Urinary incontinence in women: causes and treatment

The pattern of leaking points to the cause. The NHS describes four main types and notes that some people have a mixture of stress and urge incontinence.

Stress incontinence happens when pressure inside the bladder is greater than the strength of the urethra to stay closed. The NHS links it to weak or damaged pelvic floor muscles or a damaged urethral sphincter. Causes include damage during childbirth, particularly vaginal birth, pregnancy, obesity, damage during surgery such as a hysterectomy, neurological conditions such as Parkinson's disease or multiple sclerosis, connective tissue disorders and some medicines.

Urge incontinence usually follows overactivity of the detrusor muscle in the bladder wall, the problem called overactive bladder. Possible contributors listed by the NHS include too much alcohol or caffeine, not drinking enough, constipation, urinary tract infections, bladder tumours, neurological conditions and certain medicines.

Overflow incontinence is often due to a blockage or to a bladder muscle that does not contract fully. Total incontinence may follow a problem from birth, spinal cord injury or a fistula, a small tunnel-like hole between the bladder and a nearby area such as the vagina.

The NHS lists medicines that can upset bladder control or raise urine output: ACE inhibitors, diuretics, some antidepressants, hormone replacement therapy and sedatives. If you suspect a medicine, do not stop it yourself. A doctor can review whether a change is sensible.

Risk factors include increasing age, a family history of incontinence and having lower urinary tract symptoms. The NHS states that incontinence becomes more common in middle age and is very common over 80, but is not an inevitable part of ageing.

The NHS says urinary incontinence can usually be diagnosed after a GP consultation. The GP will ask about symptoms and may carry out a pelvic examination. You may be asked to keep a bladder diary noting how much you drink and how often you pass urine. You may then be referred to a specialist for more tests.

NHS continence services are staffed by specialist nurses, sometimes called continence advisers, and specialist physiotherapists. A GP can refer you, and in some areas you may be able to refer yourself. NICE guideline NG123 covers assessing and managing urinary incontinence and pelvic organ prolapse in women aged 18 and over, including when urodynamic testing is used.

The NHS says conservative treatments are tried first. A GP may suggest cutting down on caffeine, adjusting how much you drink, and losing weight if you are overweight. Both too much and too little fluid can worsen symptoms.

Pelvic floor muscle training is often recommended. A specialist checks whether you can contract the muscles, then gives a programme of at least 8 contractions, at least 3 times a day, for at least 3 months. The NHS states that research shows it can benefit everyone with urinary incontinence. If you cannot contract the muscles, electrical stimulation may be suggested. Biofeedback may help motivation, though the NHS says there is not much good evidence of significant extra benefit. Vaginal cones are another aid.

Bladder training is usually the first option for urge incontinence. It teaches ways to lengthen the time between feeling the need to pee and passing urine, and usually lasts at least 6 weeks.

For stress incontinence, the NHS says surgery is usually the next step if lifestyle changes and exercises are not enough. If surgery is unsuitable, the antidepressant duloxetine may help the urethra stay closed, with a review after 2 to 4 weeks. Side effects may include nausea, dry mouth, tiredness and constipation, and it should not be stopped suddenly.

For urge incontinence, an antimuscarinic such as oxybutynin, tolterodine or darifenacin may be prescribed if bladder training does not work. Mirabegron or vibegron are alternatives. Pads, handheld urinals, catheters and devices placed in the vagina or urethra can help manage leakage while you wait for treatment, though the NHS says they are not a treatment themselves.

Surgery is chosen according to the type of incontinence. The NHS gives a sling procedure for stress incontinence as an example, and says surgery for urge incontinence may involve enlarging the bladder or implanting a device that stimulates the nerve controlling the detrusor muscle.

It is not always possible to prevent incontinence. The NHS suggests keeping to a healthy weight, changing drinking habits, including less alcohol, and doing pelvic floor muscle exercises. In pregnancy, strengthening the pelvic floor may help prevent leakage.

If a cause can be treated, the NHS says this may cure the incontinence. Even when the cause cannot be removed, most women find some combination of exercise, bladder habits, products and medicine gives better control. Review with a GP or continence service if the plan is not helping.

The NHS route is GP assessment, then a continence service or women's health physiotherapist, then a gynaecology or urology team if surgery is considered. Free incontinence products are available on the NHS in some circumstances.

A private urogynaecologist or urologist may be chosen for quicker specialist review or tests such as urodynamics. The same stepwise approach applies, and a good consultation should explain why a treatment fits your type of leakage.