Urinary incontinence (UI) is a common condition characterized by involuntary leakage of urine. Causes and presentations are variable. Stress incontinence, urge incontinence, and mixed incontinence are the most common types. UI is more common in older individuals, and approximately twice as common in women than in men. The diagnosis can often be made based on a detailed medical history, a voiding diary, physical examination, and basic testing including urinalysis and measurement of postvoid residual volume (PVR). Advanced diagnostic studies may be required for patients with or incontinence refractory to treatment. Initial management involves conservative measures (e.g., management of comorbidities, pelvic floor exercises, bladder training) and provision of continence products; further treatment is based on the underlying mechanism and may involve pharmacotherapy or surgery. If left untreated, UI can have a severely detrimental effect on patients' psychosocial well-being, mobility, and independence, and can increase the risk of infection.
For the management ofand , see also the respective articles.
- Increases with age
- Up to 50% of women and up to 25% of men older than 65 years are affected.
- Sex: ♀ > ♂ (2:1) 
Epidemiological data refers to the US, unless otherwise specified.
- Neurological causes
- Genitourinary causes
- Transient causes of urinary incontinence
- General risk factors
To remember the reversible causes of acute urinary incontinence, think DIAPPERS: Delirium/confusion, Infection, Atrophic urethritis/vaginitis, Pharmaceutical, Psychiatric causes (especially depression), Excessive urinary output (hyperglycemia, hypercalcemia, CHF), Restricted mobility, Stool impaction.
|Overview of urinary incontinence |
|Underlying mechanism||Clinical features||Treatment|
|Stress incontinence|| || |
|Urge incontinence || || |
|Mixed incontinence|| |
|Total incontinence|| || |
|Overflow incontinence (overflow bladder) || || |
|Neurogenic bladder dysfunction || || || |
|Enuresis risoria || || |
Overview of pharmacotherapy
|Autonomic drugs used to treat bladder incontinence |
|Drug group||Indications||Mechanism of action|
e.g., bethanechol 
The use of muscarinic agonists may lead to urinary urgency, while the use of sympathomimetics or muscarinic antagonists may lead to urinary retention, especially if there is an untreated outlet obstruction. 
The following outlines a general approach for the workup of incontinence of unknown mechanism; if the mechanism is known, see “Diagnostics” in “” and “ .”
- All patients: Perform an initial evaluation for urinary incontinence.
- Suspected upper urinary tract involvement : Obtain renal ultrasound and laboratory studies.
- Red flags in urinary incontinence present or refractory incontinence: Referral to a specialist for further diagnostics.
Red flags in urinary incontinence 
Refer to urology or urogynecology for specialist workup if any of the following features are present:
- Associated pain
- Persistent hematuria or proteinuria
- Elevated PVR
- Symptoms suggestive of obstruction
- Suspected fistula
- Pelvic organ prolapse
- Recurrent UTIs
- Incontinence after radiation, radical pelvic surgery, or previous incontinence surgery
Initial evaluation for urinary incontinence 
Chronicity: Determine whether the incontinence is acute or chronic.
- Acute: Screen for and reassess after they have been treated. 
- Chronic: Take a general history followed by a focused history.
- Screen for relevant chronic and/or previous medical conditions and treatments.
- Assess for contributing dietary and lifestyle factors.
Focused history of incontinence
- If possible, use a validated incontinence questionnaire. 
- Inquire about symptoms that occur with voiding.
- Assess for barriers to voiding (e.g., limited mobility, which may delay patients reaching the bathroom).
- Ask patients to record fluid intake and micturition for 3–5 days using a .
Physical examination 
Lower abdominal examination
- Evaluate for bladder distention and masses.
- Perform a . 
- Digital rectal examination: Assess for fecal impaction, prostatomegaly, masses, and decreased anal sphincter tone.
- Pelvic examination: Evaluate for pelvic organ prolapse, vaginal atrophy, masses, and vaginitis. 
- Cardiovascular examination: Assess for (may worsen urge incontinence).
Neurological examination: Both spinal and cerebral pathologies can cause incontinence (see “Etiology”).
- Assess motor function of the lower extremities and sensation of the sacral dermatomes.
- Consider .
- Postvoid residual volume (PVR) 
Differentiation between types of incontinence
|Diagnostic overview of types of incontinence |
|Clinical history||Urinary stress test||Postvoid residual volume|
|Stress incontinence|| || || |
|Urge incontinence|| || |
|Overflow incontinence|| || |
|Functional urinary incontinence|| || |
Upper urinary tract studies 
- Renal ultrasound
- Creatinine and BUN: may be elevated in patients with overflow incontinence
Advanced studies 
Advanced studies are performed under specialist guidance for patients with e or incontinence refractory to initial management.
- vesicoureteral reflux and/or morphological abnormalities (e.g., diverticula, obstruction) : to detect
- to determine :detrusor and sphincter function
- Cystoscopy: to evaluate for tumors and vesicorectal and vesicovaginal fistulae
- Ultrasound pelvis : for suspected pelvic floor dysfunction
- MRI : to assess for pelvic floor defects, urinary tract anomalies, and masses
- CT with IV contrast: for suspected anatomical abnormalities, e.g., urinary tract masses, bladder wall thickening
- Identify and manage:
- Initiate for all patients.
- Start specific management based on the subtype.
- Refer patients with any of the following to urology for further management:
- Continence products (e.g., pads, external catheters) may be helpful as a temporary or permanent adjunct.
Assess the impact of incontinence symptoms on the patient's daily activities and discuss their treatment goals; use shared decision-making to individualize treatment plans.
Conservative management of urinary incontinence 
Management of comorbidities
- Treatment of conditions such as chronic cough or DM may reduce symptom severity.
- Review medication and, if possible, reduce the dose or discontinue contributing medications, e.g., diuretics.
- Refer patients with limited mobility to physical therapy and occupational therapy.
- Consider topical estrogen for postmenopausal women. 
- Smoking cessation
- Limiting consumption of alcohol and caffeine (including carbonated drinks)
- Appropriate fluid intake and timing throughout the day 
Pelvic floor physical therapy 
- Exercises that target the pelvic floor to strengthen the muscles that control urinary flow and bowel movements
- To increase efficacy, exercises may be supplemented with:
- Weighted vaginal con
Scheduled voiding regimens and patient education are used to increase leak-free intervals. 
- Timed voiding: Intervals between voiding are sequentially increased until the goal of at least 3–4 hours is met.
- Relaxation and distraction techniques: used to suppress the urge to urinate.
- Indications: urge incontinence, but also effective for stress and mixed incontinence
- Provide either alongside or after a trial of conservative management of UI.
- After a 6–8 week trial: stress incontinence 
- Alongside: all other forms of incontinence
- For further information, see:
Special patient groups
Urinary incontinence in older adults 
- Management of older patients is similar to that of other populations, but with some modifications.
- Functional incontinence due to cognitive or mobility impairment is more common than in younger patients.
- Comorbid conditions and polypharmacy can make pharmacological management challenging.
- Screen for .
- Consider cognitive testing and functional testing in all patients.
- Limit PVR measurement to patients with any of the following:
Modifications to the
- Consider life expectancy, goals of care, and the patient's and/or caregiver's ability to manage therapy when planning treatment.
- Prompted voiding may be helpful for older patients with cognitive impairment. 
- Start any medications at the lowest dose possible and follow-up frequently to assess for adverse effects.
- Consider specialist referral if conservative therapies fail or other chronic conditions need to be addressed (e.g., dementia, functional impairment).