1. Confirm the diagnosis
   • Check urine test for infection or blood.
   • Assess for pelvic organ prolapse, incomplete bladder emptying, neurologic disease, prior pelvic surgery, and whether there is also urgency leakage. Mixed incontinence may need a combined plan.
   • Keep a 3-day bladder diary and review medicines, fluid intake, constipation, smoking, weight, and chronic cough.
2. First-line treatment: supervised pelvic-floor muscle training
   • Referral to a pelvic-floor physiotherapist for at least 3 months is standard.
   • NICE recommends a program of at least 8 pelvic-floor contractions, 3 times daily, with supervision. Continue if helpful. NICE guidance
   • Weight loss if overweight, treating constipation/chronic cough, smoking cessation, and reducing excessive caffeine/alcohol can reduce leakage.
   • A continence pessary or vaginal support device may help selected women, especially if they want a non-surgical option. The AUA guideline includes pessaries, vaginal inserts, and pelvic-floor exercises among non-surgical choices.
3. If symptoms remain troublesome after conservative treatment: urogynecology/urology referral Discuss procedural choices based on severity, childbearing plans, prolapse, prior surgery, ability to empty the bladder, and preference:
   • Mid-urethral sling: common effective operation; can be retropubic or transobturator. Synthetic mesh-specific risks and alternatives must be discussed before choosing it.
   • Burch colposuspension: non-mesh surgical option.
   • Autologous fascial sling: uses the patient’s own fascia, often considered where mesh is unsuitable or in selected complex/recurrent cases.
   • Urethral bulking injections: less invasive and useful if major surgery is unsuitable or unwanted, but often less durable and repeat injections may be needed. NICE’s procedure comparison notes lower effectiveness than the main surgical procedures.
4. If this is recurrent or has failed prior surgery
   • Refer to a specialist pelvic-floor/urogynecology center. Further evaluation may include post-void residual measurement, urodynamics, and assessment for obstruction, mesh complications, intrinsic sphincter deficiency, or mixed incontinence before repeat surgery.

Medication

• Duloxetine may be considered for moderate-to-severe confirmed stress incontinence when the patient prefers medicine over surgery or is not suitable for surgery.
• It is not first-line and should only be prescribed after assessment because it can cause nausea, dizziness, dry mouth, fatigue, insomnia, mood effects, and withdrawal symptoms if stopped abruptly.
• In jurisdictions where it is licensed for this indication, the commonly referenced regimen is 40 mg twice daily, but the exact starting and maintenance plan must be set by the clinician, considering pregnancy plans, depression/anxiety history, liver/kidney disease, blood pressure, and drug interactions. NICE duloxetine recommendation and BNF prescribing information.

What she should arrange now

1. See a gynecologist, urogynecologist, urologist, or continence clinic.
2. Have a pelvic examination, urine dip/culture if needed, and measure of urine left after voiding.
3. Bring a 3-day bladder diary: fluids, toilet trips, leakage events, pads used, and triggers.
4. Start supervised pelvic-floor therapy, address constipation/chronic cough, and pursue weight reduction if applicable.
5. If severe symptoms persist after conservative care, discuss a pessary/vaginal support, urethral bulking injection, or surgery such as a sling or colposuspension.

• sudden strong urge to urinate
• frequent urination
• leakage because she cannot reach the toilet in time
• urgency or night-time frequency

• stress-triggered leakage, and
• urgency/frequency/urge-related leakage.

• Check that she empties her bladder properly, especially since “uncontrolled urine flow” could sometimes indicate overflow leakage.
• Avoid or use specialist advice with urinary retention, gastric retention, untreated narrow-angle glaucoma, severe constipation, or significant liver/kidney disease.
• Common adverse effects: dry mouth, constipation, blurred vision, dry eyes, and sometimes difficulty passing urine.

Dose

• Usual target dose: 40 mg by mouth twice daily.
• To reduce early nausea, a prescriber may begin with 20 mg twice daily for 2 weeks, then increase to 40 mg twice daily if tolerated.
• Assess benefit and adverse effects after 2 to 4 weeks. If there is no meaningful benefit or it is poorly tolerated, it should be reviewed/stopped by the prescriber.
• Swallow delayed-release/gastro-resistant capsules whole. Do not crush or open them.
• Do not stop abruptly. Taper under medical guidance to reduce withdrawal symptoms. NICE prescribing guidance lists this regimen.

Do not use duloxetine if there is

• Current use of an MAO inhibitor, or use within the required washout period.
• Uncontrolled hypertension.
• Severe liver disease / hepatic impairment.
• Severe kidney impairment or end-stage kidney disease, typically eGFR/creatinine clearance below 30 mL/min.
• A known serious allergy to duloxetine or capsule ingredients.
• Concurrent use of ciprofloxacin, enoxacin, or fluvoxamine in many product labels, because they can markedly raise duloxetine levels.
• Pregnancy or breastfeeding without a specialist discussion. For a 35-year-old, pregnancy intention and contraception should be reviewed before starting.

Use caution and review carefully with

• Depression, bipolar disorder, prior mania/hypomania, suicidal thoughts, seizures, glaucoma, bleeding tendency, substantial alcohol use, or poorly controlled blood pressure.
• Other serotonergic medicines such as SSRIs, SNRIs, tramadol, triptans, lithium, linezolid, or St John’s wort. Combining them can rarely cause serotonin syndrome.
• NSAIDs, aspirin, anticoagulants, or antiplatelets, due to a higher bleeding risk.
• Drugs that cause drowsiness or dizziness.

Important adverse effects

Medication decision now

• No specific incontinence medication can be safely selected until the seizures and mental symptoms are diagnosed and current medications are reviewed.
• Do not use duloxetine unless a psychiatrist/neurologist and the treating gynecology-urology clinician agree it is appropriate.
• Do not use solifenacin for pure stress leakage. It may worsen confusion or cognitive symptoms and can cause urinary retention. It is for urgency/overactive bladder, not leakage with cough or exertion.
• Do not self-start antidepressants, sedatives, antipsychotics, or antiseizure drugs. The choice depends on seizure type, EEG/imaging findings, pregnancy plans, diagnosis of the mental disturbance, and all current substances/medicines.

Safer immediate approach for the urinary leakage

1. Pelvic-floor physiotherapy for at least 3 months if the leakage is truly stress-related.
2. Bladder diary, pelvic examination, pregnancy test if relevant, assessment for prolapse, and measurement of urine remaining after voiding.
3. Referral to urogynecology/urology and, in parallel, neurology and mental-health services.
4. If symptoms remain severe after assessment, non-drug options such as a pessary/vaginal support or an appropriately selected procedure can be discussed.

Seek emergency care now

• a seizure lasting 5 minutes or longer, repeated seizures without full recovery, injury, pregnancy, breathing difficulty, or a first-ever seizure
• confusion, hallucinations, severe agitation, suicidal thoughts, danger to self/others, new weakness/numbness, severe headache, fever, or loss of consciousness
• new continuous urine leakage together with weakness, numbness around the groin, or bowel-control loss.