Urinary Incontinence

The types

The right treatment begins with the right type:

• Stress type: involuntary leaking in situations where the pressure inside the abdomen rises, such as coughing, sneezing, laughing or exercise.
• Urge type: leaking that comes with, or immediately after, a strong and difficult-to-postpone urge to pass urine that appears suddenly.
• Mixed type: both together.
• Overactive bladder: a sudden feeling of urgency, with frequent passing of urine and getting up at night. Leaking may or may not accompany it.

In the mixed type, treatment is directed according to the predominant complaint.

What is done in the assessment?

• A detailed history is taken and the type classified; predisposing and triggering factors are looked into.
• Urine test: a urine dipstick test is done to rule out a urinary tract infection.
• Examination: before starting supervised pelvic floor exercise, a vaginal examination is done to confirm that you can contract the muscles correctly.
• Bladder diary: you are asked to keep one for at least 3 days, covering both your working and your leisure activities.
• The amount left after passing urine: if there is doubt, ultrasound is preferred to a catheter — it is more comfortable and avoids the risk of infection that comes with a catheter.

Which tests are unnecessary?

When is bladder pressure measurement (urodynamic testing) needed?

In people in whom the history and examination clearly identify the stress type or a stress-predominant mixed type, routine urodynamic testing before a first operation is not recommended. But it needs to be done before an operation in the following situations:

• Urge-predominant mixed type, or uncertainty about the type
• Suspicion of difficulty emptying the bladder
• Accompanying pelvic organ prolapse
• A previous unsuccessful operation for stress incontinence

The first step: treatments without medicines

Pelvic floor muscle training

This is the first-line treatment in the stress or mixed type:

• A supervised programme lasting at least 3 months should be carried out.
• The programme should include at least 8 contractions three times a day.
• Devices that show muscle activity on a screen are not routinely recommended; they are considered only in people who cannot initiate a muscle contraction on their own, to support adherence.

Bladder training

In the urge or mixed type, bladder training lasting at least 6 weeks should be offered as the first step. If it is not sufficient on its own it can be combined with drug treatment.

Lifestyle

• In overactive bladder, reducing caffeine is recommended.
• Fluid intake is adjusted if it is very high or very low.
• Weight loss is recommended for those with a body mass index above 30.

Drug treatments

Urge type and overactive bladder

• Medicines that relax the bladder (anticholinergics): the first option. Before starting, the following should be explained to you: side effects such as dry mouth and constipation may indicate that the medicine is working; at least 4 weeks are needed for the full benefit; and the long-term effects on cognitive function are uncertain. Immediate-release oxybutynin is avoided in older and frail people. If those taken by mouth cannot be tolerated, forms applied through the skin may be offered.
• Beta-3 agonists (mirabegron, vibegron): used if anticholinergics are not suitable, are ineffective or cannot be tolerated.
• Desmopressin: may be considered particularly for getting up at night to pass urine where this affects quality of life. Care is needed in patients with cystic fibrosis; it is avoided in those over 65 and those with cardiovascular disease.
• Local (vaginal) oestrogen: offered to those who have complaints such as dryness, painful intercourse and irritation due to menopause and who also have an overactive bladder.

Stress type

Duloxetine should not be used as a first step; nor is it routinely offered as a second step. It may be considered as a second step, with its side effects explained, only in people who do not want surgery or are not suitable for it and who prefer drug treatment.

Surgery

Before a decision to operate, the advantages and risks of all the options should be explained. The guideline particularly emphasises discussing the long-term complications of mesh materials.

Surgery comes up after treatments without medicines and, where appropriate, drug treatment have been tried — it is not the first step.