Urinary Incontinence in Women

General Overview

• Categorise urinary incontinence (UI), direct treatment towards the predominant symptom.
  • Stress UI (SUI),
  • Mixed UI, or
  • Urgency UI/overactive bladder (OAB).
• Symptom scoring and quality‑of‑life assessment (ICIQ, BFLUTS, I‑QOL, SUIQQ, UISS, SEAPI‑QMM, ISI and KHQ)
• Physical Exam
  • Assessment of pelvic floor muscles, with routine digital assessment of contraction
  • Assessment of prolapse, refer if symptomatic and visible at or below the vaginal introitus
• Investigations
  • Urinalysis
  • Urine culture if symptomatic or UA positive leucocytes and nitrites
  • Post-void residual volume (PVR) by bladder scan or catheterisation if voiding dysfunction symptoms or recurrent UTI
    • Refer women who are found to have a palpable bladder on bimanual or abdominal examination after voiding to a specialist
  • Bladder diary x 2-3 days
  • Do NOT do initial urodynamic testing, test for urethral competence, imaging
• Referral
  • Pain
  • Pelvic masses
  • Fecal incontinence
  • Urogenital fistulae (or suspected)
  • Advanced prolapse
  • Neurological disease (or suspected)
  • Symptoms of voiding difficulty
  • Previous pelvic surgery or radiation
• Management
  • Lifestyle interventions
    • Reduce caffeine, fluid intake, and weight (if BMI>30)
  • Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention is causing incontinence, symptomatic infections, or renal dysfunction, and in whom this cannot otherwise be corrected.
  • Consider Desmopressin to reduce nocturia in women with UI or OAB who find it a troublesome symptom.
    • Caution in cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension.
  • Offer intravaginal oestrogens for the treatment of OAB symptoms in postmenopausal women with vaginal atrophy.

Stress Incontinence

• Pelvic floor muscle training
  • Consider supervised > 3 months' duration as first‑line treatment to women with stress or mixed UI
  • Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day
  • Prolong training if beneficial
  • Consider electrical stimulation and/or biofeedback for motivation or adherence
• Consider pessaries/cones or referral for surgery

Urge Incontinence (Overactive Bladder)

• Avoid bladder irritants
• Bladder training >6 weeks first-line
  • If not successful, consider trial of anticholinergic medication (caution in PVR>250mL)
    • Adverse: dry mouth, blurred vision, pruritus, tachycardia, somnolence, impaired cognition, headache and constipation
    • Oxybutynin
      • Avoid in frail elderly
    • Tolterodine
    • Darifenacin
    • Solifenacin (Vesicare)
    • Fesoterodine (Toviaz)
  • Offer a transdermal OAB drug to women unable to tolerate oral medication.
  • Offer a face‑to‑face or telephone review at 4 weeks
    • If suboptimal improvement or intolerable adverse effects change the dose, or try an alternative OAB drug, consider Mirabegron
  • Referral to secondary care if OAB drug treatment is not successful