Last reviewed:September 2019
Last updated:September  2018



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
  • 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
  • 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 (PVR)
  • cough stress test
Full details

Investigations to consider

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

Treatment algorithm



Department of Gynecology


Division of Urogynecology and Reconstructive Pelvic Surgery

Cleveland Clinic Florida




GWD has received research consultant grants from Pfizer, Cook Medical, and Alma Lasers paid to the Cleveland Clinic, and has received speaker honorarium from Allergan and Cogentix.

Clinical Fellow

Division of Urogynecology and Reconstructive Pelvic Surgery

Cleveland Clinic Florida




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 reviewersVIEW ALL

Department of Urology

University of Washington

School of Medicine




JK declares that he has no competing interests.

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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