Urinary Incontinence

Name: Urinary Incontinence
Creator: Dr. Marinos Vasilas

My Clinical Approach

Urinary incontinence remains one of the most under-reported conditions in urology. Many patients wait years before asking for help, believing it is “a normal part of ageing” or that nothing can be done. The truth is that over 80% of patients can substantially improve with accurate diagnosis and individualised treatment.

I follow the EAU Guidelines on Urinary Incontinence 2024, the recommendations of the ICI/ICS and the AUA/SUFU protocols:

Accurate classification before any treatment — SUI and UUI require completely different approaches.
At least 3 months of structured PFMT with a trained pelvic floor physiotherapist before considering surgery for SUI.
Urodynamic study only when the clinical picture is unclear, in male incontinence, after failed first-line therapy, or before invasive treatment.
Mid-urethral sling (TVT/TOT) as the gold standard for female SUI — success ~85-90% at 5 years.
Stepwise approach for UUI: lifestyle → PFMT → mirabegron / anticholinergics → botox / neuromodulation.
Holistic care: topical estrogens, constipation management, weight loss, smoking cessation, control of chronic cough.

What is urinary incontinence

Urinary incontinence is defined by the International Continence Society (ICS) as any involuntary loss of urine that may cause social, hygienic or psychological impact.

It is not a disease, but a symptom of many different conditions — from pelvic floor weakness and detrusor overactivity to neurological disease and anatomical abnormalities. Correct classification is the first step to a successful treatment plan.

Important: Incontinence is not an inevitable part of ageing. Its frequency increases with age, but effective treatments exist at every decade of life. Silence only makes the problem worse.

Classification (SUI / UUI / MUI / overflow)

SUI

Stress Urinary Incontinence

Involuntary leakage on cough, sneeze, laugh, lifting or exercise. Caused by weakness of urethral support, pelvic floor or intrinsic sphincter deficiency. Common in women after childbirth and in men after prostatectomy.

UUI

Urgency Urinary Incontinence

Sudden, strong urge to urinate that cannot be deferred — often followed by leakage. Linked to detrusor overactivity (idiopathic or neurogenic), infection, stones, neoplasm.

MUI

Mixed Urinary Incontinence

Combination of SUI + UUI. Common particularly in older women. Treatment focuses on the predominant symptom.

OUI

Overflow Incontinence

Continuous dribbling due to chronic bladder over-distension — from bladder outlet obstruction (BPH, stricture), neurogenic underactivity or medication. Always check post-void residual.

Functional Incontinence

Bladder and sphincter work normally, but the patient cannot reach the toilet in time — mobility impairment, dementia, severe neurological disease.

Causes & risk factors

In women

Vaginal deliveries (especially >2 or with large baby), post-menopausal atrophy, pelvic organ prolapse, hysterectomy, obesity, chronic cough/constipation, smoking, neurological disease (MS, Parkinson, stroke).

In men

After radical prostatectomy (5-20% persistent SUI >1 year), benign prostatic hyperplasia (overflow incontinence), neurogenic bladder after spinal cord injury / MS, after pelvic radiotherapy.

Drugs & reversible causes (DIAPPERS)

Delirium, Infection, Atrophic vaginitis, Pharmaceuticals (diuretics, opioids, anticholinergics, alpha-blockers), Psychological, Excess fluid, Restricted mobility, Stool impaction. Always exclude before classification.

Symptoms & quality-of-life impact

SUI

Leakage with cough, sneeze, laugh, exercise, lifting. Usually small volumes, no warning.

UUI

Sudden urgency, frequency (>8/day), nocturia, leakage on the way to the toilet.

Overflow

Continuous dribbling, sense of incomplete emptying, weak stream, intermittent flow.

Psychosocial impact

Social isolation, depression, sleep disturbance, sexual dysfunction, increased risk of falls in the elderly.

Assessment tools: ICIQ-SF, OAB-q, KHQ — validated questionnaires that quantify the impact and help track the response to treatment.

Diagnosis & urodynamics

Targeted history

Type, frequency, triggers, deliveries, surgery, medications, neurological history, sexual function, ICIQ-SF.

Physical examination

Abdomen, external genitalia, vaginal exam in women (atrophy, POP-Q prolapse, stress test), digital rectal exam of prostate/pelvic floor, neurological exam of lower limbs (S2-S4).

3-day bladder diary

Recording of voiding times/volumes, fluid intake, leakage episodes — a basic tool for classification and follow-up.

Urinalysis & culture

Exclude infection, haematuria, glycosuria. Check blood glucose where indicated.

Post-void residual (PVR)

Bladder scanner or catheterisation. >100 mL is meaningful; >200 mL needs evaluation for obstruction or neurogenic cause.

Urodynamic study

Not routine. Indicated for: unclear clinical picture, mixed incontinence, male incontinence, failed first-line therapy, before invasive surgery, neurogenic bladder. Includes uroflowmetry, cystometry, pressure-flow study, EMG.

24-hour pad test

Quantifies leakage — mild <10 g, moderate 11-50 g, severe >50 g. Useful before surgery and at follow-up.

Cystoscopy & imaging

When haematuria, recurrent infections, suspected stones/fistula, after pelvic radiotherapy or major pelvic surgery.

Diagnostic pitfalls: overflow incontinence may mimic SUI/UUI — always measure PVR. In men with incontinence always exclude BPH and urethral stricture. In women with mixed picture, urodynamics before surgery.

Conservative treatment (PFMT, lifestyle)

1. Pelvic floor muscle training (PFMT / Kegel)

First line for SUI and MUI. Structured programme of 3 sets × 8-12 contractions/day for at least 3 months, ideally with a trained pelvic floor physiotherapist and biofeedback or EMG. Cure/improvement: 50-70%.

2. Bladder training / timed voiding

For UUI / OAB: training to defer voiding, gradual increase of intervals (timed voiding), urge-suppression techniques. Combined with PFMT.

3. Fluid management & lifestyle

Reduce caffeine/alcohol/carbonated drinks, balanced fluid intake (~1.5-2 L), avoid excessive evening fluids, weight loss >5-10% (level 1 evidence for >50% improvement of SUI), smoking cessation, treatment of constipation.

4. Topical estrogens (post-menopausal women)

Vaginal estradiol cream/ring — improves atrophic vaginitis, reduces urgency, supportive for all forms of incontinence after the menopause. No increased systemic risk.

5. Support devices

Pessary for women with SUI and prolapse when surgery is to be avoided. Penile clamp or condom catheter as supportive measures for male incontinence. Intermittent self-catheterisation for overflow incontinence.

Medical & surgical treatment

Medication for UUI / OAB

Mirabegron 50 mg/day (beta-3 agonist) — preferred in older patients due to lower anticholinergic burden. Solifenacin, tolterodine, fesoterodine, oxybutynin — anticholinergics (avoid in dementia, narrow-angle glaucoma). Combination mirabegron + solifenacin in refractory cases (BESIDE trial).

Duloxetine for SUI

SNRI — approved in Europe for moderate-severe SUI when PFMT has failed. Not gold standard due to side effects (nausea >25%, discontinuation 30-40%). Limited role as a “bridge” before surgery.

Mid-urethral sling (TVT / TOT) — female SUI

Gold standard for refractory female SUI. Minimally invasive — polypropylene tape under the mid-urethra. Cure ~85-90% at 5 years, high satisfaction. Complications <5%: bladder perforation, retention, irritation. Discussion of mesh-related risks.

Autologous fascial sling / Burch colposuspension

Alternatives for those who avoid mesh. Autologous fascial sling: comparable outcomes, longer recovery. Burch: open or laparoscopic — historical gold standard, used when other pelvic surgery is performed concurrently.

Male sling / artificial urinary sphincter (AUS)

For post-prostatectomy SUI: AdVance sling for mild-moderate (1-2 pads/day) — success ~70%. AMS 800 AUS for moderate-severe (>3 pads/day) — gold standard, success >85% but mechanical failure at 5 years ~10-15%.

Intravesical botulinum toxin A (Botox)

For refractory UUI / neurogenic bladder: 100-200 U onabotulinumtoxinA into 20-30 detrusor sites (cystoscopic). Duration ~6-9 months, repeatable. Risk of urinary retention 5-10% — counsel about self-catheterisation.

Neuromodulation (sacral & PTNS)

Sacral neuromodulation (InterStim): implanted device for refractory UUI / non-obstructive retention. Success ~60-75%. PTNS (percutaneous tibial nerve stimulation): 12 weekly 30-minute sessions — effective, non-invasive.

Follow-up & prognosis

Reassessment at 3 and 6 months after starting conservative therapy — ICIQ-SF + bladder diary.
After sling surgery: visits at 6 weeks, 3, 6, 12 months, then annually.
Botox: repeat when symptoms return (typically 6-9 months).
AUS: annual mechanical check — revision rate ~10-15% at 5 years.
Prognosis: over 80% achieve substantial improvement with combined, individualised management.

In summary: correct classification → adequate conservative therapy → targeted procedural treatment when needed. Quality of life improves dramatically — it is never too late to seek help.

Frequently Asked Questions (FAQ)

What is urinary incontinence?

Urinary incontinence is any involuntary loss of urine that causes a social or hygienic problem. The main types are stress (SUI), urgency (UUI), mixed (MUI), overflow and functional incontinence. Each type has a different cause and treatment approach.

How common is it?

Very common and under-reported: roughly 25-45% of adult women and 10-15% of men over 60. It increases with age, after childbirth, after menopause and after prostatectomy. It is not "just part of getting older" — it is a treatable condition.

What are the main causes in women?

In women the leading causes are pelvic floor weakness (after vaginal deliveries), post-menopausal atrophy, overactive bladder, pelvic organ prolapse, obesity and chronic cough. The exact type (SUI vs UUI vs mixed) determines the treatment.

What are the main causes in men?

In men the main causes are post-radical-prostatectomy SUI, benign prostatic enlargement with overflow incontinence and neurogenic bladder dysfunction (Parkinson, stroke, MS, spinal cord injury).

How is it diagnosed?

Targeted history + physical examination + 3-day bladder diary + urinalysis/culture + post-void residual measurement. In selected cases: urodynamic study, cystoscopy, 24-hour pad test. Correct classification is essential before any treatment.

What is the first-line treatment?

Always conservative: pelvic floor muscle training (PFMT, "Kegel" exercises) with or without biofeedback, fluid/caffeine management, weight loss, and topical estrogens for post-menopausal women. Medications (anticholinergics, mirabegron) for urgency. Surgery only after adequate conservative treatment has failed.

What are the surgical options?

For female SUI: mid-urethral sling (TVT/TOT) — gold standard with ~85-90% success — or autologous fascial sling and Burch colposuspension. For male SUI: artificial urinary sphincter (AUS) for severe cases, male sling for mild–moderate. For refractory UUI: intravesical botulinum toxin, sacral neuromodulation, PTNS.

When should I see a urologist?

When incontinence affects your quality of life, when you need protective pads, when you avoid activities, or when there is haematuria, pain, recurrent infections or sudden worsening. Age is not a barrier — effective treatments exist at every stage of life.