• 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

• Treat any conditions that may be causing or contributing to the symptoms, including:
• Lower urinary tract conditions (such as urinary tract infection).
• Neurological conditions (such as Parkinson's disease and multiple sclerosis).
• Systemic conditions (such as congestive heart failure and diabetes mellitus).
• Functional and behavioural disorders (such as impaired mobility and excess alcohol use).
• Adverse effects of medication (such as rapid-acting diuretics).
• Recommend caffeine reduction if appropriate.
• Refer women with an overactive bladder with or without urgency incontinence, and those with mixed urinary incontinence, to an appropriate practitioner for a full assessment and consideration of bladder training for a minimum of 6 weeks.
• If bladder training is ineffective, offer to add in immediate-release oxybutynin with upward dose titration from an initial low dose. Encourage the woman to persist with bladder training.
• If immediate-release oxybutynin is not tolerated, consider other antimuscarinic drugs (darifenacin, fesoterodine, solifenacin, tolterodine, and trospium) or an alternative formulation of oxybutynin (modified-release tablets or transdermal patches).
• If antimuscarinic drugs are prescribed:
• Counsel the person regarding the adverse effects of these drugs — particularly elderly people, who are more prone to the antimuscarinic adverse effects (see below).
• Review after 6 weeks' treatment to assess the balance between beneficial and adverse effects.
• If beneficial, review treatment after 6 months to assess whether it is still needed.
• Continue treatment for as long as benefit is maintained and the woman wishes for it to be continued.
• Consider:
• Propiverine to treat frequency in women with an overactive bladder without incontinence.
• Intravaginal oestrogen therapy (but not systemic hormone replacement therapy) with PFMT or other treatments in postmenopausal women with vaginal atrophy, urethral pain, or dysuria.
• Review at least annually to re-assess the need for continued treatment and to monitor for symptoms of endometrial hyperplasia or carcinoma in women with a uterus.
• Long-term treatment may be required. Consider seeking specialist advice if uncertain how long to prescribe intravaginal oestrogen therapy for.
• Desmopressin (unlicensed use) if the woman has troublesome nocturia and is younger than 65 years of age without cardiovascular disease. Advise restriction of night-time intake of fluid to reduce the risk of fluid retention and water intoxication. With desmopressin, measure serum sodium (particularly in elderly people and in people at risk of hyponatraemia):
• Before starting treatment.
• 72 hours after starting treatment.
• If unwell.
• If medications change.
• If hyponatraemia is suspected.
• If conservative measures fail, refer for urodynamic investigations and consideration of sacral nerve stimulation, treatment with botulinum toxin, or surgery. See Secondary care treatments for urgency incontinence.
• In frail elderly people:
• Take into account cognitive function, mobility, dexterity, desire for treatment, and expectation.
• Where appropriate, refer for a full assessment and consideration for bladder training.
• Review current medication. Consider adding an antimuscarinic; start at the lowest dose, as adverse effects, particularly confusion, are more common in elderly people. Be aware that antimuscarinic drugs may affect cognitive function in elderly people (particularly if cognitive impairment is already present — for example dementia) and monitor regularly for this.
• Refer where appropriate to a continence adviser, the district nursing team, or elderly care team for specialist assessment for the management of incontinence.
• For some women with urgency incontinence who have cognitive impairment, limited mobility, or both, the use of toilet-assisted protocols, such as prompted or timed voiding, can be helpful.
• The following treatments are not recommended:
• Propantheline, flavoxate, or imipramine.
• Diuretics. However, these are needed if there is nocturnal polyuria secondary to cardiac failure.
• Complementary therapies (acupuncture, hypnosis, herbal medicines).

In depth