Urinary Incontinence in Women: Management

Overview

This guideline covers assessing and managing urinary incontinence and pelvic organ prolapse in women aged 18 and over. It also covers complications associated with mesh surgery for these conditions.

In June 2019, NICE withdrew recommendations 1.8.21 and 1.8.22 on the use of synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse. These have been replaced with a link to the NICE Interventional Procedures Guidance (IPG) on transvaginal mesh repair of anterior or posterior vaginal wall prolapse. For further details see update information.

This guideline replaces NICE Clinical Guideline 171 and IPG154, and is the basis of Quality Standard 77.

Collecting Data on Surgery and Surgical Complications

• Ask women having surgery for stress urinary incontinence or pelvic organ prolapse, or who have experienced complications related to these types of surgery, for their consent to enter the data listed below in a national registry. Give each woman a copy of her data.
• Providers must ensure that the following data are recorded in a national registry of surgery for urinary incontinence and pelvic organ prolapse in women:
  • the woman’s NHS number
  • hospital and consultant identifiers
  • date and details of the procedure
  • for procedures involving mesh, the mesh material, manufacturer, product unique identification code and type of sutures used
  • for procedures involving colposuspension, the type of sutures used
  • for procedures involving bulking agent, the bulking material, manufacturer and product unique identification code
  • date and details of any investigation for complications
  • date and details of any surgical or non-surgical intervention for complications.
• The national registry of surgery for urinary incontinence and pelvic organ prolapse in women must ensure that follow-up data are collected on key short- and long-term (at least 5 years) outcomes, including:
  • validated relevant outcome measures
  • adverse events including pain
  • suspected and confirmed mesh-related complications.

The national registry of surgery for urinary incontinence and pelvic organ prolapse in women should report annually and be quality assured.

Assessing Urinary Incontinence

History Taking and Physical Examination

• At the initial clinical assessment, categorise the woman’s urinary incontinence as stress urinary incontinence, mixed urinary incontinence or urgency urinary incontinence/overactive bladder. Start initial treatment on this basis. In mixed urinary incontinence, direct treatment towards the predominant symptom.
• If stress incontinence is the predominant symptom in mixed urinary incontinence, discuss with the woman the benefit of non-surgical management and medicines for overactive bladder before offering surgery.
• During the clinical assessment seek to identify relevant predisposing and precipitating factors and other diagnoses that may require referral for additional investigation and treatment.

Assessing Pelvic Floor Muscles

• Undertake routine digital assessment to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of urinary incontinence.

Urine Testing

• Undertake a urine dipstick test in all women presenting with urinary incontinence to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine.
• If women have symptoms of urinary tract infection (UTI) and their urine tests positive for both leucocytes and nitrites, send a midstream urine specimen for culture and analysis of antibiotic sensitivities. Prescribe an appropriate course of antibiotic treatment pending culture results. See the NICE guideline on urinary tract infection (lower): antimicrobial prescribing for more information.
• If women have symptoms of UTI and their urine tests negative for either leucocytes or nitrites, send a midstream urine specimen for culture and analysis of antibiotic sensitivities. Consider the prescription of antibiotics pending culture results.
• If women do not have symptoms of UTI, but their urine tests positive for both leucocytes and nitrites, do not offer antibiotics without the results of midstream urine culture.
• If a woman does not have symptoms of UTI and her urine tests negative for either leucocytes or nitrites, do not send a urine sample for culture because she is unlikely to have UTI.

Assessing Residual Urine

• Measure post-void residual volume by bladder scan or catheterisation in women with symptoms suggestive of voiding dysfunction or recurrent UTI.
• Use a bladder scan in preference to catheterisation on the grounds of acceptability and lower incidence of adverse events.

Symptom Scoring and Quality-of-Life Assessment

• Use a validated urinary incontinence-specific symptom and quality-of-life questionnaire when therapies are being evaluated.

Bladder Diaries

• Use bladder diaries in the initial assessment of women with urinary incontinence or overactive bladder. Encourage women to complete a minimum of 3 days of the diary covering variations in their usual activities, such as both working and leisure days.

Pad Testing

• Do not use pad tests in the routine assessment of women with urinary incontinence.

Urodynamic Testing

• Do not perform multichannel filling and voiding cystometry before primary surgery if stress urinary incontinence or stress-predominant mixed urinary incontinence is diagnosed based on a detailed clinical history and demonstrated stress urinary incontinence at examination.
• After undertaking a detailed clinical history and examination, perform multichannel filling and voiding cystometry before surgery for stress urinary incontinence in women who have any of the following:
  • urge-predominant mixed urinary incontinence or urinary incontinence in which the type is unclear
  • symptoms suggestive of voiding dysfunction
  • anterior or apical prolapse
  • a history of previous surgery for stress urinary incontinence.

Other Tests of Urethral Competence

• Do not use the Q-tip, Bonney, Marshall and Fluid-Bridge tests in the assessment of women with urinary incontinence.

Cystoscopy

• Do not use cystoscopy in the initial assessment of women with urinary incontinence alone.

Imaging

• Do not use imaging (MRI, CT, X-ray) for the routine assessment of women with urinary incontinence. Do not use ultrasound other than for the assessment of residual urine volume.

Indications for Referral to a Specialist Service

• In women with urinary incontinence, indications for consideration for referral to a specialist service include:
  • persisting bladder or urethral pain
  • palpable bladder on bimanual or abdominal examination after voiding
  • clinically benign pelvic masses
  • associated faecal incontinence
  • suspected neurological disease
  • symptoms of voiding difficulty
  • suspected urogenital fistulae
  • previous continence surgery
  • previous pelvic cancer surgery
  • previous pelvic radiation therapy.

Follow the recommendations on referral for urinary tract cancer in the NICE guideline on suspected cancer, for women with haematuria or recurrent or persistent unexplained UTI.

Non-surgical Management of Urinary Incontinence

Lifestyle Interventions

• Recommend a trial of caffeine reduction to women with overactive bladder.
• Consider advising women with urinary incontinence or overactive bladder and a high or low fluid intake to modify their fluid intake.
• Advise women with urinary incontinence or overactive bladder who have a BMI greater than 30 to lose weight.

Physical Therapies

Pelvic Floor Muscle Training

• Offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first-line treatment to women with stress or mixed urinary incontinence.
• Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day.
• Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training.
• Continue an exercise programme if pelvic floor muscle training is beneficial.

Electrical Stimulation

• Do not routinely use electrical stimulation in the treatment of women with overactive bladder.
• Do not routinely use electrical stimulation in combination with pelvic floor muscle training.
• Electrical stimulation and/or biofeedback should be considered for women who cannot actively contract pelvic floor muscles to aid motivation and adherence to therapy.

Behavioural Therapies

• Offer bladder training lasting for a minimum of 6 weeks as first-line treatment to women with urgency or mixed urinary incontinence.
• If women do not achieve satisfactory benefit from bladder training programmes, the combination of an overactive bladder medicine with bladder training should be considered if frequency is a troublesome symptom.

Neurostimulation

• Do not offer transcutaneous sacral nerve stimulation (surface electrodes placed above the sacrum, often known as transcutaneous electrical nerve stimulation [TENS]) to treat overactive bladder in women.
• Do not offer transcutaneous posterior tibial nerve stimulation for overactive bladder.
• Do not offer percutaneous posterior tibial nerve stimulation (needles inserted close to the posterior tibial nerve) for overactive bladder unless:
  • there has been a local MDT review and
  • non-surgical management including overactive bladder medicine treatment has not worked adequately and 
  • the woman does not want botulinum toxin type A^[A] or percutaneous sacral nerve stimulation.

Absorbent Containment Products, Urinals and Toileting Aids

• Do not offer absorbent containment products, hand-held urinals or toileting aids to treat urinary incontinence. Offer them only:
  • as a coping strategy pending definitive treatment
  • as an adjunct to ongoing therapy
  • for long-term management of urinary incontinence only after treatment options have been explored.
• Offer a review at least once a year to women who are using absorbent containment products for long-term management of urinary incontinence. The review should cover:
  • routine assessment of continence
  • assessment of skin integrity
  • changes to symptoms, comorbidities, lifestyle, mobility, medication, BMI, and social and environmental factors
  • the suitability of alternative treatment options
  • the efficacy of the absorbent containment product the woman is currently using and the quantities used.
• Reviews for women who are using absorbent containment products for long-term management of urinary incontinence should be carried out by either:
  • a registered healthcare professional who is trained in assessing continence and making referrals to specialist services or
  • a non-registered healthcare worker, under the supervision of a registered healthcare professional who is trained in assessing continence and making referrals to specialist services.

See the section on Indications for referral to a specialist service in this guideline.

Catheters

• Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention is causing incontinence, symptomatic infections or renal dysfunction, and in whom this cannot otherwise be corrected. Healthcare professionals should be aware, and explain to women, that the use of indwelling catheters in urgency urinary incontinence may not result in continence.
• Offer intermittent urethral catheterisation to women with urinary retention who can be taught to self-catheterise or who have a carer who can perform the technique.
• Give careful consideration to the impact of long-term indwelling urethral catheterisation. Discuss the practicalities, benefits and risks with the woman or, if appropriate, her carer. Indications for the use of long-term indwelling urethral catheters for women with urinary incontinence include:
  • chronic urinary retention in women who are unable to manage intermittent self-catheterisation
  • skin wounds, pressure ulcers or irritations that are being contaminated by urine
  • distress or disruption caused by bed and clothing changes
  • where a woman expresses a preference for this form of management.
• Indwelling suprapubic catheters should be considered as an alternative to long-term urethral catheters. Be aware, and explain to women, that they may be associated with lower rates of symptomatic UTI, ‘bypassing’, and urethral complications than indwelling urethral catheters.

Products to Prevent Leakage

• Do not use intravaginal and intraurethral devices for the routine management of urinary incontinence in women. Do not advise women to consider such devices other than for occasional use when necessary to prevent leakage, for example during physical exercise.

Complementary Therapies

• Do not recommend complementary therapies for the treatment of urinary incontinence or overactive bladder.

Medicines for Overactive Bladder

• Before starting treatment with a medicine for overactive bladder, explain to the woman:
  • the likelihood of the medicine being successful
  • the common adverse effects associated with the medicine
  • that some adverse effects of anticholinergic medicines, such as dry mouth and constipation, may indicate that the medicine is starting to have an effect
  • that she may not see substantial benefits until she has been taking the medicine for at least 4 weeks and that her symptoms may continue to improve over time
  • that the long-term effects of anticholinergic medicines for overactive bladder on cognitive function are uncertain.
• When offering anticholinergic medicines to treat overactive bladder, take account of the woman’s:
  • coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia)
  • current use of other medicines that affect total anticholinergic load
  • risk of adverse effects, including cognitive impairment.

For women who have a diagnosis of dementia and for whom anticholinergic medicines are an option, follow the recommendations on medicines that may cause cognitive impairment in the NICE guideline on dementia.

Choosing Medicine

• Do not offer women flavoxate, propantheline or imipramine to treat urinary incontinence or overactive bladder.
• Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health.
• Offer the 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.^[B]
• Offer a transdermal overactive bladder treatment to women unable to tolerate oral medicines.
• For guidance on mirabegron, see the NICE technology appraisal guidance on mirabegron for treating symptoms of overactive bladder.
• The use of desmopressin may be considered 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.
• Do not use 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.
• Do not offer systemic hormone replacement therapy to treat urinary incontinence.
• Offer intravaginal oestrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy.

Reviewing Medicine

• Offer a face-to-face or telephone review 4 weeks after starting a new medicine for overactive bladder. Ask the woman if she is satisfied with the treatment and:
  • if improvement is optimal, continue treatment
  • if there is no or suboptimal improvement, or intolerable adverse effects, change the dose or try an alternative medicine for overactive bladder (see the recommendations for when the first medicine is not effective and offering a transdermal patch in the section on choosing medicines), and review again 4 weeks later.
• Offer a review before 4 weeks if the adverse events of a medicine for overactive bladder are intolerable.
• Refer women who have tried taking medicine for overactive bladder, but for whom it has not been successful or tolerated, to secondary care to consider further treatment.
• Offer a further face-to-face or telephone review if a medicine for overactive bladder or urinary incontinence stops working after an initial successful 4‑week review.
• Offer a review in primary care to women who remain on long-term medicine for overactive bladder or urinary incontinence every 12 months, or every 6 months if they are aged over 75.

Surgical Management of Stress Urinary Incontinence

• There is public concern about the use of mesh procedures. For all of the procedures recommended in this section, including mesh procedures, there is evidence of benefit but limited evidence on the long-term adverse effects. In particular, the true prevalence of long-term complications is unknown.
• If a woman is thinking about a surgical procedure for stress urinary incontinence, use the NICE patient decision aid on surgery for stress urinary incontinence to promote informed preference and shared decision making. Discussion with the woman should include:
  • the benefits and risks of all surgical treatment options for stress urinary incontinence that NICE recommends, whether or not they are available locally
  • the uncertainties about the long-term adverse effects for all procedures, particularly those involving the implantation of mesh materials
  • differences between procedures in the type of anaesthesia, expected length of hospital stay, surgical incisions and expected recovery period
  • any social or psychological factors that may affect the woman’s decision.

Footnotes

[A] At the time of publication (April 2019), most botulinum toxin type A preparations did not have a UK marketing authorisation for this indication. Evidence was only available for the licensed botulinum toxin type A preparation (BOTOX, Allergan).

[B] This could be any medicine with the lowest acquisition cost from any of the medicines reviewed in 2013. The evidence review considered the following medicines: darifenacin, fesoterodine, oxybutynin (immediate release), oxybutynin (extended release), oxybutynin (transdermal), oxybutynin (topical gel), propiverine, propiverine (extended release), solifenacin, tolterodine (immediate release), tolterodine (extended release), trospium and trospium (extended release). See chapter 6 of the 2013 full guideline.