Urinary incontinence and overactive bladder

Incontinence is common, treatable, and under-discussed, and the intervention with the best evidence is a supervised pelvic floor muscle training programme — better than medication for stress incontinence, and effective for urgency and mixed incontinence too.

Stress incontinence — leaking on coughing, laughing, lifting, running — responds to pelvic floor muscle training with cure rates comparable to surgery in some trials and with better durability than surgery in the longer follow-up of the better studies. It takes 3-6 months of supervised training.

Overactive bladder and urgency — pelvic floor training, bladder training (delaying voiding by progressively longer intervals), reducing caffeine and alcohol, weight loss, and treating constipation. Anticholinergic drugs are used and have side effects including cognitive ones, particularly in older adults; there is a real case for trying behavioural treatment first.

The supplements sold for this have essentially no evidence. Pumpkin seed, soy isoflavones, and various herbal blends have small or absent trial data.

The things that need ruling out first, and they are the reason this is a clinician's conversation. A urinary infection; diabetes; a medication effect (diuretics, some antihypertensives, sedatives); vaginal atrophy (treatable with topical oestrogen); an enlarged prostate or a fibroid pressing on the bladder; a neurological condition; and, in a woman with leakage, a fistula after pelvic surgery. New incontinence is a symptom, not a diagnosis.

The practical measures. Timed and prompted voiding; treating constipation; weight loss; reducing caffeine and alcohol; adequate fluid intake but not excessive (restricting fluid concentrates the urine, irritates the bladder and makes urgency worse — a common error); and absorbent products as a bridge while the training works.

In men, always exclude prostate obstruction. A man with incontinence and a poor stream needs assessment before any behavioural programme.