What are the main types of urinary incontinence?

Stress incontinence is leakage when pressure rises in the abdomen — coughing, sneezing, laughing, lifting or exercising — because the urethra and its supports cannot stay closed. It is most common after childbirth, with obesity, around the menopause, and in men after prostate surgery. Urgency incontinence is leakage that follows a sudden, overwhelming need to pass urine that cannot be deferred, caused by the bladder muscle contracting when it should not; it usually comes with frequency and getting up at night, and together these are called overactive bladder. Many people, especially older women, have both — mixed incontinence. Overflow incontinence is constant dribbling from a bladder that does not empty. Telling these apart is the whole basis of treatment, because the treatments are completely different.

Do pelvic floor exercises really work?

Yes — properly taught and properly done, they work remarkably well, with improvement or cure rates in stress incontinence approaching those of surgery in suitable patients. The critical word is supervised. A leaflet or a brief verbal explanation produces much poorer results, because a substantial proportion of women contract the wrong muscles when taught this way — many bear down rather than lift. A physiotherapist or continence nurse checking the contraction, then prescribing a structured programme that progresses over at least three months, is what produces the benefit. This is one of the most cost-effective treatments in women's health and one of the least reliably delivered. It is also effective in men after prostate surgery, where starting before the operation speeds recovery.

Why might my doctor avoid certain bladder medicines if I am older?

Because of the anticholinergic burden. The traditional overactive bladder drugs — oxybutynin, solifenacin, tolterodine and similar — work by blocking muscarinic receptors, and these receptors are not confined to the bladder. In older people they cause dry mouth, constipation, blurred vision and confusion, and large observational studies have linked cumulative lifetime anticholinergic exposure with an increased risk of dementia. Oxybutynin crosses into the brain most readily and is specifically discouraged in older adults. Mirabegron works by a different mechanism, stimulating beta-3 receptors to relax the bladder, and avoids these cognitive effects; it does require blood pressure monitoring. This matters most in people already taking other anticholinergic drugs — some antidepressants, antihistamines and antipsychotics — where the burden accumulates across the whole medication list.

What happened with vaginal mesh?

Synthetic midurethral slings were introduced as a quick, effective and minimally invasive treatment for stress incontinence, and for many women they worked well and durably. But a significant minority developed serious complications — chronic pelvic, groin or leg pain, pain during sex, mesh eroding through the vaginal wall or into the bladder or urethra — and removal proved technically very difficult. What turned a complication into a scandal was the systemic response: inadequate consent about alternatives and risks, poor tracking of outcomes, and repeated dismissal of women reporting symptoms. Several countries suspended or restricted use, and inquiries such as the UK Cumberlege review documented the failure to listen. The consequences now are: full discussion of alternatives including autologous fascial sling, colposuspension and bulking agents; surgery only by trained surgeons within mandatory registries; and specialist centres for women needing mesh removal.

When should incontinence be investigated urgently?

Several features need prompt rather than routine assessment. Blood in the urine, whether visible or found on testing, requires investigation for bladder and kidney cancer. A pelvic mass. Continuous leakage that does not vary with activity or urge, especially after pelvic surgery, radiotherapy or a prolonged difficult labour, suggests a fistula and needs specialist referral. New neurological symptoms — leg weakness, numbness in the saddle area, back pain with bowel disturbance — may indicate cauda equina syndrome and are an emergency. Difficulty passing urine with a poorly emptying bladder needs assessment, since overflow incontinence from chronic retention can damage the kidneys. And in anyone with sudden onset, the reversible causes should be excluded first: infection, constipation, delirium, new medication, poorly controlled diabetes and reduced mobility.

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Urinary Incontinence

Q: How does GMJ News cover urinary incontinence?

GMJ News covers under-reporting and the value of direct questioning, the distinction between stress, urgency, mixed and overflow incontinence, bladder diaries and pad testing, supervised pelvic floor muscle training as first-line therapy, bladder training and overactive bladder drug selection including anticholinergic burden and mirabegron, botulinum toxin and sacral neuromodulation, the mesh sling controversy and its consent and governance implications, post-prostatectomy incontinence and artificial urinary sphincters, obstetric fistula as a global health priority, reversible causes and red flags, pelvic organ prolapse overlap and occult stress incontinence, and containment and skin care. Relevant to PHIG's women's health, ageing and rehabilitation programmes.

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Urinary incontinence affects an estimated hundreds of millions of people worldwide, with prevalence in women rising from around 20-30% in young adulthood to over 40% in later life, yet it remains among the most under-reported conditions in medicine — surveys consistently show that most affected people never mention it to a clinician, delaying help-seeking by years and accepting substantial restriction of work, exercise, travel and social life as inevitable (WHO). The clinical imperative is to distinguish stress incontinence (leakage on cough, laugh or exertion, from urethral sphincter or support failure) from urgency incontinence (leakage preceded by an overwhelming urge, from detrusor overactivity), because the treatments diverge completely; and to recognise that supervised pelvic floor muscle training for at least three months is first-line for stress and mixed incontinence with cure or improvement rates that rival surgery, making it one of the most cost-effective and most under-delivered interventions in women's health.

Key messages

Massively under-reported — most people never mention it

Urinary incontinence affects hundreds of millions worldwide, with prevalence in women rising from around 20-30% in young adulthood to over 40% in later life, and it is among the most under-reported conditions in medicine. Surveys consistently find that the majority of affected people never raise it with a clinician, with average delays of several years, and that many accept substantial restriction of work, exercise, travel, sexual activity and social life as an inevitable part of ageing or childbearing. Asking directly — a single screening question in relevant consultations — is therefore one of the highest-yield actions available.

Distinguish stress from urgency incontinence — treatments diverge completely

Stress incontinence: leakage on coughing, laughing, sneezing, lifting or exercise, without urge, caused by failure of urethral support or sphincter function — typically after childbirth, with obesity, or after prostate surgery in men. Urgency incontinence: leakage preceded by a sudden compelling desire to void that cannot be deferred, caused by detrusor overactivity, and usually accompanied by frequency and nocturia (together termed overactive bladder). Mixed incontinence has both. Overflow incontinence: continuous or post-void dribbling from chronic retention. Distinguishing these is the entire basis of management, and can usually be done from history plus a bladder diary alone.

Supervised pelvic floor muscle training is first-line — and rivals surgery

At least three months of SUPERVISED pelvic floor muscle training is first-line for stress and mixed incontinence in women, with cure or improvement rates that approach those of surgery in appropriately selected patients. The word supervised is critical: written instructions or a verbal explanation alone produce far poorer results, because a substantial proportion of women contract the wrong muscles — frequently bearing down instead of lifting — when taught without assessment. Digital assessment or biofeedback by a trained physiotherapist or continence nurse to confirm correct technique, followed by a structured progressive regimen, is what generates the benefit. It is among the most cost-effective and most under-delivered interventions in women's health.

Overactive bladder — bladder training first, then mirabegron over anticholinergics in older adults

For urgency incontinence and overactive bladder, first-line is behavioural: bladder training with scheduled voiding and progressive interval extension, urge suppression techniques, caffeine reduction and appropriate fluid management. Drug therapy follows. Antimuscarinics (solifenacin, tolterodine, oxybutynin) are effective but carry dry mouth, constipation, blurred vision and — importantly — cognitive burden: cumulative anticholinergic exposure is associated with increased dementia risk in large observational studies, and oxybutynin in particular should be avoided in older adults. Mirabegron, a beta-3 agonist, is preferred in this group, with blood pressure monitoring. Refractory cases: intradetrusor botulinum toxin (with a real risk of retention requiring self-catheterisation), percutaneous or implanted sacral neuromodulation.

The mesh sling controversy — accuracy matters in both directions

Midurethral synthetic slings were, and in many countries remain, effective and durable treatments for stress incontinence. However, serious complications — chronic pelvic and groin pain, dyspareunia, mesh exposure and erosion, and difficult removal — affected a significant minority, and inadequate consent, poor complication reporting and dismissal of patients' symptoms compounded the harm. Several countries suspended or restricted use, and inquiries (notably the UK Cumberlege review) documented systemic failure to listen to patients. The clinical implications: full disclosure of alternatives including autologous fascial sling, colposuspension and urethral bulking agents; surgery only by appropriately trained surgeons within registries with mandatory outcome reporting; and access to specialist mesh-removal centres for affected patients.

Always exclude reversible causes and red flags first

Before attributing incontinence to a chronic mechanism, exclude reversible contributors — usefully remembered as DIAPPERS: Delirium; Infection (urinary tract infection); Atrophic vaginitis; Pharmaceuticals (diuretics, alpha-blockers, sedatives, anticholinergics, calcium channel blockers, ACE inhibitors via cough); Psychological; Excess urine output (diabetes, hypercalcaemia, heart failure, excessive fluid or caffeine); Restricted mobility; Stool impaction. Red flags requiring urgent referral: visible or persistent non-visible haematuria; a pelvic mass; suspected fistula (continuous leakage, especially after pelvic surgery, radiotherapy or obstructed labour); new neurological symptoms including any suggestion of cauda equina; and voiding difficulty with a significant post-void residual.

Key statistics

20-40%+

prevalence in women, rising with age; men affected mainly after prostate surgery and with age

ICS/WHO

3 months

minimum duration of SUPERVISED pelvic floor muscle training as first-line therapy

NICE/ICS

Most never tell

the majority of affected people never raise incontinence with a clinician — ask directly

ICS/ICI

Avoid oxybutynin

in older adults — anticholinergic cognitive burden; prefer mirabegron

NICE/Beers criteria

DIAPPERS

mnemonic for reversible causes that must be excluded before chronic management

ICS/Geriatrics

Continuous leak

after obstructed labour or pelvic surgery suggests fistula — requires specialist referral

WHO/FIGO

Stress incontinence in women — approximate cure or improvement rates

Source: NICE/ICS/Cochrane. Supervised pelvic floor training approaches surgical outcomes in appropriately selected patients.

Glossary of key terms

Bladder diary and pad testing
AssessmentA three-day bladder diary — recording time and volume of every void, fluid intake with type and timing, leakage episodes and their circumstances, and pad changes — is the single most informative assessment tool and repeatedly reveals what the history alone does not: nocturnal polyuria masquerading as bladder dysfunction, excessive or caffeinated fluid intake, functional bladder capacity, and the relationship between leakage and urgency or exertion. Pad testing (1-hour or 24-hour) provides objective quantification of leakage, useful for baseline measurement and outcome assessment, particularly before and after surgery or in medico-legal contexts. Both are non-invasive, cheap and consistently underused compared with early recourse to imaging or urodynamics.

Urodynamics — when it is actually needed
InvestigationInvasive urodynamics is not required for most patients before starting conservative treatment or first-line drug therapy, and routine use before uncomplicated stress incontinence surgery is not supported by evidence (the VALUE trial found no benefit over office evaluation in straightforward cases). It IS indicated when: symptoms are mixed or unclear and the dominant mechanism will determine surgery; there is voiding dysfunction or a significant post-void residual; there is known or suspected neurological disease (neurogenic bladder, where urodynamics also assesses upper tract risk from high detrusor pressures); previous incontinence or prolapse surgery has failed; or when the planned intervention carries significant risk. Video-urodynamics adds anatomical information in complex, neurogenic and post-surgical cases.

Obstetric fistula
Global healthVesicovaginal and rectovaginal fistula caused by prolonged obstructed labour remains a devastating and preventable condition affecting an estimated hundreds of thousands of women, overwhelmingly in sub-Saharan Africa and South Asia. Mechanism: prolonged impaction of the fetal head compresses the soft tissues between it and the pelvis, causing ischaemic necrosis and subsequent breakdown, producing continuous uncontrollable leakage of urine or faeces. The consequences extend far beyond the physical: profound social consequences including divorce, ostracism, loss of livelihood, depression and destitution are typical. It is fundamentally a marker of failed access to emergency obstetric care. Surgical repair has high success rates in experienced hands, and prevention — skilled birth attendance, timely caesarean section, and delaying first pregnancy — is entirely achievable. UNFPA leads the global Campaign to End Fistula.

Post-prostatectomy incontinence
Urology/MenThe commonest cause of stress incontinence in men, following radical prostatectomy for prostate cancer, and a major determinant of post-treatment quality of life and regret. Mechanism: injury to or loss of support for the external urethral sphincter, sometimes compounded by coexisting detrusor overactivity. Most men improve substantially over the first 6-12 months, so surgical intervention is generally deferred until at least a year. Preoperative and early postoperative supervised pelvic floor muscle training accelerates recovery. For persistent incontinence: male slings for mild to moderate leakage; artificial urinary sphincter, which remains the gold standard for moderate to severe incontinence, with high satisfaction but a need for revision over time and a requirement for adequate manual dexterity and cognition to operate the pump.

Containment products and skin care
Nursing/Practical careWhere incontinence cannot be cured, well-chosen containment is not a failure of treatment but a legitimate and dignity-preserving intervention — and it is frequently done badly. Key principles: absorbent products should be matched to the volume and pattern of leakage and to mobility, and specified by a continence assessment rather than issued generically; products designed for men and women differ and are not interchangeable; and over-large pads for light leakage waste resources and reduce comfort and adherence. Incontinence-associated dermatitis is common, painful, and a direct precursor of pressure damage: prevention requires prompt changing, gentle cleansing without soap, and application of a barrier product. Indwelling catheters should be a last resort for incontinence, since they guarantee bacteriuria and carry infection, trauma, stone and bladder cancer risks with long-term use.

Pelvic organ prolapse overlap
UrogynaecologyProlapse and incontinence share risk factors — vaginal delivery, obesity, chronic straining, ageing and connective tissue factors — and frequently coexist, so assessment of one should always include assessment of the other. An important and counterintuitive interaction: a significant anterior prolapse can kink the urethra and MASK stress incontinence, which then becomes apparent only after the prolapse is repaired (occult stress incontinence). This must be discussed before prolapse surgery, and can be assessed preoperatively by reducing the prolapse and testing for leakage. Conservative management with pelvic floor muscle training and vaginal pessaries is effective for many women and should be offered before surgery; as with incontinence, the use of transvaginal mesh for prolapse has been restricted or suspended in many countries following serious complications.

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