Brain-bladder network disruption in urinary incontinence: subtype-specific patterns and targeted neuromodulation

Urinary incontinence (UI) is a highly prevalent condition, affecting more than 400 million adults worldwide. The three main subtypes-stress, urgency, and mixed-exhibit markedly different clinical features and treatment responses that cannot be fully explained by peripheral mechanisms alone.

In this narrative review, we summarise evidence suggesting that UI subtypes are associated with distinct patterns of disruption to brain networks.

We propose that the prefrontal cortex-anterior cingulate cortex-insula-periaqueductal grey circuit constitutes a core brain-bladder network and that different UI subtypes may reflect disruption to different nodes within this network. Urgency UI has been associated with reduced prefrontal-cingulate connectivity, which may impair top-down inhibition. Stress UI has been associated with reduced insular and emotion-regulation activation during bladder filling. Post-stroke UI appears to involve failure to recruit the salience network. Mixed UI is hypothesised to show combined deficits. Neuroimaging evidence from functional MRI, PET and SPECT scans is consistent with this network-based subtyping. These distinct patterns suggest differentiated candidate intervention strategies: prefrontal-targeted neuromodulation for urgency UI, insula-focused approaches for stress UI and salience network restoration for post-stroke UI, all of which remain investigational at present.

This framework conceptualises UI as a family of brain-bladder communication disorders and generates testable hypotheses for subtype-specific neuromodulation; its clinical utility requires prospective, longitudinal and interventional validation. It also identifies future research priorities for network-based diagnostics and personalised intervention.