Urinary incontinence in women: management

National Institute for Health and Care Excellence


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Initial advice and conservative treatments

Initial advice and conservative treatments

UI=urinary incontinence; SUI=stress urinary incontinence; OAB=overactive bladder; ICIQ=International Consultation on Incontinence Questionnaire; BFLUTS=Bristol Female Lower Urinary Tract Symptoms; I-QOL=Incontinence Quality of Life; SUIQQ=Stress and Urgency Incontinence and Quality of Life Questionnaire; UISS=Urinary Incontinence Severity Score; SEAPI-QMM=stress-related leak (S), emptying ability (E), anatomy (female) (A), protection (P), inhibition (I), quality of life (Q), mobility (M), and mental status (M); ISI=Incontinence Severity Index; KHQ=King’s Health Questionnaire; MDT=multidisciplinary team.

Click here to download the Initial advice and conservative treatments algorithm

  • This Guidelines summary includes care pathways for initial advice and conservative treatments, drug treatment for overactive bladder and mixed urinary incontinence, and alternative conservative management and pharmacological options. For a complete list of recommendations, please refer to the full guideline
  • Do not offer—assessments:
    • cystoscopy in the initial assessment
    • pad tests
    • Q-tip, Bonney, Marshall and Fluid-Bridge tests
    • magnetic resonance imaging, computed tomography, X-ray is not recommended for the routine assessment of women with urinary incontinence (UI). Ultrasound is not recommended other than for the assessment of residual urine volume
  • Assessment of residual urine:
    • measure post-void residual volume by bladder scan or catheterisation in women with symptoms suggestive of voiding dysfunction or recurrent urinary tract infection (UTI)
    • use a bladder scan in preference to catheterisation on the grounds of acceptability and lower incidence of adverse events
    • refer women who are found to have a palpable bladder on bimanual or abdominal examination after voiding to a specialist
  • Lifestyle advice:
    • recommend a trial of caffeine reduction to women with OAB (overactive bladder)
    • consider advising modification of high or low fluid intake in women with UI or OAB
    • advise women with UI or OAB who have a body mass index (BMI) greater than 30 to lose weight
  • Pelvic floor muscle training:
    • undertake routine digital assessment to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of UI
    • offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first-line treatment to women with stress or mixed UI
    • pelvic floor muscle training programmes should comprise at least eight contractions performed three times per day
    • continue an exercise programme if pelvic floor muscle training is beneficial
    • electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy
    • offer pelvic floor muscle training to women in their first pregnancy as a preventive strategy for UI
  • Bladder training:
    • offer bladder training lasting for a minimum of 6 weeks as first-line treatment to women with urgency or mixed UI
    • if women do not achieve satisfactory benefit from bladder training programmes, the combination of an OAB drug with bladder training should be considered if frequency is a troublesome symptom
  • Do not offer—interventions:
    • do not routinely use electrical stimulation in the treatment of women with OAB
    • do not routinely use electrical stimulation in combination with pelvic floor muscle training
    • do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training
    • do not offer transcutaneous sacral nerve stimulation to treat OAB in women
    • explain that there is insufficient evidence to recommend the use of transcutaneous posterior tibial nerve stimulation to treat OAB
    • do not offer transcutaneous posterior tibial nerve stimulation for OAB

Drug treatment for overactive bladder and mixed urinary incontinence

Drug treatment for overactive bladder and mixed urinary incontinence

UI=urinary incontinence; OAB=overactive bladder; MDT=multidisciplinary team.

Alternative conservative management and pharmacological options

Alternative conservative management and pharmacological options

UI=urinary incontinence; UTI=urinary tract infection.

  • Absorbent products, urinals, and toileting aids:
    • absorbent products, hand held urinals and toileting aids should not be considered as a treatment for UI. Use them only as:
      • a coping strategy pending definitive treatment
      • an adjunct to ongoing therapy
      • long-term management of UI only after treatment options have been explored
  • Do not use:
    • do not recommend complementary therapies for the treatment of UI or OAB
    • do not use intravaginal and intraurethral devices for the routine management of UI in women. Do not advise women to consider such devices other than for occasional use when necessary to prevent leakage, for example during physical exercise
  • Desmopressin:
    • the use of desmopressin may be considered specifically to reduce nocturia in women with UI or OAB who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension
  • Oestrogens:
    • do not offer systemic hormone replacement therapy for the treatment of UI
    • offer intravaginal oestrogens for the treatment of OAB symptoms in postmenopausal women with vaginal atrophy
  • Duloxetine:
    • do not use duloxetine as a first-line treatment for women with predominant stress UI. Do not routinely offer duloxetine as a second-line treatment for women with stress UI, although it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects

Please refer to the full guideline for more information on botulinum toxin, percutaneous sacral nerve stimulation, and referral.

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG171

National Institute for Health and Care Excellence. Urinary incontinence in women: management. September 2013
First included: February 2014.


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