Drs Vikky Morris (pictured) and Susie Orme discuss the significant morbidity caused by UI in women and how implementation of NICE Quality Standard 77 aims to improve quality of life and the care experience

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Read this article to learn more about:

  • deficiencies in service provision for women with urinary incontinence
  • the diagnosis, assessment, and management of this condition
  • how lifestyle changes can significantly improve symptoms.

Key points

Audit points

GP commissioning messages

Urinary incontinence (UI) is a treatable condition and intervention is cost effective both for the individual and for the wider healthcare community.1 However, UI is also an undertreated problem that imposes a significant burden on a person's quality of life as well as that of their caregivers.2,3

The consequences of UI can be devastating; it is also associated with an increased risk of falls and fractures associated with toileting,4 depression, social isolation, sleep disturbance, effects on skin resulting in moisture lesions, and increased risk of urinary tract infection (UTI).5–8

Available guidance

In 2010, the National audit of continence care9 demonstrated a number of deficiencies in service provision and standardised assessment for people with UI in primary and secondary care, and care-home settings (see Box 1, below).

Box 1: Key findings of the National audit of continence care 20109

Organisational audit

  • The great majority of continence services are poorly integrated across acute, medical, surgical, primary care, care home, and community settings, resulting in disjointed care for patients and carers
  • The way continence services are presently commissioned means that:
    • those providing the care are not included in the process of commissioning
    • many services are not set up to provide joined-up care across healthcare boundaries
    • most services lack a designated lead whose responsibility it is to organise, develop, and improve the delivery of continence care to patients
    • users almost never contribute to service planning or evaluation
  • Provision of training for healthcare workers to manage bladder and bowel problems is patchy across the nation, and overall occurs in less than 50% of acute hospitals.

Clinical audit

  • These gaps in organisational standards for continence care lead to gaps in clinical care
  • Overall, adherence to national guidance (NICE) for urinary and faecal incontinence is variable
  • Healthcare professionals are not consistently:
    • asking about incontinence in people who are at risk of the condition (e.g. older people)
    • providing assessment, diagnosis, and follow-through according to standard practice
    • communicating information about causes and treatments of patients' incontinence
    • asking patients about their own goals for treatment
    • assessing the impact of incontinence on quality of life
    • making care plans to achieve treatment goals and sharing these with patients and (where relevant) carers
  • Quality of care (assessment, diagnosis and treatment) is worse in older people aged 65 years and over compared with those aged under 65 years.

Royal College of Physicians. National audit of continence care: combined organisational and clinical report. London, RCGP, 2010. Available at: www.rcplondon.ac.uk/sites/default/files/full-organisational-and-clinical-report-nacc-2010.pdf

Following on from this, in September 2013, NICE issued Clinical Guideline (CG) 171 on: Urinary incontinence—the management of urinary incontinence in women.10 This guideline focused on diagnosis and treatment pathways, whether conservative, pharmacological, or surgical, for women with UI. NICE has now published Quality Standard (QS) 77 on: Urinary incontinence in women.11 The quality statements were developed bearing in mind the shortcomings illustrated in the National audit of continence care 2010 (see Box 1, above) and to encourage implementation of NICE CG171. NICE QS77 comprises seven statements, which are shown in Table 1 (see below).

Table 1: NICE quality standard for urinary incontinence in women—list of quality statements11
No.Quality statement
1 Women first presenting with UI have a physical examination, recording of the type and duration of symptoms, and categorisation of the urinary incontinence.
2 Women first presenting with UI are asked to complete a bladder diary for a minimum of 3 days and given advice about the impact that lifestyle changes can have.
3 Women with UI are only offered containment products as a temporary coping strategy, or as long-term management if treatment is unsuccessful.
4 Women with stress or mixed UI who are able to contract their pelvic floor muscles are offered a trial of supervised pelvic floor muscle training of at least 3 months' duration as first-line treatment.
5 Women with symptoms of urgency or mixed UI are offered bladder training for a minimum of 6 weeks as first-line treatment.
6 Women with UI have indwelling urethral catheters for long-term treatment only if they have an assessment and discussion of the practicalities and potential urological complications.
7 Women with overactive bladder or stress UI symptoms have a multidisciplinary team review before they are offered surgery or other invasive treatment.

UI=urinary incontinence

NICE (2015) QS77. Urinary incontinence in women. Available at: www.nice.org.uk/guidance/qs77

Reproduced with permission

NICE Quality Standard 77

NICE QS77 on UI in women is designed to ensure:11

  • a person-centred, integrated approach to provide high-quality services and care to women with UI
  • continuous improvement in quality of services
  • that healthcare professionals involved in assessing, caring for, and treating women with UI have sufficient, appropriate training and competencies to deliver the actions and interventions described in the QS77 statements
  • improvement in quality of life and experience of care for women with UI.

The expectation is that assessment and management of UI in women is effective and standardised wherever the woman is seen.

Physical examination, recording of symptoms, and categorisation of the urinary incontinence—statement 1

The clinical history should include the duration of onset and severity of the lower urinary tract symptoms (LUTS), a subjective assessment of the degree of bother associated with the symptoms, and specific questions around urgency and stress leakage of urine. As a minimum, physical examination should include palpation of the abdomen to look for gross abnormalities and inspection of the external genitalia. See Box 2, below for further information on the categorisation of UI.

Box 2: Categorisation of urinary incontinence as in CG17110

  • Stress UI is involuntary urine leakage on effort or exertion or on sneezing or coughing
  • Urgency UI is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay)
  • Mixed UI is involuntary urine leakage associated with both urgency and exertion, effort, sneezing, or coughing
  • OAB is defined as urgency that occurs with or without urgency UI and usually with frequency and nocturia. OAB that occurs with incontinence is known as 'OAB wet'. OAB that occurs without incontinence is known as 'OAB dry'. These combinations of symptoms are suggestive of the urodynamic finding of detrusor overactivity, but can be the result of other forms of urethrovesical dysfunction.

UI=urinary incontinence; OAB=overactive bladder

NICE (2013) CG171. Urinary incontinence: the management of urinary incontinence in women. Available at: www.nice.org.uk/guidance/cg171

Reproduced with permission

Bladder diaries and lifestyle changes—statement 2

Bladder diaries can be very useful in providing information regarding fluid volume input, type of fluid being drunk, urine output frequency and volume, symptoms of urgency, episodes of incontinence, and pad usage. As such they can enable healthcare professionals and the woman to understand when urgency and leakage occur, and to consider management options. Bladder diaries may also be used for monitoring the effects of treatment as a comparator.10

Lifestyle changes can significantly improve symptoms in women with UI or overactive bladder (OAB). Giving lifestyle advice to women when they first present means they can benefit from improvements as soon as possible. Lifestyle measures include:10

  • a trial of caffeine restriction, which is effective in OAB
  • modification of fluid intake (decrease or increase as appropriate), which is effective in both OAB and stress UI (SUI)
  • weight reduction in women who have UI and a body mass index greater than 30 kg/m2.

Containment products—statement 3

Incontinence products such as pads or toileting aids are not 'treatments' for UI, but are a means of containment and can allow women to continue normal activities of daily living. They are, however, costly, can cause social embarrassment, and are not a long-term solution to the problem. They should therefore not be offered unless a full assessment has been conducted or is awaited or if other treatments have failed.10

There was evidence in the National audit of continence care 2010 that women aged greater than 65 years were more likely to be offered pads than their younger counterparts.9

Supervised pelvic floor muscle training—statement 4

Pelvic floor muscle training is defined as training in repetitive selective voluntary contraction and relaxation of specific pelvic floor muscles that is delivered and evaluated by a trained healthcare professional.10

Women with stress or mixed UI are often given a leaflet on pelvic floor muscle training, but are not given the supervision of an expert to help them. When women then attend for specialist treatment they have been incorrectly performing pelvic floor muscle training for a significant period of time with no improvement in their symptoms. There is evidence that supervised pelvic floor muscle training with trained healthcare professionals significantly improves outcomes and can avoid more invasive treatments.11

It is recommended that routine digital assessment is undertaken to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of UI.10

Bladder training—statement 5

Bladder training actively involves the woman trying to increase the interval between onset of the desire to pass urine and actually going to pass urine. Bladder retraining helps a woman to begin to hold more urine for longer periods of time.

Advice for patients from the Bladder and Bowel Foundation includes:12

  • plan your retraining schedule clearly with realistic and achievable goals
  • focus on success—not on setbacks
  • be patient; bladder retraining will not be a success overnight. You will need to work hard at it for some weeks
  • be aware of any fears or worries associated with your bladder problem. In some cases these fears or worries will need to be tackled before long-lasting success is possible.

The first five statements that make up QS77 are predominantly concerned with initial assessment, diagnosis, and initial management of UI. It is therefore helpful to look at the algorithm13 from NICE CG171 that supports these statements (see Figure 1, below).10

Figure 1: Initial advice and conservative treatments algorithm
Initial advice and conservative treatments algorithm

NICE website. NICE CG 171. Urinary incontinence: The management of urinary incontinence in women. NICE, 2013.
Available at: www.nice.org.uk/guidance/cg171 Reproduced with permission.

Indwelling catheters—statement 6

Long-term indwelling urinary catheters are associated with increased risk of UTIs and can have damaging effects on the urethra.11

 

Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention causes difficulties, such as incontinence, symptomatic infections, or renal dysfunction, and in whom this cannot otherwise be corrected. Healthcare professionals should be aware of and explain to women that the use of indwelling catheters in urgency UI may not result in continence as catheters can be associated with 'bypassing' leading to continued urinary leakage.10

Long-term indwelling urethral catheters may be indicated for women with UI who:10

  • have chronic urinary retention and are unable to manage intermittent self-catheterisation
  • have skin wounds, pressure ulcers, or irritations that are being contaminated by urine until healing occurs
  • experience distress or disruption caused by bed and clothing changes
  • express a preference for this form of management as no other alternatives have been successful.

Multidisciplinary review prior to surgery—statement 7

In current clinical practice the recommended care pathway for urinary incontinence is to offer conservative and pharmacological interventions as initial treatments within primary care. The diagnosis of LUTS as stress UI, OAB, or mixed incontinence should inform the initial treatment pathway. Where the outcomes of these treatments are not optimal in terms of reaching the woman's treatment goals, a range of surgical interventions may be considered. Almost all of these treatments are offered in secondary care and women would need to be referred from primary care to receive these interventions. The treatment options should be discussed and the multidisciplinary team (MDT) should consider all available options and likelihood of success with the patient.14

It is not realistic to expect that a local NHS treatment centre will always provide all recommended treatment options and the expertise to perform them. The NICE recommendation is that the MDT should work within regional clinical networks to ensure that if a treatment option is required that is not available locally, the woman can be referred elsewhere within the regional network.14

Such an MDT review will ensure that all other possible treatment options have been considered and help the decision as to whether invasive treatment is suitable for the woman. Suggested members of the MDT include a urogynaecologist, a urologist with a special interest in female urology, a specialist nurse, a specialist physiotherapist, and a member of the care of the elderly team and/or occupational therapist for women with functional impairment. It is recommended that a colorectal surgeon with a specialist interest also attend if a woman has coexisting bowel problems.14

Challenges for primary care

The expectation is that the initial diagnosis and management of LUTS in women should take place in primary care; however, this poses a number of challenges:

  • the typical length of a GP appointment may not allow sufficient time to complete all of the recommended clinical history taking and physical examination
  • healthcare professionals may require additional training in order to improve confidence in assessing the strength of the pelvic floor and interpreting bladder diaries
  • assessment of any benefit of medication for OAB after 4 weeks of treatment will put additional pressure on primary care if established continence services within the community are not adequate.

Conclusion

Urinary incontinence in women is a common and distressing condition. The costs of containment methods (e.g. absorbent pads) are high; in contrast, treatment of UI is cost effective. Treatment of UI is always cheaper than containment and effective treatment has potential direct and indirect health economic savings.

The provision of primary care continence services and trained continence advisors is not uniform throughout the country; NICE QS77 may be used to improve and strengthen these services.

The pressures on general practice to deliver the recommendations in the absence of sufficient local continence services will be difficult without support and training.

  • The proportion of women presenting to primary care services who receive pelvic floor assessment and are taught pelvic floor exercises correctly or have access to pelvic floor physiotherapists
  • The number of women who are dissatisfied with first-line pharmacological therapy at 4-week review as a result of either a lack of efficacy or the side-effect profile
  • The number of individuals referred to secondary care services and who have had full access to an MDT review.

MDT=multidisciplinary team

Key points

  • It is important to screen women for symptoms of UI as it is a very common condition
  • All women who have LUTS and UI should be assessed by a trained professional in order to categorise their type of incontinence to aid treatment options
  • The common misconception that urinary incontinence is a natural consequence of ageing needs to be overcome to improve outcomes for older women
  • Simple conservative treatments can be very effective and should be tried before embarking on pharmacological treatments or surgical options:
    • lifestyle measures can improve symptoms
    • bladder training should be carried out for at least 6 weeks
    • pelvic floor muscle training should be supervised by a trained professional for at least 3 months
  • The implications of catheterisation should be fully discussed with the woman and very carefully considered
  • Women referred to secondary care for consideration of invasive treatment should have access to the opinion and advice of an MDT.

LUTS=lower urinary tract symptoms; UI=urinary incontinence; MDT=multidisciplinary team

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Audit points

  • The proportion of women presenting to primary care services who receive pelvic floor assessment and are taught pelvic floor exercises correctly or have access to pelvic floor physiotherapists
  • The number of women who are dissatisfied with first-line pharmacological therapy at 4-week review as a result of either a lack of efficacy or the side-effect profile
  • The number of individuals referred to secondary care services and who have had full access to an MDT review.

 

MDT=multidisciplinary team

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GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • Most people will first present to general practice and so educational packages for GPs and their staff including aids, such as bladder diary forms that patients can complete between consultations, should be made available
  • CCGs should:
    • audit their commissioned services against NICE QS77 and identify any gaps in service provision and seek to rectify them
    • look to consider effective community incontinence services to avoid expensive hospital referral and provide timely accessible support to patients and their GPs
    • ensure they commission enough suitably trained healthcare professionals to provide supervised pelvic floor muscle training
  • Local formularies should identify cost-effective pharmacotherapies for the various syndromes covered in NICE QS77.

CCGs=clinical commissioning groups; QS=quality standard.

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References

  1. Imamura M, Abrams P, Bain C et al. Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence. Health Technol Assess 2010; 14 (40): 1–188.
  2. Chang C, Gonzalez C, Lau D, Sier H. Urinary incontinence and self-reported health among the U.S. Medicare managed care beneficiaries.J Aging Health 2008; 20 (4): 405–419.
  3. Senra C, Pereira M. Quality of life in women with urinary incontinence. Rev Assoc Med Bras 2015; 61 (2): 178–183.
  4. Brown J, Vittinghoff E, Wyman J et al. Urinary incontinence: does it increase risk for falls and fractures? J Am Geriatr Soc 2000; 48 (7): 721–725.
  5. Mody L, Juthani-Mehta M. Urinary tract infections in older women: a clinical review.JAMA 2014; 311 (8): 844–854.
  6. Mishra G, Barker M, Herber-Gast G, Hillard T. Depression and the incidence of urinary incontinence symptoms among young women: results from a prospective cohort study.Maturitas 2015; 81 (4): 456–461.
  7. Holroyd S. Incontinence-associated dermatitis: identification, prevention and care. Br J Nurs 2015; 24 (9): S37–38, S40–43.
  8. Kim S, Ward E, Dicianno B, et al; National Spina Bifida Patient Registry. Factors associated with pressure ulcers in individuals with spina bifida. Arch Phys Med Rehabil 2015;96 (8): 1435–1441.e1.
  9. Royal College of Physicians. National audit of continence care: combined organisational and clinical report. London, RCGP, 2010. Available at: www.rcplondon.ac.uk/sites/default/files/full-organisational-and-clinical-report-nacc-2010.pdf
  10. NICE. Urinary incontinence: the management of urinary incontinence in women. Clinical Guideline 171. NICE, 2013. Available at:www.nice.org.uk/guidance/CG171
  11. NICE. Urinary incontinence in women. Quality Standard 77. NICE, 2015. Available at:www.nice.org.uk/guidance/qs77
  12. Bladder and Bowel Foundation. Bladder diary/retraining. Available at: www.bladderandbowelfoundation.org/bladder/bladder-treatments/conservative-treatments/ladder-diary (accessed 4 August 2015)
  13. MGP Ltd. Initial advice and conservative treatments algorithm. Guidelines, November 2013. Available at: www.guidelines.co.uk/obstetrics_gynaecology_urology_nice_ui_women_nov13 (accessed 28 July 2015).
  14. National Collaborating Centre for Women's and Children's Health. Urinary incontinence: the management of urinary incontinence in women. London, RCOG, 2013. Available at: www.nice.org.uk/guidance/cg171/evidence/cg171-urinary-incontinence-in-women-fullguideline3