The four patterns
- Stress incontinence — leakage with cough, sneeze, lifting, or exercise. Reflects weak pelvic-floor support or sphincter deficiency.
- Urge incontinence — leakage preceded by strong, sudden urgency. Part of overactive bladder.
- Mixed — features of both.
- Overflow — dribbling from a bladder that doesn't empty (obstruction or an under-active detrusor).
First-line treatment
Pelvic-floor physical therapy is high-yield for stress and mixed incontinence. Bladder training, urge-suppression techniques, and fluid/caffeine adjustments are the foundation for urge incontinence. Weight loss reduces stress-incontinence episodes.
Medical and procedural options
- Stress: pessaries, urethral bulking agents, midurethral sling procedures
- Urge: beta-3 agonists (mirabegron/vibegron), antimuscarinics, intradetrusor BOTOX, sacral or tibial neuromodulation
- Overflow: relieve obstruction (e.g., BPH treatment) or, when the bladder cannot empty, timed catheterization
Postmenopausal note
Vaginal (local) estrogen — when appropriate and prescribed by a clinician — can improve urgency, recurrent UTIs, and stress symptoms in postmenopausal women. It is separate from systemic hormone therapy.