Lower urinary tract symptoms (LUTS)
The lower urinary tract comprises the bladder and the urethra (the tube through which urine passes out of the body).
Lower urinary tract symptoms (LUTS) are common in men and women as they get older. They can include:
problems with storing urine, such as an urgent or frequent need to go to the toilet, or feeling like you need to go straight after you have just been
problems with passing urine, such as a slow stream of urine, straining to pass urine or stopping and starting as you pass urine
problems after you have passed urine, such as feeling that you've not completely emptied your bladder or passing a few drops of urine after you think you've finished
Experiencing LUTS can make urinary incontinence more likely.
Causes of urinary incontinence
Urinary incontinence occurs when the normal process of storing and passing urine is disrupted.
This can happen for a number of reasons, and certain factors may also increase your chance of developing urinary incontinence.
Some of the possible causes will lead to short-term urinary incontinence, while others may cause a long-term problem. If the cause can be treated, this may cure your incontinence.
Causes of stress incontinence
Stress incontinence occurs when the pressure inside your bladder as it fills with urine becomes greater than the strength of your urethra to stay closed (the urethra is the tube through which urine passes out of your body).
Any sudden extra pressure on your bladder, such as laughing or sneezing, can then cause urine to leak out of your urethra.
Your urethra may not be able to stay closed if the muscles in your pelvis (pelvic floor muscles) are weak or damaged, or your urethral sphincter (the ring of muscle that keeps the urethra closed) is damaged.
These problems may be caused by:
damage during childbirth, particularly if the child was born vaginally rather than by caesarean section
increased pressure on your tummy, for example because you are pregnant or obese
damage to the bladder or nearby area during surgery, such as the removal of the womb (hysterectomy) in women or removal of the prostate gland in men
neurological conditions, which affect the brain and spinal cord, such as Parkinson’s disease or multiple sclerosis
certain connective tissue disorders, such as Ehlers-Danlos syndrome
certain medications (see below)
Causes of urge incontinence
The urgent and frequent need to pass urine can be caused by a problem with the detrusor muscles in the walls of the bladder. The detrusor muscles relax to allow the bladder to fill with urine, then contract when you go to the toilet to let the urine out.
Sometimes the detrusor muscles contract too often, creating an urgent need to go to the toilet. This is known as having an 'overactive bladder'. The reason your detrusor muscles contract too often may not be clear, but possible causes include:
drinking too much alcohol or caffeine
poor fluid intake – this can cause strong, concentrated urine to collect in your bladder, which can irritate your bladder and cause symptoms of overactivity
conditions affecting the lower urinary tract (urethra and bladder), such as urinary tract infections (UTIs) or tumours in the bladder
certain medications (see below)
Causes of overflow incontinence
Overflow incontinence, also called chronic urinary retention, is often caused by a blockage or obstruction to your bladder. Your bladder may fill up as usual, but as it is obstructed you will not be able to empty it completely, even when you try.
At the same time, pressure from the urine that is still in your bladder builds up behind the obstruction, causing frequent leaks.
Your bladder can become obstructed as a result of:
Overflow incontinence may also be caused by your detrusor muscles not fully contracting, which means that your bladder does not completely empty when you go to the toilet. As a result, the bladder becomes stretched. Your detrusor muscles may not fully contract if:
there is damage to your nerves, for example as a result of surgery to part of your bowel or a spinal cord injury
you are taking certain medications (see below)
Causes of total incontinence
Total incontinence occurs when your bladder cannot store any urine at all. It can result in you either passing large amounts of urine constantly, or passing urine occasionally with frequent leaking.
Total incontinence can be caused by:
a problem with your bladder from birth
injury to your spinal cord, which can disrupt the nerve signals between your brain and your bladder
a bladder fistula, which is a small tunnel-like hole that can form between the bladder and a nearby area, such as the vagina, in women
Medications that may cause incontinence
Some medicines can disrupt the normal process of storing and passing urine, or increase the amount of urine you produce. These include:
Stopping these medications, if advised to do so by a doctor, may help resolve your incontinence.
Who is most at risk?
In addition to the causes mentioned above, there are some things that can increase your risk of developing urinary incontinence without directly being the cause of the problem. These are known as risk factors.
Some of the main risk factors for urinary incontinence include:
family history – there may be a genetic link to urinary incontinence, so you may be more at risk if other people in your family have experienced the problem
increasing age – urinary incontinence becomes more common as you reach middle age and is particularly common in people over 80
having lower urinary tract symptoms (LUTS) – a range of symptoms that affect the bladder and urethra (read about the symptoms of urinary incontinence for more information)
Diagnosing urinary incontinence
If you experience urinary incontinence, see your GP so they can determine the type of condition you have.
Try not to be embarrassed to speak to your GP about your incontinence. Urinary incontinence is a common problem and it's likely your GP has seen many people with the condition.
Your GP will ask you questions about your symptoms and medical history, including:
whether the urinary incontinence occurs when you cough or laugh
whether you need the toilet frequently during the day or night
whether you have any difficulty passing urine when you go to the toilet
whether you are currently taking any medications
how much fluid, alcohol or caffeine you drink
Your GP may suggest that you keep a diary of your bladder habits for at least three days, so you can give them as much information as possible about your condition. This should include details such as:
how much fluid you drink
the types of fluid you drink
how often you need to pass urine
the amount of urine you pass
how many episodes of incontinence you experience
how many times you experience an urgent need to go to the toilet
Tests and examinations
You may also need to have some tests and examinations so that your GP can confirm or rule out things that may be causing your incontinence. Some of these are explained below.
Your GP may examine you to assess the health of your urinary system.
If you are female, your GP will carry out a pelvic examination, which usually involves undressing from the waist down. You may be asked to cough to see if any urine leaks out.
Your GP may also examine your vagina. In over half of women with stress incontinence, part of the bladder may bulge into the vagina.
Your GP may place their finger inside your vagina and ask you to squeeze it with your pelvic floor muscles. These are the muscles that surround your bladder and urethra (the tube through which urine passes out of the body). Damage to your pelvic floor muscles can lead to urinary incontinence.
If you are male, your GP may check whether your prostate gland is enlarged. The prostate gland is located between the penis and bladder, and surrounds the urethra. If it is enlarged, it can cause symptoms of urinary incontinence, such as a frequent need to urinate.
You may also need a digital rectal examination to check the health of your prostate gland. This will involve your GP inserting their finger into your bottom.
If your GP thinks your symptoms may be caused by a urinary tract infection (UTI), a sample of your urine may be tested for bacteria. A small, chemically treated stick is dipped into your urine sample. It will change colour if bacteria are present. The dipstick test can also check the blood and protein levels in your urine.
Residual urine test
If your GP thinks you may have overflow incontinence, they may suggest a test called residual urine test to see how much urine is left in your bladder after you go for a wee.
This is usually done by carrying out an ultrasound scan of your bladder, although occasionally the amount of urine in your bladder may be measured after it has been drained using a catheter. This is a thin, flexible tube that is inserted into your urethra and passed through to your bladder.
Some further tests may be necessary if the cause of your urinary incontinence is not clear. Your GP will usually start treating you first and may suggest these tests if treatment is not effective.
A cystoscopy involves using a flexible viewing tube, known as an endoscope, to look inside your bladder and urinary system. This test can identify abnormalities that may be causing incontinence.
These are a group of tests used to check the function of your bladder and urethra. This may include keeping a bladder diary for a few days (see above) and then attending an appointment at a hospital or clinic for tests such as:
measuring the pressure in your bladder by inserting a catheter into your urethra
measuring the pressure in your abdomen (tummy) by inserting a catheter into your bottom
asking you to urinate into a special machine that measures the amount and flow of urine
Non-surgical treatments for urinary incontinence
The treatment you receive for urinary incontinence will depend on the type of incontinence you have and the severity of your symptoms.
If your incontinence is caused by an underlying condition, such as an enlarged prostate gland in men, you may receive treatment for this alongside your incontinence treatment.
Conservative treatments, which do not involve medication or surgery, are tried first. These include:
After this, medication or surgery may be considered.
This page is about non-surgical treatments for urinary incontinence. There is a separate page on surgery and procedures for urinary incontinence.
Read on to learn about the different treatments you may be offered. You can also read a summary of the pros and cons of these treatment options, allowing you to compare your treatment options.
Your GP may suggest you make simple changes to your lifestyle to improve your symptoms. These changes can help improve your condition, regardless of the type of urinary incontinence you have.
For example, your GP may recommend:
reducing your caffeine intake – caffeine is found in tea, coffee and cola and can increase the amount of urine your body produces
altering how much fluid you drink a day – drinking too much or too little can make incontinence worse
losing weight if you are overweight or obese – use the healthy weight calculator to find out if you are a healthy weight for your height
Pelvic floor muscle training
Your pelvic floor muscles are the muscles you use to control the flow of urine as you urinate. They surround the bladder and urethra (the tube that carries urine from the bladder to outside the body).
Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended.
Your GP may refer you to a specialist to start a programme of pelvic floor muscle training.
Your specialist will assess whether you are able to squeeze (contract) your pelvic floor muscles and by how much. If you can contract your pelvic floor muscles, you will be given an individual exercise programme based on your assessment.
Your programme should include doing a minimum of eight muscle contractions at least three times a day and doing the recommended exercises for at least three months. If the exercises are helping after this time, you can keep on doing them.
Research suggests that women who complete pelvic floor muscle training experience fewer leaking episodes and report a better quality of life.
In men, some studies have shown that pelvic floor muscle training can reduce urinary incontinence – particularly after surgery to remove the prostate gland.
The British Association of Urological Surgeons (BAUS) has more information on pelvic floor exercises in women (PDF, 163kb) and pelvic floor exercises in men (PDF, 174kb).
If you are unable to contract your pelvic floor muscles, using a device that measures and stimulates the electrical signals in the muscles may be recommended. This is called electrical stimulation.
A small probe will be inserted into the vagina in women or the anus in men. An electrical current runs through the probe, which helps to strengthen your pelvic floor muscles while you exercise them.
You may find electrical stimulation difficult or unpleasant to use, but it may be beneficial if you are unable to complete pelvic floor muscle contractions without it.
Biofeedback is a way to monitor how well you are doing the pelvic floor exercises by giving you feedback as you do them. There are several different methods of biofeedback:
a small probe could be inserted into the vagina in women or the anus in men – this senses when the muscles are squeezed and sends the information to a computer screen
electrodes (sticky electrical patches) could be attached to the skin of your abdomen or around the anus – these sense when the muscles are squeezed and send the information to a computer screen
There isn't much good evidence to suggest biofeedback offers a significant benefit to people using pelvic floor muscle training for urinary incontinence, but the feedback may help motivate some people to carry out their exercises.
Speak to your specialist if you would like to try biofeedback.
Vaginal cones may be used by women to assist with pelvic floor muscle training. These are small weights that are inserted into the vagina. You hold the weights in place using your pelvic floor muscles. When you can, you progress to the next vaginal cone, which weighs more.
Some women find vaginal cones uncomfortable or unpleasant to use, but they may help with stress or mixed urinary incontinence.
If you have been diagnosed with urge incontinence, one of the first treatments you may be offered is bladder training. Bladder training may also be combined with pelvic floor muscle training if you have mixed urinary incontinence.
Bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course will usually last for at least six weeks.
While incontinence products are not a treatment for urinary incontinence, you might find them useful for managing your condition while you are waiting to be assessed or waiting for treatment to take effect.
Incontinence products include:
absorbent products, such as incontinence pants or pads
hand-held urinals (urine collection bottles)
a catheter, a thin tube that is inserted into your bladder to drain urine
devices that are placed into the vagina or urethra to prevent urine leakage, for example while you exercise
Medication for stress incontinence
If stress incontinence does not significantly improve, surgery for urinary incontinence will often be recommended as the next step.
However, if you are unsuitable for surgery or you want to avoid having an operation, you may benefit from a medication called duloxetine. This can help increase the muscle tone of the urethra, which should help keep it closed.
You will need to take duloxetine by mouth twice a day and will be assessed after two to four weeks to see if the medicine is beneficial or if it is causing any side effects.
Possible side effects of duloxetine can include:
Do not suddenly stop taking duloxetine as this can also cause unpleasant effects. Your GP will reduce your dose gradually.
Duloxetine is not suitable for everyone, however, so your GP will discuss any other medical conditions you have to determine if you can take it.
Medication for urge incontinence
If bladder training is not an effective treatment for your urge incontinence, your GP may prescribe a type of medication called an antimuscarinic.
Antimuscarinics may also be prescribed if you have overactive bladder syndrome (OAB), which is the frequent urge to urinate that can occur with or without urinary incontinence.
A number of different antimuscarinic medications that can be used to treat urge incontinence, but common ones include oxybutynin,tolterodine and darifenacin.
These are usually taken by mouth two or three times a day, although an oxybutynin patch that you place on your skin twice a week is also available.
Your GP will usually start you at a low dose to minimise any possible side effects. The dose can then be increased until the medicine is effective.
Possible side effects of antimuscarinics include:
In rare cases, antimuscarinic medication can also lead to a type ofglaucoma (a build-up of pressure within the eye) called angle-closure glaucoma.
You will be assessed after four weeks to see how you are getting on with the medication, and every six to 12 months thereafter if the medication continues to help.
Your GP will discuss any other medical conditions you have to determine which antimuscarinics are suitable for you.
If antimuscarinics are unsuitable for you, or they have not helped your urge incontinence or have caused unpleasant side effects, you may be offered an alternative medication called mirabegron.
Mirabegron causes the bladder muscle to relax, which helps the bladder fill up with and store urine. It is usually taken by mouth once a day.
Side effects of mirabegron can include:
urinary tract infections (UTIs)
a fast or irregular heartbeat
palpitations (suddenly noticeable heartbeats)
Your GP will discuss any other medical conditions you have to determine whether mirabegron is suitable for you.
Medication for nocturia
A medication called desmopressin may be used to treat nocturia, which is the frequent need to get up during the night to urinate, by helping to reduce the amount of urine produced by the kidneys.
Another type of medication taken late in the afternoon, called a loop diuretic, may also prevent you from getting up in the night to pass urine. Diuretic medicine increases the production and flow of urine from your body. By removing excess fluid from your body in the afternoon, it may improve symptoms at night.
Desmopressin is licensed to treat bedwetting but is not licensed to treat nocturia. Loop diuretics are also not licensed to treat nocturia.
This means that the medication may not have undergone clinical trials(a type of research that tests one treatment against another) to see if it's effective and safe in the treatment of nocturia.
However, your GP or specialist may suggest an unlicensed medication if they think it's likely to be effective and the benefits of treatment outweigh any associated risk.
If your GP is considering prescribing desmopressin or a loop diuretic, they should tell you that it is unlicensed and will discuss the possible risks and benefits with you.
Surgery and procedures for urinary incontinence
If other treatments for urinary incontinence are unsuccessful or unsuitable, surgery or other procedures may be recommended.
Before making a decision, discuss the risks and benefits with a specialist, as well as any possible alternative treatments.
If you are a woman and plan to have children, this will affect your decision, because the physical strain of pregnancy and childbirth can sometimes cause surgical treatments to fail. Therefore, you may wish to wait until you no longer want to have any more children before having surgery.
Read on to learn about the different treatments you may be offered. You can also read a summary of the pros and cons of these treatment options, allowing you to compare your treatment options.
Surgery and procedures for stress incontinence
Tape procedures can be used for women with stress incontinence.
A piece of plastic tape is inserted through an incision inside the vagina and threaded behind the urethra (the tube that carries urine out of the body). The middle part of the tape supports the urethra, and the two ends are threaded through two incisions in either the:
By holding the urethra up in the correct position, the piece of tape can help reduce the leaking of urine associated with stress incontinence.
The effectiveness of these tape procedures is similar, with around two in every three women not experiencing any leaking afterwards. Even those who still have some leaking after surgery often find this is less severe than it was before the operation.
However, it is not uncommon for women to need to go to the toilet more frequently and urgently after this procedure, and some find they are unable to completely empty their bladder when they go to the toilet.
In some cases, the tape can wear away or move over time and further surgery may be needed at a later stage to adjust it (for example, to make it looser) or to remove it.
The British Association of Urological Surgeons (BAUS) has more information on synthetic vaginal tapes for stress incontinence (PDF, 255kb). You may also find it useful to read information from the Medicines and Healthcare products Regulatory Agency (MHRA) onvaginal tapes for stress urinary incontinence.
Colposuspension involves making an incision in your lower abdomen, lifting up the neck of your bladder, and stitching it in this lifted position. This can help prevent involuntary leaks in women with stress incontinence.
There are two types of colposuspension:
an open colposuspension – where surgery is carried out through a large incision
a laparoscopic ('keyhole') colposuspension – where surgery is carried out through one or more small incisions using special, small surgical instruments
Both types of colposuspension offer effective, long-term treatment for stress incontinence, although laparoscopic colposuspension needs to be carried out by an experienced laparoscopic surgeon.
Problems that can occur after colposuspension include difficulty emptying the bladder fully when going to the toilet, recurrent urinary tract infections (UTIs) and discomfort during sex.
BAUS has more information on bladder neck suspension (PDF, 240kb).
Sling procedures involve making an incision in your lower abdomen and vagina so a sling can be placed around the neck of the bladder to support it and prevent accidental urine leaks. The sling can be made of:
a synthetic material
tissue taken from another part of your body (an autologous sling)
tissue donated from another person (an allograft sling)
tissue taken from an animal (a xenograft sling), such as cow or pig tissue
In many cases, an autologous sling will be used and will be made using part of the layer of tissue that covers the abdominal muscles (rectus fascia). These slings are generally preferred because more is known about their long-term safety and effectiveness.
The most commonly reported problem associated with the use of slings is difficulty emptying the bladder fully when going to the toilet. A small number of women who have the procedure also find that they develop urge incontinence afterwards.
Urethral bulking agents
An urethral bulking agent is a substance that can be injected into the walls of the urethra in women with stress incontinence. This increases the size of the urethral walls and allows the urethra to stay closed with more force.
A number of different bulking agents are available and there is no evidence that one is more beneficial than another.
This is less invasive than other surgical treatments for stress incontinence in women as it does not usually require any incisions. Instead, the substances are normally injected through a cystoscope(thin viewing tube) inserted directly into the urethra.
However, this procedure is generally less effective than the other options available. The effectiveness of the bulking agents will also reduce with time and you may need repeated injections.
Many women experience a slight burning sensation or bleeding when they pass urine for a short period after the bulking agents are injected.
Artificial urinary sphincter
The urinary sphincter is a ring of muscle that stays closed to prevent urine flowing from the bladder into your urethra. In some cases, it may be suggested that you have an artificial urinary sphincter fitted to relieve your incontinence.
This tends to be used more often as a treatment for men with stress incontinence and is only rarely used in women.
An artificial sphincter consists of three parts:
a circular cuff that is placed around the urethra – this can be filled with fluid when necessary to compress the urethra and prevent urine passing through it
a small pump placed in the scrotum (when used in men) that contains the mechanism for controlling the flow of fluid to and from the cuff
a small fluid-filled reservoir in the abdomen – the fluid passes between this reservoir and the cuff as the device is activated and de-activated
The procedure to fit an artificial urinary sphincter often causes short-term bleeding and a burning sensation when you pass urine. In the long-term, it is not uncommon for the device to eventually stop working, in which case further surgery may be needed to remove it.
Surgery and procedures for urge incontinence
Botulinum toxin A injections
Botulinum toxin A (Botox) can be injected into the sides of your bladder to treat urge incontinence and overactive bladder syndrome (OAB).
This medication can sometimes help relieve these problems by relaxing your bladder. This effect can last for several months and the injections can be repeated if they help.
Although the symptoms of incontinence may improve after the injections, you may find it difficult to fully empty your bladder. If this happens, you will need to be taught how to insert a catheter (a thin, flexible tube) into your urethra to drain the urine from your bladder.
Botulinum toxin A is not currently licensed to treat urge incontinence or OAB, so you should be made aware of any risks before deciding to have the treatment. The long-term effects of this treatment are not yet known.
Sacral nerve stimulation
The sacral nerves are located at the bottom of your back. They carry signals from your brain to some of the muscles used when you go to the toilet, such as the detrusor muscle that surrounds the bladder.
If your urge incontinence is the result of your detrusor muscles contracting too often, sacral nerve stimulation – also known as sacral neuromodulation – may be recommended.
During this operation, a device is inserted near one of your sacral nerves, usually in one of your buttocks. An electrical current is sent from this device into the sacral nerve. This should improve the way signals are sent between your brain and your detrusor muscles, and so reduce your urges to urinate.
Sacral nerve stimulation can be painful and uncomfortable, but some people report a substantial improvement in their symptoms or the end of their incontinence completely.
Posterior tibial nerve stimulation
Your posterior tibial nerve runs down your leg to your ankle. It contains nerve fibres that start from the same place as nerves that run to your bladder and pelvic floor. It is thought that stimulating the tibial nerve will affect these other nerves and help control bladder symptoms, such as the urge to pass urine.
During the procedure, a very thin needle is inserted through the skin of your ankle and a mild electric current is sent through it, causing a tingling feeling and causing your foot to move. You may need 12 sessions of stimulation, each lasting around half an hour, one week apart.
Some studies have shown that this treatment can offer relief from OAB and urge incontinence for some people, although there is not yet enough evidence to recommend tibial nerve stimulation as a routine treatment.
Tibial nerve stimulation is only recommended in a few cases where urge incontinence has not improved with medication and you don't want to have botulinum toxin A injections or sacral nerve stimulation.
In rare cases, a procedure known as augmentation cystoplasty may be recommended to treat urge incontinence.
This procedure involves making your bladder bigger by adding a piece of tissue from your intestine (part of the digestive system) into the bladder wall.
After the procedure, you may not be able to pass urine normally and you may need to use a catheter. Due to this, augmentation cystoplasty will only be considered if you are willing to use a catheter.
The difficulties passing urine can also mean that people who have augmentation cystoplasty can experience recurrent urinary tract infections.
Urinary diversion is a procedure where the ureters (the tubes that lead from your kidneys to your bladder) are redirected to the outside of your body. The urine is then collected directly without it flowing into your bladder.
Urinary diversion should only be carried out if other treatments have been unsuccessful or are not suitable.
Urinary diversion can cause a number of complications, such as a bladder infection, and sometimes further surgery is needed to correct any problems that occur.
Catheterisation for overflow incontinence
Clean intermittent catheterisation
Clean intermittent catheterisation (CIC) is a technique that can be used to empty the bladder at regular intervals and so reduce overflow incontinence (also known as chronic urinary retention).
A continence adviser will teach you how to place a catheter through your urethra and into the bladder. Your urine will flow out of your bladder, through the catheter and into the toilet.
Using a catheter can feel a bit painful or uncomfortable at first, but any discomfort should subside over time.
How often CIC will need to be carried out will depend on your individual circumstances. For example, you may only need CIC once a day, or you may need to use the technique several times a day.
Regular use of a catheter increases the risk of developing UTIs.
If using a catheter every now and then is not enough to treat your overflow incontinence, you can have an indwelling catheter fitted instead. This is a catheter inserted in the same way as for CIC, but left in place. A bag is attached to the end of the catheter to collect the urine.
Preventing urinary incontinence
It is not always possible to prevent urinary incontinence, but a healthy lifestyle may reduce the chances of the condition developing.
Being obese can increase your risk of developing urinary incontinence. You may therefore be able to lower your risk by maintaining a healthy weight through regular exercise and healthy eating.
Use the healthy weight calculator to see if you are a healthy weight for your height.
Depending on your particular bladder problem, your GP can advise you about the amount of fluids that you should drink.
If you have urinary incontinence, cut down on alcohol and drinks containing caffeine, such as tea, coffee and cola. These can cause your kidneys to produce more urine and irritate your bladder.
The recommended daily limits for alcohol consumption are:
A unit of alcohol is roughly half a pint of normal-strength lager or a single measure (25ml) of spirits.
If you have to urinate frequently during the night (nocturia), try drinking less in the hours before you go to bed. However, make sure you still drink enough fluids during the day.
Pelvic floor exercises
Being pregnant and giving birth can weaken the muscles that control the flow of urine from your bladder. If you are pregnant, strengthening your pelvic floor muscles may help prevent urinary incontinence.
Men may also benefit from strengthening their pelvic floor muscles by doing pelvic floor exercises.