Simple management strategies targeted on the common underlying diagnoses (e.g. faecal impaction, urinary tract infection, vaginal prolapse) are surprisingly effective and include: stimulatory laxatives and enemas for faecal impaction or loading; treatment of urinary tract infection; changing medication (e.g. adjusting loop diuretic medication) and appropriate treatment of urinary retention. Painful urinary retention requires immediate catheterisation. Urinary retention may be helped by other strategies including stopping anticholinergic medication (e.g. tricyclic antidepressants) and changing posture for voiding (e.g. using a toilet rather than a bedpan).

If these simple and universally available management strategies fail to achieve full urinary continence then further investigation is required.

The next assessment stage requires accurate volume and frequency urine charts to be recorded by the nursing staff and post-micturition bladder scanning.

The main causes of urinary incontinence after stroke are bladder instability secondary to the stroke, bladder hypomobility (often due to diabetic neuropathy or drugs) and prostatic hypertrophy or cancer in men. As the treatment of bladder instability can involve drugs which cause urinary retention it is vital to exclude post micturition urine residual by either: a one off urinary catheterisation to measure urine residual; bladder scanning (using a portable machine on the ward performed by a trained stroke nurse) or an abdominal ultrasound examination. If the bladder is empty after micturition and the bladder charts and history suggest unstable bladder then a care plan of regular toileting and possibly anticholinergic medication would be appropriate. If prostatic obstruction is suspected men should be appropriately treated and referred. If patients still have urinary incontinence, consideration should be given to appropriate referral or urodynamic studies. Patients requiring continence aids (e.g. pads, waterproof bedding or special laundry service) must have an agreed future source of supplies prior to transfer of care (e.g. discharge from hospital stroke unit).