Urinary Incontinence Management
Initial Evaluation Framework
Begin with a focused history and physical examination to categorize incontinence type (stress, urgency, mixed, overflow, or functional), assess severity, and determine the degree of bother to the patient. 1, 2
Essential History Components
Characterize the incontinence pattern by asking specifically when leakage occurs: with physical activity/coughing/sneezing (stress incontinence) versus with sudden urge to void (urgency incontinence). 1, 2
Assess symptom severity and impact on quality of life using validated questionnaires, as 18 psychometrically robust instruments are now available for urinary incontinence assessment. 1
Document frequency and volume of leakage using a 3-day bladder diary or frequency-volume chart, which provides objective data on urinary patterns and nocturia. 2, 3
Review medical comorbidities and medications that may contribute to incontinence, including diuretics, anticholinergics, alpha-blockers, and sedatives. 2, 3
Inquire about previous treatments and their effectiveness, as this guides subsequent management decisions. 4
Physical Examination Requirements
Perform a systematic pelvic examination to assess for pelvic organ prolapse, vaginal atrophy, and pelvic floor muscle strength. 2, 3
Conduct a cough stress test with a comfortably full bladder to objectively demonstrate stress incontinence during examination. 3, 5
Assess for neurological abnormalities including perineal sensation and lower extremity reflexes to identify neurogenic causes. 2, 6
Mandatory Diagnostic Testing
Obtain urinalysis to exclude urinary tract infection, hematuria, proteinuria, or glycosuria requiring further investigation. 2, 3
Measure post-void residual urine volume to identify overflow incontinence and assess bladder emptying efficiency; elevated PVR suggests obstruction or detrusor underactivity. 2, 3
Consider urodynamic studies when the incontinence type cannot be definitively determined from history/examination, when surgical intervention is planned, or when initial treatments fail. 2, 3
Management Algorithm by Incontinence Type
Stress Urinary Incontinence
Initiate pelvic floor muscle training (PFMT) as first-line therapy for all women with stress incontinence, as this conservative approach yields significant symptom improvement without the risks of surgical intervention. 1, 4
Conservative Management (First-Line)
Prescribe supervised pelvic floor physical therapy with a trained therapist, as this demonstrates superior outcomes compared to unsupervised exercises. 1, 4
Recommend lifestyle modifications including weight loss (if BMI >25), caffeine reduction, adequate but not excessive hydration, and avoidance of heavy lifting. 7, 4
Consider pessaries or vaginal inserts for women who prefer non-surgical options or have contraindications to surgery. 7, 8
Surgical Management (When Conservative Fails)
Offer midurethral sling placement as the primary surgical option, which achieves symptom improvement in 48-90% of women with low mesh complication rates (<5%). 1, 4
Discuss alternative surgical options including Burch colposuspension and autologous fascial slings, which have robust evidence but different adverse event profiles compared to synthetic slings. 1
Reserve urethral bulking agents for patients unable to tolerate more invasive surgery, though efficacy is low and cure is rare. 2
Urgency Urinary Incontinence (Overactive Bladder)
Start with behavioral interventions and bladder training before pharmacotherapy, as these approaches have no side effects and can be highly effective. 7, 4
Behavioral Interventions (First-Line)
Implement timed voiding schedules with gradually increasing intervals between voids to increase bladder capacity. 2, 7
Prescribe pelvic floor physical therapy which benefits urgency incontinence through pelvic floor strengthening and urge suppression techniques. 7, 8
Recommend bladder training programs particularly for patients with cognitive impairment, using prompted voiding schedules. 2
Pharmacological Management (Second-Line)
Prescribe beta-3 adrenergic agonists (mirabegron) as preferred first-line medication over anticholinergics due to better side effect profile. 7
Consider anticholinergic medications as an alternative, but counsel patients about potential adverse effects including dry mouth, constipation, and cognitive impairment in elderly patients. 7, 8
Reassess symptoms at 2-4 weeks after initiating medication to determine treatment success and adjust therapy accordingly. 2
Procedural Interventions (Third-Line)
Offer onabotulinumtoxinA bladder injections for refractory urgency incontinence, which provides symptom improvement in appropriately selected patients. 7, 4
Consider percutaneous tibial nerve stimulation as a minimally invasive neuromodulation option. 7, 4
Reserve sacral neuromodulation for patients who fail conservative and medical management, as this requires surgical implantation. 7, 4
Mixed Incontinence
Treat the predominant symptom first using the corresponding algorithm above, then address residual symptoms with targeted therapy. 1, 8
Recognize that urgency-predominant mixed incontinence should be managed per overactive bladder guidelines initially. 1
Overflow Incontinence
Initiate clean intermittent catheterization for patients with elevated post-void residual and overflow incontinence. 7
Identify and treat the underlying cause including bladder outlet obstruction or detrusor underactivity through appropriate referral. 7, 8
Special Populations and Considerations
Post-Prostate Treatment Incontinence (Men)
Offer pelvic floor muscle exercises immediately post-operatively after radical prostatectomy, as this improves time-to-continence compared to controls. 1
Counsel patients that continence recovery typically occurs within 12 months of surgery, though most men are not continent at catheter removal. 1
Consider surgical intervention as early as 6 months if incontinence is not improving despite conservative therapy and symptoms are bothersome. 1
Offer artificial urinary sphincter as first-line surgical option for severe post-prostatectomy incontinence, though failure rates are approximately 24% at 5 years. 1, 2
Pediatric Incontinence
Implement urotherapy as the mainstay of treatment for all types of urinary incontinence in children, including education, regular voiding schedule, proper posture, and adequate hydration. 9
Address underlying constipation aggressively, as treatment can lead to resolution of urinary symptoms in up to 89% of cases with daytime incontinence. 9
Consider enuresis alarm therapy for monosymptomatic nocturnal enuresis, as it shows superior long-term success rates compared to medications. 9
Red Flags Requiring Urgent Referral
Immediately refer to urology or urogynecology when any of the following are present: 2, 3
Hematuria without infection (requires cystoscopy to exclude malignancy) 2, 3
Severe back pain with urinary incontinence (cauda equina syndrome until proven otherwise—requires emergent MRI within hours) 6
Advanced pelvic organ prolapse beyond the introitus 4
Neurological disease affecting bladder function 2
Persistent incontinence >6 months post-prostate surgery despite conservative therapy 1
Abnormal PSA or suspected prostate pathology 2
Critical Pitfalls to Avoid
Do not attribute incontinence to aging alone without proper evaluation, as this leads to undertreatment of a highly treatable condition. 4, 5
Do not proceed with incontinence surgery until bladder outlet obstruction (urethral stricture, bladder neck contracture) is treated, as obstruction decreases surgical success rates. 2
Do not delay evaluation with conservative trials when red flags are present, particularly severe back pain suggesting cauda equina syndrome. 6
Do not use the Wexner score for anal incontinence despite its widespread use, as it lacks published psychometric validation data. 1
Do not overlook the substantial gap between prevalence and treatment-seeking behavior—only 25% of affected women seek care despite effective treatments being available. 4, 5