Synopsis
Classify urinary leakage without dismissing it as ageing, identify retention, infection, neurological and cancer danger, and provide conservative, pharmacological and referral care adapted to cognition, mobility, renal function and personal goals.
- Classify leakage as urgency, stress, mixed, overflow, continuous or functional by history, diary, examination and residual volume when indicated.
- First-line assessment asks urgency, exertional leak, frequency, nocturia, stream, emptying, fluid, bowel, mobility, cognition, medicines, pads and goals.
- Use urine dipstick in women as NICE advises and culture when symptomatic infection or testing criteria apply; do not treat asymptomatic bacteriuria routinely.
- Measure post-void residual by bladder scan when voiding dysfunction, recurrent infection, neurological disease or overflow is suspected.
- A three-day bladder diary records time, volume, intake, urgency and leakage and separates small-volume urgency from true polyuria.
- First-line urgency management is bladder training for at least six weeks, fluid and caffeine adjustment, constipation treatment and mobility-access optimisation.
- First-line stress or mixed incontinence care includes supervised pelvic-floor muscle training for at least three months, targeted to confirmed contraction ability.
- In frailty or cognitive impairment, prompted or timed toileting, clear routes, clothing adaptation and carer training may outperform another bladder drug.
- Before an antimuscarinic, review cognition, constipation, glaucoma risk, emptying and total anticholinergic burden; avoid immediate-release oxybutynin in frail older women.
- Mirabegron is an option for overactive bladder when antimuscarinics are contraindicated, ineffective or not tolerated, with blood-pressure, interaction, renal and hepatic review.
Key red flags
New urinary retention with saddle sensory loss, bilateral weakness or severe back pain requires emergency cauda equina assessment.
Fever, rigors, hypotension, delirium or flank pain with urinary symptoms requires sepsis and upper-tract obstruction assessment.
Visible haematuria, recurrent unexplained infection, pelvic mass or weight loss requires cancer-appropriate investigation.
Painful palpable bladder, overflow leakage or acute kidney injury requires urgent residual-volume and obstruction assessment.
Continuous leakage after pelvic surgery or radiotherapy can indicate fistula and requires specialist review.
Sudden new incontinence with delirium, marked thirst, hyperglycaemia or medication change should trigger acute reversible-cause assessment.
Weak stream, incomplete emptying, dribbling and a high residual indicate voiding failure.
Retention or incontinence with saddle or bilateral leg signs requires emergency spinal assessment.
Investigation priorities
Classify storage, volume and timing patterns first line.
Management branches
An older adult reports new or persistent urinary leakage.
- Assess urgency, stress, voiding, volume, bowel, medicine, cognition, mobility and red flags and examine relevant systems.
- Use bladder diary, urine testing and post-void residual when indicated to distinguish storage, polyuria, infection and emptying failure.
- Agree a conservative plan targeted to subtype and function, with containment and skin protection while treatment develops.