Dr Julian Spinks reviews the NICE guideline on the management of urinary incontinence in women, the need for improvements in diagnosis, and the availability of services

Urinary incontinence (UI) in women is a common condition, which has previously been under-recognised and under treated. Primary care has a key role in the early diagnosis and management of the condition. For this reason, a priority for the Guideline Development Group of the 2006 NICE guideline on Urinary incontinence: the management of urinary incontinence in women1 was to provide clear advice for GPs on the assessment, diagnosis, and treatment of this condition.

The publication of the NICE guideline was preceded by two Department of Health documents: Good practice in continence services,2 which highlighted the need for adequate assessment and management of patients; and The national service framework for older people,3 which promised the introduction of integrated continence services. In theory, the combination of these three publications has the potential to transform services for women with UI.

Prevalence and impact of UI

Research suggests that the vast majority of women with UI are unknown to the healthcare services. One community based study compared those women known to have incontinence with a postal survey on prevalence of UI and results showed that a significant number of patients had not been identified. Among patients reporting moderate or severe UI, only one third had received any intervention.4 This emphasises the need for clinicians to actively enquire about incontinence at appropriate opportunities, such as cervical cytology and contraception reviews, and well-woman checks.

The economic impact of UI is significant to both the NHS and patients, with costs estimated at £743 million in the UK.5 There is also a major impact on quality of life for women who have UI, with:6

  • 60% avoiding going away from home
  • 50% feeling odd or different from others
  • 45% avoiding public transport
  • 40% reporting avoidance of sexual activity through fear of incontinence.

Assessment

The NICE guideline on managing UI in women recommends that the first stage of management is to distinguish between the main types of UI and related conditions. These are:1,7

  • Stress UI—involuntary leakage on effort, coughing, sneezing, or physical activity
  • Urge UI—an intense desire to pass urine that results in involuntary leakage of urine. This is a variant of overactive bladder (OAB), which presents as urinary frequency, urgency, and nocturia, with or without associated incontinence
  • Mixed UI—features of both stress and urge incontinence.

In many cases, history alone can be used to distinguish between the different types of UI. In addition to the presenting complaint, the GP should enquire about previous surgery, obstetric and gynaecological problems, medication, and co-existing conditions that might affect the urinary tract.1,7 In patients where there is risk of cognitive decline, a mental state examination may be helpful.7

The examination of a patient with UI should include abdominal palpation for masses or a palpable bladder. A vaginal examination can identify smaller pelvic masses, bladder distension, pelvic organ prolapse, and vaginal atrophy. It is also useful at this stage to check if the patient is capable of performing a pelvic floor contraction as this may guide later therapy. If there is a history of constipation, a rectal examination may detect impaction leading to urinary symptoms.7

Very few investigations are required at initial assessment. A urine sample should be tested with a dipstick for blood, protein, leukocytes, nitrite, and glucose. If the dipstick is positive or the patient has symptoms of a urinary tract infection, midstream urine should be sent to microbiology for testing.1,7 Occasionally, the history may suggest co-morbidities, such as diabetes or renal disease, and if this is the case, blood tests for these conditions may be indicated. More complex investigations, such as ultrasound scanning or urodynamics, are not required before initial management.1,7

The most useful tool at the initial assessment of UI is probably a bladder diary completed by the patient, which covers a minimum of 3 days.1,7 This allows the woman to document her fluid input, urine output, and any episodes of incontinence (together with the circumstances when these occurred). This can aid in determining the type and severity of UI. It also provides a baseline against which to judge treatment success.

Referral

Some patients may require referral after initial assessment by the GP. Red flags and indications for referral are shown in Table 1.1

Table 1: Indecations for referral1

Red flags—urgent referral is required if any of the following are present:

  • Microscopic haematuria in women aged over 50 years
  • Macroscopic/visible haematuria
  • Recurrent or persistent UTI associated with haematuria in women aged over 40 years
  • Suspected malignancy of the urogenital organs

Routine referral should take place if either of the following are present:

  • A palpable bladder, either abdominally or vaginally after voiding
  • Symptomatic prolapse of the uterus visible at, or below, the introitus

Consider referral in women with any of the following:

  • Clinically benign pelvic mass
  • Suspected neurological conditions
  • Associated faecal incontinence
  • Voiding difficulty
  • Previous continence surgery
  • Persistent bladder or urethral pain
  • Previous pelvic cancer surgery or radiotherapy

Non-pharmacological interventions

Lifestyle modifications
The NICE guideline recommends that initial treatment is based on the type of UI present. If the patient has mixed UI, treatment is aimed at the dominant type. For all types of incontinence, lifestyle advice includes weight reduction (if obese) and modification of high or low fluid intake. If OAB is present, caffeine intake should be reduced.1,7

Physical and behavioural therapies
Women with stress UI should be offered supervised pelvic floor muscle training (PFMT) (also known as pelvic floor exercises). The woman should aim to carry out a minimum of 24 contractions a day.1,7 The technique needs to be trained and monitored—instruction sheets and booklets are not sufficient. In cases of urge UI, OAB, or mixed UI, bladder retraining is recommended as the first-line treatment. This re-educates the overactive bladder to allow increased intervals between voids, and greater warning time before leakage becomes unavoidable. This treatment is less technique-dependent than PFMT, but is still more successful if taught by a trained clinician. Both therapies require time to take effect, and so a minimum of 3 months for PFMT, and 6 weeks for bladder retraining is recommended.1,7

Pads and catheters
The guideline sends a clear message about devices such as pads and catheters: they are not treatments, and should only be used if treatment has failed or as a coping strategy while awaiting definitive management. This applies equally to the residential or nursing home patient.7

Drug treatment

The NICE guideline found that there was little to choose between the different antimuscarinic treatments for urge UI/OAB and urge-predominate mixed UI.1 However, the price differential between immediate-release (IR) non-proprietary oxybutynin and other preparations or drugs makes IR oxybutynin the first-line choice if bladder training has been ineffective. However, this comes with the penalty of higher side-effects. Darifenacin, solifenacin, tolterodine, trospium, or an extended-release or transdermal formulation of oxybutynin remain useful for patients who have not responded or are unable to tolerate oxybutynin.

The only drug licensed for stress UI is duloxetine. A combination of relatively poor efficacy and high levels of reported side-effects led the Guideline Development Group to reject it as a first- or second-line treatment. However, it may still have a place for women who are unwilling to undergo, or who are not suitable for surgical treatment. If atrophic vaginitis is present, a trial of intravaginal oestrogens may help OAB/urge UI but not stress UI.1,7

Referral for surgery

If treatment in primary care is unsuccessful, the NICE guideline recommends referral for specialised assessment and treatment by surgeons, urologists, or urogynaecologists experienced in the management of UI.1,7 For stress UI, surgical tape techniques that support the bladder neck are recommended as alternatives to conservative management. In women with urge UI/OAB, surgery is less common, but for those patients who are severely affected, bladder augmentation may be offered. For women who have not responded to conservative treatments, sacral nerve stimulation is a management option for UI resulting from detrusor overactivity.1,7

Response to the guideline

Some of the recommendations from the NICE guideline have proved controversial. The recommendation of IR oxybutynin as a first-line drug treatment was criticised by patient groups due to the higher side-effect profile. However, evidence indicates that all antimuscarinic agents result in a high discontinuation rate.8 The economic argument also remains valid as there have been no changes to alter the balance of cost efficacy between IR oxybutinin and other agents.

There was also debate over the recommendation that women with pure stress UI do not need urodynamics prior to surgery. This recommendation caused, and continues to cause consternation and criticism from some specialists.9 The definitive answer to the controversy is unlikely to appear until the results of a prospective trial are available.

The requirement for PFMT to be supervised has been strengthened by a recent health technology assessment by the Health Services Research Unit at the University of Aberdeen.10 This unpublished research looked at 88 trials of non-pharmacological and surgical treatments for stress UI and found a clear correlation between the number of supervised sessions a woman received and the success of the treatment. The research also found that biofeedback in combination with PFMT improved the outcome of treatment.

Availability of continence services

Many of the guideline recommendations on the management of UI in women have proven to be capable of being implemented in primary and secondary care. However, the biggest disappointment has been the lack of progression in continence services. The National audit of continence care for older people found that only 58% of PCTs had integrated continence services and in only 67% of hospitals were these services led by a professional.11 Overall, the availability of continence advisers was reported to be one per 8400 patients with UI.10 These statistics suggest that continence care is still a low priority in many areas. A commissioning guide on the conservative management of UI in women has been produced by NICE12 and it is hoped that commissioners in primary care organisations and commissioning groups will use it to build new services to offer women with UI the treatment they need and deserve.

Conclusion

The identification, diagnosis, and initial treatment of women with UI should be taking place in primary care. The NICE guideline gives healthcare professionals in primary care clear guidance on how to manage women with UI, but for it to be implemented successfully, practices, commissioners, and continence services need to work together to produce improved patient services.

Key Points

  • UI is a common but under-recognised condition in women, with a significant cost and quality of life impact
  • The main types of UI—stress, urge, and mixed UI—can often be distinguished by history alone
  • Abdominal and vaginal examination, and urinalysis are recommended at initial examination
  • A 3-day bladder diary is a useful tool for diagnosis and management
  • The predominate symptom should be treated—first-line treatments are 3 months of supervised PFMT for women with stress UI, or 6 weeks of bladder retraining for urge UI or OAB
  • Antimuscarinic drugs for OAB have similar levels of efficacy—immediate-release oxybutynin is the first-line preparation
  • Referral is required for red-flag symptoms and may be required if initial treatment is unsuccessful
  • Pads and catheters are not treatments, and should only be used if treatments have failed or as a coping strategy
UI=urinary incontinence; PFMT=pelvic floor muscle training; OAB=overactive bladder
  • PBC consortia should review their continence services and also audit current referrals to secondary care
  • Continence services provided by an acute trust may incur tariff charges and be expensive; the service should be provided in the community if this is the case
  • There is a large element of unmet need for UI and it is right and proper to try and stimulate appropriate demand from patients not accessing services
  • PBC consortia will need to consider increased drug costs, need for physiotherapy services, and appropriate referrals for surgery to meet this new demand
  • Tariff costs: gynaecology outpatient = £144 (new), £76 (follow up)a
  1. National Institute for Health and Care Excellence. Urinary incontinence: the management of urinary incontinence in women. Clinical Guideline 40. London: NICE, 2006. Available at: www.nice.org.uk/CG040.
  2. Department of Health. Good practice in continence services. London: DH, 2000. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005851
  3. Department of Health. National service framework for older people. London: DH, 2001. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066
  4. Thomas T, Plymat K, Blannin J, Meade T. Prevalence of urinary incontinence. Br Med J 1980; 281 (6250): 1243–1245.
  5. 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.
  6. Norton P, MacDonald L, Sedgwick P, Stanton S. Distress and delay associated with urinary incontinence, frequency, and urgency in women. BMJ 1988; 297 (6657): 1187–1189.
  7. National Collaborating Centre for Women’s and Children’s Health. Urinary incontinence: the management of urinary incontinence in women. London: NICE, 2006. Available at: www.nice.org.uk/CG040
  8. Shaya F, Blume S, Gu A et al. Persistence with overactive bladder pharmacotherapy in a Medicaid population. Am J Manag Care 2005; 11 (4): S121–S129.
  9. Agur W, Housami F, Drake M, Abrams P. Could the National Institute for Health and Care Excellence guidelines on urodynamics in urinary incontinence put some women at risk of a bad outcome from stress incontinence surgery? BJU Int 2009; 103 (5): 635–639.
  10. Vale L. Health technology assessment on non-surgical management of female stress urinary incontinence. Presentation at Annual Conference of Association for Continence Advice. 10th June 2009.
  11. Wagg A, Potter J, Peel P et al. National audit of continence care for older people: management of urinary incontinence. Age Ageing 2008; 37 (1): 39–44.
  12. NICE website. Urinary continence service for the conservative management of urinary incontinence in women. www.nice.org.uk/usingguidance/commissioningguides/uiwomen/UrinaryContinenceService.jsp (accessed 10 August 2009).G