Urinary Incontinence in Women
NICE guideline [NG123] Urinary incontinence and pelvic organ prolapse in women: management. Last updated: Jun 2019.
NICE CKS Incontinence – urinary, in women. Last revised: Jan 2025.
Background information added accordingly.
Date: 15/12/25
Background Information
Definition and Types
Urinary incontinence: any involuntary leakage of urine
Main types of urinary incontinence:
| Type | Mechanism | Causes and contributing factors | Key Features |
|---|---|---|---|
| Stress incontinence | Urethral support system dysfunction (weakened / damaged urethral sphincter, pelvic floor muscles, connective tissues) → inability to maintain urethral closure upon ↑ intra-abdominal pressure |
|
Involuntary leakage upon events that ↑ intra-abdominal pressure:
|
| Urge incontinence | Overactive bladder (detrusor overactivity – involuntary contractions of detrusor muscles) | Idiopathic in most women
|
Involuntary leakage accompanied / preceded by urgency (a sudden compelling desire to pass urine that is difficult to defer)
Bedside test: ask the woman to cough with a full bladder (urinary leakage is indicative of urge incontinence) |
| Mixed incontinence | Combination of stress and urge mechanisms | Symptoms of both stress and urge incontinence | |
| Overflow incontinence | Bladder neck obstruction / impairment of detrusor contractility |
|
Continuous dribbling in the absence of urgency |
| Functional incontinence | Inability to reach the bathroom due to physical or cognitive impairment |
|
|
The main risk factor for developing any type of urinary incontinence is older age due to physiological changes with natural ageing (e.g. decreased bladder capacity and feeling of fullness, decreased rate of detrusor muscle contraction, decreased pelvic floor muscle resistance, increased residual urine volume)
Be aware that overactive bladder and urge urinary incontinence are related but not synonymous:
- Overactive bladder refers to a symptom complex characterised by urinary urgency, usually with frequency and nocturia, with or without urge urinary incontinence.
- Urge urinary incontinence occurs when symptoms of overactive bladder are accompanied by involuntary leakage of urine.
Therefore, overactive bladder may exist without incontinence, whereas urge urinary incontinence represents overactive bladder with leakage
Diagnosis
Investigation Diagnosis
Routine assessment for ALL patients:
| Assessment | Purpose | Description |
|---|---|---|
| Bladder diary (minimum 3 days) | To characterise urinary symptoms (i.e. type of incontinence) and severity | A bladder diary should cover variations in usual activities (such as working and leisure days) and document:
|
| Urine dipstick | To exclude differential diagnoses | Important differential diagnoses to exclude:
|
| Post-void bladder scan | To assess residual bladder volume | ↑ Residual volume suggests incomplete bladder emptying, which may be caused by:
|
| Assess pelvic floor muscle contractions | To assess pelvic floor function and suitability for pelvic floor muscle training | Performed by digital vaginal examination.
Muscle strength may be graded using the Modified Oxford Scale (0–5) |
Urodynamic testing (multichannel filling and voiding cystometry) should only be performed if:
- Type of urinary incontinence is unclear
- Urge-predominant mixed urinary incontinence
- Voiding dysfunction suspected
- Anterior or apical prolapse
- History of previous surgery for stress urinary incontinence
Do not use pad tests (quantifying urine leak by weighing absorbent pads before and after a set period during normal activities) in the routine assessment of women with urinary incontinence.
Management
It’s common for various types of urinary incontinence to co-exist. Management of urinary incontinence depends on the predominant presentation.
Urge Incontinence (Overactive Bladder)
Approach (step up if ineffective):
- Step 1: conservative management
- Step 2: pharmacological management
- Step 3: invasive management
Conservative / General Management
Offer bladder retraining for 6 weeks – urge incontinence specific
Advice for any type of incontinence
- Weight loss (if BMI >30)
- Regulate fluid intake
- Avoid bladder stimulants (e.g. caffeine)
- Absorbent containment products, hand-held urinals, and toileting aids
- NICE says not to offer as a treatment, but only as a coping strategy / adjunct / after treatment options have been explored
Pharmacological Management
- 1st line: anti-cholinergic (e.g. oxybutynin, darifenacin, tolterodine)
- 2nd line: beta-3 receptor agonist (e.g. mirabegron, vibegron)
Consider desmopressin to manage bothersome nocturia
Common reasons to avoid antimuscarinics are:
- Glaucoma
- Patient of old age / at risk of cognitive impairment / with cognitive impairment
- Known myasthenia gravis
Invasive Management
Options for proven overactive bladder (by urodynamic studies):
- 1st line: botulinum toxin A injection
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty (patient must be willing and able to self-catheterise)
- Last resort: urinary diversion via ileal conduit
Stress Incontinence
Approach (step up if ineffective):
- Step 1: conservative management
- Step 2: pharmacological or invasive management
Conservative / General Management
Offer pelvic floor muscle training for at least 3 months (at least 8 contractions, 3 times per day) – stress incontinence specific
Advice for any type of incontinence
- Weight loss (if BMI >30)
- Regulate fluid intake
- Avoid bladder stimulants (e.g. caffeine)
- Absorbent containment products, hand-held urinals, and toileting aids
- NICE says not to offer as a treatment, but only as a coping strategy / adjunct / after treatment options have been explored
Pharmacological Management
Consider duloxetine if patient prefers pharmacological management over invasive management.
Invasive Management
Options:
- Colposuspension
- Autologous rectus fascial sling
- Retropubic mid-urethral mesh sling
Consider intramural bulking agents if the above are not suitable / acceptable.
Overflow Incontinence
If there is persistent urinary retention and cannot be corrected:
- 1st line: intermittent urethral catheterisation
- 2nd line: indwelling suprapubic catheters (preferred over long-term urethral catheters)
Whenever feasible, intermittent catheterisation is preferred over an indwelling catheter, due to lower infection risk (catheter-associated UTI) and better preservation of bladder function.