AKT · Obstetrics & gynaecology/Menopause & vulval

Urinary incontinence (women)

Stress (sphincter/pelvic-floor) vs urgency (detrusor overactivity)

Overview

Involuntary urine leakage. The two core types behave oppositely and have opposite first-line treatments: STRESS (leak on cough/effort — sphincter/pelvic-floor weakness) vs URGENCY/overactive bladder (sudden urgency ± leak — detrusor overactivity); many women have a MIXED picture, treated by the predominant type.

Recognise

Stress: leakage on coughing, laughing, lifting, exercise — no urge beforehand
Urgency/OAB: sudden compelling urge, frequency, nocturia, urge leakage
Mixed: both — treat the predominant symptom first
Risk factors: parity/vaginal delivery, age, obesity, menopause, prolapse

Red flags

Visible haematuria, recurrent UTI, pain, palpable bladder/mass, or new symptoms >50y → exclude malignancy/retention before attributing to simple incontinence

Differentials & how to tell them apart

Overactive bladder (urgency UI)urgency-driven; bladder training + antimuscarinic — NOT pelvic-floor-first

Stress UIeffort-related leak; pelvic-floor training first — NOT antimuscarinic

Overflow incontinencechronic retention, dribbling, palpable bladder — high post-void residual

Fistulacontinuous leak (e.g. post-surgery/obstetric) — not effort/urge related

UTIdysuria, positive dip/culture — transient

Investigations

Bladder diary (≥3 days), urinalysis (exclude infection/haematuria), post-void residual if voiding symptoms. Vaginal exam (prolapse, pelvic-floor contraction). Urodynamics before surgery / if diagnosis unclear.

Management

Stress: ≥3 months supervised pelvic-floor muscle training · Urgency: ≥6 weeks bladder training

1Stress UI: supervised pelvic-floor muscle training for ≥3 months (≥8 contractions TDS) first-line. Urgency UI/OAB: bladder training for ≥6 weeks first-line. Lifestyle: weight loss, reduce caffeine, treat constipation.Gate: Get the type right first — antimuscarinics are for URGENCY, pelvic-floor training is for STRESS; giving the wrong one fails
2Urgency: add an antimuscarinic (or mirabegron if antimuscarinics unsuitable). Stress: duloxetine if surgery declined.
3Refractory: urodynamics then specialist — stress: colposuspension/autologous sling (mesh tape restricted); urgency: botulinum toxin A, percutaneous tibial nerve stimulation, sacral neuromodulation.

Antimuscarinics (oxybutynin, solifenacin, tolterodine) — urgency UI 2nd-line; avoid immediate-release oxybutynin in frail elderly (anticholinergic load/falls)

Mirabegron — β3-agonist for urgency UI if antimuscarinics unsuitable (caution in uncontrolled hypertension)

Duloxetine — stress UI if surgery declined/unsuitable (SNRI)

Intravaginal oestrogen — postmenopausal women with OAB/atrophy

Key points

In frail older women avoid immediate-release oxybutynin (anticholinergic burden → confusion, falls). Postmenopausal atrophy → intravaginal oestrogen helps OAB.

Monitor & prognosis

Symptom/bladder-diary response; review medication efficacy and anticholinergic burden.

Conservative measures help most; surgery effective for refractory stress UI.

Source: NICE NG123 (urinary incontinence & pelvic organ prolapse in women)