Urinary incontinence and interstitial cystitis

• Urinary incontinence is the involuntary loss of urine; it is a symptom, not itself a disease, and it nearly always has a reversible or treatable cause.
• Five mechanisms cover almost every patient: stress (urethral support or sphincter failure), urgency/overactive bladder (uninhibited detrusor contraction), overflow (outlet obstruction or weak detrusor), functional (barriers to reaching the toilet), and mixed (usually stress with urgency).
• The first visit sorts the type by history and a bladder diary. Around the bedside, check the abdomen, the pelvic floor and the perineum, and dip the urine. A single question, "Do you leak when you cough, or when you get the urge?", separates the two common types.
• Initial management is conservative and directed at the type. Pelvic floor training is first-line for stress and mixed incontinence, and bladder training is first-line for urgency incontinence; add drugs only when these fail.
• Interstitial cystitis/bladder pain syndrome is chronic bladder or pelvic pain with urgency and frequency, diagnosed only after infection and cancer are excluded. Treatment is stepped, and stabilising the patient matters as much as the drug.

By the end of this page you should be able to:

1. Define urinary incontinence and list the five types, with the mechanism that produces each.
2. Take a history and keep a bladder diary that distinguishes stress, urgency and overflow incontinence.
3. Plan the initial investigation (urinalysis, post-void residual, examination, and when to add urodynamics) for each type.
4. Choose and explain the correct first-line management for each type, including the drugs used for urgency incontinence and their anticholinergic risks.
5. Describe the excluded causes and stepwise treatment of interstitial cystitis/bladder pain syndrome.
6. Adapt your plan when urine culture, bladder scan, urodynamics or drugs are not available.

Incontinence is common and rises with age, yet it is frequently not reported unless asked about. It is not an inevitable consequence of ageing, and nearly every patient can be helped, even when cure is not possible. A small leak that occurs only with a specific stress can be as disabling as continuous wetting, so how much it bothers the patient matters more than the volume.

Urinary incontinence occurs in all age groups. Stress incontinence is most common in younger and middle-aged women after childbirth or pelvic surgery; urgency incontinence becomes more common with age; overflow incontinence becomes more common in older men with prostatic enlargement and in people with neurological disease. Functional incontinence tracks frailty, cognitive impairment and the environment more than bladder physiology. Figures vary widely between surveys because definitions and reporting differ, and prevalence rises in studies that use active screening. Incontinence in men is under-studied relative to women, and a man with new incontinence deserves the same early assessment as a woman. ^[2]

Risk rises with age, female sex (childbirth, menopause and pelvic floor change), prostate disease and treatment in men, neurological disease (stroke, dementia, multiple sclerosis, Parkinson disease, spinal cord injury, diabetic neuropathy), obesity, constipation and faecal impaction, some drugs (diuretics, alpha-blockers, sedatives, anticholinergics, calcium channel blockers), diabetes and high fluid intake, and any condition that limits mobility or dexterity. Many causes are reversible: a new infection, a new drug, constipation, hyperglycaemia, atrophic vaginitis or immobility. Look for these before labelling a patient with a chronic type.

Transient incontinence is often reversible; persistent incontinence has an anatomical or neurological mechanism behind it. An older adult who becomes incontinent in hospital usually has more than one factor (delirium, a new drug, an intravenous drip, an unfamiliar bed, a urinary infection). Treating those factors before naming a type is as important as any drug.

Stress incontinence is most often caused by weakness of the pelvic floor support (the "hammock" under the urethra) so that the urethra is not compressed during a cough, and in men by damage to the internal or external sphincter after prostate surgery or radiation. It is a mechanical problem, which is why mechanical fixes (training or surgery) help and drugs do not.

Urgency incontinence shares the symptom set of overactive bladder, the syndrome of urgency, frequency and nocturia with or without incontinence, caused by detrusor overactivity. In younger women urgency incontinence can be idiopathic; in older adults and neurological disease, infection, bladder outlet obstruction and constipation all provoke detrusor activity. Caffeine, excess fluid and alcohol worsen it, which is why they are addressed first. ^[3]

Overflow incontinence deserves particular care because the patient may deny urgency and never feel full, yet the pressure in the bladder is high and can silently damage the upper tracts. An older man with a poor stream and a new leak may not have "incontinence" at all, but retention with overflow.

Functional incontinence is the most commonly missed. The bladder is working; the environment is not. It is the leading cause of incontinence in care homes, and it improves when staff, timing and equipment change, not when bladder drugs are added.

Mixed incontinence is the commonest pattern in older women, and the two components do not respond to the same treatment, so identifying which one dominates is the most useful question in the history.

Ask the patient to describe the leak in their own words, then test it against the types. Key questions:

• What makes it happen: a cough or movement, or a sudden urge you cannot stop?
• When does it happen: day only, or also at night?
• How much is lost: drops, a splash, or whole wet bladder?
• How often, and over how long?
• Any warning, or does it happen before you realise?
• What is the stream like: strong, hesitant, split, or dribbling?
• Pain, fever or blood suggests infection or other disease, not simple incontinence.
• Bowel habit, constipation and prolapse symptoms in women, prostate symptoms in men.
• Mobility, cognition and the home environment.
• Drugs: diuretics, sedatives, anticholinergics, alpha-blockers, calcium channel blockers.
• Obstetric and surgical history in women; radiotherapy or prostate surgery in men.
• Neurological symptoms.
• Impact on daily life, sleep and mood.

A bladder diary is part of the history. It records drinks, voids and leaks over at least 3 days covering both work and leisure days. It gives daytime and night-time frequencies, typical voided volumes, urgency, and the relation of leaks to activities, and it is more reliable than recall. In urgency incontinence the diary often shows small, frequent voids driven by urgency rather than by volume. ^{[1] [2]}

Examine the abdomen (for a distended or palpable bladder, scars, masses), the perineum and pelvis, and the neurological system. In women, inspect the vulva and vagina, assess for pelvic floor muscle contraction, test for stress incontinence with a cough test, and assess for prolapse. In men, examine the prostate by rectal examination. Check perianal sensation, reflexes and posture, and look for oedema. A simple check of memory, gait and dexterity in an older patient explains more functional incontinence than any bladder test.

The pelvic floor should be assessed before pelvic floor training is started, and the patient must be able to contract it correctly. Involuntary relaxation of the pelvic floor is a normal part of passing urine, but if the floor relaxes when it should contract, that is a key training target. ^[1]

Most incontinence is real incontinence of one of the five types. Important alternatives and associated conditions include urinary tract infection, bladder or urethral pathology, urogenital atrophy in women, fistula (especially after childbirth or pelvic surgery), and neurological disease. Haematuria, recurrent infection or persistent bladder pain should trigger referral for cancer screening. In women, a pelvic mass or abnormal prolapse needs its own assessment. In men, prostatic pathology must be considered.

The aim is to classify, to catch the reversible causes, and to identify who needs specialist testing. For most patients this can be done in primary care.

1. History and bladder diary (as above).
2. Urine dipstick in everyone, for blood, glucose, protein, leucocytes and nitrites. If infection is suspected, send a midstream urine sample for culture and treat on the basis of the result. Do not give antibiotics to an asymptomatic positive dipstick. ^[1]
3. Examination of the abdomen, pelvis and nervous system.
4. Post-void residual measured by bladder scan (preferred to catheterisation for comfort and safety) in women with symptoms of voiding dysfunction or recurrent urinary tract infection, and in anyone whose history suggests overflow. A low residual reassures; a raised residual points to obstruction or underactivity and changes management toward catheterisation. ^[1]
5. Symptom and quality-of-life questionnaire, when therapy is being evaluated. ^[1]
6. Pad testing and Q-tip, Bonney, Marshall and Fluid-Bridge tests are not used in routine assessment, and imaging (MRI, CT, X-ray) is not used other than to measure residual urine. Cystoscopy is not used in the initial assessment of uncomplicated incontinence. ^[1]

Multichannel filling and voiding cystometry is not performed before primary surgery for stress or stress-predominant mixed incontinence that is diagnosed clinically and demonstrated on examination. Urodynamics is added before surgery when the type is unclear, when there is urge-predominant mixed incontinence, when voiding dysfunction is suspected, when prolapse is present, or after previous continence surgery. The result matters mainly for planning: it should not be requested for every patient. ^[1]

• Measure and discuss impact, and set realistic goals. Cure is not always possible, but improvement always is.
• Lifestyle. Recommend a trial of caffeine reduction, advise on modifying very high or very low fluid intake, and advise weight loss where the body-mass index is above 30. Treat constipation, which worsens both stress and urgency leakage. Advise stopping smoking and reducing heavy lifting. ^[1]
• Absorbent containment products, hand-held urinals and toileting aids are not used to treat incontinence. They are offered only as a coping strategy while definitive treatment is awaited, as an adjunct, or for long-term management after treatment options have been explored. Review women using them at least once a year, checking skin integrity and suitability of the product. ^[1]
• Complementary therapies are not recommended. ^[1]

Pelvic floor muscle training is first-line for stress and mixed incontinence: a supervised trial of at least 3 months. Programmes comprise at least 8 contractions performed 3 times a day. Continue the exercises if they help. Biofeedback and electrical stimulation are not used routinely, and are reserved for patients who cannot voluntarily contract the pelvic floor, to aid motivation. ^[1]

If non-surgical treatment fails and the woman chooses surgery, the options are colposuspension (open or laparoscopic), an autologous rectus fascial sling, and a retropubic mid-urethral mesh sling. Transobturator mesh is limited to specific circumstances, and single-incision short mesh slings are restricted to clinical trials. The preoperative discussion must cover the benefits, the uncertainties about long-term adverse effects (especially mesh), anaesthesia, recovery and social factors. Intramural bulking agents are a third-line option when surgery is unsuitable or unwanted, with the caveat that effects may wear off. A retropubic mesh sling carries a risk of urinary retention and mesh exposure, so follow-up within 6 months includes vaginal examination, with access to further referral for recurrent symptoms or complications. ^[1]

Absorbent products should not be the end of the story: every woman with stress incontinence should be offered a trial of pelvic floor training and, if it fails, a surgical discussion, before containment becomes long-term.

Bladder training is first-line for urgency and mixed incontinence: a minimum of 6 weeks. It teaches postponing the first urge, progressively lengthening the interval between voids, and using distraction and pelvic floor contraction to suppress urgency. Add pelvic floor training in women. If benefit is partial, combine an overactive bladder medicine with bladder training when frequency is troublesome. ^{[1] [3]}

If training fails, pharmacological options are:

• Antimuscarinic drugs (anticholinergics) are the mainstay. They block muscarinic (mainly M3) receptors in the detrusor and raise functional bladder capacity. Commonly used agents and typical adult starting doses are: oxybutynin immediate release 5 mg two to three times daily (start 2.5 mg in older adults), oxybutynin extended release 5 to 10 mg once daily, tolterodine immediate release 1 mg twice daily or extended release 2 mg once daily, solifenacin 5 mg once daily (maximum 10 mg), darifenacin 7.5 mg once daily (maximum 15 mg), trospium 20 mg once or twice daily (maximum 40 mg daily), and fesoterodine (where available). ^{[5] [3]}
• Antimuscarinics are contraindicated with urinary or gastric retention and with uncontrolled narrow-angle glaucoma; tolterodine and trospium are also contraindicated in myasthenia gravis. They worsen constipation, can prolong the QT interval (solifenacin, tolterodine) and can cause urinary retention in men with prostatic obstruction. Use them carefully in anyone with cognitive impairment, and do not offer oxybutynin immediate release to older women at higher risk of sudden physical or mental decline. ^{[1][5] [3]}
• Anticholinergic burden is the central caution in older adults. Antimuscarinics add to the load already carried by many drugs for sleep, depression, allergy, Parkinson disease and pain, and the cumulative effect is confusion, constipation, dry mouth, impaired balance and falls. Total anticholinergic load and the risk of cognitive impairment must be weighed before prescribing, the medicine with the lowest acquisition cost is offered first, and antimuscarinics are reviewed at 4 weeks, then at 12 months (6 months if the patient is over 75). Trospium, a quaternary ammonium compound that does not easily cross the blood-brain barrier, is sometimes chosen when central side effects are a concern, though clinical evidence of advantage is limited. ^[1][5]
• Do not offer flavoxate, propantheline or imipramine for incontinence. ^[1]
• Mirabegron, a beta-3 adrenoceptor agonist, relaxes the detrusor during filling. It is recommended as an option when antimuscarinics are unsuitable, ineffective or not tolerated. ^[1] The typical adult dose is 25 mg once daily, increased to 50 mg once daily after 4 to 8 weeks if needed. ^[2] It can raise blood pressure, so it is not recommended in severe uncontrolled hypertension, and blood pressure is monitored, especially in hypertensive patients. Mirabegron has systemic anticholinergic-independent interactions (CYP2D6 inhibition) and adds to urinary retention risk in men with bladder outlet obstruction, so use it cautiously with muscarinic antagonists. Renal and hepatic impairment adjustments apply. ^{[2] [3]}
• Transdermal oxybutynin is used when oral therapy is not tolerated. ^[1]
• Vaginal oestrogen is offered to women with overactive bladder symptoms who also have genitourinary symptoms and signs of menopause; systemic hormone replacement does not treat incontinence. ^[1]
• Desmopressin may be considered for troublesome nocturia, with caution, and avoided in women over 65 with cardiovascular disease or hypertension. ^[1]
• Botulinum toxin A (100 units as the initial dose) injected into the bladder wall is offered after a multidisciplinary review for women whose overactive bladder, confirmed as detrusor overactivity on urodynamics, has not responded to non-surgical management and drugs. The woman must be willing to perform clean intermittent catheterisation if retention occurs, and the response is reviewed within 12 weeks, increasing later doses to 200 units if they are needed. ^{[1] [3]}
• More invasive options (percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion) are reserved for specialist centres.

Treat the cause: remove the obstruction (for example prostate surgery, treatment of urethral stricture) and re-assess. Review renal function and comorbidity. Intermittent urethral catheterisation is offered to women with urinary retention who can self-catheterise or have a carer, and to men with persistent retention or underactive detrusor when obstruction is not correctable or the detrusor is acontractile. Clean intermittent catheterisation is the safest route because it relieves the high pressure without the infection risk of an indwelling catheter. Indwelling catheters (urethral or suprapubic) are reserved for the indications in the guideline, such as skin breakdown, distress or inability to self-catheterise; women should be told that they may not be continent with an indwelling catheter. Suprapubic catheters have lower rates of symptomatic infection and urethral complications than urethral catheters. ^[1]

Drugs will not help a bladder that works. The treatment is of the environment and the person: timed toileting, reachable toilets, adjusted bed height, good lighting, familiar clothing, continence pads as a coping measure (not a treatment), and treating pain, infection, constipation and the drug list. In a care home, a simple toileting schedule often helps, because many residents are continent between scheduled visits.

A vaginal pessary is considered for symptomatic pelvic organ prolapse, alone or with pelvic floor training, and it can reduce prolapse-associated stress incontinence in some women. More than one pessary fitting may be needed. Before starting, vaginal oestrogen is considered when menopausal genitourinary symptoms are present, and the woman is told about possible complications (discharge, bleeding, expulsion, difficulty removing it) and that the pessary must be removed at least once every 6 months to prevent serious complications. Women at risk of complications are reviewed in a pessary clinic every 6 months. ^[1]

Topical (vaginal) oestrogen is offered to women with overactive bladder symptoms and genitourinary symptoms and signs of menopause, and is considered when a pessary is used. Systemic hormone replacement therapy does not treat incontinence. ^[1]

Older adults often have mixed incontinence with a functional overlay. The plan should be to treat the treatable components and not to reach for antimuscarinics first. Where an antimuscarinic is used, choose the agent and dose that minimise central effects, start low, review cognition, and always re-examine the drug list, the environment and constipation. ^[1]

Stress incontinence in men most often follows prostate surgery or radiotherapy and is usually managed by a continence surgeon. Drugs for urgency incontinence work in men as well as women, but antimuscarinics can worsen urinary retention in prostatic obstruction, mirabegron can do the same, and benign prostatic hyperplasia itself may need treatment. Non-neurogenic male LUTS guidelines apply the same principles of history, diary, flow and residual, but the evidence base and the surgical options differ from the NICE women's guideline.

Pregnancy and delivery stretch the pelvic floor, and leakage is common in the third trimester and postpartum. Pelvic floor muscle training during and after pregnancy reduces stress incontinence, but a new leak in pregnancy should still be assessed, not dismissed. Surgical treatment is not offered in pregnancy; training and support are.

Incontinence in neurological disease may be from detrusor overactivity, impaired sensation, retention with overflow or a combination. The assessment above still applies, but the threshold for urodynamics, intermittent catheterisation and specialist urology referral is lower, because silent retention and renal risk are greater.

Pain, not urgency, is the defining symptom. It may be felt over the suprapubic area, the urethra, the vulva, the vagina, the rectum, the lower abdomen or the back, and it may be described as pressure rather than pain. Urgency and frequency are almost universal (frequency in 92% and urgency in 84% of patients in one study), and patients void to relieve pain rather than to avoid incontinence, which is a useful distinction from overactive bladder. Urgency preceding pain by years is common. Symptoms may worsen with specific foods or drinks, with bladder filling, during the premenstrual period, with stress and with sexual intercourse. ^[3]

Median time for the full symptom complex of frequency, urgency and pain to develop was 2 years in one study, and recognition that the early presentation is pain followed by voiding symptoms prevents years of misdiagnosis. Men may be labelled as having chronic prostatitis/chronic pelvic pain syndrome when the pain and voiding profile fits IC/BPS, and the same stepwise treatment applies.

Diagnosis is clinical and requires excluding other causes. The basic assessment is a careful history, physical examination (including a focused pelvic examination, pelvic floor muscles and tender trigger points) and laboratory testing (urinalysis and urine culture; urine cytology if the patient smokes or has unexplained haematuria). Baseline pain and voiding scores are recorded so treatment effect can be measured. Cystoscopy and/or urodynamics are considered when the diagnosis is in doubt; they are not necessary in an uncomplicated presentation. Cystoscopy is also the test that identifies Hunner lesions (see below). ^[3]

Cystoscopy under anaesthesia with short-duration (a few minutes), low-pressure (under 80 to 100 cm H2O) hydrodistension may be used for diagnosis and for symptom relief. High-pressure, long-duration hydrodistension (greater than 10 minutes) is not offered because it is associated with bladder rupture and sepsis without consistent additional benefit. ^[3]

The AUA approach is conservative first and individualised by symptom severity, patient preference and response, not a fixed timetable. ^[3]

1. First line. Education about normal bladder function, what is known and not known about IC/BPS, the fact that no single treatment works for most patients, and that acceptable control may require several trials, including combinations. Self-care and behavioural modification: identify and avoid personal triggers (commonly coffee, tea, alcohol, citrus, carbonated drinks, and foods high in potassium), maintain appropriate fluid volume and concentration, use heat or cold over the bladder or perineum, plan toileting and fluid timing, manage constipation, and learn pelvic floor relaxation (not strengthening). Stress management techniques help patients cope with symptom flares. ^[3]
2. Second line. Manual physical therapy of pelvic, abdominal and hip trigger points if trained clinicians are available (pelvic floor strengthening exercises such as Kegels should be avoided, because they can worsen pain). Multimodal pain management, with onward referral for intractable pain. Oral medications: amitriptyline, cimetidine, hydroxyzine and pentosan polysulfate may be given as second-line oral options, in alphabetical order with no implied hierarchy; all are Options and benefit is unpredictable. ^[3] Intravesical (bladder instillation) treatment with dimethyl sulfoxide, heparin or lidocaine may also be offered. ^[3]
   • Pentosan polysulfate sodium 100 mg taken 3 times daily, at least 1 hour before or 2 hours after meals, is the oral therapy specifically licensed for IC/BPS. Patients are reassessed after 3 months; if improvement has not occurred, treatment may be continued for another 3 months, and the clinical value of continuing beyond 6 months without improvement is not known. Retinal pigmentary changes have been reported with long-term use, so baseline and periodic retinal examinations are recommended. ^{[4] [5]}
   • Amitriptyline is typically used at low dose at night and titrated; cimetidine and hydroxyzine are low-cost alternatives. Intravesical dimethyl sulfoxide is the instillation with the longest evidence base; heparin and lidocaine are also used. Benefit from any of these is modest and variable. ^[3]
   • Multimodal pain management (pharmacological, physical and psychological) should be started at this stage rather than later, because pain control determines quality of life more than voiding symptoms do. ^[3]
3. Third line. Cystoscopy under anaesthesia with hydrodistension for diagnosis and relief, and fulguration (or injection of triamcinolone) of any Hunner lesions seen. Hunner lesions are inflammatory patches that can be missed unless the bladder is distended. ^[3]
4. Fourth to sixth line. Neurostimulation; oral cyclosporine A or intradetrusor botulinum toxin A; and, only in carefully selected, end-stage, small fibrotic bladders after everything else has failed, major surgery (substitution cystoplasty, urinary diversion, usually without cystectomy). ^[3]
5. Not offered. Long-term oral antibiotics, intravesical bacillus Calmette-Guerin, intravesical resiniferatoxin, and long-term systemic glucocorticoids should not be offered. ^[3]

Multiple treatments may be combined at any stage, and ineffective ones are stopped. If no improvement occurs after several approaches, the diagnosis should be reconsidered. ^[3]

Like other chronic pelvic pain conditions, IC/BPS is best managed in a team: alongside urology, consider physiotherapy, pain medicine, gynaecology and psychology.

• Classification does not require technology. The type is diagnosed from the history and a simple examination. A cough test and a 3-day bladder diary can be completed on paper by anyone.
• Urine dipstick, reading as for blood, glucose and nitrites, is cheap and widely available and remains the minimum investigation. Where culture is unavailable, a stained (Gram) smear, clinical context and response to empiric treatment are used.
• Residual urine is estimated clinically or by a basic ultrasound scanner. In the absence of any scanner, a post-void catheter with strict asepsis both measures and relieves, but infection risk makes this a last resort. If a high residual is found, teach clean intermittent self-catheterisation with boiled, cooled water, clean hands and any clean container, with clear instruction on when to stop.
• Pelvic floor training, bladder training, timed toileting and counselling cost nothing and are the most effective treatments in any setting. A pelvic floor physiotherapist is the most valuable specialist referral; if absent, a trained nurse or midwife is the next best.
• Antimuscarinics and mirabegron may be unavailable or unaffordable. Generic immediate-release oxybutynin and tolterodine are usually the cheapest; where no drug is available, extend bladder training and use containment without stigma.
• Interstitial cystitis in low-resource settings is usually under-recognised. Education, trigger avoidance, self-care and amitriptyline (which is cheap and widely available) are the realistic first and second steps; pentosan polysulfate may not be obtainable or affordable, and hydrodistension or botulinum toxin is a tertiary centre procedure.
• Referral triggers that hold anywhere: visible haematuria, recurrent infection, a palpable or painful bladder, and any neurological sign.

• Incontinence is a symptom with a mechanism; classify it before treating it, because the treatments differ.
• The five types are stress, urgency/overactive bladder, overflow, functional and mixed, and the history usually sorts them.
• Bladder diary for at least 3 days, urine dipstick in everyone, and post-void residual when voiding symptoms or infection suggest it.
• Pelvic floor muscle training is the first treatment for stress and mixed incontinence; bladder training is the first treatment for urgency incontinence.
• Anticholinergic drugs are the mainstay for urgency incontinence, but their cumulative burden, especially in older adults, is the main reason to stop or change them; mirabegron is the alternative.
• Overflow incontinence is covert retention; measure the residual and teach intermittent self-catheterisation.
• Functional incontinence is treated by fixing the environment, not the bladder.
• Interstitial cystitis/bladder pain syndrome is diagnosed by excluding infection and cancer, and treated stepwise from education and self-care to instillation, pentosan or amitriptyline, and then specialist procedures.
• Nothing on this page replaces a local guideline or a clinician who knows the patient.

• Acute kidney injury
• Diuretics
• Hydronephrosis
• Nephrolithiasis
• Menopause and genitourinary syndrome (where the renal and genitourinary topics are built out)

This topic covers the book pages B2:525 Urinary incontinence and B2:525 Interstitial cystitis.