The management of adult urinary incontinence

Urinary incontinence is very common in adults, either as stress, urge or mixed urinary incontinence. A thorough assessment is necessary to identify the underlying urological abnormality and to guide appropriate management. Conservative approaches consist of treating constipation, the use of containment devices, weight loss, bladder training and pelvic floor muscle training. Medical management frequently consists of the use of antimuscarinics and more recently newer agents such as mirabegron. Surgical management is considered if previous therapies fail. Urodynamic assessment and subsequent multidisciplinary team review is commonly undertaken prior to invasive therapy. Surgical options include slings, bulking agents, botulinum toxin A, neuromodulation, artificial urinary sphincter and augmentation cystoplasty. All these options are discussed in this article, including indications, outcomes and side-effects. Areas for future development are also highlighted, with particular emphasis placed on the increasing number of males with urinary incontinence following radical prostate surgery. For all patients, a stepwise approach is recommended, beginning with the least invasive options before moving onto more complex surgery with higher risk of severe complications. Patients with refractory urinary incontinence should be considered for entry into clinical trials where novel therapies are being assessed.