AKT · Renal & urology/Urological cancer & LUTS

Urinary incontinence

Involuntary urine leakage — stress (sphincter), urgency (detrusor overactivity), overflow, or mixed/neurogenic

Overview

Involuntary leakage of urine, classified by mechanism because the type dictates treatment: stress (leak on coughing/exertion — sphincter weakness), urgency/overactive bladder (sudden compelling urge — detrusor overactivity), mixed, overflow (chronic retention) and functional/neurogenic. The high-yield exam point is the type-specific first-line: pelvic-floor training for stress, bladder training for urge.

Recognise

Stress: leakage on coughing/sneezing/exertion (raised intra-abdominal pressure); risk — childbirth, menopause, prostate surgery, obesity
Urgency/OAB: sudden compelling urge with leakage, frequency, nocturia; overflow: dribbling with a palpable bladder (chronic retention — BPH, neurogenic)
Mixed (both); functional (mobility/cognition); neurogenic (cord/MS/diabetes)

Red flags

Overflow incontinence from chronic retention with AKI (palpable bladder) → catheter + relieve obstruction
Associated neurology (saddle anaesthesia, leg weakness) → exclude cauda equina; haematuria → exclude malignancy

Differentials & how to tell them apart

Overflow (chronic retention)palpable bladder, dribbling — relieve obstruction; don't give antimuscarinics

UTI / reversible causeinfection, constipation, diuretics, delirium — treat the reversible factor

Fistula / structuralcontinuous leakage (vesicovaginal fistula) — different management

Investigations

Bladder diary, urinalysis (exclude infection/haematuria), post-void residual/bladder scan; vaginal/prostate exam; urodynamics if diagnosis unclear or before surgery; assess for reversible factors (drugs, constipation, UTI, mobility).

Management

Stress → pelvic-floor training (→duloxetine); Urge → bladder training (→antimuscarinic/mirabegron)

1Classify the type (bladder diary, urinalysis, post-void residual) and treat reversible factors. Stress incontinence → supervised pelvic-floor muscle training; urgency/OAB → bladder training first.Gate: Overflow incontinence (chronic retention, palpable bladder) needs the obstruction relieved — do NOT give an antimuscarinic (worsens retention); exclude cauda equina if neurology, and malignancy if haematuria.
2Stress: add duloxetine or surgery (sling/colposuspension) if conservative measures fail. Urgency: add an antimuscarinic (oxybutynin — avoid in the frail elderly) or mirabegron; specialist options (Botox, neuromodulation) for refractory OAB.

Stress incontinence: supervised pelvic-floor muscle training (≥3 months) first-line; then duloxetine or surgery — the UBO/SPD rule — Stress → Pelvic-floor → Duloxetine; surgery (e.g. colposuspension/sling) for refractory

Urgency/OAB: bladder training (≥6 weeks) first-line; then antimuscarinic (oxybutynin — avoid in frail elderly) or mirabegron — Urge → Bladder-training → Oxybutynin/mirabegron; mirabegron if anticholinergic burden a concern

Overflow: relieve the obstruction / catheter — treat retention/BPH; do NOT give antimuscarinics (worsen retention)

Treat reversible factors + lifestyle — caffeine/fluid advice, weight loss, treat constipation/UTI, review drugs

Key points

Classify FIRST — the type dictates treatment. Stress → Pelvic-floor training → Duloxetine (S-P-D). Urge/OAB → Bladder training → Oxybutynin/mirabegron (U-B-O; avoid oxybutynin in frail elderly — falls/confusion). Overflow → relieve obstruction, NOT antimuscarinics. (Cross-ref O&G for women's continence.)

Monitor & prognosis

Symptom diary/response, post-void residual, drug side-effects (anticholinergic burden).

Often improves substantially with type-specific conservative therapy.

Source: NICE NG123 (incontinence); cross-ref O&G