reading & references

  1. Urinary incontinence: The management of urinary incontinence in women; NICE Clinical Guideline (Sept 2013)
  2. Urinary incontinence in neurological disease; NICE Clinical guideline (Aug 2012)
  3. Management of urinary incontinence in primary care; Scottish Intercollegiate Guidelines Network - SIGN (2005)
  4. Price N, Currie I; Urinary incontinence in women: diagnosis and management. Practitioner. 2010 Mar;254(1727):27-32, 2-3.
  5. Cook K et al; Urinary Incontinence in the Older Adult, American College of Clinical Pharmacy, 2012
  6. Thirugnanasothy S; Managing urinary incontinence in older people. BMJ. 2010 Aug 9;341:c3835. doi: 10.1136/bmj.c3835.
  7. Norton P, Brubaker L; Urinary incontinence in women. Lancet. 2006 Jan 7;367(9504):57-67.
  8. Townsend MK, Danforth KN, Rosner B, et al; Body mass index, weight gain, and incident urinary incontinence in middle-aged women. Obstet Gynecol. 2007 Aug;110(2 Pt 1):346-53.
  9. Guidelines on Urinary Incontinence; European Association of Urology (March 2013)
  10. Mishra GD, Cardozo L, Kuh D; Menopausal transition and the risk of urinary incontinence: results from a British prospective cohort. BJU Int. 2010 Oct;106(8):1170-5. doi: 10.1111/j.1464-410X.2010.09321.x.
  11. Forsgren C, Lundholm C, Johansson AL, et al; Vaginal hysterectomy and risk of pelvic organ prolapse and stress urinary incontinence surgery. Int Urogynecol J. 2012 Jan;23(1):43-8. doi: 10.1007/s00192-011-1523-z. Epub 2011 Aug 18.
  12. Gyhagen M, Bullarbo M, Nielsen TF, et al; The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013 Jan;120(2):144-51. doi: 10.1111/j.1471-0528.2012.03301.x. Epub 2012 Mar 14.
  13. Baydock SA, Flood C, Schulz JA, et al; Prevalence and risk factors for urinary and fecal incontinence four months after vaginal delivery. J Obstet Gynaecol Can. 2009 Jan;31(1):36-41.
  14. Matthews CA, Whitehead WE, Townsend MK, et al; Risk factors for urinary, fecal, or dual incontinence in the Nurses' Health Study. Obstet Gynecol. 2013 Sep;122(3):539-45. doi: 10.1097/AOG.0b013e31829efbff.
  15. MacArthur C, Glazener C, Lancashire R, et al; Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. BJOG. 2011 Jul;118(8):1001-7. doi: 10.1111/j.1471-0528.2011.02964.x. Epub 2011 Apr 8.
  16. Hirsch AG, Minassian VA, Dilley A, et al; Parity is not associated with urgency with or without urinary incontinence. Int Urogynecol J. 2010 Sep;21(9):1095-102. doi: 10.1007/s00192-010-1164-7. Epub 2010 May 11.
  17. The management of lower urinary tract symptoms in men; NICE Clinical Guideline (May 2010)
  18. Suburethral synthetic sling insertion for stress urinary incontinence in men; NICE Interventional Procedure Guideline (March 2008)
  19. British National Formulary

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Michelle Wright
Current Version:
Peer Reviewer:
Dr Helen Huins
Last Checked:
25/11/2013
Document ID:
2903 (v23)
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