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Guidelines on urinary incontinence 

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Diagnostic evaluation

History and physical examination

  • The history should include:
    • type (stress, urgency, or mixed)
    • timing and severity of urinary incontinence (UI)
    • associated voiding and other urinary symptoms
  • Identify patients who need rapid referral to an appropriate specialist. These include patients with:
    • associated pain
    • haematuria
    • a history of recurrent urinary tract infection, pelvic surgery (particularly prostate surgery), or radiotherapy
    • constant leakage suggesting a fistula
    • voiding difficulty
    • suspected neurological disease
  • The patient should also be asked about other ill health and for the details of current medications, as these may impact on symptoms of UI

Questionnaires

  • Use a validated and appropriate questionnaire when standardised assessment is required

Voiding diaries

  • Ask patients with urinary incontinence to complete a voiding diary
  • Use a diary duration of between 3 and 7 days

Urinalysis and urinary tract infection

  • Perform urinalysis as a part of the initial assessment of a patient with urinary incontinence
  • If a symptomatic urinary tract infection is present with urinary incontinence, reassess the patient after treatment
  • Do not routinely treat asymptomatic bacteriuria in elderly patients to improve urinary incontinence

Post-voiding residual volume

  • When measuring post-void residual urine volume, use ultrasound
  • Measure post-void residual in patients with urinary incontinence who have voiding symptoms
  • Measure post-void residual when assessing patients with complicated urinary incontinence
  • Post-void residual should be monitored in patients receiving treatments that may cause or worsen voiding dysfunction, including surgery for stress urinary incontinence

Urodynamics (concerning only neurologically intact adults with urinary incontinence)

  • Clinicians carrying out urodynamics in patients with urinary incontinence should:
    • ensure that the test replicates the patient’s symptoms
    • interpret results in the context of the clinical problem
    • check recordings for quality control
    • remember there may be physiological variability within the same individual
  • Advise patients that the results of urodynamics may be useful in discussing treatment options, although there is limited evidence that performing urodynamics will predict the outcome of treatment for uncomplicated urinary incontinence
  • Do not routinely carry out urodynamics when offering treatment for uncomplicated urinary incontinence
  • Perform urodynamics if the findings may change the choice of invasive treatment
  • Do not use urethral pressure profilometry or leak point pressure to grade severity of incontinence or predict the outcome of treatment
  • Urodynamic practitioners should adhere to standards defined by the International Continence Society

Pad testing

  • Have a standardised duration and activity protocol for pad test
  • Use a pad test when quantification of urinary incontinence is required
  • Use repeat pad test after treatment if an objective outcome measure is required

Imaging

  • Do not routinely carry out imaging of the upper or lower urinary tract as part of the assessment of urinary incontinence

Disease management

Conservative management

  • In clinical practice, it is a convention that non-surgical therapies are tried first because they usually carry the least risk of harm. Conventional medical practice encourages the use of simple, relatively harmless, interventions before resorting to those associated with higher risks

Simple medical interventions

Correction of underlying disease/cognitive impairment

  • Urinary incontinence, especially in the elderly, can be caused or worsened by underlying diseases, especially conditions that cause polyuria, nocturia, increased abdominal pressure or central nervous system disturbances. These conditions include:
    • cardiac failure
    • chronic renal failure
    • diabetes
    • chronic obstructive pulmonary disease
    • neurological disease including stroke and multiple sclerosis
    • general cognitive impairment
    • sleep disturbances, e.g. sleep apnoea
    • depression
    • metabolic syndrome

Adjustment of medication

  • Although changing drug regimens for underlying disease may be considered as a possible early intervention for UI, there is very little evidence of benefit. There is also a risk that stopping or altering medication may result in more harm than benefit
  • Take a drug history from all patients with urinary incontinence
  • Review any new medication associated with the development or worsening of urinary incontinence

Constipation

  • Studies have shown strong associations between constipation and UI. Constipation can be improved by behavioural, physical and medical treatments
  • Adults with urinary incontinence who also suffer from constipation should be given advice about bowel management in line with good medical practice

Containment (pads etc)

  • Ensure that adults with urinary incontinence and/or their carers are informed regarding available treatment options before deciding on containment alone
  • Suggest use of disposable insert pads for women and men with light urinary incontinence
  • In collaboration with other healthcare professionals with expertise in urinary incontinence, help adults with moderate/severe urinary incontinence to select the individually best containment regimen considering pads, external devices and catheters, balancing benefits and harms
  • The choice of pad, from the wide variety of different absorbent materials and designs available, should be made with consideration of the individual patient’s circumstance, degree of incontinence and preference

Lifestyle changes

  • Examples of lifestyle factors that may be associated with incontinence include obesity, smoking, level of physical activity and diet. Modification of these factors may improve UI
  • Encourage obese women with urinary incontinence to lose weight and maintain weight loss
  • Advise adults with urinary incontinence that reducing caffeine intake may improve symptoms of urgency and frequency but not incontinence
  • Patients with abnormally high or abnormally low fluid intake should be advised to modify their fluid intake appropriately in line with good medical practice
  • Counsel female athletes experiencing urinary incontinence with intense physical activity that it will not predispose to urinary incontinence in later life
  • Patients with urinary incontinence who smoke should be given smoking cessation advice in line with good medical practice

Behavioural and physical therapies

  • Offer bladder training as a first-line therapy to adults with urgency urinary incontinence or mixed urinary incontinence
  • Offer prompted voiding for adults with incontinence, who are cognitively impaired
  • Offer supervised intensive pelvic floor muscle training (PFMT), lasting at least 3 months, as a first-line therapy to women with stress urinary incontinence or mixed urinary incontinence
  • Pelvic floor muscle training programmes should be as intensive as possible
  • Offer PFMT to elderly women with urinary incontinence
  • Offer PFMT to post-natal women with urinary incontinence
  • Consider using biofeedback as an adjunct in women with stress urinary incontinence
  • Offer PFMT to men undergoing radical prostatectomy to speed recovery of incontinence
  • Do not offer electrical stimulation with surface electrodes (skin, vaginal, anal) alone for the treatment of stress urinary incontinence
  • Consider offering electrical stimulation as an adjunct to behavioural therapy in patients with urgency urinary incontinence
  • Do not offer magnetic stimulation for the treatment of incontinence or overactive bladder in adult women
  • Offer, if available, percutaneous posterior tibial nerve stimulation as an option for improvement of urgency urinary incontinence in women who have not benefitted from antimuscarinic medication
  • Support other healthcare professionals in use of rehabilitation programmes including prompted voiding for elderly care-dependent people with urinary incontinence

Conservative therapy in mixed urinary incontinence

  • Treat the most bothersome symptom first in patients with mixed urinary incontinence
  • Warn patients with mixed urinary incontinence that the chance of success of pelvic floor muscle training is lower than for stress urinary incontinence alone

Management and treatment of women presenting with urinary incontinence

  • Please refer to the full guideline for the surgical treatment algorithm

Algorithm for the management of urinary incontinence in women 1280x1524

Management and treatment of men presenting with urinary incontinence

  • Please refer to the full guideline for the surgical treatment algorithm

Algorithm for the management of urinary incontinence in men 1280x1524

Pharmacological management

Antimuscarinics

  • Offer antimuscarinic drugs to adults with urgency urinary incontinence who failed conservative treatment
  • Consider extended release formulations in patients who do not tolerate immediate release antimuscarinics
  • If antimuscarinic treatment proves ineffective, consider dose escalation or offering an alternative treatment
  • Consider using transdermal oxybutynin if oral antimuscarinic agents cannot be tolerated due to dry mouth
  • Offer and encourage early review (of efficacy and side effects) of patients on antimuscarinic medication for urgency urinary incontinence

Antimuscarinic drugs in the elderly

  • In older people being treated for urinary incontinence, every effort should be made to employ non-pharmacological treatments first
  • Long-term antimuscarinic treatment should be used with caution in elderly patients, especially those who are at risk of, or have, cognitive dysfunction
  • When prescribing antimuscarinic for urgency urinary incontinence, consider the total antimuscarinic load in older people on multiple drugs
  • Consider the use of mirabegron in elderly patients if additional antimuscarinic load is to be avoided

Mirabegron

  • In patients with urgency urinary incontinence and an inadequate response to conservative treatments offer mirabegron, unless they have uncontrolled hypertension

Drugs for stress urinary incontinence

  • Duloxetine can be used with caution to treat women with symptoms of stress urinary incontinence
  • Duloxetine should be initiated using dose titration because of high adverse event rates

Oestrogen

  • Offer post-menopausal women with urinary incontinence vaginal oestrogen therapy, particularly if other symptoms of vulvovaginal atrophy are present
  • Vaginal oestrogen therapy for vulvovaginal atrophy should be prescribed long-term. In women with a history of breast cancer, the treating oncologist needs to be consulted
  • For women taking oral conjugated equine oestrogen as hormone replacement therapy who develop or experience worsening urinary incontinence, discuss alternative hormone replacement therapies
  • Advise women who are taking systemic oestradiol who suffer from urinary incontinence that stopping the oestradiol is unlikely to improve their incontinence

Desmopressin

  • Consider offering desmopressin to patients requiring occasional short-term relief from daytime urinary incontinence and inform them that this drug is not licensed for this indication
  • Monitor plasma sodium levels in patients on desmopressin
  • Do not use desmopressin for long-term control of urinary incontinence

Drug treatment in mixed urinary incontinence

  • Treat the most bothersome symptom first in patients with mixed urinary incontinence
  • Offer antimuscarinic drugs or beta-3 agonists to patients with urgency-predominant mixed urinary incontinence
  • Consider duloxetine for patients with mixed urinary incontinence unresponsive to other conservative treatments and who are not seeking cure

Now Test and reflect: view our multiple choice questions

full guideline available from…

uroweb.org/guideline/urinary-incontinence

Burkhard FC, Bosch JLHR, Cruz F et al. EAU guidelines on urinary incontinence. March 2017

First included: October 2013.