Managing urinary incontinence in women's health

Urinary incontinence (UI) affects almost 40% of women in Australia and is a common reason for presentation in primary care. The three main types are stress urinary incontinence (SUI), urge urinary incontinence (UUI), often associated with overactive bladder (OAB) syndrome, and mixed urinary incontinence (MUI).

Assessment

The initial assessment should focus on determining the type of incontinence, as this will guide management. Asking when leakage occurs is often the most useful starting point. SUI is characterised by leakage during activities that increase intra-abdominal pressure, such as coughing, sneezing or exercise. UUI is associated with a sudden compelling desire to void and is often accompanied by symptoms of OAB, including urinary frequency and nocturia. MUI combines features of both.

A detailed history should also identify features that suggest more complex pathology, including pain, haematuria, recurrent urinary tract infections, previous pelvic surgery or pelvic irradiation. Examination should include abdominal, pelvic and perineal examination to assess for pelvic masses, pelvic organ prolapse and signs of genitourinary syndrome of menopause (GSM). Asking the patient to contract their pelvic floor muscles during examination can provide a simple assessment of pelvic floor strength, and if appropriate, a cough stress test may demonstrate stress incontinence.

Investigations

In most cases, initial investigations are readily available in primary care. A bladder diary can be helpful in characterising symptoms and monitoring response to treatment. Urinalysis should be performed for all women, with urine culture if infection is suspected. Referral to secondary care should be considered for women with significant pelvic organ prolapse, recurrent urinary tract infections, suspected neurological causes, diagnostic uncertainty, or haematuria to exclude underlying pathology, including malignancy.

Management

Conservative management forms the cornerstone of treatment for all types of incontinence. Lifestyle measures such as weight loss, reducing caffeine intake, smoking cessation and appropriate fluid management should be discussed with every patient. Supervised pelvic floor muscle training (PFMT) is the first-line treatment for SUI, while bladder training is recommended for women with UUI or OAB symptoms. Women with SUI who have not improved following at least three months of supervised PFMT may benefit from specialist referral to discuss surgical options.

Duloxetine can be considered for women who decline surgery or are not suitable surgical candidates. Antimuscarinic medication or a beta-3 agonist such as mirabegron may be appropriate for women with UUI if bladder training alone is insufficient. Vaginal oestrogen can improve urinary symptoms associated with GSM, while pelvic organ prolapse may benefit from pessary management or referral for surgical assessment where appropriate. Referral should also be considered for women whose symptoms persist despite optimised conservative management.

Finally, women should be reassured that effective treatments are available and that incontinence should not be accepted as a normal part of ageing. Continence products can improve confidence and quality of life while assessment and treatment are underway.

GPs are ideally placed to identify women with urinary incontinence, initiate evidence-based treatment and provide ongoing support. Early intervention can significantly improve symptoms, quality of life and confidence.

- Dr Samantha Miller, MBChB

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References

1. National Institute for Clinical Excellence (NICE)(2019). Urinary incontinence and pelvic organ prolapse in women. https://www.nice.org.uk/guidance/ng123
2. National Institute for Clinical Excellence (NICE)(2021). Pelvic floor dysfunction: prevention and non-surgical management. https://www.nice.org.uk/guidance/ng210/
3. National Institute for Clinical Excellence (NICE). Clinical Knowledge Summaries (CKS) (2025). Incontinence - urinary, in women, https://cks.nice.org.uk/topics/incontinence-urinary-in-women/
4. BMJ Best Practice (2026) Urinary incontinence in women. https://bestpractice.bmj.com/topics/en-gb/169
5. International Continence Society (ICS)(2020). Urinary Incontinence in Women. https://www.ics.org/folder/standardisation/ici-algorithms/d/3-urinary-incontinence-in-women/download
6. Milsom, I., & Gyhagen, M. (2019). The prevalence of urinary incontinence. Climacteric: the journal of the International Menopause Society, 22(3), 217–222. https://doi.org/10.1080/13697137.2018.1543263
7. Continence Health Australia. https://www.continence.org.au/about-incontinence/what-is-incontinence/statistics-on-incontinence/
8. The Royal Australian College of General Practitioners (2021). Pelvic floor muscle training for women. https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/patient-resources/rehab-pain-management/pelvic-floor-muscle-training-for-women
9. The Royal Australian College of General Practitioners (2024). Managing female stress urinary incontinence in a post-mesh era: What to do and when to refer. https://www1.racgp.org.au/ajgp/2024/may/managing-female-stress-urinary-incontinence-in-a-p