History

1. Categorise the urinary incontinence (see ISC definitions below)
   1. Stress urinary incontinence (SUI)
   2. Mixed urinary incontinence (MUI)
   3. Urgency urinary incontinence/overactive bladder (UUI / OAB)
2. Start initial treatment on this basis
3. In MUI direct treatment towards the predominant symptom
4. Identify relevant predisposing and precipitating factors and other diagnoses that may require referral for additional investigation and treatment
5. Assess menopausal status
6. Assess bowel problems, including constipation

Examination

• Abdominal examination
  • Any pelvic mass
  • Palpable bladder
• PV examination
  • Prolapse
  • Pelvic floor tone assessment
  • Vulvo-vaginal atrophy (VVA)
• Other Examinations
  • BP and heart rate, if considering prescribing Mirabegron
  • Post void residual (PVR): Ideally should be assessed using a bladder scanner but may be assessed by in-and-out catheter or abdominal ultrasound scan. In general, PVR greater than 300mL is considered significant and warrants referral to duty urologist. 

Urine testing

• Urine dip for glucose, blood, protein, nitrites and leucocytes
• If symptomatic of a UTI and urine positive for leucocytes and nitrites treat with antibiotics and send MSSU (detailing which antibiotics have been commenced).
• If not symptomatic, but urine is positive for leucocytes and nitrites, send MSSU but do not treat.

Indications for referral to a specialist service

• Persisting bladder or urethral pain → Urology
• Palpable bladder on bimanual or abdominal examination after voiding → Urology
• Suspected malignant pelvic mass - Urgent Suspected Cancer (USC) → referral to Gynaecology
• Clinically benign pelvic mass → Gynaecology
• Associated faecal incontinence → Pelvic Floor Physiotherapy
• Suspected neurological disease → Neurology
• Symptoms of voiding difficulty → Urology
• Suspected urogenital fistulae → Gynaecology
• Previous continence surgery → Gynaecology
• Previous pelvic cancer surgery → Gynaecology
• Previous pelvic radiation therapy → Gynaecology
• Visible haematuria → USC referral to Urology 
• Persistent non-visible haematuria → USC referral to Urology
• Functional issues with mobility → refer to Physiotherapy / Occupational therapy as required.

Initial Management:

• Eliminate caffeine
• Stop smoking
• Lose weight: aim for a BMI below 30
• Manage constipation
• Advise patient to keep well hydrated (concentrated urine causes bladder irritation)
• Limit fluid intake 2 to 4 hours before bed if patient has bothersome nocturia 
• Pelvic floor physiotherapy for at least 3 months 
• If pelvic organ prolapse present and causing prolapse symptoms → refer to Physiotherapy for 3 to 6 months as above.
  If symptoms persist → refer to Gynaecology pelvic floor clinic.
  Pelvic floor physiotherapists can also directly refer the patient to the clinic after their assessment and treatment if more input is required to save primary care appointment and re-referral. 
• If patient is post-menopausal and has vulvo-vaginal atrophy:
  Prescribe estradiol vaginal tablets (10 microgram) or topical oestrogen: estriol cream (Ovestin 0.1%). Commence nightly for 2 weeks, reduce to alternate nights for 2 weeks followed by twice weekly application for maintenance. If there are physical issues using the vaginal tablet or cream, the 3 monthly estradiol ring (Estring) could be an alternative.
• Non-hormonal alternatives on the Highland Formulary include Hyalofemme, Replens and Sylk vaginal moisturisers. Alternative, non-formulary preparations available to be bought are Regelle and YES vaginal moisturisers. 

New in NICE 2019

• Only offer absorbent containment products, urinals and toileting aids
  
  • as a coping strategy pending definitive treatment
  • as an adjunct to ongoing therapy
  • For long-term management of urinary incontinence only after treatment options have been explored.

If all conservative management does not improve symptoms, offer a trial of medication in addition to ongoing conservative measures. Medication should be commenced at the lowest possible dose and may be increased. Side effects can limit tolerance and should be monitored.

1st Line: Trial for 4 to 6 weeks then review:

• Solifenacin 
  • 5mg, oral, once daily. Dose can be increased to 10mg once daily after 3 to 4 weeks. 

Cautions and contraindiations: see  

Or, if antimuscarinics contra-indicated, alternative first line treatment:

• Mirabegron 50mg, oral, once daily
  • if patient has renal or hepatic impairment, use reduced dose of 25mg once daily

Cautions and contraindiations: see  

Renal and hepatic impairment: See sections 4.2 and 4.4 in the Summary of Product Characteristics for dosing information. 

2nd Line: Trial for 4 to 6 weeks then review:

• Mirabegron 50mg, oral, once daily
  • if patient has renal or hepatic impairment, use reduced dose of 25mg once daily

Cautions and contraindiations: see  

Renal and hepatic impairment: See sections 4.2 and 4.4 in the Summary of Product Characteristics for dosing information. 

Review and Follow Up in Primary Care:

• If stable and symptoms improved, review in primary care annually (or every 6 months if aged over 75)
• If no improvement after trial of 2 medications or intolerant to medication refer to urology incontinence clinic

New in NICE 2019

When offering anticholinergic medicines to treat overactive bladder, take account of:

• Coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia)
• Current use of other medicines that affect total anticholinergic load
• Anticholinergic burden calculator: http://www.acbcalc.com
• Risk of adverse effects, including cognitive impairment

Patients using absorbent containment products for long-term management of urinary incontinence should have an annual review by the district nurse including:

• Routine assessment of continence
• Assessment of skin integrity
• Changes to symptoms, co-morbidities, lifestyle, mobility, medication, BMI, and social and environmental factors
• The suitability of alternative treatment options
• The efficacy of the absorbent containment product the patient is currently using and the quantities used

Conservative measures:

• 3 to 6 months of supervised pelvic floor exercises with specialist pelvic floor physiotherapist
• Weight loss to reach healthy BMI
• Reduce / Modify high impact physical activity
• Avoid constipation
• Manage chronic cough

Only offer absorbent containment products, urinals and toileting aids

• as a coping strategy pending definitive treatment
• as an adjunct to ongoing therapy
• For long-term management of urinary incontinence only after treatment options have been explored.

Review and Follow Up in Primary Care:

Refer to Urology Incontinence Clinic if no improvement in symptoms with conservative measures above.
Refer to Gynaecology Pelvic Floor Clinic if pelvic organ prolapse found on examination and simultaneously refer for Pelvic Floor Physiotherapy.

Patients using absorbent containment products for long-term management of urinary incontinence should have an annual review by the district nurse including:

• Routine assessment of continence
• Assessment of skin integrity
• Changes to symptoms, co-morbidities, lifestyle, mobility, medication, BMI, and social and environmental factors
• The suitability of alternative treatment options
• The efficacy of the absorbent containment product the patient is currently using and the quantities used

New in NICE 2019

If a patient is considering a surgical procedure for stress urinary incontinence, the following should be discussed:

• The benefits and risks of all surgical treatment options for stress urinary incontinence that NICE recommends, whether or not they are available locally
• The uncertainties about the long-term adverse effects for all procedures, particularly those involving the implantation of mesh materials
• Differences between procedures in the type of anaesthesia, expected length of hospital stay, surgical incisions and expected recovery period
• Any social or psychological factors that may affect the patient's decision

Surgical options for Stress Urinary Incontinence (SUI) offered at Raigmore

• Autologous rectal fascial sling
  • https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Autologous%20female%20sling.pdf
• Urethral bulking with Bulkamid
  
  • https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Urethral%20bulking.pdf
  • https://bulkamid.com/patients/

Surgical options for SUI offered at other (tertiary) centres

• Gynaecology: Colposuspension → Aberdeen Royal Infirmary
  (Professor Abdel-Fattah, Professor Kevin Cooper)
  https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Colposuspension.pdf
• Artificial Urinary Sphincter → Western General Hospital, Edinburgh (Mr Ammar Alhasso)
  NB this is only for patients who have had failed surgery for SUI
  https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/AUS%20female.pdf

Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for patients with urinary retention that is causing incontinence, UTIs or renal dysfunction.
Indications for the use of long-term indwelling urethral catheters for patients with urinary incontinence include:

• Chronic urinary retention for those who are unable to manage intermittent self-catheterisation
• Skin wounds, pressure ulcers or irritations that are being contaminated by urine
• Distress or disruption caused by bed and clothing changes
• Where a patient expresses a preference for this form of management

Indwelling suprapubic catheters should be considered as an alternative to long-term urethral catheters following assessment and review by Urology.

In NHS Highland for women:

• With suspected TransVaginal Tension Free Tape (TVT) or Trans-Vaginal Obturator Tape (TVTO) erosion → refer urgently to Urology
• With suspected mesh erosion following prolapse organ repair → refer urgently to Gynaecology Pelvic Floor Clinic

New NICE 2019

For women who report new-onset symptoms who have had mesh surgery for urinary incontinence or pelvic organ prolapse, evaluate whether the symptoms may be mesh-related. These symptoms include:

• Pain or sensory change in the back, abdomen, vagina, pelvis, leg, groin or perineum that is:
  • Either unprovoked, or provoked by movement or sexual activity and
  • Either generalised, or in the distribution of a specific nerve, such as the obturator nerve
  • Causing vaginal problems including discharge, bleeding, painful sexual intercourse, penile trauma or pain in sexual partners
• Or if there are
  • Urinary problems including recurrent infection, incontinence, retention, or difficulty or pain during voiding
  • Bowel problems including difficulty or pain on defaecation, faecal incontinence, rectal bleeding or passage of mucus
  • Symptoms of infection, either alone or in combination with any of the symptoms outlined above

• Urge incontinence: Complaint of involuntary loss of urine associated with urgency.
• Stress urinary incontinence (SUI): Complaint of involuntary loss of urine on effort or physical exertion including sporting activities, or on sneezing or coughing.
• Mixed urinary incontinence (MUI): Complaints of both stress and urgency urinary incontinence, i.e. involuntary loss of urine associated with urgency and also with effort or physical exertion including sporting activities or on sneezing or coughing.
• Overactive Bladder (OAB): Urinary urgency, usually accompanied by increased daytime frequency and/or nocturia, with urinary incontinence (OAB-wet) or without (OAB-dry), in the absence of urinary tract infection or other detectable disease.
• Nocturia: The number of times urine is passed during the main sleep period. Having woken to pass urine for the first time, each urination must be followed by sleep or the intention to sleep. This should be quantified using a bladder diary.
• Nocturnal polyuria: Increased proportional production of urine during the night-time compared with the 24 hour urine volume. 

• Urinary Incontinence in Women: NICE Clinical Guideline (CG171) Published September 2013; Most recent update: April, 2019.
• International Continence Society: www.ics.org
• Definitions glossary: www.baus.org.uk
• Patient information leaflets for SUI: https://bulkamid.com/patients/