Guideline name: Urinary incontinence and pelvic organ prolapse in women: management [NG123]
Update type: Guideline replaces a set of previous guidelines
Published: April 2019
- NICE recently published a guideline on assessment and management of urinary incontinence and pelvic organ prolapse in women aged ≥18 years.
- The recommendations in this summarised version of the guideline have been restricted to the assessment and management of urinary incontinence and overactive bladder (OAB) in primary care settings.
History and physical examination
- Following initial clinical assessment, classify the urinary incontinence as stress urinary incontinence, mixed urinary incontinence or urgency urinary incontinence/OAB.
- If stress incontinence is the predominant symptom in mixed urinary incontinence, discuss benefits of non-surgical management with the patient before considering surgery.
- Look out for relevant predisposing and precipitating factors and other diagnoses that may necessitate referral for additional investigation and treatment.
- Routine digital assessment should be performed to confirm pelvic floor muscle contraction prior to initiating pelvic floor muscle training.
- Urine dipstick test is recommended for detecting the presence of blood, glucose, protein, leucocytes and nitrites in the urine.
- UTI’s should be treated appropriately.
Other urinary assessments
- Measure post-void residual volume using bladder scan (first choice) or catheterisation when symptoms suggest voiding dysfunction or recurrent UTI.
- A validated urinary incontinence-specific symptom and quality-of-life questionnaire should be used in the evaluation of therapies
- Use of bladder diaries is recommended for the initial assessment of women with urinary incontinence or OAB.
- Pad testing is not routinely recommended.
- After a detailed clinical history and examination, urodynamic testing should be performed before surgery for stress urinary incontinence in women having the following:
- Urge-predominant mixed urinary incontinence or urinary incontinence with type unclear
- Symptoms suggesting voiding dysfunction
- Anterior or apical prolapse
- Previous surgery for stress urinary incontinence.
Cystoscopy and imaging
- Cystoscopy and imaging (MRI, CT, X-ray) are not recommended for routine assessment of women with urinary incontinence. Use ultrasound only for assessing residual urine volume.
Referral to specialist
- Indications for referral of women with urinary incontinence to a specialist service include
- Persistent bladder or urethral pain
- Palpable bladder on examination after voiding
- Benign pelvic masses
- Associated faecal incontinence
- Suspected neurological disease
- Suspected urogenital fistulae
- Voiding difficulty
- Prior continence or pelvic cancer surgery
- Prior pelvic radiation therapy.
- If haematuria or recurrent or persistent unexplained UTI are seen, follow the NICE guideline on suspected cancer for recommendations on referral for urinary tract cancer.
- Lifestyle changes recommended for women with OAB include:
- Caffeine reduction
- Modification of fluid intake
- Weight loss for women with BMI ≥30.
- Offer trial of supervised pelvic floor muscle training (8 contractions x 3 times/day for minimum 3 months) as first-line therapy for stress or mixed urinary incontinence.
- Perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training is not recommended.
- The programme should be continued if beneficial.
- Offer bladder training (minimum 6 weeks) as first-line therapy to women with urgency or mixed urinary incontinence.
- If bladder training programmes alone fail to provide satisfactory benefit, they may be combined with OAB medicine.
- Before initiating therapy for OAB, discuss the following with patients:
- Likelihood of success of the medicine
- Common adverse effects associated with the medicine.
- Certain adverse effects of anticholinergic drugs, including dry mouth and constipation are an indicator that the drug is starting to have an effect.
- Substantial benefits may not be evident until the medicine is taken for at least 4 weeks and symptoms may continue to improve over time.
- There are uncertainties regarding the long-term effects of anticholinergic drugs on cognitive function.
- Consider the following before prescribing anticholinergic drugs for OAB:
- Comorbidities (incomplete bladder emptying, cognitive impairment or dementia)
- Concurrent use of drugs likely to affect total anticholinergic load
- Risk of adverse events, including cognitive impairment.
- For women with dementia being considered for anticholinergic drug therapy, follow the NICE guideline on dementia for recommendations on drugs that may cause cognitive impairment.
Choice of medicine
- Flavoxate, propantheline or imipramine are not recommended for treating urinary incontinence or OAB.
- Oxybutynin (immediate release) is not recommended for older women with a higher risk of a sudden decline in their physical or mental health.
- A transdermal drug is suitable for patients unable to tolerate oral medicines.
- Desmopressin may be specifically considered for reducing troublesome nocturia. Use cautiously in those with cystic fibrosis and avoid use in those aged >65 years with cardiovascular disease or hypertension.
- Systemic hormone replacement therapy is not recommended for treating urinary incontinence.
- Intravaginal oestrogens are suitable for postmenopausal women with vaginal atrophy experiencing symptoms of OAB.
- Medication review should be conducted either face-to-face or via telephone 4 weeks after starting a new medicine for OAB. The review may be conducted earlier medication-related adverse events are intolerable.
- If medication has been unsuccessful or not tolerated, referral to secondary care for further treatment is recommended.
- If medication stops working after an initial 4-week review, a further face-to-face or telephone review is recommended.
- For women taking long-term medication for OAB or urinary incontinence, an ongoing review (every 12 months, or every 6 months if aged >75 years) is recommended.
This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP, FFCI, FRSA