My Clinical Approach to Urinary Incontinence
Urinary incontinence is one of the most socially “silent” urological problems — many patients delay bringing it up for years, wrongly believing it is “just part of getting older” or that no treatment exists.
My approach always starts with correctly identifying the mechanism — stress, urgency, mixed or overflow — before discussing any treatment, with particular attention to male incontinence after prostate surgery.
- Clear identification of the incontinence type before any treatment decision.
- Individualised diagnostic work-up — not routine urodynamics or cystoscopy for everyone.
- A stepwise approach: conservative → medical → surgical, depending on the type.
- Specific expertise in male incontinence after radical prostatectomy.
What Is Urinary Incontinence
Urinary incontinence is defined as involuntary loss of urine, with different possible causes. It is a common condition that can significantly affect quality of life, and should not be considered a “normal and inevitable part of ageing” that does not warrant assessment.
Leakage with coughing, urgency incontinence and overflow-related leakage are not managed in the same way.
The first question is not “which medication do I need?” but “which type of incontinence do I have?” — because incontinence is not a single disease but a symptom with different underlying mechanisms.
Which Type of Incontinence Do I Have?
I leak when I cough or lift something heavy
More likely Stress Urinary Incontinence (SUI)
It hits me suddenly and I can’t hold it
More likely Urgency Incontinence (UUI)
Weak stream & dribbling with a full bladder
Needs work-up for retention/overflow
A definitive diagnosis requires medical assessment — the patterns above are indicative, not a self-diagnosis tool.
The main types of incontinence are:
Stress Urinary Incontinence (SUI)
Leakage with coughing or exercise is more characteristic of stress urinary incontinence.
It occurs when abdominal pressure increases, for example with coughing, sneezing, laughing, lifting or running, without a preceding urge to urinate necessarily being present. It is related to inadequate support or closure of the urethra.
“I Leak When I Cough or Laugh” – This pattern is more characteristic of stress incontinence, but a single symptom does not confirm a definitive diagnosis — a full assessment is needed.
Urgency Urinary Incontinence & Overactive Bladder (OAB)
Sudden urgency and the inability to reach a toilet in time are more characteristic of urgency incontinence.
It is an involuntary loss of urine accompanied or preceded by a strong urge to urinate. It is often linked to overactive bladder (OAB), but OAB can exist with or without incontinence. See our page on Overactive Bladder.
“I Can’t Make It to the Toilet in Time” — this is more consistent with urgency incontinence, particularly when preceded by a sudden strong urge, frequency and nighttime urination. It should not be confused with stress incontinence.
Mixed Urinary Incontinence
It involves both stress and urgency symptoms in the same patient.
Treatment must be guided by the dominant symptom, its severity, and the patient’s priorities — not every case is managed with a single treatment.
Overflow Incontinence & Post-Void Residual
A high post-void residual completely changes the assessment, and retention/overflow must be ruled out.
It can occur when the bladder does not empty properly and a significant amount of urine remains. Possible findings:
Possible causes include benign prostatic enlargement, urethral obstruction, an underactive bladder, neurological disease or medications. It should not be treated with overactive-bladder medications without prior assessment for retention.
Post-Void Residual (PVR)
PVR is the amount of urine remaining in the bladder after voiding and can be estimated with a bladder ultrasound scan. A rigid, universal PVR cut-off is not used to define retention without the appropriate clinical context.
Continuous & Functional Incontinence
Continuous Incontinence
Continuous leakage of urine requires a different assessment. Possible causes may include a fistula, an ectopic ureter in the appropriate context, or severe sphincter dysfunction.
Functional Incontinence
A patient may leak because mobility limitations, cognitive impairment or environmental barriers prevent them from reaching a toilet in time — this does not necessarily indicate a primary bladder disorder.
Urinary Incontinence in Women
Possible risk factors include:
Pregnancy and vaginal delivery can affect the pelvic floor, urethral support, and continence mechanisms, but not every woman develops incontinence — it is not an inevitable consequence of childbirth.
Menopause
Genitourinary syndrome of menopause may be associated with urgency, recurrent urinary infection and other urological symptoms. In selected women, topical vaginal estrogen may have a role for specific urological symptoms/recurrent urinary infection — systemic hormone therapy is not presented here as a universal cure for incontinence.
Urinary Incontinence in Men
Possible causes include prostate surgery, radical prostatectomy, BPH surgery (TURP/HoLEP/TURis), overactive bladder, BPH with retention, neurological conditions or sphincter dysfunction.
Male incontinence is not a rare or purely post-surgical problem — it can have multiple causes that need separate assessment.
Incontinence After Radical Prostatectomy
After radical prostatectomy, the main pattern is usually post-prostatectomy stress incontinence, due to changes in the sphincter mechanism. Urgency/OAB symptoms may also coexist. See our pages on Robotic Radical Prostatectomy and Laparoscopic Radical Prostatectomy.
“How Long Does It Take After Prostatectomy?”
Return of continence is gradual and varies depending on the patient and surgical factors. We do not give a universal recovery time, percentage, or fixed number of months without individual context.
Pelvic Floor After Prostatectomy
Pelvic floor muscle training may be used preoperatively in selected protocols and postoperatively, with appropriate guidance. Doing more Kegels does not always mean a better outcome — correct technique is what matters.
Incontinence After BPH Surgery (TURP / TURis / HoLEP)
Temporary leakage can appear after surgery for obstructive prostate disease in selected patients. Persistent incontinence should be assessed for a stress mechanism, urgency/OAB, sphincter dysfunction, residual obstruction, or bladder dysfunction.
Not every post-surgical leakage should be assumed to be sphincter injury — a specific assessment of the mechanism is needed.
Neurological Causes
Conditions such as spinal cord disease/injury, multiple sclerosis, Parkinson’s disease, stroke, diabetic neuropathy and other neurological disorders can significantly change the diagnostic and treatment approach.
See also our page on Neurogenic Bladder.
Medications, Weight, Caffeine & Constipation
Medications
Certain medication classes can affect continence, such as diuretics, sedatives, medications that affect bladder contractility, alpha-blockers in specific contexts, or medications affecting cognition/mobility. We do not recommend stopping prescribed medication without your treating physician.
Body Weight
Increased body weight can be particularly relevant to female stress incontinence. Weight loss may improve symptoms in selected overweight patients.
Caffeine & Alcohol
In urgency/frequency, caffeine and alcohol can worsen symptoms in some patients — without requiring universal complete avoidance.
Fluid Intake
Fluid intake should be appropriate and individualised. We do not recommend extreme fluid restriction, nor the advice to “drink as much water as possible.”
Constipation
Chronic constipation can affect pelvic floor/bladder symptoms. Managing it may be part of conservative treatment.
How Is Incontinence Diagnosed?
Assessment should establish:
Medical History & Bladder Diary
History includes questions such as when the leakage occurs, whether it happens with coughing/exercise, whether it is preceded by urgency, pad use, nighttime urination, difficulty emptying, previous surgery, deliveries, medications and neurological history.
Bladder Diary
A bladder diary can record voiding time, urine volume, fluid intake, urgency, leakage, pad use and nighttime urination, over a specific period as instructed by the physician. It is particularly helpful in distinguishing OAB/mixed incontinence.
Pad Test
A pad test can be used for objective quantification of urine loss in selected patients. It is not mandatory in every case.
Urinalysis & Culture
A urinary infection can temporarily cause or worsen urgency, frequency and leakage. Urinalysis is part of the initial assessment where appropriate. See our page on Cystitis.
Clinical Examination
In Women
This may include a pelvic exam, prolapse assessment, vaginal atrophy, pelvic floor contraction assessment and a cough stress test, according to clinical indication. Leakage synchronous with coughing during the clinical exam can support a diagnosis of stress incontinence, but it does not, on its own, constitute the entire diagnostic pathway.
In Men
This may include an abdominal exam, genital exam, prostate assessment where appropriate, neurological assessment, observation of stress leakage and post-void residual, depending on the clinical context.
Uroflowmetry
Uroflowmetry can help when there is suspicion of outlet obstruction, a weak stream, voiding dysfunction or incomplete emptying, and is performed in our clinic as part of the individualised assessment.
Bladder Ultrasound
Ultrasound assessment can evaluate the bladder, post-void residual and, where relevant, the upper urinary tract. Not every patient with incontinence needs a full renal ultrasound — the need is assessed case by case.
Do I Need Urodynamic Testing?
Urodynamic testing is not required for every patient, but is particularly useful in complex or unclear cases.
It may have greater value in unclear diagnosis, mixed/complex symptoms, voiding dysfunction, elevated residual, neurological disease, previous failed surgical treatment, or in selected patients before invasive treatment, according to current guidelines. It is not a routine prerequisite for every uncomplicated SUI case.
What Does Urodynamic Testing Show?
It assesses bladder filling, detrusor activity, bladder sensation, compliance, leakage with straining, the voiding phase and outlet function.
It is performed in our clinic as part of the individualised diagnostic approach. See also our page on Urodynamic Study.
Do I Need Cystoscopy?
Not routine for every patient with incontinence.
It may be needed when there is blood in the urine, recurrent infection, suspected obstruction/foreign body, complications from previous surgery, suspected urethral/bladder pathology, or in selected preoperative contexts. See our page on Flexible Cystoscopy.
Conservative Management
This includes pelvic floor muscle training, bladder training, weight management, appropriate fluid intake management, treating constipation, reducing caffeine in selected patients, and managing chronic cough/smoking cessation — depending on the incontinence phenotype.
Pelvic Floor Muscle Training (Kegels)
Pelvic floor exercises are an important first-line option for stress incontinence and post-prostatectomy incontinence, but must be done correctly.
Pelvic floor muscle training (PFMT) has a particular role in female stress incontinence, mixed incontinence, and incontinence after radical prostatectomy, with an appropriately guided programme. What matters:
“Do Kegel Exercises Help?” They can help significantly in selected types of incontinence, but they must be done correctly and they are not a treatment for overflow incontinence.
Bladder Training
Bladder training has a greater role in urgency, OAB and mixed incontinence, and involves structured behavioural training. It should not be confused with pelvic floor strengthening — it is a different approach.
Medical Therapy
Overactive bladder medications are not a treatment for classic stress incontinence.
Stress Incontinence
Medication options are limited.
Urgency Incontinence / OAB
There are established pharmacological options.
Antimuscarinics
These have a role in urgency incontinence/OAB, not classic stress incontinence. Possible side effects include dry mouth, constipation and cognitive effects in vulnerable patients. We do not list dosing here.
Beta-3 Agonists
These have a role in OAB/urgency incontinence. The choice depends on blood pressure, comorbidities, drug interactions, previous treatment and tolerability. We do not list dosing here.
Anticholinergic Burden
Particularly in older patients, the total anticholinergic burden from all medications can be relevant and is taken into account in treatment selection — without this meaning a universal contraindication.
Duloxetine
May be considered for female stress incontinence in a selected context. It is not a surgical treatment and may be associated with side effects/discontinuation. Availability varies by country. We do not list dosing here.
Vaginal Estrogen
In postmenopausal women it may be used in the appropriate context of genitourinary syndrome/OAB/recurrent urinary infection. It does not, on its own, cure established stress incontinence.
Surgical Treatment of Female Stress Incontinence
Possible options, depending on current guidelines, include a midurethral sling, an autologous fascial sling, colposuspension, and bulking agents. No single procedure is appropriate for every woman.
Midurethral Sling
This aims to support the mid-urethra through a minimally invasive surgical approach. There are variations (retropubic vs transobturator) with different effectiveness/complication profiles. No one guarantees 100% continence.
Mesh & Safety: The midurethral sling for stress incontinence should not be simplistically conflated with all transvaginal mesh techniques for prolapse. There can be rare but significant complications specific to mesh, and patient information/consent is essential.
Autologous Fascial Sling
Uses the patient’s own tissue and is an established alternative in selected women. It is not presented as universally superior.
Colposuspension (Burch)
Remains a relevant option in selected women, not an outdated technique.
Bulking Agents
These are a less invasive periurethral/intraurethral approach, with a possible need for repeat treatment and generally a different durability/effectiveness profile compared to sling surgery. They are not equivalent to a sling in every patient.
Advanced Treatments for Resistant Urgency Incontinence
For resistant OAB/urgency incontinence, according to current guidelines, the following may be considered:
Intravesical Botulinum Toxin
Used for resistant OAB/urgency incontinence. Possible risks include urinary infection, elevated post-void residual, urinary retention, and a possible need for intermittent self-catheterisation. We do not list dosing or the procedural protocol here.
Sacral Neuromodulation
An established advanced treatment for selected patients with resistant urgency/OAB. It is not used to treat stress incontinence.
Posterior Tibial Nerve Stimulation (PTNS)
Has a role in selected patients with OAB. Its availability in our clinic depends on individualised assessment.
“I Have Incontinence After Radical Prostatectomy – What Are My Options?”
Initially, this may include monitoring during recovery, pelvic floor rehabilitation, symptom quantification and assessment for a mixed/urgency component. Persistent, bothersome stress incontinence may lead to surgical assessment.
Male Sling
May be appropriate for selected men, usually depending on severity, sphincter function, radiation history, previous procedures and other patient factors.
Artificial Urinary Sphincter
Persistent incontinence after radical prostatectomy can be surgically treated in appropriate patients with a male sling or an artificial urinary sphincter.
This is an established surgical option particularly for moderate to severe male stress incontinence, often after prostate surgery. The system includes a cuff around the urethra, a control mechanism (pump) and a pressure-regulating balloon, without going into procedural detail here. No one guarantees complete dryness in every patient.
Factors considered in patient selection:
- Manual dexterity.
- Cognitive function.
- Condition of the urethra.
- Previous radiation therapy.
- Risk of infection/erosion.
- Possible future need for device revision.
It is not presented as a one-time device without a possible need for revision — potential future revisions are part of its design.
Male Sling vs Artificial Urinary Sphincter
| Male Sling | Artificial Urinary Sphincter | |
|---|---|---|
| Typical use | Selected mild/moderate SUI | Moderate/severe SUI |
| Mechanism | Urethral support/repositioning | Mechanical continence device |
| Patient operates the device | Usually not | Yes |
| Radiation/history | Affects choice | Affects risk/choice |
| Revision | Possible | Possible device revisions |
Treating Overflow Incontinence
Treatment targets the underlying cause — benign prostatic enlargement/outlet obstruction, urethral stricture, an underactive bladder, or neurological dysfunction — not simply suppressing bladder activity. See our page on Benign Prostatic Hyperplasia and the symptom Urinary Retention.
Incontinence & Urinary Tract Infection
A urinary infection can cause temporary worsening of urgency, frequency and leakage. Chronic incontinence should not automatically be attributed to infection.
Incontinence & Blood in Urine
Blood in the urine is not characteristic of simple incontinence and needs a separate assessment. If blood in the urine is present, it should not be assumed to be explained by leakage. See our page on Blood in Urine.
When to Seek Urgent Evaluation
Seek urgent medical evaluation for:
Sudden incontinence together with new neurological symptoms needs urgent evaluation.
Quality of Life
Incontinence can significantly affect exercise, sleep, work, travel, sexual activity and social participation.
There are many treatment options depending on the incontinence phenotype — you do not need to simply “live with” the problem.
Incontinence Pads & Daily Management
Incontinence pads help manage symptoms but do not treat the underlying cause. They can be used alongside the diagnostic/treatment process.
“Do I Have to Wear Pads Forever?”
Not necessarily.
The possibility of improvement depends on the type, severity, cause, treatment, age/comorbidities, and previous surgery.
“Can It Be Cured?”
Many forms can be significantly improved or effectively treated with conservative, medical, or surgical therapy. It is not true that incontinence is always completely cured in every patient.
The Patient Journey
Involuntary loss of urine
The starting point.
When does it happen?
With coughing/exercise → Stress. With sudden urgency → Urgency/OAB. Both → Mixed. With a weak stream/incomplete emptying → Overflow.
History + urinalysis + examination + PVR
Initial assessment.
Bladder diary / uroflowmetry / selected urodynamic testing
Depending on complexity.
Stress → PFMT → selected surgical treatment if it persists
An individualised approach.
Urgency → bladder training → medication → Botox/neuromodulation/PTNS where indicated
Gradual escalation.
Post-prostatectomy stress → rehabilitation → selected male sling/artificial sphincter
A specific male pathway.
Overflow → treatment of the retention/obstruction
Addressing the underlying cause.
This is an informational overview, not a self-treatment algorithm — each case is discussed individually with the treating urologist.
Frequently Asked Questions
What is urinary incontinence?
It is involuntary loss of urine. It is not a single disease but a symptom with different possible mechanisms, which is why treatment depends on the type.
What are the main types of incontinence?
The main types are stress urinary incontinence (SUI), urgency urinary incontinence (UUI), mixed incontinence, overflow incontinence, continuous incontinence and functional incontinence. In men, an important context is incontinence after radical prostatectomy.
Why do I leak urine when I cough?
This pattern is more characteristic of stress urinary incontinence (SUI), related to inadequate urethral support or closure during increased abdominal pressure. However, a single symptom does not confirm a definitive diagnosis.
Why can’t I make it to the toilet in time?
This is usually associated with urgency incontinence, particularly when it is preceded by a sudden, strong urge to urinate, often with frequency and nighttime urination. It differs from stress incontinence.
What is mixed incontinence?
It is the combination of stress and urgency symptoms in the same patient. Treatment is guided by the dominant symptom, severity, and the patient’s priorities, not a single one-size-fits-all approach.
What is overflow incontinence?
It occurs when the bladder does not empty properly and a significant amount of urine remains, leading to dribbling, a weak stream or frequent small voids. The underlying cause of obstruction or bladder dysfunction needs to be investigated.
What tests are needed?
Usually a medical history, urinalysis, a bladder diary and assessment of post-void residual urine. In selected cases, uroflowmetry, urodynamic testing or cystoscopy may be needed.
What is a bladder diary?
It is a record of voiding times, urine volume, fluid intake, urgency/leakage episodes and nighttime urination over a defined period. It is particularly helpful in distinguishing types of incontinence.
Do I need urodynamic testing?
Not every patient needs it. It has greater value in unclear diagnoses, mixed/complex symptoms, voiding dysfunction, neurological disease, or before selected invasive treatment.
Do pelvic floor (Kegel) exercises help?
They can help significantly in selected types of incontinence, particularly stress incontinence and post-prostatectomy incontinence, but they must be performed with correct technique — guidance from a specialised pelvic floor physiotherapist improves outcomes.
Is there medication for incontinence?
It depends on the type. For urgency incontinence/overactive bladder there are established pharmacological options (antimuscarinics, beta-3 agonists). For classic stress incontinence, medication options are limited.
When is surgery needed?
When persistent, bothersome symptoms do not improve sufficiently with conservative/medical therapy, depending on the type of incontinence, its severity, and patient preference.
What is a sling?
It is a surgical technique to support the urethra (in women) or the sphincter mechanism (in men, after prostatectomy), with different variations (midurethral sling, autologous fascial sling, male sling).
What is Botox for the bladder?
It is an intravesical injection of botulinum toxin used for resistant urgency incontinence/overactive bladder when other treatments have not been sufficiently effective. It is not used for stress incontinence.
What is an artificial urinary sphincter?
It is an implantable device that mechanically takes over urethral closure, mainly in men with moderate to severe stress incontinence, often after prostate surgery.
Is incontinence normal after radical prostatectomy?
Temporary leakage can appear in many men during early recovery. Return of continence is gradual and varies. Persistent bothersome leakage needs assessment, not indefinite waiting.
When is a male sling considered?
In selected men with mild to moderate stress incontinence after prostatectomy, depending on sphincter function, radiation history and other factors.
Can incontinence be cured?
Many forms can be significantly improved or effectively treated with conservative, medical or surgical therapy. It is not true that every case is completely cured in every patient.
Is incontinence normal with age?
It is more common at older age, but it should not be considered an inevitable, "normal" part of ageing that does not warrant assessment — treatment options exist at any age.
When does incontinence need urgent evaluation?
With new inability to urinate, significant urinary residual with symptoms, new neurological deficit, saddle numbness, visible blood in urine, fever/signs of systemic infection, or sudden severe new incontinence with neurological symptoms.
Related Topics
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Urinary incontinence is not treated the same way in every patient. Distinguishing between stress, urgency, mixed and overflow incontinence is the essential first step to choosing correctly between pelvic floor training, medical therapy, advanced overactive bladder treatments, or surgical restoration of the sphincter mechanism.
References & Sources
- EAU Guidelines on Non-neurogenic Female LUTS — uroweb.org
- EAU Guidelines on Non-neurogenic Male LUTS — uroweb.org
- Haylen BT, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29:4–20.
- Dmochowski RR, et al. Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol 2010;183:1906–1914.
- Sandhu JS, et al. Incontinence after prostate treatment: AUA/SUFU guideline. J Urol 2019;202:369–378.
Medical Editorial
Medically reviewed by Dr. Marinos Vasilas – Urologist – Andrologist
Dr. Marinos Vasilas runs a private urology clinic in Rhodes, with expertise in the diagnosis and treatment of urinary incontinence in women and men, including incontinence after radical prostatectomy, with uroflowmetry, urodynamic testing and flexible cystoscopy available in the clinic.
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