Urinary incontinence

Last updated: March 28, 2025

Summary

Urinary incontinence (UI) is a common condition characterized by involuntary leakage of urine. Causes and representations are variable. Stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence are the most common types. UI is more common in older individuals, and approximately twice as common in women than in men. The diagnosis can often be made based on a detailed medical history, a voiding diary, physical examination, and basic testing including urinalysis and measurement of postvoid residual (PVR). Advanced diagnostic studies may be required for patients with red flags in urinary incontinence or incontinence refractory to treatment. Management depends on the underlying cause and may involve conservative measures (e.g., management of comorbidities, pelvic floor exercises, bladder training), pharmacological treatment, minimally invasive procedures, or anti-incontinence surgery. Untreated UI can lead to skin irritation and urinary tract infection (UTI) and potentially result in negative effects on a patient's psychosocial well-being, mobility, and independence.

For the management of stress urinary incontinence and overactive bladder and urgency urinary incontinence, see the respective articles.

Epidemiology

Prevalence ^[1]
- Increases with age
- Up to 50% of women and up to 25% of men older than 65 years are affected.
Sex: ♀ > ♂ (2:1) ^[2]
- SUI and mixed incontinence are the most common types of incontinence in female patients.
- UUI is the most common type in male patients.

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Idiopathic
Neurological causes
- Multiple sclerosis
- Spinal injury
- Normal-pressure hydrocephalus
- Dementia
- Delirium
Genitourinary causes
- Trauma to the pelvic floor
- Intrinsic sphincter deficiency
- Urethral hypermobility in women
- Impaired detrusor contractility
- Bladder outlet obstruction
- Pelvic floor weakness
- Urogenital fistula
Transient causes of urinary incontinence
- Drugs (e.g., diuretics)
- UTI
- Postmenopausal atrophic urethritis
- Psychiatric causes (especially depression, delirium/confused state)
- Excessive urinary output (in conditions like hyperglycemia, hypercalcemia, CHF)
- Stool impaction
- Impaired mobility
General risk factors

To remember the reversible causes of acute urinary incontinence, think DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output (hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.

Overview

Overview of urinary incontinence ^[3]^[4]^[5]
	Underlying mechanism	Clinical features	Treatment
Stress urinary incontinence	Urethral hypermobility in women (bladder outlet incompetence) secondary to: Poor pelvic support caused by pelvic postmenopausal estrogen loss Connective tissue disorders Childbirth (i.e., damage to the pelvic floor muscle levator ani and/or the S2–S4 nerve roots) Intrinsic sphincter deficiency, caused by: Aging Obesity Pelvic trauma Prostate surgery (in men) Increase in intraabdominal pressure (e.g., from laughing, sneezing, coughing, exercising) → ↑ pressure within the bladder → bladder pressure > urethral sphincter resistance to urinary flow	Positive urinary stress test: urinary leakage during activities that increase intraabdominal pressure (e.g., coughing, Valsalva maneuver)	Trial of conservative management of UI for 6–8 weeks ^[5] Consider a vaginal pessary. In refractory or severe incontinence, refer to a specialist for: ^[4] Injection of periurethral bulking agents Anti-incontinence surgery See “Treatment of SUI” for additional information.
Urgency urinary incontinence ^[6]	Inflammatory conditions (e.g., UTI) or neurogenic disorders → sphincter dysfunction, detrusor overactivity, or overactive bladder → premature contractions of the detrusor muscle and initiation of a normal micturition reflex	Strong, sense of sudden urgency, followed by involuntary leakage	Conservative management of UI Pharmacological treatment for UUI Antimuscarinics (e.g., oxybutynin) Beta-3 agonists (e.g., mirabegron) Interventional procedures (e.g., sacral nerve stimulation, injection of botulinum toxin into the bladder wall) See “Treatment of UUI” for additional information.
Mixed incontinence	Combination of mechanisms of SUI and UUI	May have any of the clinical features above	Conservative management of UI Treat the most bothersome symptom first, e.g., antimuscarinics for UUI. ^[3]^[7]^[8]
Total incontinence	Complete loss of sphincter function (due to previous surgery, nerve damage, metastasis) or abnormal anatomy (fistula between urinary tract and skin)	Urinary leakage occurs at all times, with no associated preceding symptoms or specific trigger activity.	Short-term management: pads and external catheters ^[9] Long-term management: usually surgical (e.g., fistula repair), in consultation with urology and/or urogynecology ^[3]
Overflow incontinence (overflow bladder) ^[10]	Impaired (weak) detrusor contractility due to:^[11] Neurogenic bladder in multiple sclerosis Neuropathy and polyuria in diabetes mellitus Spinal cord injury Medication adverse effects Bladder outlet obstruction (e.g., BPH) Both mechanisms can lead to incomplete bladder emptying → bladder overfilling → chronically distended bladder with ↑ bladder pressure → dribbling of urine (leak) when intravesical pressure > outlet resistance	Frequent, involuntary intermittent/continuous dribbling of urine in the absence of an urge to urinate Occurs only when the bladder is full Often occurs with changes in position Postvoid residual urine volume (seen on ultrasound or with catherization)	Short term management includes: Intermittent catheterization: for scheduled bladder emptying Alpha-1 antagonists: for outlet obstruction in men Muscarinic agonists: for detrusor underactivity ^[12] Long-term management includes treatment of the urinary obstruction, e.g.: Correction of pelvic organ prolapse Transurethral resection of the prostate Urethral dilation or urethroplasty See also “Treatment of urinary retention.”
Neurogenic lower urinary tract dysfunction ^[13]^[14]^[15]	Suprasacral spinal cord lesion (e.g., multiple sclerosis) → detrusor-sphincter dyssynergia with simultaneous contractions of the detrusor muscle and involuntary activation of the urethral sphincter	Urinary retention and/or UUI	Guided by patient and/or caregiver preference Voiding dysfunction alpha blockers Intermittent self-catheterization Storage dysfunction Pelvic floor physical therapy Bladder training Antimuscarinic agents Beta-3 agonists may be useful in improving storage parameters. ^[15] Further management of NLUTD may include minimally invasive (e.g., botulinum injections) or surgical treatments (e.g., sphincterotomy) depending on the underlying condition. See also “Management of urinary incontinence” and “Treatment of urinary retention.”
	Sacral or infrasacral lesion (e.g., conus medullaris syndrome) → detrusor underactivity with normal or reduced urethral sphincter tone	Urinary retention and overflow incontinence
	Suprapontine lesion (e.g., Parkinson disease) → disrupted inhibition of the pontine micturition center → involuntary detrusor contractions	Urinary incontinence without urinary retention
Giggle incontinence ^[16]	Unknown; not related to stress or detrusor weakness	Affects children Involuntary complete voiding triggered by laughing Voiding behavior is otherwise normal (not a feature of enuresis).	Conservative management of UI Reassurance Oxybutynin (second line)

Neural control of micturition: parasympathetic nervous system → S2–S4 ventral root → inferior hypogastric plexus → contraction of the detrusor muscle → voluntary relaxation of the external urethral sphincter muscle via the pudendal nerve → micturition

SUI is caused by urethral dysfunction, while UUI is caused by bladder dysfunction. Mixed incontinence is a combination of both. ^[17]

Urinary incontinence Urinary bladder (male) Urinary bladder (female)

Diagnosis

Approach

All patients
- Perform an initial evaluation for urinary incontinence.
- Screen for red flags in urinary incontinence.
Suspected upper urinary tract involvement : Obtain renal ultrasound and laboratory studies.
Red flags in urinary incontinence present or refractory incontinence: Refer to a specialist for advanced studies.

Red flags in urinary incontinence ^[3]^[5]^[17]

Refer to urology or urogynecology for specialist workup if any of the following features are present:

Associated pain
Persistent hematuria or proteinuria
Elevated PVR
Symptoms suggestive of obstruction
Suspected fistula
Pelvic organ prolapse
Recurrent UTIs
Incontinence after radiation, radical pelvic surgery, or previous incontinence surgery

Initial evaluation for urinary incontinence ^[3]^[4]^[18]

Focused history

Use a validated incontinence questionnaire if possible. ^[3]^[5]
Inquire about symptoms that occur with voiding.
Assess for barriers to voiding (e.g., limited mobility, which may delay patients reaching the bathroom).
Ask patients to record fluid intake and micturition for 3–5 days using a voiding diary.
Obtain a relevant social and medical history, including:
- Transient causes of urinary incontinence
- Local causes (back, bowel, gynecologic, or bladder surgery; constipation; pelvic organ prolapse)
- Systemic conditions (congestive heart failure, chronic cough , neurological disease)
- Contributing dietary and lifestyle factors.

Physical examination ^[3]^[17]

Lower abdominal examination: Evaluate for bladder distention and masses.
Digital rectal examination: Assess for fecal impaction, prostatomegaly, masses, and decreased anal sphincter tone.
Pelvic examination: Evaluate for pelvic organ prolapse, vaginal atrophy, masses, and vaginitis. ^[3]
Cardiovascular examination: Assess for signs of fluid overload (may worsen urge incontinence).
Neurological examination: Both spinal and cerebral pathologies can cause incontinence (see “Etiology”).
- Assess motor function of the lower extremities and sensation of the sacral dermatomes.
- Consider cognitive testing.

Initial diagnostics

The following outlines a general approach for the workup of undifferentiated incontinence.

Urinary stress test: performed for all patients to distinguish SUI from other types of UI ^[5]
Urinalysis
- Positive urinary nitrites and/or leukocyte esterase: suggestive of a UTI; send urine culture.
- Isolated microhematuria: obtain diagnostics for hematuria ^[19]
- Glucosuria: If present, screen for diabetes. ^[20]
Postvoid residual (PVR) ^[10]
- Indications ^[3]^[5]^[17]
  - Suspected overflow incontinence
  - Diagnostic uncertainty
  - Patients being considered for specialist referral
- Findings: Elevated PVR suggests either decreased bladder contractility or urethral obstruction. ^[4]^[17]
Pad test: Consider to determine symptom severity. ^[21]^[22]
- Performed over a set period of time ranging from 1–24 hours
- Patients drink a set amount of fluids before perform specific activities while wearing preweighed incontinence pads.
- The pad is weighed again after the trial to determine the volume of incontinence.

Perform a urinary stress test in all patients to distinguish between SUI and UUI.

Differentiation between types of incontinence

Diagnostic overview of types of incontinence ^[17]
	Clinical history	Urinary stress test	Postvoid residual
Stress urinary incontinence	Leakage with coughing, sneezing, and/or exercising	Leakage with coughing	< 50 mL
Urgency urinary incontinence	Symptoms of UUI	Usually negative May have delayed leakage ^[17]	< 50 mL
Overflow incontinence	No symptoms of SUI or UUI	No leakage	> 200 mL
Functional urinary incontinence	Patients may have: Mobility issues Symptoms of cognitive impairment	No leakage	Variable
Patients with features of both SUI and UUI have mixed incontinence.

Upper urinary tract studies ^[3]^[23]

Renal ultrasound
- Indications include:
  - Hematuria
  - Neurogenic incontinence
  - Elevated PVR
  - Comorbid renal disease
- Findings may show:
  - Hydronephrosis associated with overflow incontinence
  - Urinary tract pathology, e.g., malignancy
Creatinine and BUN: may be elevated in patients with overflow incontinence

Only perform upper urinary tract studies if the initial assessment indicates a possible renal pathology and/or renal impairment due to urinary retention and vesicoureteral reflux. ^[5]^[23]

Advanced studies ^[3]^[4]^[24]

Advanced studies are performed under specialist guidance for patients with red flags in urinary incontinence or incontinence refractory to initial management.

Micturating cystourethrogram: to detect vesicoureteral reflux and/or morphological abnormalities (e.g., diverticula, obstruction)
Urodynamic studies: to determine detrusor and sphincter function
Cystoscopy: to evaluate for tumors and vesicorectal and vesicovaginal fistulae
Ultrasound pelvis : for suspected pelvic floor dysfunction
MRI : to assess for pelvic floor defects, urinary tract anomalies, and masses
CT with IV contrast: for suspected anatomical abnormalities, e.g., urinary tract masses, bladder wall thickening

Management

This section provides an overview of the management of UI. For specific information, see “Treatment of SUI,” “Treatment of UUI,” and “Treatment of urinary retention.”

Approach ^[3]

Identify and manage:
- Transient causes of urinary incontinence (e.g., UTI, constipation)
- Barriers to voiding
- Risk factors for and causes of UI (see “Etiology of urinary incontinence”)
Offer incontinence products to prevent dermatological complications and improve patient comfort.
Educate patients on lifestyle recommendations for UI.
Further management depends on the type of incontinence and can include:
- Pelvic floor physical therapy
- Pharmacological treatment
- Interventional management
Refer patients with any of the following to urology or urogynecology for further management:
- Red flags in UI
- Neurogenic incontinence or total incontinence
- Refractory incontinence

Assess the impact of incontinence symptoms on the patient's daily activities and discuss their treatment goals; use shared decision-making to individualize treatment plans.

Conservative management of urinary incontinence ^[6]^[8]

Incontinence products ^[25]

Offer to all patients to prevent skin breakdown and improve comfort.
Products may be used alone or in combination and include:
- Pads and diapers
- Barrier creams
- External urinary catheters
The following products may be considered by a specialist for refractory incontinence. ^[25]
- Urethral inserts
- Continence pessaries
- Penile clamps
- Indwelling catheters

Management of risk factors and causes

Treat common comorbidities, e.g.:
Advise smoking cessation.
Reduce the dose of or discontinue contributing medications (e.g., diuretics).
Refer patients with limited mobility to physical therapy and occupational therapy.
Refer patients with SUI and UUI to pelvic floor physical therapy. ^[27]

Lifestyle recommendations for UI

Limiting consumption of alcohol and caffeine (including carbonated drinks)
Discuss appropriate fluid intake and timing throughout the day ^[5]

Bladder training

Scheduled voiding regimens and patient education are used to increase leak-free intervals. ^[4]
- Timed voiding: Intervals between voiding are sequentially increased until the goal of at least 3–4 hours is met.
- Relaxation and distraction techniques: used to suppress the urge to urinate
Indications: UUI, but also effective for SUI and mixed incontinence

Pharmacological treatment

Used in the management of UUI, urinary retention, or outlet obstruction
Adverse effects and interactions may limit use (see “Pharmacotherapy in older adults”).

Autonomic drugs used to treat bladder incontinence ^[3]^[4]^[5]
Drug group	Indications	Mechanism of action
Muscarinic antagonists e.g., oxybutynin	UUI (detrusor overactivity)	Blocks M3 receptor → detrusor muscle relaxation
Beta-3 agonists (sympathomimetics) e.g., mirabegron	UUI (detrusor overactivity)	Stimulates β3 receptor → detrusor muscle relaxation → increased bladder capacity
Muscarinic agonists e.g., bethanechol ^[10]^[12]	Urinary retention	Stimulates M3 receptor → detrusor muscle contraction → emptying of the bladder
Alpha-1 antagonists e.g., tamsulosin	Outlet obstruction associated with BPH	Blocks α1 receptor → relaxation of smooth muscles in the bladder neck and prostate → reduced obstruction of urinary outflow

The use of muscarinic agonists may lead to urinary urgency, while the use of sympathomimetics or muscarinic antagonists may lead to urinary retention, especially if there is an untreated outlet obstruction. ^[3]

No pharmacological treatments are FDA-approved for SUI; management is either conservative (e.g., physiotherapy) or surgical. ^[4]

Mechanism of action of medications used in micturition problems

Interventional management

Minimally invasive procedures
- For SUI: periurtheral bulking
- For UUI: sacral neuromodulation, botulinum toxin injections, posterior tibial nerve stimulation
Anti-incontinence surgery
- Choice of procedure depends on type of incontinence
- See “Treatment of SUI,” “Treatment of UUI,” and “Treatment of urinary retention” for more information.

Special patient groups