Clinical Education

Mixed continence

Mixed urinary incontinence:

  • Urinary incontinence (UI) is a symptom that can affect women of all ages, with a wide range of severity and impact on quality of life. It is common but not normal.
  • Mixed urinary incontinence is a combination of stress urinary incontinence and urgency urinary incontinence.
  • Mixed urinary incontinence is defined as involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing.
  • There are many barriers to seeking advice/treatment for symptoms of UI. We also know that many women are not able to contract their pelvic floor muscles effectively, so if a woman reports symptoms please refer for further assessment.

Main presenting features:

  • Leakage of urine on effort or exertion or on sneezing or coughing.

As well as

  • A sudden, intense need to empty the bladder which is often difficult to delay.
  • The urge sensation may be linked to specific triggers, for example arriving home (latch-key urgency), a change of position or the sound of running water.
  • An associated increase in urinary frequency or nocturia.
  • For more information on stress or urgency urinary incontinence please see the separate information sheets for each condition.

Your assessment before referral:

Urine dipstick screening to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine.
Vaginal examination to identify evidence of pelvic organ prolapse or pelvic mass. May also include pelvic floor muscle assessment, if within your scope of practice.
Where appropriate the use of OAB drugs and/or topical oestrogen should be discussed.

Physiotherapy management:

If you feel that your patient has mixed urinary incontinence refer her to physiotherapy. The physiotherapist will complete a detailed assessment, following which she will work with your patient with the aim of resolving or reducing her symptoms. This may include:

Advice on an individualised pelvic floor muscle exercise programme
Advice on fluid intake (following completion/analysis of a bladder diary)
Education on daily activities, general exercise, diet, weight loss and smoking cessation
Referral to the community continence services, for further tests or assessment of containment products, if required
If conservative management fails the physiotherapist may discuss referral to the urological/gynaecological consultant. Where appropriate the use of OAB drugs and/or topical oestrogen should be discussed.

Referrals to consultant-led services:

If your patient describes any of the following symptoms they should be referred urgently, following locally-agreed pathways, to the appropriate consultant-led service.

Microscopic haematuria in women aged 50 years and older
Visible haematuria
Recurrent or persisting UTI associated with haematuria in women aged 40 years and older
Suspected malignant mass arising from the urinary tract
Further indications for consideration for referral to a consultant-led service include:

Persisting bladder or urethral pain
Clinically benign pelvic masses
Associated faecal incontinence
Suspected neurological disease
Symptoms of voiding difficulty
Suspected urogenital fistulae
Previous continence surgery
Previous pelvic cancer surgery
Previous pelvic radiation therapy