• Advise, and give information on, weight loss if the woman has a body mass index of 30 kg/m² or greater (see the CKS topic on Obesity).
• Advise the woman to avoid drinking either excessive amounts, or small amounts, of fluid each day. The recommended daily intake is six to eight glasses of water (or other fluid).
• Although there is no evidence that modification of other behaviours improves incontinence symptoms, consider providing advice on regulating bowel habit, stopping smoking, or increasing physical exercise. Improving mobility may be helpful to disabled elderly women.

In depth

• Reserve the use of absorbent products for the following circumstances:
• To cope with urinary leakage whilst awaiting assessment and treatment.
• To contain leakage whilst awaiting response to ongoing treatment.
• For women with severe cognitive or mobility impairment that precludes further assessment or treatment.
• For long-term management only after all treatment options have been explored.
• If appropriate, refer to a continence adviser or the district nursing service to enable provision of the most suitable daytime and night-time protection (such as pads).
• If the woman is keen to purchase an intravaginal or intraurethral device, advise that they may only be used occasionally to prevent incontinence (such as during physical exercise).
• Do not recommend the use of menstrual tampons for incontinence.
• Ring pessaries are not recommended.

In depth

• Refer to a gynaecologist or urogynaecologist if there is associated prolapse that is symptomatic or visible at or below the introitus.
• Otherwise, refer to an appropriate practitioner for full assessment and consideration for a programme of supervised pelvic floor muscle training (PFMT) that should ideally last for at least 3 months. Women require an individualized programme based on assessment.
• Digital assessment of pelvic floor muscle contraction should be done before implementation of a PFMT programme.
• At a minimum, eight pelvic floor muscle contractions should be performed at least three times a day.
• The woman should be reviewed after 12 weeks or as required to assess response.
• The woman should be advised to continue taught PFMT exercises if she is experiencing sufficient benefit.
• The use of weighted vaginal cones or multicomponent behavioural therapy (bladder training plus PFMT) may improve the outcome of PFMT, but requires specialist provision and high levels of motivation in the woman.
• Biofeedback may assist motivation, and electrical stimulation may be of help to women who cannot initiate a pelvic floor muscle contraction.
• If initial conservative treatments fail or if the woman expresses a preference, consider:
• Referring to a urologist, urogynaecologist, or gynaecologist for urodynamic investigations and surgery. See Secondary care treatments for stress urinary incontinence.
• Offering duloxetine as a second-line treatment, but only if the woman prefers pharmacological to surgical treatment or is not suitable for surgical treatment.
• Drug treatment with alpha 1A-adrenoreceptor agonists (for example, pseudoephedrine) is not recommended.
• In frail elderly people:
• Treat any reversible causes or contributing factors to stress urinary incontinence (such as cognitive impairment, urinary tract infection, excess fluid intake, restricted mobility, constipation, or adverse effects of medications).
• Take into account desire and suitability for treatment. Where appropriate, refer for full assessment and consideration of PFMT.
• Refer where appropriate to a continence adviser, the district nursing team, or elderly care team for specialist assessment for the management of incontinence.

In depth