A GP's Guide to NICE Guidelines on Women's Urinary Incontinence 

Dr Julian Spinks

Disclosures

June 08, 2020

Dr Julian Spinks, GP partner, Strood in Kent, adviser to the Association for Continence Advice, also sat on the guideline committee which developed the NICE guidelines for female urinary incontinence and pelvic organ prolapse.

This article originally appeared on Univadis, part of the Medscape Professional Network.  This transcript has been edited for clarity.

Both female urinary incontinence and pelvic organ prolapse are very common conditions and ones which have a high level of taboo attached to them, and they have a big impact on the quality of life for those who suffer them.

I am Dr Julian Spinks. I am a GP partner in Strood in Kent. I am also an adviser to the Association for Continence Advice. I sat on the guideline committee which developed the NICE guidelines for female urinary incontinence and pelvic organ prolapse.

Rising Concerns

Since the last NICE guidelines on female urinary incontinence in 2013, concerns have arisen about the possible complications of surgery for female urinary incontinence and pelvic organ prolapse, and as a result the organisation felt that the guidelines should be revisited and revised.

Urinary incontinence is very common in women and it gets worse as they get older, both in the number of people suffering from it, and the severity of the condition.

Likewise, pelvic organ prolapse is very common. In primary care in the UK, you are looking at about 8.4% of women with it, and when examined about 50% of women have pelvic organ prolapse present. One in 10 of those are going to need treatment with surgery and re-operation is very common at about 19%.

Aetiology

The aetiology of some urinary incontinence and pelvic organ prolapse is often associated with damage to the pelvic floor, particularly happening in women after childbirth.

Also, it can be due to problems like overactive bladder where the bladder becomes over sensitised, the muscle contracts more often, and then that leads to incontinence.

Urinary incontinence is defined by the International Continence Society as any complaint of involuntary leakage of urine.

There are several kinds of urinary incontinence, but three are the most common in women:

  • The first is stress urinary incontinence, which is leakage associated with activity such as sport, coughing, or sneezing

  • The second is urgency incontinence, which is loss of urine associated with, or just after, urgency, which is an intense desire to pass urine which is difficult to delay

  • The third type is mixed incontinence, where a woman has features of both previous types

OAB

Overactive bladder, or OAB, is a syndrome where there is a lot of urgency for the woman and this can be associated with urgency incontinence.

On top of that, there is frequency of micturition and nocturia.

It is split into two types. If the woman does have incontinence, it is known as OAB wet. If she doesn’t it is known as OAB dry.

The condition is associated with urodynamic findings such as detrusor over-activity but can be caused by other reasons.

Pelvic Organ Prolapse

Pelvic organ prolapse is defined as the descent of one or more pelvic structures including the anterior vaginal wall, the posterior vaginal wall, the cervix and uterus, or the vaginal vault.

It’s typically perceived by women as lumps or something coming down into the vagina. It can be associated with bladder and bowel problems.

Taboo

One of the challenges is that the taboo associated with urinary incontinence and prolapse means that women may not reveal to you that they have the problem.

So, it’s good to use opportunities, such as when you are doing other examinations, to ask them whether they have this problem. Also, you can use clues, like if they smell of urine, it may indicate they have a problem.

Also, when it goes onto treatment, a lot of women will have either unrealistic expectations that you will always be able to get them completely dry, or may actually have the opposite and think that urinary incontinence is a normal part of ageing, which it isn’t.

Leakage

Very often, women with urinary incontinence will come along complaining that they are leaking urine.

They may talk about having to go and buy pads to be able to go out and about. The leaking may be associated with activity in the case of stress incontinence.

And in other situations, they may feel like they just can’t get to the toilet quickly enough and therefore they leak, indicating urgency incontinence.

Lumps and Bulges

Pelvic organ prolapse typically presents with a woman who is worried that there is a lump or a bulge in the vagina or a dragging down sensation. They can also have urinary problems, bowel problems, and sometimes pain in the pelvis, in the back or even going down into the leg.

In urinary incontinence and pelvic organ prolapse the history is very important, because actually most of the subgroups of these diseases can be determined with a careful history.

So you will start by asking questions about perhaps the leakage, the amount they are having, when it is happening, how many times a day, what you are doing when the leakage happens.

Likewise, you might ask what causes the lump to come down in the vagina.

You need to do a background, looking at the previous medical history, asking about things like their obstetric history, whether they have had problems during childbirth or afterwards.

Likewise, any surgery, particularly pelvic surgery or cancer surgery is important.

Finally, you need to look at any other conditions they may have had in the past which may have a bearing on incontinence such as diabetes, or kidney disease, or other pelvic problems.

Examination

Examination is also important in urinary incontinence and pelvic organ prolapse.

It starts with an abdominal examination looking for organomegaly for masses and if the bladder is palpable above the pelvic brim.

Vaginal examination is also important, looking for masses, looking to see if there are things like vaginal atrophy.

And it’s an opportunity to ask the woman to see if they can contract their pelvic floor, as that will tell you if they can voluntarily do this.

Dipstick

It is recommended you do a urine dipstick looking for potential infection or for blood in the urine, and also if the woman complains of symptoms that suggest an infection, then a mid-stream urine should be sent off.

There isn’t a recommendation in the NICE guideline, but some practices may have a bladder scanner or an ultrasound machine, and you may want to do a residual urine to see if one of those is present.

Bladder Diary

There are some very useful tools. The most important of these is a bladder diary. This is done over 3 days by the woman and records the fluid intake that they take, the urine output, and also episodes of incontinence, when they happen and under what circumstances.

This is very helpful in distinguishing whether they have things like frequency, and whether the incontinence is associated with urgency or is a stress pattern associated with activity.

Making Assumptions

It is important that you do not assume that urinary incontinence or pelvic organ prolapse is entirely to do with pelvic problems.

Urinary incontinence, high output of urine for example associated with diabetes, can make the situation worse or precipitate it. Likewise, kidney function can make a difference as well.

Obesity can play a role in the formation of urinary incontinence, so actually looking at that situation is important.

Likewise women who cough a lot, and this may be associated with cigarette smoking, are more likely to have both incontinence and pelvic organ prolapse.

Identifying Type

So after your initial assessment of the woman, your history, your examinations and your basic investigations, the most useful thing is to characterise the type of incontinence the woman has.

So, you may find it is predominately stress urinary incontinence, or urgency incontinence.

In the case of mixed where both sets of symptoms are there, it is useful to pick the predominant symptom because that is the one you are going to treat first.

The first thing I would advise women would be to look at lifestyle changes, and that includes things like avoiding excessive caffeinated drinks, particularly in urgency incontinence, looking at whether they should either increase or decrease the amount of fluid they take because both of those can have an effect, and finally, if they have a body mass index over 30, advising them to lose weight may make a difference.

Next Steps

After that, it depends on the type of incontinence. If they have an urgency incontinence, then you may be giving them advice about bladder retraining, which is a behavioural approach, and there are leaflets available that can help guide people through this, although the result is better with supervised bladder retraining.

With stress urinary incontinence, the first line is pelvic floor muscle training, which needs to take place over 3 months.

This does need to be supervised by someone who knows what they are doing.

One exception is that there is no point in getting women to do pelvic floor muscle training if they cannot contract the pelvic floor, there a referral to someone who can either do physiotherapy or stimulation is important.

Medication

There is a role for drug therapy for women with urinary incontinence, particularly overactive bladder.

The mainstay group of medication for this are anticholinergics. There are a range of these, and the recommendation is that you prescribe the one with the lowest acquisition costs.

Unfortunately, anticholinergics are associated with a large number of side effects, particularly things like dry mouth, constipation, and indigestion.

Unfortunately, there may be problems in long-term use with cognitive decline, ie, things like dementia.

There is an alternative to anticholinergics for overactive bladder and urgency incontinence. This is mirabegron. The NICE guidance on this is that it should be used second line, really only in women who are either unable to use anticholinergics, or for whom anticholinergics have not worked.

Specialist Referral

Some women will require referral for specialist services. This may be because the treatments that you have tried so far have not worked, but also there are conditions which would be a red or yellow flag which means early referral is necessary.

This could be due to painful voiding, retention of urine, or a palpable bladder, urogenital fistulas, faecal incontinence associated with it, and any pelvic masses that you think are not cancerous.

Of course, cancer should result in a 2 week wait referral.

On top of that, people who have had previous surgery, either for urinary incontinence or for pelvic cancer, or if they’ve had pelvic radiation, these are unlikely to respond to treatment in primary care, so a referral to a specialist is needed.

It may be through a continence service, or if it is going direct to a hospital specialist, it could be a urogynaecologist, or a urologist, or a pelvic surgeon.

Finally, in some areas, they may be seen by a pelvic floor physiotherapist.

They are going to get a more detailed history taken and a careful examination. They may have some tests, one of which is urodynamics, which is recommended in some circumstances by the NICE guideline.

This is a way of actually seeing how the bladder performs and can detect things like overactive bladder and stress urinary incontinence to help guide the specialist.

They can also have things like residual urine and some more complex investigations in limited circumstances.

Secondary Care

The treatment a patient might expect in secondary care will depend somewhat on the type of incontinence or pelvic organ prolapse that they have.

With urgency incontinence, they may revisit bladder retraining, or anticholinergics, or other medications.

If that doesn’t work, then they may be offered Botulinum toxin A, which is injected into the bladder, and that actually reduces urgency incontinence.

If that doesn’t work, then there is also transcutaneous sacral nerve stimulation where an electrode is implanted into the spinal cord, which again reduces the unwanted contractions of the bladder.

Finally, in really very limited circumstances, they may have surgery to either augment the bladder or to divert the urinary tract, but this is pretty rare.

In the case of stress urinary incontinence, pelvic floor muscle training again may be tried. If this doesn’t work, then surgery may be offered to the woman, and this is a change in the new guideline in that there has been a move away from offering tapes and meshes first-line towards offering things like Burch colposuspension which don’t involve these tapes.

Summary

As we come to the end of this short film, I hope you’ve found out that you can manage pelvic organ prolapse and urinary incontinence in primary care with a history, examinations and basic investigations, and some medications that you can prescribe together with lifestyle advice.

Remember that women are at the centre of this, and working with them is very important because this is a chronic disease. So thank you very much for watching and goodbye.

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