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Management and follow-up pathway

Management is stepped and depends on the predominant type of incontinence. Most patients can be managed successfully in primary care with conservative methods; referral is for red flags or failure of first-line treatment.

General measures for all patients

  • Education: explain the mechanism of symptoms and realistic timelines; give written information (you can recommend the patient section).
  • Weight loss if BMI > 30 kg/m² (in the PRIDE trial, ~8% weight loss reduced incontinence episodes by 47% vs 28% in controls).
  • Fluid intake: correct high or low intake based on the diary.
  • Caffeine: trial of reduction in OAB.
  • Constipation, smoking, chronic cough — address.
  • Medication review: diuretics, ACE inhibitors, sedatives — adjust where possible.

Stress and mixed incontinence

  1. Supervised pelvic floor muscle training for at least 3 months: at least 8 contractions 3 times a day. Confirm on vaginal examination that the patient contracts correctly.
  2. If unable to contract — biofeedback or electrical stimulation as an adjunct.
  3. Review at 3 months: diary, ICIQ-SF, subjective assessment.
  4. If the response is inadequate and the woman wants further treatment — refer to a urologist/urogynaecologist to discuss surgery. Pessaries or vaginal devices are an option for those who don't want or can't have surgery.

Drugs are not standard treatment for stress incontinence.

Urgency incontinence and OAB

  1. Bladder training for at least 6 weeks: timed voiding with gradually increasing intervals and urge-suppression techniques.
  2. Post-menopausal women with vaginal atrophy — local vaginal oestrogen.
  3. If the response is inadequate — drug treatment: antimuscarinics (considering anticholinergic burden, especially in older and frail patients) or a β3-agonist.
  4. Review effect and tolerability 4 weeks after starting or changing a drug.
  5. If two drugs are ineffective or not tolerated — refer to a specialist (botulinum toxin, neuromodulation).

Follow-up visit

What to assess

  • bladder diary compared with baseline;
  • change in ICIQ-SF;
  • adherence to exercises and technique;
  • drug side effects;
  • whether the patient's goal has been reached.

Timing

  • pelvic floor training — at 3 months;
  • bladder training — at 6 weeks;
  • new drug — at 4 weeks;
  • long-term drug treatment — review annually (more often in older women).

When to refer

  • red flags — see the assessment pathway;
  • failure of conservative treatment when the patient wants to continue treatment;
  • surgery is being considered;
  • complex cases: previous continence surgery, radiotherapy, neurological disease, significant residual urine.

Special groups

  • Pregnant and postnatal women: pelvic floor training from the first pregnancy; surgery for SUI is usually deferred until childbearing is complete.
  • Older and frail women: consider cognition, mobility, access to a toilet and anticholinergic burden; for functional incontinence, assisted timed voiding.

Communication

Decisions about drug and surgical treatment are made together, after discussing expected benefits, risks, alternatives and reproductive plans. Document the discussion and the agreed plan.

Sources

  1. NICE guideline NG123. 2019. nice.org.uk
  2. Subak LL, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. 2009;360(5):481–490.
  3. Dumoulin C, et al. Cochrane Database Syst Rev. 2018;10:CD005654.
  4. AUA/SUFU Guideline on Idiopathic Overactive Bladder. 2024. auanet.org
  5. EAU Guidelines on Non-neurogenic Female LUTS. uroweb.org