• Very common in older adults
• Associated with:
o Falls
o Depression
o Institutionalisation
• Key types: urge, stress, overflow, functional (sometimes separately discussed)
Mechanism
• Detrusor overactivity → involuntary bladder contractions
• Common triggers: running water, cold exposure, urgency
Causes
• Idiopathic (most common)
• Neurological disease:
o Stroke
o Parkinson’s disease
o Multiple sclerosis
Management
• First-line: bladder retraining (timed voiding, delayed voiding techniques)
• Reduce caffeine, alcohol
• Antimuscarinics (e.g., oxybutynin, tolterodine, solifenacin)
o Avoid in frail elderly → risk of confusion, falls, constipation, dry mouth
• Beta-3 agonists (e.g., mirabegron): alternative if antimuscarinics not tolerated
Mechanism
• Pelvic floor muscle weakness or urethral sphincter incompetence
• Leakage with ↑ intra-abdominal pressure: coughing, laughing, lifting
Causes
• Postpartum
• Postmenopausal (oestrogen deficiency)
• Obesity
Management
• First-line: pelvic floor muscle training (at least 3 months)
• Lifestyle modifications (weight loss, smoking cessation)
• Pessary (in pelvic organ prolapse)
• Pharmacotherapy:
o Duloxetine (serotonin-noradrenaline reuptake inhibitor)
Second-line option; increases urethral sphincter tone
Side effects: nausea, insomnia
• Surgery: mid-urethral sling, colposuspension
Mechanism
• Bladder overdistension due to impaired emptying
• Leads to continuous dribbling ± palpable bladder
Causes
• Obstructive:
o Benign prostatic hyperplasia (BPH)
o Urethral stricture
o Pelvic mass
• Neuropathic (detrusor underactivity):
o Diabetes mellitus (autonomic neuropathy)
o Spinal cord lesions (e.g., MS, cauda equina)
Management
• Immediate: catheterisation to relieve retention
• Treat underlying cause (e.g., alpha-blockers for BPH, surgery if needed)
• Intermittent self-catheterisation for chronic cases
Concept
• Inability to reach toilet in time due to:
o Cognitive impairment (e.g., dementia)
o Mobility issues
o Environmental barriers
Management
• Address mobility aids, improve toilet access
• Scheduled toileting assistance
• Continence products as supportive measure
Extra Revision Pearls
• Post-void residual volume:
o 100 mL suggests incomplete emptying (overflow component)
• Antimuscarinics caution:
o Avoid in narrow-angle glaucoma
o Avoid in elderly with cognitive impairment
• Conservative measures first-line for all types whenever possible
• Urodynamic studies:
o Usually reserved if diagnosis uncertain or before surgical interventions
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
