Urinary Incontinence in women: Management

NICE 123

Organisation of specialist services

Local / Regional Multidisciplinary Teams

	Local MDTs For women with primary stress incontinence (SI) , overactive bladder (OAB) or primary prolapse	Regional MDTs Dealing with complex pelvic floor dysfunction & mesh-related problems
Work scope	Review proposed treatment for ALL women offered invasive procedures Review the proposed management if wider healthcare provider input needed Work in a clinical network with access to regional MDT Member of local MDT should attend ALL local MDT meetings	Should review proposed treatment if: Repeat continence surgery Repeat, Same-site prolapse surgery Preferred treatment option NA in referring hospital Coexisting bowel problems needing additional colorectal intervention Vaginal mesh for prolapse is a t/m option Mesh complications or unexplained symptoms after mesh Considering surgery & may wish to have children in future Members of regional MDT should attend meetings when their specific expertise is needed
Should include	2 consultants expert in managing incontinence +/ POP Specialist Nurse in urogynae, urology or continence Physiotherapist specialist in pelvic floor	UroGynaecology Subspecialist Urologist expert in female urology Specialist Nurse in urogynae, urology or continence Physiotherapist specialist in pelvic floor Radiologist expert in pelvic floor imaging Colorectal surgeon expert in pelvic floor problems Pain specialist expert in pelvic pain management
May also include	Member of elderly care team Occupational therapist Colorectal surgeon	Healthcare pressional trained in bowel biofeedback & trans-anal irrigation Clinical psychologist Member of elderly care team Occupational therapist Surgeon skilled in obturator region operations Plastic surgeon
Should have ready access to		Psychology Psychosexual cousnselling Chronic pain managment Neurology

Collecting data on surgery and surgical complications

Seek consent from woman undergoing SUI/POP surgery or had relevant complications→ to enter data in national registry
Ensure following data included in national registry

Woman’s NHS #
Hospital & consultant identifiers
Date & details of procedure
If mesh involved→ mesh material, manufacturer, product unique ID code & type of sutures
Colposuspension→ type of suture
Bulking agents→ bulking material, manufacturer & product unique ID code
Date & details of any investigations for complications — surgical/ non-surgical interventions for complications
Followup data in national registry must include: short/ long term (atleast 5 years)

Validated relevant outcome measures
Adverse events including pain
Suspected/confirmed mesh0related complications
National registry for surgery for urinary incontinence/POP→ should report annually & be quality assured

Assessing urinary incontinence

History taking and physical examination

At initial clinical assessment→Categorize urinary incontinence as → SUI, Mixed, OAB or urgency
Start initial treatment on this basis
If mixed UI→ treat most prominent symptoms

If stress incontinence predominant→ discuss with woman benefits of non-surgical
If overactive bladder → offer medicines
Identify relevant predisposing & precipitating factors / other diagnosis that may need referral for additional investigations & treatment

Assessing pelvic floor muscles

Routine digital assessment before use of supervised pelvic floor muscle training (PFMT)

Urine testing

Urine dipstick for ALL women with urinary incontinence to detect blood, glucose, protein, leukocytes and nitrites in urine
UTI symptoms + urine positive for both leukocytes/nitrites→ send MSU for culture sensitivity. Prescribe appropriate antibiotics pending culture results
UTI symptoms + urine negative for either leukocytes/nitrites→ send MSU for culture sensitivity. Consider antibiotics pending culture results
No UTI symptoms + urine positive for both leukocytes/ nitrites → Do NOT offer antibiotics without MSU culture results
No UTI symptoms + urine negative for either leukocytes/ nitrites → Do NOT send urine for culture sensitivity because UTI unlikely

Assessing residual urine

Measure post-void residual volume by bladder scan or catheterization (if symptoms suggest recurrent UTI or voiding dysfunction)
Bladder scan preferable [SBA]

Symptom scoring & QoL assessment

Use a validated urinary incontinence-specific symptom & QoL questionnaire

Bladder diaries

Use bladder diary in initial assessment
Minimum of 3 days of diary covering usual activities

Pad testing→ Do Not use in routine assessment

Urodynamic testing

If SUI or stress-predominant mixed UI diagnosed on detailed clinical history/examination→ do not perform multichannel filling & voiding cystometry before primary surgery
After history / examination → perform multichannel cystometry in following women [SBA]

Urge-predominant Mixed urinary incontinence / if type is unclear
Voiding dysfunction symptoms
Anterior/ Apical prolapse
History of previous surgery for SUI

Other tests of urethral competence

Do not use→ Q-tip, Bonney, Marshall and Fluid-Bridge tests

Cystoscopy

Do not use→ in initial assessment of women

Imaging

Do not use imagine (MRI, CT, X-ray) for routine assessment
Do not use USG except for assessing residual urine volume

Indications for referral to specialist service

Persisting bladder/ urethral pain
Palpable bladder on biannual or abdominal exam after voiding
Clinically benign pelvic masses
Associated faecal incontinence
Suspected neurological disease
Voiding difficulty symptoms
Suspected urogenital fistulae
Previous continence surgery
Previous pelvic cancer surgery
Previous pelvic radiation therapy

Non-surgical management of urinary incontinence

Lifestyle interventions

Recommend→ trial of reduced caffeine in OAB
Consider→ modify fluid intake (high/low according to incontinence or OAB)
Advise→ weight loss in BMI >30 plus OAB/ incontinence

Physical therapies

Pelvic Floor Muscle Training (PFMT)

Stress or mixed UI→ offer a trial of supervised PFMT → for at least 3 months as first-line treatment
PFMT → at least 8 contractions performed 3 times per day
Do not use perineometry or pelvic floor electromyography as biofeedback as a routine
If PFMT beneficial→ continue the exercise program

Electrical Stimulation

Consider for women who cannot actively contract pelvic floor muscles to aid motivation and adherence to therapy
Do not use

For treatment of OAB
Routinely in combination with PFMT

Behavioral Therapies

Urgency / mixed UI→ Offer bladder training for minimum of 6 weeks as first-line treatment
If not achieved satisfactory benefit→ Consider OAB medicine if frequency is problematic symptom

Neurostimulation

DO NOT offer Transcutaneous Sacral Nerve Stimulation (TENS) or Transcutaneous Posterior Tibial Nerve Stimulation for treatment of OAB
DO NOT offer → Percutaneous Posterior Tibial Nerve Stimulation for OAB UNLESS

Local MDT review and
Non-surgical (including medicines) not worked adequately and
Woman does not want BOTOX-A or Percutaneous Sacral Nerve Stimulation

Absorbent containment products, urinals and toileting aids

Do not offer to TREAT urinary incontinence
Offer ONLY

As a coping strategy (awaiting definitive treatment)
As an adjunct to ongoing therapy
For long-term management of UI only after treatment options explored
For women using absorbent containment products for long-term management→ offer review once a year which should cover

Routine assessment of continence
Assessment of skin integrity
Changes to symptoms, comorbidities, lifestyle, mobility, medication, BMI and social/environmental factors
Suitability of alternative options
Efficacy of products and quantities used
Reviews should be carried out by either:

Registered healthcare professional→ trained in continence assessment & referrals to specialist services or
Non-registered healthcare worker→ under supervision of registered healthcare professional trained as above

Catheters

Consider bladder catheterization(intermittent or indwelling urethral or suprapubic) [SBA]
persistent urinary retention is causing incontinence,
symptomatic infections
renal dysfunction (which cannot be corrected otherwise)

Explain to women→ use of indwelling catheters in urgency urinary incontinence may not result in continence
Offer intermittent urethral catheterization→ to woman [SBA]

who can be taught to self-cathetrise or
have carer who can do it

Indications for use of long-term indwelling urethral catheters [EMQ]

Chronic urinary retention which is not manageable by intermittent self catheterization
Skin wounds, pressure ulcers or irritations contaminated by urine
Distress/disruption by bed/clothing changes
If woman prefers this form of management
Consider indwelling supra public catheter→ as an alternative. Explain to woman→ its association with decreased rates of symptomatic UTI, ‘bypassing’ and urethral complications

Products to prevent leakage

DO NOT use→ intravaginal/ intraurethral devices for routine management of UI
Occasional use only, like during physical exercise

Complementary therapies — Do not recommend

Medicines for OAB

Before starting medicines→ explain to woman

Likelihood of success
Common adverse effects
Some adverse effects of anticholinergic medicine like dry mouth/constipation→ may indicate that medicine started to have an effect
Substantial benefits may take 4 weeks of regular medicine intake and symptoms may improve over time
Long-term effects of anticholinergic medicines on cognitive function → uncertain
When offering anticholinergic medicines → take account of woman’s

Coexisting conditions (like poor bladder emptying, cognitive impairment or dementia)
Current use of other medicines
Risk of adverse effects including cognitive impairment
Women with dementia and anticholinergic drugs an option→ follow NICE guidance on dementia

Choosing medicine

Offer

Do not

1. anticholinergic medicine with the lowest acquisition cost to treat overactive bladder or mixed urinary incontinence in women. If the first medicine for overactive bladder or mixed urinary incontinence is not effective or well-tolerated, offer another medicine with a low acquisition cost. 2. transdermal overactive bladder treatment to women unable to tolerate oral medicines. 3. mirabegron 4.desmopressin may be consider specifically to reduce nocturia in women with urinary incontinence or overactive bladder who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension. 5.intravaginal oestrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy.

1. flavoxate, propantheline or imipramine to treat urinary incontinence or overactive bladder. 2. oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health. 3. duloxetine as a first-line treatment for women with predominant stress urinary incontinence. Do not routinely offer duloxetine as a second-line treatment for women with stress urinary incontinence, although it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects. 4. systemic hormone replacement therapy to treat urinary incontinence.

Do Not offer flavoxate, propantheline or imipramine to treat UI or OAB
Do Not offer oxybutynin (immediate release) to older women at higher risk of sudden deterioration in their physical or mental health
Offer→ anticholinergic medicine with lowest acquisition cost to treat OAB or mixed UI
If first medicine not effective/well-tolerated→ offer another with low acquisition cost
Offer→ transdermal OAB treatment who are unable to tolerate oral medicines
Consider desmopressin→ specifically to reduce nocturia. Use with caution in women with cystic fibrosis and avoid in over 65 years with cardiovascular disease or HTN
Duloxetine
- Do not use as 1st-line with predominant SUI
- Do not routinely offer as 2nd-line with SUI
Offer a 2nd-line therapy if woman prefer pharmacological to surgical treatment or are unsuitable for surgical treatment
Do Not offer systemic HRT to treat UI
Offer intravaginal estrogens to treat OAB in postmenopausal with vaginal atrophy

Reviewing medicine

After 4 weeks of starting new medicine → offer face-to-face or telephone review

Ask woman if satisfied with treatment and
If optimal improvement→ continue treatment
No or suboptimal improvement or intolerable adverse effects→ change the dose or try an alternative medicine

If adverse events intolerable → offer review before 4 weeks
Offer→ Refer to secondary care→ if medicine taken but not successful or tolerated
Offer further face-to-face or telephone review→ if medicine stops working after an initial successful 4-week review
Review in primary care→ if remain on long-term medicine→ 12 months
If age >75 years→ every 6 months review

Invasive procedure for OAB

OAB not responded to non-surgical management or medicines & who wish to discuss further options
Offer urodynamic testing to check if detrusor overactivity is responsible for her OAB symptoms and

If detrusor overactivity→ offer invasive procedure
No detrusor overactivity→ seek further advice from local MDT

Botulinum toxin type A injection (Botox A)

After local MDT review

Offer→ bladder wall injection with Botox A to women with OAB due to detrusor overactivity not responded to non-surgical/drug treatment
Consider→ bladder wall injection with Botox A in women with OAB symptoms but no urodynamic detrusor overactivity (if non-surgical treatment failed and women does not wish other invasive treatments)
Discuss benefits/risks of treatment with Botox type A with woman and explain

Likelihood of complete or partial symptom relieve
Process of clean intermittent catheterization, risks and how long need to be continued
Risk of adverse effects including increased UTI risk
Not much evidence about how long injections work for, how well they work in long term and their long-term risks
Start→ Botox type A only if woman wiling (in case of having significant voiding dysfunction)

To perform clean intermittent catheterisation on regular basis as long as needed or
To accept temporary indwelling catheter if unable to perform clean intermittent catheterisation

Initial dose→ 100 units
Offer face-to-face or telephone review within 12 weeks of first treatment with Botox A to assess response to treatment / adverse effects and

If good symptom relief→ tell how to self-refer for prompt specialist review if symptoms return & offer repeat treatment as necessary
If inadequate symptom relief → consider increasing subsequent dose to 200 units and review within 12 weeks
No effect→ discuss with local MDT

If symptom relief adequate after 100 units but lasted for < 6months → consider increasing the dose to 200 units & review within 12 weeks
Do not offer Botox type B to women with OAB

Percutaneous Sacral Nerve Stimulation

Offer PSNS after local or regional MDT review if OAB has not responded to non-surgical management including medicine and:

Not responded to Botox type A or
Not prepared to accept risks of needing catheterisation associated with Botox type A
Discuss→ long-term implications of PSNS including

Need for test stimulation and probability of test success
Risk of failure
Long-term commitment
Need for surgical revision
Adverse effects
Tell woman→ how to self refer if symptoms return after PSNS procedure

Augmentation cystoplasty

Restrict → only for management of idiopathic detrusor overactivity who have not responded to non-surgical management & are willing to self-catheterize
Preoperative counselling should include→

common/serious complications:

bowel disturbance
metabolic acidosis
mucus production and/or retention in bladder,
UTI
Urinary retention

Discuss→ small risk of malignancy
Provide→ life-long follow-up

Urinary diversion

Consider only when non-surgical management fails plus Botox type A, PSNS and augmentation cystoplasty not appropriate or unacceptable
Provide→ life-long follow-up

Surgical management of Stress Urinary Incontinence

Public concern about use of mesh procedures
There is evidence of benefits but limited evidence on long-term adverse effects
True prevalence of long-term complications → unknown
If a woman thinking about surgical procedure for SUI→ discuss with women

Benefits/risk of ALL surgical options (regardless of local availability)
Uncertainties about long-term adverse effects for all procedures (especially involving mesh)
Difference b/w procedures, type of anesthesia, expected hospital stay, surgical incisions & expected recovery period
Any social or psychological factors effecting woman’s decision
If non-surgical for SUI failed plus women wishes to think about surgical procedure→ offer her choice of

Colposuspension (open or laparoscopic) or
Autologous rectus fascial sling
retro public mid-urethral mesh sling

Consider intramural bulking agents if alternative surgical procedures are not suitable or acceptable
Explain to women

These are permanent injectable material
Repeat injection may be needed to achieve effectiveness
Less effective than surgical procedures
Limited evidence on long-term effectiveness /adverse events

If intramural bulking agent injected→ give written information about bulking agent including name, manufacturer, date of injection and injecting surgeons name/contact details
If woman’s chosen procedure not available from insulting surgeon→ refer her to an alternative surgeon
Providers must ensure→ data be recorded in national registry

Mid-urethral Mesh Sling Procedures

When offering retropubic mid-urethral mesh sling→ advice woman it is a permanent implant and complete removal may not be possible
If retropubic mid-urethral mesh sling inserted→ give woman written information about implant, including its name, manufacturer, date of insertion and implanting surgeons name/contact details
When planning retro public mid-urethral mesh sling procedure, surgeons should→

Use device manufactured from type 1 macroporuous polypropylene mesh
Consider using retro pubic mid-urethral mesh sling colored for high visibility, ease of insertion/revision

Do not offer transobturartor approach unless specific clinical circumstances (for example, previous pelvic procedures) in which the retropubic approach should be avoided.
Do not use ‘top-down’ retropubic mid-urethral mesh sling approach or single-incision sub-urethral short mesh sling insertion except as part of clinical trial

Artificial Urinary Sphincters

Do not offer → unless previous SUI surgery failed
If inserted → Offer postoperative follow-up and ensure review access if needed

Procedures that should not be offered

Do not offer following to treat SUI

Anterior colporrhaphy
Needle suspension
Para vagina defect repair
Porcine dermis sling
Marshall-Marchetti-Krantz procedure

Follow-up after surgery

Offer follow-up → within 6 months to ALL women who had surgical procedure to treat SUI
If had retropubic mid-urethral mesh sling→ follow-up should include vaginal examination to check for exposure or extrusion of mesh sling
Ensure if women has surgery for SUI→ referral access if recurrent symptoms or suspected complications
Primary surgery failed

Seek advice on assessment / manage to from regional MDT or
Offer woman advice about managing symptoms if she does not wish to have another surgical procedure & explain→ she can opt for referral later