Some people leak when they laugh or sneeze; others leak because they cannot hold it in front of the bathroom door. Both are called “urinary incontinence,” but the reason urine leaks is different, so the order of treatments likely to help is different too. That is why care begins by working out in which moments the leaks happen. If you have written down the situations over a few days, that record is the best material for this process.
What types of urinary incontinence are there?
Urinary incontinence in women is broadly divided into stress, urge, and mixed, where both are present. Because different changes are happening in the body in each case, the first step of treatment differs as well.
| Type | When urine leaks | Main related change | Where treatment starts |
|---|---|---|---|
| Stress urinary incontinence | Moments when the belly tightens, such as coughing, sneezing, laughing, running, or lifting something heavy | The pelvic floor muscles and tissues that support the urethra weaken, for example after childbirth or with aging | Pelvic floor muscle exercise, weight management |
| Urge urinary incontinence | A sudden, strong urge, leaking before you reach the bathroom | Overactive bladder, in which the bladder contracts on its own before it is full | Bladder training, cutting back on caffeine, medicine if needed |
| Mixed urinary incontinence | Both of the situations above | Both changes are present together | The more bothersome side first, both approaches together |
Stress urinary incontinence is the most common type in women, and many people with stress urinary incontinence also have symptoms of urgency. Rarely, urine leaks in small amounts as if overflowing because the bladder does not empty well; in that case the problem of passing urine has to be looked at first, so the approach is entirely different. If your stream is weak and you keep feeling that urine is left after you finish, be sure to mention it at your visit.
What is checked at a clinic visit?
In most cases, the type is identified through a medical history, an examination, a bladder diary, and a urine test; measuring residual urine or urodynamic testing is added only when needed. You do not have every test from the start.
- Medical history We ask when and in what situations you leak and how much it bothers you day to day. Past childbirth and surgery, whether you have gone through menopause, and the medicines you take also affect the cause and the choice of treatment.
- Examination A pelvic exam checks whether the bladder or uterus has dropped and whether you can contract the pelvic floor muscles properly. Sometimes we also see directly whether urine leaks when you cough with a full bladder.
- Bladder diary You record the times you pass urine and how much, the situations when you leaked, and what you drank. The UK's National Institute for Health and Care Excellence (NICE) recommends keeping it for at least 3 days, including both working days and days off.
- Urine test This checks for signs of blood, sugar, and inflammation. Infections such as cystitis can cause symptoms of urgency, so they are looked at before incontinence treatment.
- Residual urine measurement The amount left in the bladder right after you pass urine is measured, usually by ultrasound. It is checked if passing urine is difficult or cystitis keeps coming back.
- Urodynamic testing The bladder is filled through a thin tube while pressure changes in the bladder and urethra are measured. It is considered before surgery when the type is unclear, in mixed incontinence where symptoms of urgency are more prominent, when there is difficulty passing urine, or when you have had incontinence surgery before.
How is stress urinary incontinence treated?
The first treatment is pelvic floor muscle exercise. NICE recommends supervised exercise for at least 3 months, at least 3 times a day, with at least 8 contractions each time. If it helps, you keep going after that.
The key to this exercise is using the right muscles. If you repeat it while tightening your buttocks, thighs, or belly, or while holding your breath, the muscles that actually support the urethra may barely move. That is why an examination checks whether your pelvic floor muscles contract properly before you start.
- Weight management: If your body mass index is over 30, losing weight alone can reduce the pressure on the belly and may help the symptoms.
- Managing constipation and coughing: Repeated straining tends to make symptoms worse, so these are treated as well.
- Electrical stimulation and biofeedback: These are supportive methods that help people who find it hard to contract the muscles on their own learn the contraction and keep up the exercise. They are not added routinely for everyone.
- Medicine: Medicines available for stress urinary incontinence have only partial effects and carry a burden of side effects, so they are not used as the first treatment.
How is urge urinary incontinence treated?
Bladder training and lifestyle adjustments come first, and medicine is added if those are not enough. NICE recommends trying bladder training for at least 6 weeks.
Bladder training is practice in gradually lengthening the time between bathroom trips, based on your bladder diary. You also learn how to let the urge settle instead of rushing off the moment it comes. Try cutting back on caffeinated drinks such as coffee and green tea, and rather than simply drinking less water, use your records to check whether you are drinking too much or too little and adjust. Drinking far too much or far too little can both make the discomfort worse.
The medicines mainly used are anticholinergics or beta-3 agonists, which reduce sudden bladder contractions. You need to take them for at least 4 weeks to judge whether they work, and side effects such as dry mouth and constipation can occur. Because the effect of long-term anticholinergic use on cognitive function is not yet clear, the choice is made after checking your age, other medicines, and conditions such as glaucoma or residual urine. If changes such as vaginal dryness after menopause are also present, vaginal estrogen may be considered.
If medicine does not control the symptoms, botulinum toxin injections into the bladder wall or treatment that stimulates the sacral nerves may be considered at a specialist medical institution. After a botulinum toxin injection, the bladder may not empty completely and you may need to insert a thin tube yourself to drain urine, so this possibility is explained before you decide.
What is treated first in mixed urinary incontinence?
The more bothersome symptom is treated first, and pelvic floor muscle exercise and bladder training are often started together. Which one is the bigger problem becomes relatively clear when you separate the “number of leaks when coughing” from the “number of leaks from urgency” in your bladder diary.
NICE recommends that even when stress symptoms are larger, you first discuss the effect of non-surgical treatment and overactive bladder medicines rather than having surgery first. Surgery that supports the urethra treats leakage when you cough, so symptoms of urgency may remain after surgery, and rarely they may even appear for the first time or get worse. That is why, in mixed incontinence where symptoms of urgency are greater or the type is unclear, the bladder's condition is checked with urodynamic testing before surgery.
When is incontinence surgery considered, and what should you know?
Incontinence surgery is mainly considered for stress urinary incontinence, or mixed incontinence where the stress component is larger, when non-surgical treatment has not brought enough improvement and daily life is significantly affected. Along with the severity of symptoms, how much they bother you in daily life and what you hope for weigh heavily in the decision.
The most widely used method is the midurethral sling. Through a small incision inside the vagina, a synthetic tape is placed under the middle of the urethra so that the urethra is supported when you cough. Depending on the route the tape takes, there are methods that pass behind the pubic bone, methods that pass toward the inner thigh, and short-tape methods done through a single incision. Other options include a sling made from your own fascia, surgery that lifts and secures the bladder neck, and injecting a bulking material into the urethral wall. Injection is less demanding, but it is relatively less effective, and its effect fades over time, so repeat injections may be needed.
If you are planning a future pregnancy, please tell us in advance. Pregnancy and childbirth can affect the result of surgery, so we think about the timing together. After surgery, the first check is whether you can pass urine well, and you are examined again within 6 months to look at remaining symptoms and the condition of the tape. If you cannot pass urine at all after surgery, if pain keeps getting worse, or if you develop a fever, contact the medical institution where you had surgery right away.
Where do non-surgical procedures such as laser and physical therapy fit in?
They do not replace pelvic floor muscle exercise and lifestyle adjustments; they are options considered together with them after the type and symptoms are confirmed. At LILEAP, we offer consultations on physical therapy and laser therapy for relieving urinary incontinence, and we first confirm what type of incontinence you have before discussing whether they are suitable.
However, the evidence on how well vaginal laser works for stress urinary incontinence is not yet sufficient. NICE notes that no clear short-term safety problems have been reported, but considers the evidence on long-term efficacy and safety inadequate in both quality and quantity, and recommends using it only in the context of research. Laser procedures and surgery that places tape work on different principles, so if you are considering a procedure, ask for an explanation of the changes you can expect, its limits, and the other options.
If you see blood in your urine, it hurts when you pass urine, or urine does not come out well, do not assume it is only incontinence; see a doctor first. We have summarized how to tell apart the moments of leakage in Urinary incontinence symptoms and diagnosis, the roles of exercise, training, and medicine in Non-surgical urinary incontinence care, and what to check before surgery in Surgical treatment for urinary incontinence. If symptoms of urgency came with pain, also read the article on whether it might be cystitis and what to check when cystitis keeps coming back.