This is edition 2 of the series. Edition 1 was knees. Same questions, same order, same standard for a supplement as a drug: what goes wrong, what’s sold to you, what the trials show, what’s worth testing, and when not to wait.
The grades: Strong means large or repeated randomised trials agree. Moderate or Weak means trials help but are smaller, less certain or disagree. Cross-sectional means measured at one point in time, so cause and effect can’t be separated. No benefit means it was tested properly and didn’t work. Guideline means what NICE recommends.
1. Is it just age?
Partly, and it’s worth being honest about which part.
- For men, the prostate tends to enlarge after 50, and the NHS lists it as a common cause of difficulty peeing, needing to go suddenly and often, and getting up at night.
- For women, pregnancy, childbirth and menopause all change the pelvic floor and the tissues around the bladder.
- Your genes play a part too. A 2024 review of 34 studies found that prostate-related symptoms, urge leaking and getting up at night run in families more than stress leaking does (Moore 2024).
But common isn’t the same as untreatable. Some of the strongest evidence in this whole series is for bladder problems, and the treatments that work best are things you do, not things you buy.
The three problems people lump together:
- Stress leaking: a leak when you cough, sneeze, laugh, lift or run. Usually a pelvic floor problem.
- Urge leaking or overactive bladder: a sudden “I have to go now”, often more often than you’d like, sometimes not making it in time.
- Getting up at night (nocturia): sometimes the bladder, sometimes how much and what you drink in the evening, sometimes something else entirely.
The fix depends on which one you have, which is why a few days of a bladder diary (what you drink, when you go, when you leak) is worth more than anything you can buy.
I know a lot of people who go just in case, in all sorts of situations, and I don’t remember it being so common when I was younger. To be fair, I did it myself before boxing: once you’re gloved up and heading into the ring it’s not an easy fix, and the last thing you want is a low blow with a full bladder. Same before a run, when you want to go flat out with no distractions. I still tell clients to go before a session. Partly it’s so we’re not stopping mid-set and stretching a rest period at the wrong moment for the training effect we’re after. Partly it’s the core work. On a Swiss ball especially, you can’t engage properly if you’re distracted by needing to go, and a full bladder changes the tension and control you have in your pelvic floor and your breathing.
That’s going for a reason. Going every time you leave the house, “just in case”, is a habit, and it’s one worth noticing.
In women, voiding before the bladder is full (researchers call it “premature voiding”) is reported more often in older age groups than in younger women. It’s also linked with more bothersome bladder symptoms, especially urgency (Newman 2021, 316 women; RISE for HEALTH, Berry 2025, 2,327 women). Cross-sectional These studies can’t tell us whether the habit causes the symptoms or the symptoms cause the habit; the authors say so. That’s one reason bladder training, which gradually stretches the time between visits, is the first-line treatment for urgency.
2. What NICE recommends
For women (NICE NG123, 2019):
- Supervised pelvic floor muscle training for at least 3 months, first line for stress or mixed leaking (1.4.4).
- Bladder training for at least 6 weeks, first line for urge or mixed leaking (1.4.11).
- A trial of cutting caffeine for overactive bladder (1.4.1).
- Adjusting fluid intake if you drink a lot or very little (1.4.2).
- Losing weight if your BMI is over 30 (1.4.3).
- Electrical stimulation: don’t routinely use it for overactive bladder (1.4.8), or routinely add it to pelvic floor training (1.4.9). Complementary therapies: not recommended (1.4.24).
For men (NICE CG97, last updated 2015):
- Supervised bladder training for men with urgency and frequency, with fluid and lifestyle advice.
- Supervised pelvic floor muscle training for men with stress leaking after prostate surgery, for at least 3 months before other options.
- “Do not offer homeopathy, phytotherapy or acupuncture” for these symptoms in men (1.8.1). Phytotherapy means herbal products, which includes saw palmetto.
3. What’s sold to you vs what works and can’t be sold
What’s sold: pads and pants (useful, and NICE supports them while you get sorted, but they manage the problem rather than fix it), prostate supplements, cranberry and D-mannose products, “pelvic floor” chairs and stimulators, and vaginal laser treatments.
What works best: pelvic floor training done properly, bladder training, sorting out what and when you drink, and for some people losing weight. None of it can be sold, so none of it is advertised.
Things you do
| What | What happened | Source | Grade |
|---|---|---|---|
| Pelvic floor muscle training (women with stress leaking) | 56% reported cure vs 6% with no treatment (8 times more likely); 74% cured or improved vs 11%. Across all types of leaking, about one fewer leak a day. Side effects rare and minor | Cochrane, Dumoulin 2018 (31 trials, 1,817 women) | Strong For stress leaking; moderate for other types |
| Weight loss (overweight women, average age 53) | About 8% weight loss over 6 months: weekly leaks fell 47% vs 28% in the control group, mainly stress leaks | PRIDE trial, Subak 2009, NEJM (338 women) | Strong One large RCT |
| Bladder training | First line in NICE for urge leaking (women) and overactive-bladder symptoms (men) | NICE NG123 1.4.11; NICE CG97 | Guideline No effect size quoted here |
| Cutting caffeine | NICE recommends a trial for overactive bladder | NICE NG123 1.4.1 | Guideline No effect size quoted here |
On “doing it properly”: many people who say pelvic floor exercises “didn’t work” were never shown how, or stopped after a fortnight. NICE’s standard is supervised training for at least three months. That’s the real gap: not a missing product, but missing coaching and consistency.
Things that are sold
| What | What happened | Source | Grade |
|---|---|---|---|
| Saw palmetto (men, prostate symptoms) | No better than placebo, even at three times the usual dose over 72 weeks. A 2023 Cochrane review of 27 trials: “little to no benefit” for symptoms or quality of life, high-certainty evidence. NICE: don’t offer herbal products for these symptoms in men | Barry 2011, JAMA (369 men); Cochrane, Franco 2023; NICE CG97 1.8.1 | No benefit Strong evidence |
| Cranberry products (preventing urine infections) | About 26% fewer infections in women with recurrent UTIs (RR 0.74), and fewer in children and after medical procedures. Little or no benefit in older people in care homes, in pregnancy, or with bladder-emptying problems | Cochrane, Williams 2023 (50 trials, 8,857 people) | Moderate For the right group. One of the supplements in this series that holds up, but not for everyone |
| D-mannose (preventing urine infections) | In 598 women with recurrent UTIs in UK general practice, 51% on D-mannose and 56% on placebo had another infection within 6 months, a difference that could be chance. The authors: it “should not be recommended” for prevention in this group | Hayward 2024, JAMA Intern Med | No clear benefit One good trial |
| Magnetic “pelvic floor” chairs | Five small studies, about 219 women, mostly without a comparison group; reported improvements, especially combined with pelvic floor training | Sacarin 2025 (systematic review) | Weak Not good enough to choose a chair over supervised training |
| Vaginal CO₂ laser (stress leaking) | No better than sham laser when both groups also did supervised pelvic floor training | Sigurdardóttir 2025, Maturitas (37 women) | No benefit One small sham-controlled trial, so not the last word |
| Electrical stimulation (overactive bladder) | NICE: don’t routinely use | NICE NG123 1.4.8 | Guideline |
Notice that cranberry passes and saw palmetto fails. That’s the point of holding everything to the same standard: some supplements earn their place for the right person, and some don’t, whatever the label says.
Conventional treatments
Medicines for overactive bladder and for an enlarged prostate, and surgery for stress leaking, all have their place, and your GP or a specialist will weigh them up with you. NICE puts the conservative steps above first for most people. This edition doesn’t grade the medicines one by one; that’s a post of its own.
4. What’s worth testing
- A urine test if there’s any sign of infection: burning, cloudy or smelly urine, a sudden change. That’s a GP or pharmacy test, and it’s quick.
- A bladder diary for 3 to 7 days. It’s free, it’s where good bladder care starts, and it often shows the answer: a lot of tea late in the evening, or going “just in case” every hour.
- Men with prostate-type symptoms: see your GP, who will talk you through the checks, which may include a PSA blood test. Whether to have one is a decision to make with your GP, as the result can be misleading both ways. More in the PSA decision.
- What I wouldn’t sell you: a gut or hormone test to explain a leaking bladder, unless something else in your history points that way.
5. When not to wait
From the NHS:
- Blood in your pee, even once, even if it then goes away: ask for an urgent GP appointment or use NHS 111. It may look pink, red or dark brown. (Beetroot, some medicines and periods can be mistaken for it.)
- A urine infection with a very high or low temperature, shivering, or pain in your back just under the ribs: ask for an urgent GP appointment or get help from NHS 111. If you’re confused, drowsy or finding it hard to speak, call 999 or go to A&E.
- You can’t pee at all: ask for an urgent GP appointment or get help from NHS 111.
- Men over 50 with difficulty starting, a weak flow, or getting up at night: see your GP. It’s usually the prostate enlarging, but it’s worth checking.
6. Where to start
- Keep a bladder diary for a few days.
- Work out which problem it is: stress, urge, night-time or a mix.
- Stress leaking: pelvic floor training, ideally shown by a pelvic health physiotherapist, for at least three months.
- Urge leaking: bladder training, and try cutting caffeine.
- Night-time: look at what you drink in the last few hours before bed, including alcohol, before you blame your bladder.
- Before buying anything, check it against the table above. Cranberry may be worth it for recurrent infections; saw palmetto isn’t.
I sell supplements. I’m telling you saw palmetto doesn’t work and cranberry might, because that’s what the trials say.
Sources
- NICE NG123. Urinary incontinence and pelvic organ prolapse in women: management (2019), recommendations 1.4.1–1.4.4, 1.4.8–1.4.9, 1.4.11, 1.4.24. nice.org.uk/guidance/ng123
- NICE CG97. Lower urinary tract symptoms in men: management (2010, updated 2015), recommendations 1.1.12, 1.3.2–1.3.4, 1.3.6, 1.8.1. nice.org.uk/guidance/cg97
- NHS. Blood in urine; Urinary tract infections (UTIs); Enlarged prostate. nhs.uk, read 8 October 2026.
- Dumoulin C et al. Cochrane 2018. PMID 30288727. doi:10.1002/14651858.CD005654.pub4
- Subak LL et al. (PRIDE). NEJM 2009. PMID 19179316. doi:10.1056/NEJMoa0806375
- Barry MJ et al. (CAMUS). JAMA 2011. PMID 21954478. doi:10.1001/jama.2011.1364
- Franco JVA et al. Cochrane 2023. PMID 37345871. doi:10.1002/14651858.CD001423.pub4
- Williams G et al. Cochrane 2023. PMID 37947276. doi:10.1002/14651858.CD001321.pub7
- Hayward G et al. JAMA Intern Med 2024. PMID 38587819. doi:10.1001/jamainternmed.2024.0264
- Sacarin 2025. J Clin Med. PMID 41375799. doi:10.3390/jcm14238496
- Sigurdardóttir 2025. Maturitas. PMID 40617073. doi:10.1016/j.maturitas.2025.108658
- Moore 2024. BJU Int. PMID 39187949. doi:10.1111/bju.16517
- Newman 2021. Int J Nurs Stud Adv. PMID 35498154. doi:10.1016/j.ijnsa.2021.100052
- Berry 2025 (RISE for HEALTH). J Womens Health. PMID 40029194. doi:10.1089/jwh.2024.0743