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Ten top tips - The woman with urinary incontinence

Dr Julian Spinks on easy ways to improve management of a common and embarrassing problem

Dr Julian Spinks on easy ways to improve management of a common and embarrassing problem


The patient may not present with urinary incontinence. Five million women in the UK have urinary incontinence or overactive bladder bc ut the stigma associated with the condition may prevent them from seeking help. If a women presents with any gynaecological or urinary symptoms it is helpful to ask about urinary incontinence. Also ask when they attend for smears or other checks.


It is not just older women. Stress incontinence is largely caused by childbirth so some women as young as teenagers can develop the problem. Urge incontinence often appears later in life but, in the very elderly, diminishing mobility causes a slight fall in the prevalence of incontinence.


The history makes the initial diagnosis. The three main types of incontinence – stress, urge and mixed – can normally be distinguished on history. Ask the women if she leaks on coughing, sneezing or activity (stress) or if she has an intense need to urinate before the leakage (urge). If she has both then the picture is mixed. Nocturia is a sign of overactive bladder associated with urge incontinence. The medical, gynaecological and obstetric history may point to the aetiology.


Examine the patient abdominally and vaginally. The abdominal examination is largely to look for unusual pathology such as masses. A palpable bladder suggests significant enlargement – normally over 300ml – and possible outflow obstruction. The vaginal examination can show prolapse, uterine enlargement or atrophic changes. Also use this opportunity to check pelvic muscle tone.


Fancy investigations are generally not required. All women should have urinalysis to detect sugar and infection. Any symptoms of UTI or a positive result for infection should lead to an MSU. As the diagnosis is clinical, confirmation using urodynamics or other imaging is not required in most straightforward cases.


Get a three-day bladder diary. Ask the woman to complete a three-day diary detailing time and volume of fluid input and urine output together with episodes/amount of leakage and the activity at the time. This is a very useful tool to confirm diagnosis, estimate severity/impact on life and can be repeated to check improvement after treatment. In working women it is useful to include work days and days off.


Treat the predominant symptom. Initial treatment depends on the type of incontinence present. In mixed incontinence, treat the more troublesome symptom. First-line specific therapy for stress incontinence is three months of pelvic floor exercises. These should be taught; an instruction leaflet is not sufficient. In urge incontinence, bladder training for at least six weeks is the first step. Antimuscarinic drugs can be used if bladder training is unsuccessful. All of the preparations available have similar efficacy. Standard-release oxybutynin is the cheapest by some margin but has a higher level of side-effects including dry mouth and constipation.


Some patients may require referral. Many patients can be treated without referral to specialist services, but alarm symptoms or signs may require urgent referral. These include haematuria (all ages with frank haematuria plus women over 50 with microscopic haematuria), pelvic masses and recurrent UTI with haematuria. Routine referral may be required for other reasons including previous pelvic surgery or radiotherapy, bladder pain, difficulty voiding, or if there is prolapse at or below the introitus. Patients who fail to respond to first line therapies may also require specialist interventions such as tension-free vaginal tape for stress incontinence.


Lifestyle measures can help. The woman should lose weight if their BMI is high. Restricting caffeine and stopping smoking can help. Excessive or insufficient fluid intake can worsen incontinence. In older patients, mobility aids may allow them to reach the toilet in time.


Pads, appliances and catheters are not treatments. They should only be used as coping aids while awaiting treatment or if treatment has failed.

Julian Spinks is a GP in Strood, Kent, and was also a member of the NICE guideline development group on urinary incontinence

Competing interests: Dr Spinks has receive honoraria from pharmaceutical companies working in the field of urinary incontinence

leak quote

Ask the women if she leaks on coughing, sneezing or activity

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