Urinary Incontinence — Male & Female

Female urinary incontinence

Very common — affects 30–50% of women, more common with increasing age, after childbirth, or post-menopause. Presents as stress incontinence (leakage triggered by pressure — coughing, laughing) or urge incontinence (overactive bladder, not making it to the toilet in time).

Diagnosis is usually clinical — history plus targeted examination.

Complicated vs uncomplicated

SUI is complicated in women with a neurological condition affecting the urinary tract, or concurrent pelvic pathology (prolapse, previous pelvic surgery, radiotherapy). Complicated SUI, or incontinence of unclear cause (e.g. possible urge incontinence or stress-incontinence-with-detrusor-overactivity), warrants specialist referral.

Haematuria is a red flag in any incontinence work-up — refer to urology for possible underlying bladder cancer (see bladder-cancer.md).

Reduce or eliminate aggravating drugs

• May aggravate incontinence generally: ACE inhibitors, prazosin, labetalol
• Overflow incontinence: anticholinergics, TCAs
• Urge incontinence: caffeine, cholinergics, sedatives (antidepressants, antihistamines, antipsychotics, hypnotics), alcohol, loop diuretics, lithium

Conservative management (first-line for all patients)

Pelvic floor muscle training (PFMT) should be recommended as first-line for all SUI patients — strong evidence base, particularly in mild–moderate severity: achieves continence in roughly 1 in 3 women (NNT 3). Hold contractions ~10 seconds, repeat frequently (~40×/day); referral to a pelvic floor physiotherapist (for biofeedback) improves outcomes; trial for 3 months.

Urge incontinence-specific: bladder training (hold 10–15 minutes when the urge to void occurs), reduce caffeine, treat constipation, avoid “just in case” voiding, maintain a healthy weight.

Continence pessaries can help SUI, but need an experienced clinician for fitting and patient understanding of care/risks (vaginal erosion/ulceration, rarely fistula) — generally reserved for women too frail for surgery, or as a temporising measure for younger women wanting to complete childbearing first. Continence aids (pads, liners, briefs) protect skin and support daily activities in the meantime.

Medical therapy — urge incontinence

• Anticholinergics: oxybutynin 2.5mg at night, increasing as needed to 5mg TDS (or a patch applied for 3–4 days)
• Beta-3 agonist: mirabegron (Betmiga) 25mg daily increasing to 50mg daily — side effect: raised BP; takes up to 8 weeks for full effect

Surgical options — stress incontinence

Considered for persistent/complex SUI after conservative management fails:

Option	Notes
Urethral bulking agents (e.g. Bulkamid)	Minimally invasive, endoscopic; injected trans/periurethrally to improve outlet resistance; short-term efficacy 30–90%; less efficacious than other options but rapid recovery (often day case) — suits mild SUI
Mid-urethral slings (synthetic mesh)	Remain a viable option despite the mesh controversy — see below
Burch colposuspension	Mesh-free; sutures the anterior vaginal wall to Cooper’s ligaments. 2017 Cochrane review: 85–90% success at 1 year, 70% at 5 years — possibly less durable medium-term continence than a mid-urethral sling
Autologous (fascial) sling	Mesh-free alternative
Artificial urinary sphincter	Not first-line; for recurrent/persistent/severe SUI — implanted cuff/pump/reservoir system; ~75% continence at 10 years, but up to 46% need revision surgery

Transvaginal mesh remains under heightened scrutiny following well-documented safety concerns — synthetic mid-urethral slings remain a viable surgical option for SUI, but counsel on the mesh controversy specifically, recognise mesh complications, and involve a specialist mesh service if complications arise.

Botulinum toxin injection is an option for refractory urge incontinence/overactive bladder.

Male urinary incontinence

Most commonly post-prostatectomy stress incontinence, from sphincter damage during prostate surgery — see mens-health’s benign-prostatic-hypertrophy.md/prostate-cancer.md for the surgical context. Conservative management (pelvic floor exercises, continence aids) is first-line; persistent cases may need a male sling procedure or artificial urinary sphincter, analogous to the female surgical options above.