The NICE guideline on urinary incontinence will help GPs to manage this condition successfully, says DrJulian Spinks
Female urinary incontinence (UI) is a common and disabling condition. The Leicestershire MRC study found that over one-third of women aged over 40 years had significant urinary symptoms, such as frequency, urgency, or leakage of urine.1
Despite this, over 50% of women wait for over 2 years before they seek help.2 Reasons for this delay include embarrassment, not wanting to 'bother' their GP, the false assumption that this is an inevitable part of ageing, or a lack of awareness about available treatments.3
When I speak to patients, they report that the situation is often fairly poor when they do seek help. Advice and treatment in both primary and secondary care is inconsistent, and even contradictory. Frequently the only offer of help is absorbent pads.
Hopefully the new NICE guideline on female UI,4 published in October 2006, will change this situation by providing the information that clinicians need to manage this condition effectively.
Key points in the guideline
The first key message in the guideline is that UI is a treatable condition, and that pads and other containment devices are not treatments. Although they may have a limited role in helping while a patient waits to respond to treatment, long-term use should be reserved for patients who cannot be managed in other ways such as drug therapy or surgery.
The other key message is that the initial management of UI does not require special skills, complex tests, or fancy bits of equipment. In fact, management of this disorder is well within the capabilities of primary care.
Initially, treatment is based on the clinical diagnosis. Urinary incontinence can be split into three types, normally according to the patient's symptoms:
- urge/overactive bladder (OAB)
The symptoms should be picked up when taking a full history, as will red flags such as haematuria, pain and voiding problems, predisposing conditions, and lifestyle factors such as caffeine and alcohol.4 The recommended examination is a simple abdominal and vaginal examination to look for masses, urinary retention, prolapse, and pelvic floor muscle tone. Urinalysis is required but no urodynamic investigation is needed before conservative treatment is started.4
To complete the initial assessment, women should be encouraged to complete a 3-day bladder diary detailing fluid input, urine output, and episodes of leakage.
The initial treatment recommended for stress or mixed UI is at least 3 months of supervised pelvic floor muscle training (PFMT).4 This could be carried out in the practice or the patient can be referred to a continence service. Likewise, a minimum of 6 weeks bladder training is recommended in urge UI/OAB.4 In mixed UI, GPs should treat the predominant symptom (although treating all symptoms will not be harmful). Weight loss, smoking cessation and fluid intake modification may also help.
The guideline also simplifies the drug choice for those who do not respond to initial therapy.
The recommendation is standard release oxybutynin as first-line therapy for urge incontinence/OAB.4 Other antimuscarinic therapies are reserved for those who cannot tolerate oxybutynin. Duloxetine is not recommended for first- or second-line treatment of stress UI, but can be used as an alternative to surgery.4
Other aspects of UI
In a first for NICE, the guideline looks at the competencies of surgeons treating UI. This does not directly affect GPs, but it is reassuring when surgery is required. The guideline also details the information that should be given to patients before surgery takes place.
Prevention of UI is not forgotten, with a recommendation that PFMT is offered to all women during their first pregnancy.
The algorithm provided with the guideline is particularly useful as it provides a summary of nearly all that a GP might need to know about managing female UI.
However, one big problem remains. Urinary incontinence has never been a significant part of a GP's training, and many practitioners still view it as a 'nursing problem'. The guideline shows that this attitude is now outdated but, unless GPs choose to rise to the challenge of UI, patients will continue to lose out.
- Perry S, Shaw C, Assassa P et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: The Leicestershire MRC Incontinence Study. Leicestershire MRC Incontinence Study Team. J Public Health Med 2000; 22 (3): 427–434.
- Sykes D, Castro R,Pons M et al. Characteristics of female outpatients with urinary incontinence participating in a 6-month observational study in 14 European countries. Maturitas 2005; 52 (Suppl 2): S13–23.
- Shaw C,Tansey R, Jackson C et al.Barriers to help seeking in people with urinary symptoms. Fam Pract 2001; 18 (1): 48–52.
- National Institute for Health and Care Excellence. Urinary incontinence: the management of urinary incontinence in women. Clinical Guideline No 40. London: NICE, 2006.