Urinary incontinence and pelvic organ prolapse in women

This updated guideline covers both the surgical and non-surgical management of urinary incontinence (UI), and includes advice on the use of controversial vaginal mesh procedures, which NICE recommends should remain available despite concerns about long term effects. Our summary focuses on the non-surgical management of UI, the assessment of pelvic organ prolapse, and when to refer for either condition

ASSESSMENT OF URINARY INCONTINENCE

At the initial clinical assessment, categorise the woman’s urinary incontinence (UI) as stress UI, mixed UI, or urgency UI/overactive bladder (OAB). Start initial treatment on this basis. In mixed IU, focus on the predominant symptom. If stress incontinence is the predominant symptom in mixed UI, discuss the benefits of non-surgical management and drug treatments before offering a surgical referral.

All women presenting with UI should have a urine dipstick test 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 (MSU) for culture and analysis of antibiotic sensitivities. Prescribe an appropriate course of antibiotic treatment pending culture results. See our Guidelines in a Nutshell summary of Prescribing for lower urinary tract infections (NG109) http://www.practicenurse.co.uk/index.php?p1=articles&p2=1821

• If women do not have symptoms but their urine tests positive for leucocytes and nitrites, do not offer antibiotics with the results of the MSU culture
• If a woman does not have symptoms and her urine tests negative, do not send a urine sample for culture as she is unlikely to have a UTI.

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

Use bladder diaries in the initial assessment of women with UI or OAB; women should complete at least 3 days of the diary to include both working and leisure days.

NON-SURGICAL MANAGEMENT OF URINARY INCONTINENCE

Lifestyle interventions

Recommend a trial of caffeine reduction to women with overactive bladder (OAB)

Consider advising women with UI or OAB and a high or low fluid intake to modify their fluid intake

Advise women with UI or OAB who have a BMI greater than 30kg/m2 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 a first-line treatment to women with stress or mixed UI. Training programmes should comprise at least 8 contractions performed 3 times per day. The exercise programme should be continued if it is beneficial. Electrical stimulation techniques should not be routinely used in the treatment of women with OAB.

Behavioural therapies

Offer bladder training lasting a minimum of 6 weeks as first line treatment to women with urgency or mixed UI. If this does not provide satisfactory alone, and if frequency is a troublesome symptom, consider combining bladder training with an OAB medicine.

Containment products

Do not offer absorbent containment products, hand-held urinals or toileting aids to treat UI. Offer them only as:

• A coping strategy pending definitive treatment
• As an adjunct to ongoing therapy
• For long-term management of UI only after other treatment options have been explored

Women who are using absorbent containment products for long-term management of UI should be offer a review at least once a year, to 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

Review should be carried out by a healthcare professional who is trained in assessing continence and making referrals to specialist services, or a healthcare assistant under the HCP’s supervision.

Catheters

Bladder catheterisation (intermittent, indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention is causing incontinence, symptomatic infections or renal dysfunction, in whom this cannot otherwise be corrected. HCPs should explain to women that the use of indwelling catheters in urgency UI may not result in continence. Indications for the use of long-term indwelling urethral catheters 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 may be associated with lower rates of symptomatic UTI, ‘bypassing’ and urethral complications than indwelling urethral catheters.

Do not use intravaginal and intraurethral devices for routine management of UI.

Do not recommend complementary therapies for the treatment of UI or OAB.

MEDICINES FOR OVERACTIVE BLADDER

Before starting drug treatment for OAB, explain to the woman:

• The likelihood of the medicine being successful
• The common adverse effects associated with the drug
• That some adverse effects of anticholinergic drugs, such as dry mouth and constipation, may indicate that it is starting to work
• That substantial benefits may not be apparent until the drug has been taken for at least 4 weeks, and that symptoms may continue to improve over time
• That long-term effects of anticholinergic drugs for OAB on cognitive function are uncertain.

Before prescribing an anticholinergic drug, take account of:

• Coexisting conditions (such as poor bladder emptying, cognitive impairment, dementia)
• Current use of other drugs that affect total anticholinergic load
• The risk of adverse events, including cognitive impairment. See also recommendations on drugs that may cause cognitive impairment in the NICE guideline on dementia (NG97) https://www.nice.org.uk/guidance/ng97/chapter/Recommendations#medicines-that-may-cause-cognitive-impairment

For drugs that can be used for the treatment of urinary frequency and incontinence, see the treatment summary in the BNF https://bnf.nice.org.uk/treatment-summary/urinary-frequency-enuresis-and-incontinence.html

Specific recommendations

• Do not offer flavoxate, propantheline or imipramine to treat UI or OAB
• Do not offer oxybutynin (immediate release) to older women who may be at higher risk of sudden deterioration in physical or mental health
• Offer the anticholinergic drug with the lowest acquisition cost
• If the first agent is not effective or well-tolerated, offer an alternative with a low acquisition cost
• Offer a transdermal OAB treatment for women unable to tolerate an oral preparation
• Consider desmopressin specifically to reduce nocturia in women with UI or OAB. Use with caution in women with cystic fibrosis and avoid in women over 65 years with cardiovascular disease or hypertension.
• Do not use duloxetine as first- or second-line treatment for women with stress UI, but it can be offered second-line to women who would prefer pharmacological management to surgery, or who are unsuitable for surgery.
• Do not offer systemic hormone replacement therapy to treat UI.
• Offer intravaginal oestrogens to treat OAB in postmenopausal women with vaginal atrophy

Medicines review

Review women starting a new medicine for OAB after 4 weeks (face-to-face or by telephone). Ask if she is satisfied with the treatment. If there is improvement, continue treatment but if there is no or suboptimal improvement, or intolerable adverse effects, change the dose or try an alternative drug treatment, and review after 4 weeks. Review before 4 weeks if the adverse effects of a drug are intolerable.

Refer women who have tried drug treatment for OAB that has not been successful or tolerated to secondary care to consider further treatment options.

Review women who remain on long-term medication for OAB or UI every 12 months, or every 6 months if they are aged over 75.

INDICATIONS FOR SPECIALIST REFERRAL

• Persisting bladder or urethral pain
• Palpable bladder on bimanual or abdominal examination after voiding
• Clinically benign pelvic mass
• Associated faecal incontinence
• Suspected neurological disease
• Symptoms of voiding difficulty
• Suspected urogenital fissure
• Previous continence surgery
• Previous pelvic cancer surgery
• Previous pelvic radiation therapy

INVASIVE PROCEDURES FOR OVERACTIVE BLADDER

For women with OAB that has not responded to non-surgical management or drug treatment, and who wish to discuss further treatment options:

• Offer urodynamic investigation to determine whether detrusor overactivity is causing her symptoms
• If there is no detrusor overactivity, seek advice on further management from the local multidisciplinary team (MDT)

If there is detrusor overactivity, the MDT may offer

• Botulinum toxin type A injection
• Percutaneous sacral nerve stimulation

SURGICAL MANAGEMENT OF STRESS URINARY INCONTINENCE

There is public concern about the use of mesh procedures, for which there is evidence of benefit but limited evidence on the long-term adverse effects, and the true prevalence of long-term complications is unknown.

If a woman is thinking about a surgical procedure for stress UI, use the NICE patient decision aid on surgery for stress urinary incontinence https://www.nice.org.uk/guidance/ng123/resources/patient-decision-aids-and-user-guides-6725286109 to promote informed preference and shared decision-making.

Surgical options include colposuspension, an autologous rectus fascial sling or a retropubic mid-urethral mesh sling. The guideline development group considered that, on balance, all three procedures should continue to be made available to women, but that women should be provided with sufficient information to arrive at an informed preference.

Alternatively, an intramural bulking agent may be considered if alternative surgical procedures are unsuitable or unacceptable.

Procedures that should not be offered for stress incontinence include anterior coporrhaphy (vaginal wall repair), needle suspension, paravaginal defect repair, porcine dermis sling or the Marshall-Marchetti-Krantz procedure. Artificial urinary sphincters should be considered for stress UI only if previous surgery has failed.

See the full guideline for further information.

ASSESSING PELVIC ORGAN PROLAPSE

For women presenting in primary care with symptoms or an incidental finding of vaginal prolapse:

• Take a history to include symptoms of prolapse, urinary, bowel and sexual function
• Perform an examination to rule out a pelvic mass or other pathology and to document the presence of prolapse
• Discuss the woman’s treatment preferences with her, and refer if needed
• Consider specialist investigation of bothersome urinary symptoms, symptoms of obstructed defecation or faecal incontinence, pain and symptoms that are not explained by examination findings.

Management options of pelvic organ prolapse include no treatment, non-surgical treatment and surgical options. Discuss options with the woman, taking into account

• The woman’s preferences
• Site of prolapse
• Lifestyle factors
• Comorbidities including cognitive or physical impairments
• Age
• Desire for childbearing
• Previous abdominal or pelvic floor surgery
• Risks and benefits of individual procedures

Lifestyle modification

Consider giving advice and information on:

• Losing weight, if the woman has a BMI greater than 30kg/m2
• Minimising heavy lifting
• Preventing or treating constipation

Topical oestrogen

Consider vaginal oestrogen for women with pelvic organ prolapse and signs of vaginal atrophy. Consider an oestrogen-releasing ring for women who have cognitive or physical impairments that might make vaginal pessaries or creams difficult to use.

Pelvic floor muscle training

Consider a programme of supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic pelvic organ prolapse quantification (POP-Q) stage 1 or 2.

Consider a vaginal pessary for women with symptomatic pelvic organ prolapse, alone or in conjunction with pelvic floor muscle training. Refer to a urogynaecology service if pessary care is not available locally. Before starting pessary treatment:

• Consider treating vaginal atrophy with topical oestrogen
• Explain that more than 1 pessary fitting may be needed to find a suitable pessary
• Discuss the effect of different types of pessary on sexual intercourse
• Describe complications including vaginal discharge, bleeding, difficulty removing pessary and pessary expulsion
• Explain that the pessary should be removed at least once every 6 months to prevent serious complications

SURGICAL OPTIONS

Surgery for pelvic organ prolapse is an option for women whose symptoms have not improved with, or who have declined, non-surgical treatment.

As above, there is public concern about the use of mesh products. For the recommended procedures, there is some evidence of benefit but limited evidence on long-term effectiveness and adverse events, and the true prevalence of long-term complications is unknown.

Surgical options include vaginal hysterectomy, vaginal sacrospinus hysteropexy with sutures, Manchester repair (unsuitable for women who wish to have children in the future) or sacro-hysteropexy with mesh (abdominal or lapascopic). The proposed treatment should be reviewed by a regional MDT if the woman wishes to have children in future.

Use the Surgery for uterine prolapse patient decision aid https://www.nice.org.uk/guidance/ng123/resources/surgery-for-uterine-prolapse-patient-decision-aid-pdf-6725286112 to promote informed preference and shared decision-making.

See the full guideline for further information.

NICE NG123. Urinary incontinence and pelvic organ prolapse in women, April 2019

https://www.nice.org.uk/guidance/ng123