Urinary incontinence: causes, types and PFMT
Understand stress, urgency and mixed urinary incontinence, main causes, and why PFMT is first-line conservative treatment.
Urinary incontinence affects approximately 1 in 3 women at some point in their lives, and many men — particularly those who have undergone prostate surgery. Despite its prevalence, it remains one of the least reported health problems: embarrassment, normalisation and lack of awareness about treatment options mean many people live for years with a problem that is treatable.
This guide explains the main types of incontinence, their causes, and why conservative treatment should always be the first step.
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Types of urinary incontinence
Stress incontinence
Occurs when any increase in abdominal pressure — coughing, sneezing, laughing, jumping, running, lifting — causes involuntary urine leakage.
The main cause is a pelvic floor and/or urethral closure mechanism that cannot withstand the rise in pressure. Risk factors include vaginal delivery, excess weight, chronic cough, repetitive straining, and high-impact physical activity without pelvic floor conditioning.
This is the type that responds best to PFMT: NICE guidelines recommend a minimum of 3 months of supervised PFMT as first-line therapy.
Urgency incontinence (overactive bladder)
Characterised by a sudden, difficult-to-control need to urinate, which may or may not be accompanied by urine leakage. The underlying cause is detrusor overactivity. Common triggers include hearing running water, arriving home, cold temperatures or anxiety.
Mixed incontinence
A combination of both types above. The most frequent presentation in clinical practice.
Overflow incontinence
Caused by bladder outlet obstruction or detrusor underactivity: the bladder does not empty completely and fills until dribbling occurs. More common in men with prostatic enlargement.
Causes and risk factors
| Factor | Impact |
|---|---|
| Pregnancy and vaginal delivery | Stretching and potential muscle and nerve injury |
| Overweight and obesity | Chronic increase in intra-abdominal pressure |
| Chronic cough | Repeated strain on the pelvic floor |
| Menopause | Reduced oestrogen, tissue atrophy |
| Prostate surgery | Injury to urethral closure mechanisms |
| Chronic constipation | Repeated straining during defaecation |
Why PFMT is the first-line treatment
The evidence is clear and consistent:
- NICE NG123: recommends as the first option for stress incontinence “a minimum of 3 months of supervised PFMT including at least 8 contractions performed 3 times daily.”
- Cochrane CD005654: supervised PFMT significantly reduces the frequency and severity of urine leaks compared with no treatment.
- ICS: includes PFMT as first-line therapy for all types of functional incontinence.
PFMT has no side effects, is reversible, and is compatible with any other intervention. It should therefore be trialled before considering surgery or medication in most cases.
Explore the scientific evidence →
The role of habits and bladder behaviour
Adequate hydration: 1.5–2 litres of water daily. Reduce caffeine (coffee, tea, cola) and alcohol, which irritate the bladder.
Bladder retraining: for urgency incontinence, this involves training the bladder to gradually wait longer between voids. The interval between bathroom visits is increased by 15 minutes each week.
Managing constipation: a high-fibre diet, adequate hydration and correct defaecation technique (feet on a footstool to align the rectum) all help.
Body weight: weight loss in overweight individuals has a direct impact on stress incontinence by reducing chronic intra-abdominal pressure.
When to seek professional help
- Incontinence that does not improve after 8–12 weeks of consistent PFMT
- Severe incontinence that significantly affects quality of life
- Pelvic pain
- Suspected pelvic organ prolapse
- Haematuria (blood in the urine)
FAQ
Is urinary incontinence a normal part of ageing?
It is common but neither normal nor inevitable. Many people normalise it as part of ageing or the postpartum period, but incontinence is a treatable dysfunction. PFMT has strong evidence for improving or resolving many cases.
Should I drink less water to reduce leaks?
No. Reducing fluid intake can concentrate urine, irritate the bladder and worsen urgency. The recommendation is to maintain adequate hydration (1.5–2 litres per day) and reduce bladder irritants such as caffeine and alcohol.
How long does conservative treatment take to work?
With PFMT adherence, most studies show significant improvements between 8 and 12 weeks. Optimal results are often achieved between 3 and 6 months.
If PFMT does not work, what are the options?
Second-line options include medication (anticholinergics or beta-3 agonists for urgency), pessaries (for prolapse), periurethral bulking injections, and surgery (mid-urethral sling for severe stress incontinence). All must be discussed with a specialist.
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