Last reviewed: 23 Dec 2021
Last updated: 20 May 2020



History and exam

Key diagnostic factors

  • involuntary urine leakage on effort, exertion, sneezing, or coughing
  • involuntary urine leakage accompanied by or immediately preceded by urgency
  • frequency of urination
  • suggestive bladder diary
  • vaginal bulge/pressure
  • urogenital atrophy
  • history of cognitive impairment
  • back injury
  • dysuria
  • abnormal mental state
  • pooling of urine in vaginal tract
  • urethral discharge or tenderness

Other diagnostic factors

  • nocturia
  • uterine prolapse or posterior support weakness
  • abnormal bulbocavernosus and wink reflexes
  • weakened sphincter tone
  • chronic heart failure
  • diabetes mellitus
  • excess fluid intake
  • postvoid dribbling
  • hematuria
  • history of recurrent urinary tract infections
  • enlarged uterus
  • fecal impaction
  • loss of perineal sensation

Risk factors

  • increasing age
  • white ethnicity
  • pregnancy
  • obesity
  • postmenopausal status
  • functional impairment
  • lower urinary tract symptoms
  • long-term residence in a care facility
  • dementia
  • family history of incontinence
  • childhood enuresis
  • chronic cough
  • diabetes mellitus
  • depression
  • chronic heart failure
  • smoking
  • constipation
  • fecal incontinence
  • high-impact physical activity
  • pelvic organ prolapse
  • genitourinary and pelvic surgery
  • radiation exposure
  • stroke and other central nervous system/spinal disorders
  • Parkinson disease
  • multiple sclerosis
  • diuretic use
  • caffeine consumption
  • alcohol consumption
  • antihistamine use
  • sedative use
  • hypnotic use
  • narcotic analgesic use
  • anticholinergic use
  • antidepressant use
  • antipsychotic use
  • alpha-adrenergic agonist use
  • calcium-channel blocker use

Diagnostic investigations

1st investigations to order

  • empty supine stress test
  • urinalysis
  • postvoid residual measurement
  • cough stress test

Investigations to consider

  • pad test
  • urodynamic testing
  • Q-tip test
  • transperineal ultrasound
  • cystourethroscopy

Treatment algorithm



G. Willy Davila, MD

Medical Director

Women and Children’s Services

Urogynecology and Pelvic Reconstructive Surgery

Holy Cross Medical Group

Fort Lauderdale




GWD is a consultant/advisory board member for Boston Scientific and Laborie/Cogentix, and a speaker for Laborie/Cogentix, Astellas, Alma, and Ferring. GWD has received research grants from POP Medical, Pfizer, Cook Biomedical, Alma, and Coloplast.

Laura Martin, DO

Assistant Professor

University of Miami

Urology Department

Female Pelvic Medicine and Reconstructive Surgery




LM declares that she has no competing interests.


Dr G. Willy Davila and Dr Laura Martin would like to gratefully acknowledge Dr Alexandriah N. Alas, Dr Aimee Lynn Smith, Dr Marjorie Jean-Michel, and Dr Peter A. Castillo, the previous contributors to this topic.


ANA, ALS, MJM, and PAC declare that they have no competing interests.

Peer reviewers

James Kuan, MD, FRSC, FACS

Department of Urology

University of Washington

School of Medicine




JK declares that he has no competing interests.

Mohamed Y. Hammadeh, MSc (Urol), FEBU, FRCS (Eng. Urol), Diploma ME (UCL)

Consultant Urological Surgeon

Foundation Training Programme Director

South London Healthcare NHS Trust

Queen Elizabeth Hospital




MYH declares that he has no competing interests.

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