Synopsis
Deliver the two principal behavioural treatments for urinary incontinence with correct selection, supervision, dose, safety review and outcome measurement.
- Confirm by digital vaginal assessment that the person can contract the pelvic floor before prescribing a strengthening programme.
- Supervised pelvic-floor muscle training is first-line for stress or mixed urinary incontinence and should continue for at least three months.
- The NICE programme contains at least eight contractions three times daily, individualised to strength, endurance, coordination and relaxation.
- Teach both sustained and quick contractions and pre-contract before cough or lift; repeatedly stopping urine midstream is not the training method.
- Do not add electrical stimulation, perineometry or EMG biofeedback routinely; consider stimulation or biofeedback when an effective contraction cannot be performed.
- Bladder training is first-line for urgency or mixed incontinence and should run for at least six weeks with a diary, planned intervals and urge-management strategies.
- Increase the voiding interval gradually without painful overfilling; protect hydration, mobility and toilet access and adapt for frailty, cognition and occupation.
- If frequency remains troublesome after bladder training, an OAB medicine can be combined with continued training rather than replacing it.
Key red flags
New inability to void, painful bladder distension or overflow with neurological symptoms requires urgent retention assessment.
Visible haematuria, fever, flank pain, severe dysuria or recurrent unexplained infection needs investigation beyond behavioural training.
Pelvic-floor exercise that consistently provokes pelvic pain, obstructed voiding or dyspareunia may indicate overactivity rather than weakness and needs specialist assessment.
Continuous watery vaginal leakage after birth or pelvic surgery raises concern for fistula or urinary injury.
Severe prolapse ulceration, vaginal bleeding or inability to reduce an acutely painful prolapse requires prompt gynaecological review.
Investigation priorities
Confirm the person can contract and relax the intended muscles and establish an individual baseline.
Management branches
Stress leakage is present and an urgent or structural cause has been excluded.
- Confirm contraction and relaxation digitally, assess strength and endurance, and identify pain, prolapse or voiding features that modify training.
- Prescribe at least eight contractions three times daily, combining sustained and quick work with full relaxation and pre-contraction before pressure events.
- Supervise for at least three months, review technique and functional outcomes, and continue maintenance if benefit is achieved.