Key content
 Urinary incontinence (UI) affects up to 69% of the female population at some point in their lives but remains under-reported. There are three main types of UI: stress, urgency and mixed.
 It is recommended to try conservative approaches as first-line measures in the management of all types of UI. These include lifestyle interventions such as adjustment of fluid intake and weight loss, physical and behavioural therapies(pelvic floor muscle training, electrical stimulation, vaginal cones
and bladder training programmes) and occasionally
containment devices.
 Initial management of UI, in most cases, renders itself to primary care settings: this involves appropriate assessment of women’s symptoms, including quality of life (QOL) assessment, appropriate
simple investigations (such as urine analysis) and conservative treatment.
 Appropriate referral pathways to secondary and tertiary levels of
care are necessary. Regular audit should take place to assess the
efficacy of management options and referral pathways.
 UI has significant adverse affects on women’s QOL. Hence patient
reported outcome measures (PROMs) have been highlighted in
recent NHS reports as a means of assessing effectiveness of care
from the patient’s perspective by gauging patient health status or
health-related QOL.
Learning objectives
 To gain an understanding of the assessment and various conservative
management options for common types of UI in women.
 To explore the existing evidence base for such conservative
management modalities and to analyse the effect of the current
economic climate and reorganisation of services on the
conservative management approach.
 To recognise the important role of patient reported outcome
measures as well as service and user involvement, in the assessment
of clinical and cost-effectiveness of various treatment options of UI
in women.
Ethical issues
 Should conservative measures such as weight loss and smoking
cessation be a pre-requisite for offering further
management options?
 In the present climate of scarce health resources should more
emphasis be placed on the active role of patients in their own
management? Will reorganisation of the NHS pose any threat to
the conservative measures for treating UI in women?
 Is it acceptable to take a ‘one size fits all’ approach to management
of common types of UI?
Keywords: female urinary incontinence / integrated continence service / patient reported outcome measures / pelvic floor muscle training

Introduction

Pathway for referral
1. Microscopic haematuria in women >50 years
2. Visible haematuria
3. Recurrent or persisting UTI
4. Suspected mass arising from urinary tract
5. Symptomatic prolapse visible below introitus
6. Feeling a palpable bladder on bimanual examination after voiding
7. Suspected neurological disease
8. Associated faecal incontinence
9. Persisiting bladder or urethral pain
10. Clinically benign pelvic mass
11. Symptoms of voiding dysfunction
12. Suspected urogenital fistula

tress incontinence
First-line therapy is pelvic
floor muscle training
• Digitally assess pelvic floor
muscle contraction
• PFMT to consider eight
contractions/ three times
per day
•
treatment
If beneficial continue
• Do not routinely advise
electrical stimulation/
biofeedback during PFMT
Lifestyle interventions
••
Weight loss
Modify fluid intake
• Constipation management

Pure OAB
• In case of voiding dysfunction or recurrent UTI, check postvoid residual
(not catheter)
Reduce caffeine intake ••
If frequency/urgency
bothersome add
anticholinergic
Not recommended:
• Urodynamics
• Ultrasound (except to
assess residual)
• Routine use of pad tests
• Cystoscopy

Mixed UI
Determine treatment based on
predominant stress/UI as the
dominant symptom

Conclusion
The conservative management of female UI, including
pharmacotherapy if indicated, should ideally start from
primary care, with more complicated cases to be referred to
secondary care or tertiary care through properly conceived
care pathways. Though not life threatening, UI is disabling
and has significant effects on QOL and social stigma. Careful
assessment and conservative management of incontinence
can be the mainstay of therapy in most cases. The recent
restructuring of the NHS and delivery of incontinence care
through AQPs needs to embrace these in order to provide
quality care to women with UI.