Understanding Mixed Incontinence vs. Cauda Equina Syndrome — What Every Practitioner Should Know
At Revitalize Clinic in Gravesend, we believe in combining individualised care, science and experience to achieve truly effective treatment. I’m Elliott Reid – clinic lead osteopath, personal trainer and councillor for the Institute of Osteopathy – and I’d like to share insights from a vital CPD session we delivered with physiotherapist Charmaine Mensa, where we explored pelvic health, mixed urinary incontinence and cauda equina syndrome (CES) — including how to differentiate them and recognise “red flags”.
Why this topic matters
Pelvic health issues such as urinary incontinence are very common, yet they are often overlooked or misattributed. Meanwhile, cauda equina syndrome is a rare but serious neurological condition requiring urgent recognition. As practitioners (whether osteopath, personal trainer or pelvic health clinician), our role includes not only treatment but high‑quality screening and appropriate referral.
Better understanding of these conditions improves patient outcomes — it helps the general public stay active, pain‑free and confident — consistent with the ethos of Revitalize Clinic.
Mixed urinary incontinence — what is it?
In the session Charmaine explained that mixed urinary incontinence refers to a combination of stress incontinence (leakage with cough/sneeze/exertion) and urge incontinence (a strong, sudden need to void) in the same patient. It is very common among women (and increasingly recognised in men) though far less urgent in terms of neurological compromise.
Some of the key contributing factors include:
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Weak pelvic floor muscles (often following childbirth, other loading or ageing changes)
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Hormonal changes — for example post‑menopausal decline in oestrogen affects connective tissue in the pelvis and bladder support
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Lifestyle irritants such as caffeine, alcohol, UTIs
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Neurological conditions (though these are less common and often require a different pathway)
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Ageing, prior surgery or pelvic organ prolapse
Because mixed incontinence often impacts quality of life (exercise avoidance, embarrassment, pad use) it is absolutely a key treatment area — but it is not the same urgency as what we must consider for CES.
Understanding Cauda Equina Syndrome (CES)
CES is a serious neurological emergency: the nerve roots around the end of the spinal cord (the “horse‑tail” bundle) become compressed or damaged. The consequences can be severe: persistent bladder/bowel dysfunction, sexual dysfunction, lower‑limb weakness and more. Cleveland Clinic+2AANS+2
Key points about CES:
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Symptoms may include urinary retention (i.e., inability to feel bladder fullness or void normally) and/or incontinence. AANS+1
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Saddle anaesthesia (numbness or altered sensation in the perineal, genital or inner‑thigh region) is a hallmark red flag. SIA+1
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Bilateral leg symptoms (pain, weakness, numbness) or sudden change in neurology may be present. sicot-j.org
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It’s urgent — delayed diagnosis can lead to permanent damage. Surgery within 24‑48 hours often gives much better outcomes. AANS+1
Differentiating mixed incontinence vs CES — important for screening
In our CPD session we emphasised how crucial it is to ask the right questions when a patient presents with pelvic‑bladder/bowel and/or back/leg symptoms. The difference in urgency and referral pathway is significant.
Mixed incontinence tends to present with:
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Leakage when coughing, sneezing, jumping, laughing (stress incontinence)
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Urgent need to void or leak before reaching toilet (urge incontinence)
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No major neurological signs such as leg weakness, saddle numbness or retention of urine
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A more gradual onset (for example slowly worsening since childbirth, menopause, or with ageing)
CES (or suspected cauda equina) should prompt immediate concern if you find:
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Sudden change in bladder control: inability to feel bladder fullness, difficulty voiding, retention or overflow incontinence. thompsons.law+1
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New onset or rapidly progressing bilateral leg symptoms (pain, numbness, weakness)
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Saddle sensory disturbance (numbness or altered sensation in perineum/genitals) sicot-j.org+1
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New bowel dysfunction (incontinence or severe constipation) in the context of suspected nerve compression
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Any combination of the above in someone with back pain or spinal risk factors
As Charmaine pointed out in the session — even if a patient already has pelvic health issues, one must remain vigilant: if there’s a change in symptoms (especially in the last 2 weeks) this raises suspicion. For example: a patient with known pelvic floor issues now cannot feel bladder fullness, or develops bilateral leg tingling — this could signal CES and needs urgent referral. SpringerLink
Practical screening questions & red‑flags to document
From our shared discussion, here are key questions and signs to use in practice:
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Bladder: “Do you feel your bladder fill? How often do you need to void? Are you able to empty fully? Any urgency or leakage without warning?”
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Bowel: “Any changes in your bowel habit? Incontinence? Straining? Fullness? Any new onset in the last few weeks?”
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Saddle area: “Any numbness or tingling between your legs / around your genitals / in your bottom? Any change in sensation when wiping after passing urine/poo?”
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Legs: “Any tingling, weakness, or numbness in one or both legs? Has this changed recently? Is it worse when you walk / stand / sit? Is it on both sides?”
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Other risk factors / red‑flags: History of cancer, unexplained weight loss (> 5 % body weight in 6 months), significant night pain, steroid use, spinal infection risk. PMC+1
Be sure to document: onset (when did it start), progression (has it changed), severity, bilateral vs unilateral, any retention of urine, any new bowel/sexual dysfunction. As we stressed in the CPD session: “If in doubt, send for urgent review.” The medico‑legal stakes are high in missed CES. The Times
Integrating into your osteopathy/personal training/pelvic health practice
At Revitalize Clinic we merge osteopathy, strength & conditioning, and pelvic health insight. Here’s how we apply this topic:
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Initial screening: Every new patient with back pain, leg symptoms or pelvic/bladder/bowel concerns receives a thorough history and red‑flag screening — even if they present for “just” musculoskeletal pain or personal training guidance.
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Differential triage: If the presentation is classic for mixed incontinence (gradual onset, stress/urge symptoms, no neurology), then we can progress with pelvic floor strengthening, exercise modification, lifestyle advice. If any red‑flags of CES exist, referral to GP/urgent imaging is warranted immediately.
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Treatment for mixed incontinence: Once CES is excluded, we can proceed with pelvic floor activation, progressive load management (e.g., squats or core programming while teaching pelvic floor engagement/relaxation), education around triggers (caffeine, alcohol, UTIs, menopause changes). As Charlene described, a patient needs to learn pelvic floor ‘squeeze then relax’ with functional movements before heavier training.
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Collaboration & communication: As an osteopath/personal trainer/counsellor you may uncover signs of CES even if the patient came for fitness or pain relief. Early interdisciplinary communication (GP, urology, neurosurgery) is key.
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Patient education: Explain the difference between “common pelvic floor weakness” (which we treat) and “urgent neurological change” (which we must refer). Encourage patients to monitor changes and report new symptoms immediately.
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Documentation & safety netting: Always document the screening, findings, advice given (including that you explained the possible seriousness if CES suspected). Provide written information/leaflets. As noted in the session: “early detection is key.”
Why this matters for you (and your clients/patients)
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For patients: Knowing that not all incontinence is “just old age” or “just childbirth” empowers them to seek help and regain quality of life. At Revitalize Clinic we want people active, pain‑free, confident.
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For practitioners: Being alert to CES protects you and your practice from overlooking a rare but devastating condition — which, if missed, can lead to life‑changing outcomes (bladder/bowel/sexual dysfunction, disability).
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For fitness & strength training: Many clients leak when they train through weakness in the pelvic floor — but you need to be sure you’re not missing an underlying neurological issue before simply programming more load.
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For osteopathy/pelvic health: It aligns with our ethos of blending research, clinical skills and individualised service. The session with Charmaine emphasised the evidence around red‑flags (for example, studies show red‑flags like saddle anaesthesia are more specific than sensitive). PubMed+1
Take‑home summary
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Mixed urinary incontinence (stress + urge) is common, treatable and a quality‑of‑life issue — but not the same urgency as neurological syndromes.
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Cauda equina syndrome is rare, but when suspected it’s a medical emergency — early referral matters.
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Good history‑taking and red‑flag screening is essential: changes in bladder/bowel, saddle area sensation, bilateral leg symptoms must be acted on.
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In our multidisciplinary practice at Revitalize Clinic, we ensure screening, differentiation, appropriate referral and then targeted treatment (whether pelvic floor rehab or fitness programming) for each individual.
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Remember: “If in doubt, refer” — and always document your screening, advice and any onward referral.