The NICE guideline on the management of urinary incontinence (UI) in women was published in October 2006.1,2 For the first time, this NICE guideline makes recommendations about the requisite competence required of surgeons operating on incontinent women. However, this guideline is not all about surgery and much of its content is highly relevant to the primary healthcare team.
Any gradings listed are taken from the full guideline.2
Why is incontinence management important?
Urinary incontinence is a problem that, although more common in later life, is by no means confined to the elderly. It affects approximately 25% of adult women.3
It is not a fatal condition, but women with this problem experience a considerable loss of quality of life4 and are at risk of considerable associated co-morbidity, for example:5
- skin and urinary tract infection
- risk of institutionalisation.
Incontinence is still associated with a social taboo and is talked about reluctantly. Many women suffer with the condition for years before seeking help, or mention the problem to their doctor as an aside at the end of a consultation for another matter. Treatment is often not actively pursued by clinicians, either through ignorance about what can be done, or because the condition is not thought of as serious enough to warrant attention; and, of course, it is not sexy or part of QOF2 and, therefore, there is no incentive to treat people appropriately.
The National Audit of Continence Care for Older People (http://continenceaudit2006.rcplondon.ac.uk) has found evidence of poor service provision, assessment, and management, with a massive reliance on pads to manage the problem.6 Thus, it is estimated that the annual cost to the NHS of managing UI is £743 million, or approximately £248 per woman per year, with much of that expenditure on pads.7,8 Many women also spend substantial additional amounts of their own money on pads from high street suppliers.9
There will be many women with incontinence and bladder problems on a GP's list, but they are frequently unidentifiable from general practice clinical records, often only being found in either district nurse, continence service, or other nursing notes. This may reflect the reluctance of patients to present with the problem or the fact that GPs attach little importance to the complaint. These issues make incontinence a truly hidden problem.
The NICE guideline covers the initial assessment and clinical management of a woman with incontinence. For the majority of women, this process starts in primary care.
Developing the guideline
The guideline is available in several forms: the full guideline, a quick reference guide, an implementation guide, a slide set, a costing template and report, and a version for patients. There are also audit criteria available on the NICE website.
The guideline was developed according to the standard method of grading research papers to produce evidence statements and recommendations. Where there was no available research evidence, not an infrequent finding in this area, the guideline development group (GDG) made recommendations based upon expert consensus.2
The guideline recommends that all women attending for healthcare advice, for any reason, should be asked about bladder and bowel health. Given the high prevalence of the problem, this appears to be a reasonable approach.
Once incontinence is detected, a specific history and physical examination should be performed in order to reach a presumptive diagnosis — the GDG felt that, on the balance of probability, this was possible and would be able to guide initial management. A bladder diary, kept for a minimum of 3 days, is also recommended.1 Based on the available evidence, the information from the 3-day bladder diary gives the best return in terms of compliance and completion, when compared with a 1-day (complete but insufficient data) or a 7-day diary.
The presence of haematuria, both macroscopic and microscopic, in women over the age of 50 years should be referred to a specialist, as should any urogenital prolapse beyond the introitus [Grade D (GPP)]. The presence of bladder or urethral pain should also warrant specialist referral.1
Of a more contentious nature is the finding of faecal incontinence. This guideline suggests that specialist referral should be considered; however, the forthcoming NICE guideline on the management of faecal incontinence — now in draft form — indicates that this condition should also be managed in primary care for the vast majority of patients.10
Challenges for GPs
What challenges does the assessment and diagnosis of incontinence present to the GP? First, there is the issue of time. Taking a focused history, conducting an examination, and reviewing medication (including urinalysis [Grade D (GPP)] and an assessment of post voiding residual urine where clinically indicated [Grade B (DS)]) will be demanding on a GP's time. This is certainly the case when more than one visit is necessary to discuss the results of the urine dipstick and bladder diary prior to management being initiated.
Second, a chaperone will routinely be required when an intimate examination is to be carried out. The guideline suggests that in addition to an abdominal examination to exclude significant retention, a pelvic assessment is required to look for signs of urogenital atrophy, pelvic organ prolapse, infection, or excoriation.2 A bimanual examination is also recommended to look for ovarian and uterine pathology,2 and a rectal examination should also be performed where clinically indicated.2 A suitable chaperone may not always be available to GPs, which is particularly important if the doctor is male.
The majority of women will present with one of three symptomatic subtypes of urinary incontinence:
- stress urinary incontinence — the involuntary loss of urine on effort or exertion, sneezing, or coughing
- urgency incontinence — loss of urine in response to urinary urgency
- mixed urinary incontinence — incontinence associated with both exertion and a response to urgency.
The overactive bladder syndrome (OAB — also known as frequency–urgency syndrome) may or may not result in urinary incontinence.
Depending upon the diagnosis, which for the majority of women will be either stress, urge, or mixed urinary incontinence (i.e. symptoms of both) the following therapies are recommended.
For stress or mixed urinary incontinence a 3-month programme of supervised pelvic floor muscle therapy (PFMT) is the first-line approach [Grade A]. This, according to the guideline, requires an initial assessment of pelvic floor muscle strength (by an appropriately skilled practitioner),2 although the available data on the effectiveness of PFMT did not always report that had been done [Grade D (GPP)]. The number of people trained to carry out this examination is low and it is, therefore, not available to all.
In the recent National Audit of Continence Care for Older People, only 69 out of 101 PCTs in England and Wales reported that they had staff who were able and trained to do abdominal, rectal, and vaginal exams.6 In addition, supervised programmes of PFMT include more than offering advice or giving out leaflets of instruction, as they also provide monitoring and continued motivation. Data from the audit show that 90% of primary care continence services have specialist nurses, but only 47% have continence-trained physiotherapists.6 The ability of generalist nurse practitioners (practice nurses, district nurses) to fulfill this need is not known but there is undoubtedly a large gap in training and expertise.
Women who are unable to contract their pelvic floor muscle and who do not want to be considered for surgery should be referred to continence specialists for other treatment modalities, such as electrical stimulation [Grade D (GPP)] or medication (duloxetine) [Grade A]. Treatment with duloxetine, a serotonin noradrenaline reuptake inhibitor, which is also indicated for depression, requires careful counselling and dose titration to maximise adherence. There is a high withdrawal rate seen in clinical practice, which is mostly due to the associated nausea that can lead to up to 70% of women being unable to take their medication.11
For women experiencing urgency incontinence, OAB, or mixed symptoms, a 6-week course of bladder training is recommended [Grade A].
This too needs careful explanation and some monitoring and encouragement, both of which are time consuming. The use of intravaginal oestrogens is recommended for post menopausal women who have OAB and vaginal atrophy.
If drug therapy for OAB or mixed UI is required then immediate-release (IR) generic oxybutynin is recommended as the first-line treatment [Grade A]. Oxybutynin is cheaper than any of the antimuscarinics and is undoubtedly effective, even at doses as low as 2.5 mg twice daily,12,13 but the number of withdrawals from treatment because of side-effects (dry mouth, constipation, etc.) is high, although never systematically evaluated at these low doses.
This course of treatment presents yet another challenge. The dose needs to start low and the patient must be reviewed to monitor progress, with the dose being adjusted accordingly. This requires extra visits to the surgery — the economic model in the guideline allowed for only one and this is likely to underestimate the true number. However, the value of these extra visits should not be underestimated given the plentiful evidence for a beneficial non-drug effect seen in clinical trials.14
Starting the patient on a high dose of oxybutynin IR (5 mg three times daily) is, in the majority of cases, doomed to fail and may discourage her from seeking further help.15
The guidance recommends any of the other alternative antimuscarinic drugs:
- oxybutynin ER
- transdermal oxybutynin
- tolterodine IR or ER
Additionally, darifenacin is now available in the UK. A minimum duration of 12 weeks' therapy is required before maximum benefit in terms of reduction in urinary frequency, urgency, and incontinence episodes is gained.
Promoting best practice
Undoubtedly, adherence to the guideline will improve care for women with incontinence. There remains a need for care to be organised in a way that delivers the integrated continence services promoted in Good Practice in Continence Services,16 and the National Service Framework for Older People,17 and for a structured audit of care for all adults.
The Department of Health has commented that all relevant policies, with respect to incontinence, are now in place, but there still seems to be a lack of implementation. Commissioning organisations should refer to the available guidance when specifying services to ensure that they meet the requirements for integrated services.
The primary healthcare team is central to the care for women with urinary incontinence and to the cost savings envisaged by the new NICE guideline. There is a continuing need to train members of the team so they can provide the level of care required.
NICE implementation tools
NICE has developed the following tools to support implementation of its guideline on the management of urinary incontinence in women. They are now available to download from the NICE website: www.nice.org.uk.
- Women with urinary incontinence should have access to SNS if conservative options have failed
- Local provision of SNS should be identified; if unavailable, commissioning this service from other regional teams should be considered
- Integrated continence services should be the goal for commissioning
- National Institute for Health and Care Excellence. Urinary incontinence: The management of urinary incontinence in women. Clinical Guideline No 40. London: NICE, 2006.
- National Collaborating Centre for Women's and Children's Health. Urinary incontinence: The management of urinary incontinence in women. London: Royal College of Obstetricians and Gynaecologists, 2006.
- Hunskaar S, Burgio K, Clark A et al. Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse: In: Abrams P, Khoury S, Cardozo L, Wein A (Eds). WHO-ICS International Consultation on Incontinence. Third edn. Paris: Health Publications Ltd, 2005, pp 255–312.
- Ko Y, Lin S, Salmon J, Bron M. The impact of urinary incontinence on quality of life of the elderly. Am J Manag Care 2005;11 (4 Suppl): S103–111.
- Wagg A. Urinary incontinence – older women: where are we now? BJOG 2004; 111 (Suppl 1): 15–19.
- Wagg A, Peel P, Lowe D, Potter J, on behalf of the Continence Working Party. Report of the National Audit of Continence Care for Older People (65 years and above) in England, Wales & N Ireland. London: Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, 2006.
- Turner D, Shaw C, McGrother C et al. The cost of clinically significant urinary storage symptoms for community dwelling adults in the UK. BJU Int 2004; 93 (9): 1246–1252.
- Papanicolaou S, Pons M, Hampel C et al. Medical resource utilisation and cost of care for women seeking treatment for urinary incontinence in an outpatient setting. Examples from three countries participating in the PURE study. Maturitas 2005; 52 (Suppl 2): S35–47.
- Wagg A, Cox J, Porkess S, Das Gupta R. Pad use and costs in women seeking care for their urinary incontinence in the UK and ROI: Data from the PURE study (UK). Int Urogynecol J 2006; 17 (S8).
- Vella M, Duckett J. Do women comply with duloxetine? A prospective study assessing patient compliance with duloxetine and its efficacy in treating women with stress incontinence and mixed symptoms Int Urogynecol J 2006; 17 (S8).
- Szonyi G. Collas D, Ding Y, Malone-Lee J. Oxybutynin with bladder retraining for detrusor instability in elderly people: a randomized controlled trial. Age Ageing 1995; 24 (4): 287–291.
- Bemelmans B, Kiemeney L, Debruyne F. Low-dose oxybutynin for the treatment of urge incontinence: good efficacy and few side effects. Eur Urol 2000; 37 (6): 709–713.
- Chapple C, Martinez-Garcia R, Selvaggi L. A comparison of the efficacy and tolerability of solifenacin succinate and extended release tolterodine at treating overactive bladder syndrome: results of the STAR trial. Eur Urol 2005; 48 (3): 464–470.
- Milsom I, Abrams P, Cardozo L et al. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int 2001; 87 (9): 760–766.
- Department of Health. Good practice in continence services. London: DH, 2000.
- Department of Health. National Service Framework for Older People. London: DH, 2001.G