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Urinary Incontinence and Pelvic Organ Prolapse in Women (Part 1) (NICE NG…
Urinary Incontinence and Pelvic Organ Prolapse in Women (Part 1)
(NICE NG 123 - Apr 2019)
Assessment
Categorise urinary incontinence and start initial treatment based on this
:
Stress urinary incontinence (SUI)
: Involuntary urine leakage on effort, exertion, sneezing, or coughing.
Mixed urinary incontinence (MUI)
: Involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing. Direct treatment towards predominant symptom.
Urgency urinary incontinence/overactive bladder (OAB)
: Involuntary urine leakage accompanied or immediately preceded by urgency. OAB is urgency that occurs with or without urgency urinary incontinence and usually with frequency and nocturia.
Identify predisposing and precipitating
risk factors
Pelvic floor muscles
: Undertake routine digital assessment to confirm pelvic floor muscle contraction before use of supervised pelvic floor muscle training
Symptom scoring and QOL assessment
: Use a validated urinary incontinence-specific symptom and QOL questionnaire when therapies are being evaluated
Invasive Procedures for OAB
Neurostimulation
DO NOT
offer transcutaneous sacral nerve stimulation (known as transcutaneous electrical nerve stimulation - TENS) or transcutaneous posterior tibial nerve stimulation for OAB
DO NOT offer percutaneous posterior tibial nerve stimulation for OAB unless all of the following
:
Local MDT review
Non-surgical management including OAB medication not worked adequately
Patient declines percutaneous sacral nerve stimulation or botulinum toxin type A (Botox)
Offer urodynamic testing to determine whether detrusor over-activity is causing OAB symptoms
:
1. If detrusor over-activity
: Offer Botox or urinary diversion
2. If there is no detrusor overactivity
: Advise local MDT and consider treatment with Botox
Botulinum toxin type A (Botox)
OFFER to women with OAB caused by detrusor overactivity
that has not responded to non-surgical management
CONSIDER in women with symptoms of OAB but urodynamic testing has not demonstrated detrusor overactivity
, if symptoms have not responded to non-surgical management and the woman does not wish to have other invasive treatments
Start treatment only if the patient is willing, in the event of developing significant voiding dysfunction:
To perform clean intermittent catheterisation on a regular basis for as long as required
To accept a temporary indwelling catheter if unable to perform clean intermittent catheterisation
Initial dose
: 100 units
Offer review within 12 weeks of first treatment
If good response: Advise to self-refer if symptoms return and offer repeat treatment as necessary
If inadequate response: Consider increasing subsequent doses of Botox to 200 units and review within 12 weeks
If adequate response but effect lasts <6 months: Consider increasing subsequent doses of Botox to 200 units and review within 12 weeks
If no response: Discuss with local MDT
Percutaneous sacral nerve stimulation
Offer to women after MDT if OAB has not responded to non-surgical management:
Symptoms have not responded to Botox
OR
Not prepared to accept risks of needing catheterisation associated with Botox
Urinary diversion
: Consider for women with OAB only when non-surgical management has failed, and Botox, percutaneous sacral nerve stimulation, and augmentation cystoplasty are not appropriate or unacceptable. Provide life-long follow-up.
Augmentation cystoplasty
Restrict for the management of idiopathic detrusor overactivity in women who have not responded to non-surgical management and who are willing and able to self-catheterise.
Adverse effects: Bowel disturbance, metabolic acidosis, mucous production and/or retention in the bladder, UTI, urinary retention, malignancy
Provide life-long follow-up
If stress incontinence is the predominant symptom:
Discuss benefit of non-surgical management and medication for overactive bladder before offering surgery
Investigations
Urine testing
Perform a urine dipstick in all women
to look for blood, glucose, protein, leucocytes, and nitrites in urine
Symptoms of UTI and urine positive for both leucocytes and nitrites
: Send urine MC&S and prescribe antibiotics pending culture results
Symptoms of UTI and urine negative for either leucocytes and nitrites
: Send urine MC&S and consider antibiotics pending culture results
No symptoms of UTI but urine positive for both leucocytes and nitrites
: Send MC&S but do not offer antibiotics without culture results
No symptoms of UTI and urine negative for either leucocytes or nitrites
: Do not send MC&S as unlikely to be UTI
Residual urine: Measure post-void residual volume by bladder scan
(preferably) or catheterisation in women with symptoms suggestive of voiding dysfunction or recurrent UTI
Bladder diaries
: Recommended in the initial assessment of women with urinary incontinence or overactive bladder. Encourage to complete a minimum of 3 days covering variations in usual activities.
Urodynamic testing
DO NOT perform
before primary surgery if
SUI or stress-predominant MUI is diagnosed
based on history and demonstrated SUI at examination
Perform before surgery for SUI in women with any of the following
:
Urge-predominant MUI or urinary incontinence in which type is unclear
Symptoms suggestive of voiding dysfunction
Anterior or apical prolapse
Previous surgery for SUI
Tests of urethral competence
:
DO NOT
use the Q-tip, Bonney, Marshall, or Fluid-Bridge tests
Cystoscopy
:
DO NOT
use cystoscopy in initial assessment of women with urinary incontinence alone
Imaging
:
DO NOT
use for routine assessment.
DO NOT use ultrasound
other than to
assess residual urine volume
.
Non-Surgical Management
1. Lifestyle interventions
Advise caffeine reduction
(OAB)
Modification of fluid intake
(UI/OAB)
Weight loss if BMI >30
(UI/OAB)
2. Pelvic floor muscle training
.
First-line treatment for SUI/MUI
: Offer a trial of supervised pelvic floor muscle training for
at least 3 months duration
Pelvic floor muscle training programmes should comprise
at least 8 contractions performed 3 times a day
Continue an exercise programme
if pelvic floor muscle training is beneficial
DO NOT
use perineometry or pelvic floor electromyography as biofeedback as a routine part of 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 urinary incontinence
Electrical stimulation
Consider in women who
cannot actively contract their pelvic floor muscles
to aid motivation and adherence to therapy
DO NOT
routinely use in treatment of OAB or in combination with pelvic floor muscle training
2. Behavioural therapies
First-line treatment for OAB/MUI
: Offer bladder training for
at least 6 weeks
If no benefit,
combination of an OAB medication with bladder training
should be considered if
frequency
is a troublesome symptom
Absorbent containment products
Offer as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy, or for long-term management only after treatment options have been explored
Offer review at least once a year
to women using these products for long-term management of urinary incontinence
Catheters
Can be
intermittent, indwelling urethral, or suprapubic
Consider for women in whom
persistent urinary retention
is causing incontinence, symptomatic infections, or renal dysfunction
Indwelling suprapubic catheters
: Associated with lower rates of symptomatic UTI, "bypassing", and urethral complications compared to urethral catheters
Offer intermittent urethral catheterisation
: Women with urinary retention who can be taught to self-catheterise
Indications for long-term indwelling urethral catheters
Chronic urinary retention in women unable to manage intermittent self-catheterisation
Skin wounds, pressure ulcers, irritations being contaminated by urine
Distress or disruption caused by bed and clothing changes
Patient preference
Explain that use of
indwelling catheters in OAB
may not result in continence
Drug therapy for OAB
Adverse effects of anticholinergics
: Dry mouth, dry eyes, constipation
Explain that substantial benefits may not be noticeable for
at least 4 weeks
and that symptoms may continue to improve over time
Offer the anticholinergic medicine
with the lowest acquisition cost to treat MUI or OAB
DO NOT
offer the following therapies:
Flavoxate, propantheline or imipramine to treat UI or OAB
Systemic hormone replacement therapy to treat UI
Oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health
Offer intravaginal oestrogens
to treat OAB symptoms in postmenopausal women with vaginal atrophy
Desmopressin
May be considered specifically to reduce nocturia in women with UI or OAB
Caution in women with cystic fibrosis and avoid in women >65 with cardiovascular disease or hypertension
Offer a
transdermal OAB treatment
to women unable to tolerate oral medicines
Reviewing medication
Review 4 weeks after starting a new medication
Review women who remain on long-term medication for OAB or UI every 12 months, or every 6 months if >75 years
Drug therapy for SUI
Duloxetine
DO NOT
use as first-line treatment for women with predominant SUI
Offer as second-line treatment if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment
Surgical Management of SUI
2. Colposuspension (open or laparoscopic)
: Lifting up of tissue around neck of the bladder, and suspending it using synthetic stitches
3. Autologous rectus fascial sling
: Sling is made using body tissue from the abdomen, and placed behind the urethra to support it
1. Retropubic mid-urethral mesh sling
Permanent implant
and complete removal may not be possible
Use a device manufactured from
type I macroporous polypropylene mesh
Consider using a sling
coloured
for high visibility for ease of insertion and revision
DO NOT
offer a transobturator approach unless there are specific clinical circumstances in which the retropubic approach should be avoided, or use the top-down retropubic mid-urethral mesh sling approach or single-incision sub-urethral short mesh sling insertion except as part of a clinical trial.
Involves placing a strip of synthetic mesh behind the urethra to support it in a sling
4. Intramural bulking agents
to the urethra
Procedures that should NOT be offered
:
Anterior colporrhaphy
Needle suspension
Paravaginal defect repair
Porcine dermis sling
Marshall-Marchetti-Krantz procedure
Artificial urinary sphincters
Follow-up
: Offer follow-up
within 6 months
. Include a
vaginal examination
to check for exposure or extrusion of the mesh sling if appropriate.
Possible complications
: Urinary retention, urgency or incontinence, infection, abdo/pelvic pain, pelvic organ prolapse, painful intercourse, mesh related (exposure, discharge, bleeding, painful sex, recurrent infections, altered sensation)
Indications for Referral to Specialist Service
Persistent bladder or urethral pain
Palpable bladder after voiding
Clinically benign pelvic masses
Associated faecal incontinence
Suspected neurological disease
Symptoms of voiding difficulty
Suspected urogenital fistulae
Previous continence surgery
Previous pelvic cancer surgery
Previous pelvic radiation therapy
Haematuria or recurrent/persistent unexplained UTI