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Urinary incontinence in women. October 2006. Changing clinical practice . NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations to work towards implementing guidelines Compliance will be monitored by the Healthcare Commission.

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Urinary incontinence

in women

October 2006

changing clinical practice
Changing clinical practice
  • NICE guidelines are based on the best available evidence
  • The Department of Health asks NHS organisations to work towards implementing guidelines
  • Compliance will be monitored by the Healthcare Commission
need for this guideline
Need for this guideline
  • Urinary incontinence (UI) commonly affects women of all ages
  • It can seriously affect physical, psychological and social wellbeing
  • The impact on families and carers may be profound
  • Estimated current cost to the NHS is £233 million annually
ui is common but hidden
UI is common but hidden
  • Estimated 4 million women over 40 years regularly incontinent in UK
urinary incontinence
Urinary incontinence
  • Defined as involuntary urinary leakage
  • May occur as a result of:
    • functional abnormalities of the lower urinary tract
    • other illnesses
  • These tend to cause leakage in different situations
spot the risk factors
Spot the risk factors

Associations and possible risk factors include:

  • age
  • obstetric factors such as pregnancy and parity
  • menopause and hysterectomy
  • lower urinary tract symptoms
  • family history and genetics
  • smoking, diet and obesity
  • cognitive or functional impairment
treatment pathway

Lifestyle interventions

Assess and categorise

Refer

Stress UI

Mixed UI

OAB with or without urge UI

Urodynamics if appropriate, not routinely for pure stress UI

Stress UI

OAB with or without urge UI

AssessmentConservative managementSurgical management

Treatment pathway
what the guideline covers
What the guideline covers
  • Initial assessment and investigation
  • Conservative management, including:bladder trainingsupervised pelvic floor muscle trainingpharmacological therapy
  • Multi-channel cystometry
  • Surgical treatment options
  • Competencies for surgeons performing operations
assess and investigate
Assess and investigate
  • Assess using:
    • bladder diaries
    • urine dipstick test
    • post void residual volume

Consider:

    • fluid intake
    • caffeine consumption
    • weight loss

Categorise and treat according to type of UI

support initial assessment
Support initial assessment
  • Raise awareness of NICE recommendations and develop training opportunities to focus on key aspects
  • Review and update local referral and care pathways
  • Use local multidisciplinary and specialist teams, such as integrated continence services
  • Use tools and questionnaires to support symptom scoring and quality of life assessment
offer training and drugs
Offer training and drugs
  • Pelvic floor muscle training
  • Eight contractions, three times a day, 3 months minimum
  • Bladder training
  • 6 weeks minimum
  • Antimuscarinic drugs
  • Immediate-release oxybutynin as first choice Offer support and advice for side effects
  • Multi-channel cystometry, ambulatory urodynamics or videourodynamics are not recommended before starting conservative treatment
support conservative choices
Support conservative choices
  • Review who is offering supervised pelvic floor muscle training and bladder training locally
  • Update prescribing policies and formularies in line with the guideline
  • Underline the importance of support and advice about side effects when prescribing medication for UI
use cystometry if appropriate
Use cystometry if appropriate
  • Multi-channel filling and voiding cystometry is recommended before surgery if:
    • detrusor overactivity suspected
    • previous surgery has been done for stress UI or anterior compartment prolapse
    • symptoms suggest voiding dysfunction
  • Also consider ambulatory urodynamics or videourodynamics
offer surgical management
Offer surgical management
  • If conservative treatments have failed for:
  • overactive bladder with or without urge UI offer

- sacral nerve stimulation

  • stress UI offer
      • - retropubic mid-urethral procedures
      • alternatively colposuspension or rectus fascial sling
skills for surgeons
Skills for surgeons
  • Surgeons undertaking surgery should:
    • receive appropriate training in the management of UI and associated disorders, or
    • work within a multidisciplinary team with this training
    • regularly carry out surgery for UI in women
support surgical options
Support surgical options
  • Review local access, consider use of regional services
  • Formally assess current practice for surgeons
  • Maintain skills with a minimum annual workload - 20 cases per year per primary procedure
  • Nominate a clinical lead within each surgical unit
  • Encourage surgeons to submit outcomes to national registries
treatment pathway19

Lifestyle interventions

Assess and categorise

Refer

Stress UI

Mixed UI

OAB with or without urge UI

Urodynamics if appropriate, not routinely for pure stress UI

Stress UI

OAB with or without urge UI

AssessmentConservative managementSurgical management

Treatment pathway
access tools online
Access tools online
  • Costing tools
    • costing report
    • costing template
  • Audit criteria
  • Implementation advice
  • Available from: www.nice.org.uk/CG040
access the guideline online
Access the guideline online
  • Quick reference guide – a summary www.nice.org.uk/CG040quickrefguide
  • NICE guideline – all of the recommendations www.nice.org.uk/CG040niceguideline
  • Full guideline – all of the evidence and rationale www.nice.org.uk/CG040fullguideline
  • Understanding NICE guidance – a plain English version www.nice.org.uk/CG040publicinfo