Urinary Incontinence ✅

🩺 Scope note: This summary is mainly based on NICE NG123, which covers urinary incontinence in women aged 18+. Male LUTS/incontinence is covered separately in NICE CG97.

📖 Introduction

Urinary incontinence is the involuntary leakage of urine. In practice, the most important subtypes are stress, urgency (often part of overactive bladder), and mixed incontinence. Assessment should identify the likely subtype, exclude reversible or sinister causes, and guide conservative treatment first.

💊 Always review medicines. Drugs can worsen continence by increasing urine production, impairing awareness or mobility, causing cough, causing retention, or increasing anticholinergic burden.

🔎 Main Types

• 💨 Stress incontinence: leakage with raised intra-abdominal pressure such as coughing, sneezing, or exercise.
• ⚡ Urgency incontinence: leakage associated with a sudden compelling desire to pass urine, often with frequency and nocturia as part of overactive bladder.
• 🔀 Mixed incontinence: features of both stress and urgency incontinence.

⚙️ Important Contributors

• 🤰 Pregnancy, vaginal delivery, and pelvic floor trauma
• ⚖️ Obesity
• 🧓 Menopause and urogenital atrophy
• 🧠 Neurological disease
• 🦠 Urinary tract infection
• 💊 Drugs such as diuretics, sedatives, opioids, alpha-blockers, ACE inhibitors, and medicines causing retention or constipation

👩‍⚕️ NICE Initial Assessment

• History: onset, urgency, stress triggers, frequency, nocturia, voiding symptoms, haematuria, UTIs, obstetric/gynaecological history, neurological disease, bowel symptoms, medicines, and impact on quality of life.
• Examination: abdomen, pelvic examination where appropriate, and assessment for prolapse or incomplete emptying.
• Urine dipstick for all women presenting with urinary incontinence.
• Bladder diary for a minimum of 3 days.
• Post-void residual only if symptoms suggest voiding dysfunction or there is recurrent UTI.

🧠 Do not over-investigate early. NICE says do not routinely use cystoscopy in the initial assessment of women with urinary incontinence alone, and do not routinely use imaging apart from ultrasound for residual urine volume.

🚩 When to Refer / Escalate

• Persistent bladder or urethral pain
• Palpable bladder after voiding
• Pelvic mass
• Associated faecal incontinence
• Suspected neurological disease
• Voiding difficulty
• Suspected urogenital fistula
• Previous continence surgery, pelvic cancer surgery, or pelvic radiotherapy

🚨 Cancer red flag: follow NICE NG12 for haematuria. Visible haematuria — not incontinence itself — is the key trigger for suspected bladder/renal cancer referral.

🩺 First-Line Non-Surgical Management

• ☕ Caffeine reduction for overactive bladder symptoms
• 💧 Modify fluid intake if very high or very low
• ⚖️ Weight loss if BMI >30
• 💪 Supervised pelvic floor muscle training for at least 3 months as first-line treatment for stress or mixed incontinence
• 📌 PFMT programmes should include at least 8 contractions, 3 times per day
• 🕒 Bladder training for at least 6 weeks as first-line treatment for urgency or mixed incontinence

💊 Medicines (NICE-Aligned)

• Overactive bladder / urgency symptoms: offer an anticholinergic with the lowest acquisition cost first.
• If the first anticholinergic is ineffective or not tolerated, try another anticholinergic.
• Do not offer immediate-release oxybutynin to older women at higher risk of sudden physical or mental deterioration.
• Mirabegron (and now also vibegron) are options if antimuscarinics are contraindicated, ineffective, or cause unacceptable side effects.
• Offer a review at 4 weeks after starting a new overactive bladder medicine.
• Duloxetine is not first-line for stress incontinence and is not routinely second-line, though it may be considered if surgery is unsuitable or the woman prefers medication.
• Offer vaginal oestrogen to women with overactive bladder symptoms plus genitourinary symptoms/signs associated with menopause.
• Do not use systemic HRT to treat urinary incontinence.

🔬 Further / Specialist Treatments

• Botulinum toxin type A for refractory overactive bladder after MDT review; initial dose 100 units, with counselling about UTI risk and possible need for intermittent catheterisation.
• Percutaneous sacral nerve stimulation may be offered after MDT review if medicines and other non-surgical treatment have failed and botulinum toxin has failed or is unacceptable.
• Do not offer transcutaneous sacral nerve stimulation (TENS) or transcutaneous posterior tibial nerve stimulation for overactive bladder.

🏥 Stress Incontinence Surgery (after failed conservative treatment)

• NICE surgical choices include:
  • Colposuspension (open or laparoscopic)
  • Autologous rectus fascial sling
  • Retropubic mid-urethral mesh sling with specific counselling and registry requirements
• Bulking agents may be considered if other surgery is unsuitable or unacceptable, but they are less effective and may need repeat injections.
• Do not routinely offer a transobturator mesh approach unless there are specific clinical reasons to avoid the retropubic route.

🧪 Urodynamics

• Do not routinely perform multichannel filling and voiding cystometry before primary surgery if stress or stress-predominant mixed incontinence is clearly diagnosed from history and examination.
• Do perform it before surgery if the type is unclear, symptoms are urge-predominant mixed, there are voiding symptoms, prolapse, or previous stress incontinence surgery.

🧠 Teaching Pearl

Urinary incontinence is not “just ageing.” The pathophysiology usually reflects either urethral support failure (stress incontinence), detrusor overactivity (urgency incontinence), or a mixture of both. That is why NICE starts with symptom pattern recognition and conservative therapy: pelvic floor training targets outlet support, while bladder training and OAB medicines target detrusor overactivity.

📚 References

• NICE NG123: Urinary incontinence and pelvic organ prolapse in women: management
• NICE NG123 recommendations
• NICE CG97: Lower urinary tract symptoms in men: management
• NICE NG12: Suspected cancer: recognition and referral
• NICE TA290: Mirabegron for treating symptoms of overactive bladder