NICE summary
The recommendations in this Best Practice topic are based on authoritative international guidelines, supplemented by recent practice-changing evidence and expert opinion. For your added benefit, we summarise below the key recommendations from relevant NICE guidelines.
Key NICE recommendations on diagnosis
This summary covers urinary incontinence in women aged 18 and over.
At initial clinical assessment, categorise urinary incontinence as stress urinary incontinence, urgency urinary incontinence/overactive bladder, or mixed urinary incontinence:[63]
Stress urinary incontinence: involuntary urine leakage on effort, exertion, sneezing or coughing
Urgency urinary incontinence: involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay)
Overactive bladder (OAB): urgency that occurs with or without urgency urinary incontinence, and usually with frequency and nocturia
Mixed urinary incontinence: involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing.
Identify relevant predisposing and precipitating factors and other diagnoses that may require referral for additional investigation and treatment.[63]
Perform a urine dipstick to detect blood, glucose, protein, leucocytes and nitrites in the urine. See the NICE guideline for information on interpreting and acting on the results.[63]
Refer women using a suspected cancer pathway referral for:[150]
Bladder or renal cancer if they are aged 45 and over and have:
Unexplained visible haematuria without urinary tract infection (UTI) or
Visible haematuria that persists or recurs after successful treatment of UTI
Bladder cancer if they are aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
Consider non-urgent referral for bladder cancer in women aged 60 and over with recurrent or persistent unexplained UTI.[150]
Measure post-void residual volume by bladder scan (preferred) or catheterisation in women with symptoms suggestive of voiding dysfunction or recurrent UTI.[63]
Use bladder diaries in the initial assessment.[63]
Encourage completion of a minimum of 3 days of the diary, covering variations in usual activities (e.g., work and leisure days).[63]
In the assessment of women with urinary incontinence, do not use:[63]
Pad testing or imaging (MRI, CT, X-ray) routinely
Ultrasound other than for the assessment of residual urine volume
Cystoscopy in the initial assessment of women with urinary incontinence alone
The Q-tip, Bonney, Marshall and Fluid-Bridge tests of urethral competence.
Consider referral to a specialist service if any of the following are present:[63]
Persisting bladder or urethral pain
Symptoms of voiding difficulty
Palpable post-void bladder on examination
Clinically benign pelvic masses
Associated faecal incontinence
Suspected neurological disease
Suspected urogenital fistulae
Previous continence or pelvic cancer surgery
Previous pelvic radiation therapy.
Links to NICE guidance
Urinary incontinence and pelvic organ prolapse in women: management (NG123) June 2019. https://www.nice.org.uk/guidance/ng123
Suspected cancer: recognition and referral (NG12) May 2025. https://www.nice.org.uk/guidance/ng12
Key NICE recommendations on management
Start initial treatment based on the category of urinary incontinence. In mixed urinary incontinence, direct treatment towards the predominant symptom.
Use a validated urinary incontinence-specific symptom and quality-of-life questionnaire when therapies are being evaluated.
Non-surgical and non-pharmacological management
Discuss lifestyle interventions:
Advise weight loss if BMI >30
Consider advising modification of fluid intake if this is high or low
Recommend a trial of caffeine reduction to women with OAB.
Offer a trial of at least 3 months’ of supervised pelvic floor muscle training (which should comprise at least 8 contractions performed 3 times per day) as first-line treatment for stress or mixed urinary incontinence, after confirming pelvic floor muscle contraction on routine digital assessment. Continue an exercise programme if trial is beneficial.
Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training.
Electrical stimulation and/or biofeedback should be considered for women who cannot actively contract their pelvic floor muscles to aid motivation and adherence to therapy, but do not routinely use electrical stimulation in combination with pelvic floor muscle training.
Offer bladder training (minimum of 6 weeks) as first-line treatment for urgency or mixed urinary incontinence.
If satisfactory benefit is not achieved from bladder training, consider combining bladder training with an OAB medicine if frequency is a troublesome symptom.
Bladder catheterisation is an option for selected women with urinary incontinence. See the NICE guideline for more information.
Do not:
Use electrical stimulation routinely for OAB
Offer absorbent containment products, hand-held urinals or toileting aids other than: as coping strategies pending definitive treatment; as adjuncts to ongoing therapy; or for long-term management only after exploring treatment options
Offer a review of long-term use of absorbent containment products at least annually (see the NICE guideline for how to carry out this review)
Use intravaginal and intraurethral devices to manage urinary incontinence routinely. These should only be considered for occasional use when necessary to prevent leakage (e.g., during exercise)
Offer transcutaneous sacral or posterior tibial nerve stimulation for OAB
Recommend treatment with complementary therapies.
Pharmacological management
Offer an anticholinergic medicine to treat OAB or mixed urinary incontinence. See the NICE guideline for anticholinergic medicine options.
Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health.
Before using an anticholinergic medicine:
Consider coexisting conditions (e.g., poor bladder emptying, cognitive impairment or dementia), current use of other medicines affecting total anticholinergic load, and the woman’s risk of adverse effects (including cognitive impairment)
Explain that some adverse effects (e.g., dry mouth, constipation) may indicate the medicine taking effect, and that long-term effects on cognitive function are uncertain.
If the first anticholinergic medicine is not effective or well-tolerated, offer another anticholinergic medicine.
Mirabegron and vibegron (beta-3 agonists) are recommended as options for treating the symptoms of OAB if anticholinergics are not suitable, do not work well enough, or have unacceptable side effects.
Offer a transdermal OAB treatment to women unable to tolerate oral medicines.
Offer vaginal oestrogen to women with OAB symptoms and genitourinary symptoms and signs associated with menopause (e.g., vulvovaginal dryness, discomfort or irritation; pain with sex; discomfort or pain when urinating; thinning, drying or inflammation of the vaginal walls; loss of elasticity affecting the vaginal muscles; shortening of the vagina).
Desmopressin may be considered specifically to reduce troublesome nocturia in women with urinary incontinence or OAB.
It should be avoided in women aged over 65 years with cardiovascular disease or hypertension (and used with particular caution in cystic fibrosis).
Do not use duloxetine first-line for stress-predominant urinary incontinence.
Duloxetine should not be routinely offered second-line for stress urinary incontinence, but may be offered second-line if surgery is unsuitable or the woman prefers pharmacological treatment. If used, women should be counselled about adverse effects.
Do not offer:
Flavoxate, propantheline or imipramine to treat urinary incontinence or OAB
Systemic hormone replacement therapy to treat urinary incontinence.
Explain that medicine started for OAB may not produce substantial benefits until after 4 weeks, and symptoms may continue to improve over time.
Offer a review 4 weeks after starting a new medicine for OAB (or before 4 weeks if the adverse effects are intolerable). Check the woman’s satisfaction with treatment and:
If improvement is optimal, continue treatment
If there is no or suboptimal improvement, or intolerable adverse effects, change the dose or try an alternative medicine for OAB, and review again 4 weeks later.
Offer a further review if a medicine for OAB or urinary incontinence stops working after an initial successful 4-week review.
Offer a review in primary care to women on long-term medicine for OAB or urinary incontinence every 12 months, or every 6 months if they are aged over 75 years.
Further treatment options
Refer to secondary care for consideration of further treatment options (e.g., invasive procedures for OAB, surgery for stress urinary incontinence) if non-surgical management (including, where appropriate, pharmacological treatments) of urinary incontinence or OAB is unsuccessful or not tolerated.
Urodynamic investigation should be offered to identify detrusor overactivity in women with OAB that has not responded to non-surgical management or treatment with medicine who wish to discuss further treatment options.
In stress-predominant mixed urinary incontinence, the benefits of non-surgical management and medicines for OAB should be discussed before surgery is offered.
© NICE (2019) (2025) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Links to NICE guidance
Urinary incontinence and pelvic organ prolapse in women: management (NG123) June 2019 https://www.nice.org.uk/guidance/ng123
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