Urinary incontinence

1
Urinary incontinence in women
October 2006
2
Changing clinical practice

• NICE guidelines are based on the best available
  evidence
• The Department of Health asks NHS organisations
  to work towards implementing guidelines
• Compliance will be monitored by the Healthcare
  Commission

3
Need for this guideline

• Urinary incontinence (UI) commonly affects women
  of all ages
• It can seriously affect physical, psychological
  and social wellbeing
• The impact on families and carers may be profound
• Estimated current cost to the NHS is 233 million
  annually

4
UI is common but hidden

• Estimated 4 million women over 40 years regularly
  incontinent in UK

5
Urinary incontinence

• Defined as involuntary urinary leakage
• May occur as a result of
• functional abnormalities of the lower urinary
  tract
• other illnesses
• These tend to cause leakage in different
  situations

6
How UI presents
Classification Symptoms
Stress UI on effort, exertion, or sneezing or coughing
Mixed UI with urgency and exertion, effort, sneezing or coughing
Urge UI or overactive bladder syndrome (OAB) with or immediately preceded by a sensation of urgent need to urinate, with or without frequency
7
Spot the risk factors

• Associations and possible risk factors include
• age
• obstetric factors such as pregnancy and parity
• menopause and hysterectomy
• lower urinary tract symptoms
• family history and genetics
• smoking, diet and obesity
• cognitive or functional impairment

8
Treatment pathway
9
What the guideline covers

• Initial assessment and investigation
• Conservative management, including? bladder
  training ? supervised pelvic floor muscle
  training ? pharmacological therapy
• Multi-channel cystometry
• Surgical treatment options
• Competencies for surgeons performing operations

10
Assess and investigate

• Assess using
• bladder diaries
• urine dipstick test
• post void residual volume
• Consider
• fluid intake
• caffeine consumption
• weight loss
• Categorise and treat according to type of UI

11
Support initial assessment

• Raise awareness of NICE recommendations and
  develop training opportunities to focus on key
  aspects
• Review and update local referral and care
  pathways
• Use local multidisciplinary and specialist teams,
  such as integrated continence services
• Use tools and questionnaires to support symptom
  scoring and quality of life assessment

12
Manage conservatively
Stress UI MixedUI Urge UI or OAB First pregnancy
Pelvic floor muscle training
Bladder training
Antimuscarinic treatment
13
Offer training and drugs

• Pelvic floor muscle training
• Eight contractions, three times a day, 3 months
  minimum
• Bladder training
• 6 weeks minimum
• Antimuscarinic drugs
• Immediate-release oxybutynin as first choice
  Offer support and advice for side effects
• Multi-channel cystometry, ambulatory urodynamics
  or videourodynamics are not recommended before
  starting conservative treatment

14
Support conservative choices

• Review who is offering supervised pelvic floor
  muscle training and bladder training locally
• Update prescribing policies and formularies in
  line with the guideline
• Underline the importance of support and advice
  about side effects when prescribing medication
  for UI

15
Use cystometry if appropriate

• Multi-channel filling and voiding cystometry is
  recommended before surgery if
• detrusor overactivity suspected
• previous surgery has been done for stress UI or
  anterior compartment prolapse
• symptoms suggest voiding dysfunction
• Also consider ambulatory urodynamics or
  videourodynamics

16
Offer surgical management

• If conservative treatments have failed for
• overactive bladder with or without urge UI offer
• - sacral nerve stimulation
• stress UI offer
• - retropubic mid-urethral procedures
• alternatively colposuspension or rectus fascial
  sling

17
Skills for surgeons

• Surgeons undertaking surgery should
• receive appropriate training in the management of
  UI and associated disorders, or
• work within a multidisciplinary team with this
  training
• regularly carry out surgery for UI in women

18
Support surgical options

• Review local access, consider use of regional
  services
• Formally assess current practice for surgeons
• Maintain skills with a minimum annual workload
  - 20 cases per year per primary procedure
• Nominate a clinical lead within each surgical
  unit
• Encourage surgeons to submit outcomes to national
  registries

19
Treatment pathway
20
Target resources
Recommendations with significant resource impact Annual cost 000s
Urodynamic investigations before conservative treatment -3,019
Urodynamic investigations before primary surgery -321
Sacral nerve stimulation 307

Total net saving of implementing the UI guideline -3,033
21
Access tools online

• Costing tools
• costing report
• costing template
• Audit criteria
• Implementation advice
• Available from www.nice.org.uk/CG040

22
Access the guideline online

• Quick reference guide a summary
  www.nice.org.uk/CG040quickrefguide
• NICE guideline all of the recommendations
  www.nice.org.uk/CG040niceguideline
• Full guideline all of the evidence and
  rationale www.nice.org.uk/CG040fullguideline
• Understanding NICE guidance a plain English
  version www.nice.org.uk/CG040publicinfo