URINARY INCONTINENCE IN WOMEN

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Urinary Incontinence in Women — Label, Train & Step Up

Urinary incontinence is common and under-reported. This sheet gives how to classify the leak, what to exclude, first-line training, and the next steps in drugs, devices and surgery.

🎯 AT A GLANCE — URINARY INCONTINENCE IN WOMEN

Estimates of urinary incontinence range from 3% to 55% of women, depending on the definition; at least half never tell a doctor

Stress, urge, mixed, overflow and functional are the types; mixed is the commonest overall, and you treat the more bothersome symptom

Classify the leak before choosing treatment

First-line treatment for all types is conservative and has no major harms: weight loss, fluid and caffeine changes, bladder training and pelvic floor muscle training

Up to 38% of women with stress incontinence alone are cured after at least 3 months of pelvic floor training

Drugs for urge give modest benefit and cure is rare; combining a drug with behavioural therapy works better than either alone

Systemic oestrogen can make incontinence worse

Ask every woman about leakage, because most will not mention it; name the type; exclude red flags and reversible causes; then start with training before any drug or operation.

🚨 DO NOT JUST TREAT THE LEAK — INVESTIGATE OR REFER IF…

There is gross haematuria, recurrent urinary infection or pain — exclude stones and bladder cancer

She has new retention, a high post-void residual or kidney dysfunction

Leakage is constant, or began after surgery, radiotherapy or a difficult delivery — suspect a vesicovaginal or other fistula (from memory)

There are nerve signs, such as weakness, numbness or faecal incontinence with a neurological deficit

A pelvic mass, or a prolapse that bulges outside the vagina

Conservative treatment has failed, or she prefers a procedure — refer to a urogynaecologist

STEP 1 · RECOGNISE AND ASSESS — name the type and look for a cause

🔍 THE TYPES

Type	She leaks when	Typical woman
Stress	She coughs, sneezes, laughs or exerts herself	Younger women; second most common in older women
Urge	There is a sudden strong desire to pass urine; often frequency and nocturia	Most common in older women; caused by detrusor overactivity
Mixed	Both stress and urge	The most common overall
Overflow	The bladder is full and dribbles	Drugs with anticholinergic effect, or nerve disease
Functional	She cannot reach the toilet in time	Limited mobility, memory or mood

🩺 ASSESSMENT

Ask about triggers, urgency, frequency, nocturia, pad use, a bulge, bowel symptoms, pain, blood in the urine, deliveries and operations, drugs, and how much it bothers her

Look for reversible causes: urinary infection, constipation, vaginal atrophy, drugs such as diuretics and sedatives, poor mobility, and confusion (from memory)

Ask her to keep a bladder diary and fill in a symptom questionnaire

Examine the abdomen, nervous system and pelvis; try to show stress leakage with a cough; check for prolapse and for atrophy

Send a urinalysis and measure the post-void residual when indicated

Before surgery, objectively demonstrate stress leakage and check bladder emptying; do urodynamics when the diagnosis is unclear (from memory)

STEP 2 · TREAT — conservative care first, then step up

🧭 FROM THE LEAK TO THE TREATMENT

💊 TREATMENT OPTIONS

Option	What to do	Notes
Lifestyle	Lose weight if overweight (stress); cut fluids, caffeine and fizzy drinks; treat constipation; stop smoking	Useful for all types
Pelvic floor muscle training	3 sets of 8 to 10 contractions, each held 6 to 8 seconds, 3 to 4 times a week, for 15 to 20 weeks; extend the hold to 10 seconds	Most effective for stress incontinence; supervised teaching helps
Bladder training	Suppress the urge, then extend the interval by 30 to 60 minutes; aim to pass urine every 3 to 4 hours	For urge; scheduled or prompted voiding if memory is poor
Vaginal pessary or devices	A pessary for stress incontinence if she is pregnant, unfit for surgery or after failed surgery; tibial nerve stimulation for urge	Urethral plugs carry a high risk of infection
Drugs for urge	An antimuscarinic for 4 to 8 weeks (long-acting and selective if possible), or mirabegron	Avoid antimuscarinics in dementia, narrow-angle glaucoma and retention, and with caution in older women; mirabegron raises blood pressure
Vaginal oestrogen	Low-dose, for atrophy and sometimes urge	Systemic oestrogen may worsen incontinence
Duloxetine for stress	Off-label	Reduces leakage but does not cure; 45% stop because of side effects
Botulinum toxin, sacral neuromodulation	For urge that does not respond to drugs	Botulinum lasts 3 to 6 months; neuromodulation is an implant
Stress surgery	Midurethral sling (TVT is the most common), Burch colposuspension, bulking agents	Only after conservative care fails; risks include new urgency, voiding difficulty, prolapse and repeat surgery; bulking cures or improves 18 to 40%

Say: “Pelvic floor exercises work best if you do them every day for months, so we shall check you are doing them correctly.” Review at 4 to 8 weeks before adding a drug.

STEP 3 · COUNSEL — what she needs to hear

🗣️ WHAT TO TELL HER

Leaking urine is common and treatable; she is not alone and need not feel ashamed

Start with exercises and bladder habits; they work, and have no harm

Drinking less does not cure it: pass urine about every 3 to 4 hours, and avoid caffeine, fizzy drinks and drinking late at night (from memory)

Treat constipation and a chronic cough, because they strain the pelvic floor (from memory)

Medicines can dry the mouth and constipate; the benefit is modest

Surgery is for stress leakage that has not improved; discuss goals, risks and future pregnancy first

⚠️ COMMON PITFALLS

Not asking, so she suffers in silence

Starting a drug before classifying the leak

Giving an antimuscarinic to a woman with retention, dementia or glaucoma

Expecting drugs to treat stress incontinence

Operating without demonstrating stress leakage or measuring emptying

Missing a fistula in a woman who leaks constantly after delivery or surgery (from memory)

Prescribing systemic oestrogen for leakage

Teaching pelvic floor exercises once and not following up

Memory Aid

LEAKS

Five steps for urinary incontinence.

L

Label the type — stress, urge, mixed, overflow, functional

E

Exclude red flags — blood, retention, fistula, nerve signs

A

Advise first — weight, fluids, bladder training, pelvic floor

K

Keep a diary — and review at 4 to 8 weeks

S

Step up — drugs, devices, then surgery

Remember: most women improve with training alone; drugs and surgery come after it.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the AAFP article “Clinical Management of Urinary Incontinence in Women” (2013): types, prevalence, lifestyle, bladder training, pelvic floor training schedule, devices, drugs, procedures and surgery; and a summary of the ACOG and AUGS practice bulletins (assessment, classification, referral and red flags). The AAFP article is from 2013, so newer guidance may differ. I could not read the NICE NG123 text. Items marked “from memory” (reversible causes, fistula, urodynamics, counselling) were not checked. Drug doses are not given here; availability and protocols differ in India: follow local practice.