NICE 123: Urinary Incontinence in women: Management

This is the part 1 of summary of the NICE guideline “Urinary Incontinence & Pelvic Organ Prolapse in Women: Management” published in April 2019. As this is a long guideline, so I decided to cover it in two posts.

• There are some changes in this guideline. This guideline provides information about management of women having urinary incontinence and pelvic organ prolapse, outline of the service organization and how the services should be provided (which are relevant for the health professionals working in UK)
• This post #1 of summary covers organization of specialist services, data collection on surgery, assessing urinary incontinence (UI), non-surgical management of UI and surgical management of stress urinary incontinence (SUI)
• This rest of the topics will covered in next post
• It is advised to read the original guideline to grasp the topic and to make sure no important point is missed
• The guideline can be downloaded by clicking here: NG 123 Urinary Incontinence & POP in women: Management
• Some other relevant links of this topic are also provided at the end of this post

Kindly let me know if this post was helpful and suggestions to improve future posts are welcome.

Thanks

NICE 123 Urinary Incontinence and Pelvic Organ Prolapse in women: Management

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, Sam-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

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

• 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→ where persistent urinary retention is causing  incontinence, symptomatic infections or 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 who can be taught to self-cathetrise or have carer who can do it
• Indications for use of long-term indwelling urethral catheters

• 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

• 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 and 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
• Also include option of 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
• 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

The second part of this guideline covering pelvic organ prolapse management will be added soon. Please keep following the blog. 

You may also like:

Module 18: Urogynaecology & Pelvic Floor Problems

Continence surgery at POP repair

NICE 133: Hypertension in Pregnancy Part 1 Part 2

NICE 121: Intrapartum Care of women with Medical Disorders 

NICE 140: Abortion Care

NICE Guidelines

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