• Scenario: Initial assessment and referral: covers how to determine what sort of incontinence the woman has; how to carry out a full assessment of underlying causes, severity, and the impact on the woman's life; and who to refer for further investigations.
• Scenario: Management of stress incontinence: covers lifestyle advice; whether to recommend pads or containment devices; and the conservative management of stress incontinence, including when to refer to secondary care.
• Scenario: Management of urgency incontinence: covers lifestyle advice; whether to recommend pads or containment devices; and the conservative management of urgency incontinence and overactive bladder, including when to refer to secondary care.

• Determine what type of incontinence the woman has, and
• Identify any causes or conditions that are exacerbating the urinary incontinence, and
• Determine how severe the incontinence is, and
• Determine the effect of the incontinence on the woman's quality of life.

• Categorize the symptoms as stress urinary incontinence, urgency incontinence, mixed urinary incontinence, or incontinence due to another cause (such as a fistula, urethral diverticulum or chronic urinary retention).
• From the history:
• Determine whether the incontinence occurred:
• When coughing, sneezing, lifting, or exercising — likely to be stress urinary incontinence.
• When there was sudden urgency, or the person felt that they needed to empty their bladder but could not reach the toilet fast enough, often accompanied by frequency and nocturia — likely to be urgency incontinence associated with overactive bladder syndrome.
• If symptoms of stress urinary incontinence and urgency incontinence both occur — likely to be mixed urinary incontinence.
• If the incontinence is associated with neither of the above (this is rare), ask about:
• Voiding difficulty (hesitancy, straining to void, poor or intermittent urinary stream, and recurrent dribbling incontinence) — likely to be chronic urinary retention (overflow incontinence).
• Constant passive leakage of urine and often total incontinence — likely to be a fistula (vesicovaginal, urethrovaginal, or ureterovaginal).
• Post-void dribbling, dyspareunia, and dysuria — consider a urethral diverticulum.
• Look for:
• Stress urinary incontinence.
• During pelvic examination, ask the woman to cough with a full bladder and observe the external urethral meatus for leakage at the time of the first cough.
• The absence of urine leakage on coughing does not rule out stress urinary incontinence; this may be due to an empty bladder. Sometimes a full bladder may cause urethral obstruction and an absence of stress urinary incontinence. A cough may also precipitate a detrusor contraction.
• Cystourethrocele.
• Over 50% of women with stress urinary incontinence have a cystourethrocele.
• Chronic urinary retention (overflow incontinence).
• Examine the abdomen for a palpable bladder. However, an enlarged bladder may be difficult to palpate.
• Urethral diverticulum.
• During vaginal examination, feel for a soft, tender mass on the anterior vaginal wall and look for urethral discharge or tenderness.
• Tests:
• No laboratory tests are necessary to determine whether the woman has stress urinary incontinence or urgency incontinence.
• A residual urine measurement is needed to diagnose chronic urinary retention (overflow incontinence).
• Formal urodynamic testing (multichannel cystometry) is not recommended before starting conservative treatment.
• Tests of urethral competence, magnetic resonance imaging, and cystoscopy are not recommended in the initial assessment of women with urinary incontinence.

In depth

To identify any causes or conditions that may exacerbate urinary incontinence or overactive bladder:

• Perform dipstick analysis of the urine in all women presenting with urinary incontinence to test for active infection and glycosuria.
• If the woman has symptoms of a urinary tract infection (UTI) and dipstick analysis is positive for both leukocytes and nitrites, send a mid-stream urine sample (MSU) and offer an antibiotic whilst waiting for the culture result.
• If the woman has symptoms of a UTI and dipstick analysis is positive for either leukocytes or nitrites (but not both), send an MSU and consider offering an antibiotic whilst waiting for the culture result.
• If the woman has symptoms of a UTI and dipstick analysis is negative for both nitrites and leukocytes, depending on clinical symptoms, decide whether to send an MSU and whether to offer an antibiotic.
• If the woman has no symptoms of a UTI and dipstick analysis is positive for both leukocytes and nitrites, send an MSU and do not offer antibiotics without the result of the urine culture.
• If the woman has no symptoms of a UTI and dipstick analysis is negative for either leukocytes or nitrites or both, do not routinely send an MSU and do not offer antibiotics.
• Perform a vaginal examination.
• Test for weak pelvic musculature by asking the woman to squeeze the examining finger to assess the strength and endurance of muscle tone.
• Look for evidence of pelvic organ prolapse — central (vault), anterior (cystocele), or posterior (rectocele), and atrophic vaginitis.
• Look for a pelvic mass.
• Ask about previous investigations and treatment, urinary tract disorders, low spinal surgery, previous surgery for incontinence, prolapse or hysterectomy, ano-rectal problems, and obstetric history.
• Previous surgery for urinary incontinence or pelvic organ prolapse may interfere with the normal support mechanisms of the vagina and urethra.
• Consider whether medication (including over-the-counter medication, such as herbal diuretics) could be causing or exacerbating the incontinence.
• Consider other factors, such as:
• Obesity.
• Smoking.
• High fluid, alcohol, and caffeine intake.
• Constipation.
• Consider and look for neurological conditions (particularly if there is urgency and/or chronic urinary retention [overflow incontinence]).
• Consider and look for systemic disease, such as heart failure and diabetes mellitus (particularly if there is urgency incontinence and nocturia).
• In elderly women in particular, look for cognitive impairment and consider the effect of restricted mobility and dexterity.

In depth

• Ask how often the woman is incontinent, at what times, and during which activities.
• Ask about the use of pads or changing of clothing.
• Ask the woman whether she restricts her daily fluid intake and how often she passes urine, including at night.
• Ask the woman to keep a bladder diary for 3 days to document the amount and types of fluids drunk, individual voided volume, frequency of micturition, episodes of incontinence, and pad and clothing changes. Ask her also to record episodes of urgency.
• Ask about associated symptoms, such as daytime and night-time urinary frequency.

In depth

• Ask about the effect on her social life.
• Ask about the effect on sexual function.
• Consider using an assessment tool, such as the International Consultation on Incontinence Questionnaire.
• Also assess desire for treatment, and expectations and motivation.

In depth

• Refer urgently (within 2 weeks) to a urologist if the woman has:
• Macroscopic (visible) haematuria without urinary tract infection.
• Unexplained microscopic (non-visible) haematuria and is 50 years of age or older.
• Recurrent or persistent urinary tract infection with haematuria and is 40 years of age or older.
• A suspected malignant mass arising from the urinary tract or pelvis.
• Refer to an appropriate specialist (urologist or urogynaecologist), using clinical judgement to determine urgency, if there is:
• A bladder that is palpable on abdominal or bimanual examination after voiding and/or chronic urinary retention (overflow incontinence)/voiding difficulties. The post-void residual volume will need to be measured.
• Symptomatic pelvic organ prolapse that is visible at or below the introitus.
• Persistent bladder or urethral pain (refer urgently if cancer is suspected).
• A pelvic mass that is clinically benign, such as uterine enlargement.
• Associated faecal incontinence.
• Suspected or known neurological disease.
• Suspected urogenital fistula.
• A history of previous prolapse surgery, incontinence surgery, pelvic cancer surgery, or previous radiation therapy.
• Recurrent urinary tract infection.
• Microscopic (non-visible) haematuria in a woman who is younger than 50 years of age.
• Refer to a renal physician if there is also proteinuria or raised serum creatinine levels.
• Refer non-urgently to a urologist if there is no proteinuria and serum creatinine level is normal.
• Complex comorbid medical disease and multiple medications.

In depth

• 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

• 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