Nice | Urinary incontinence in women

This new guideline on urinary incontinence in women updates advice on which medications to use.

Drugs used in managing incontinence

Oxybutynin (immediate release - IR), Tolterodine IR and Darifenacin (once daily) should be used first-line.

When trying a new medication, warn the patient that it can take 4/52 to be effective. Pick the lowest cost alternative to try next. If oral drugs can't be tolerated, patches can be tried. They advise to avoid Oxybutynin IR in frail elderly women.

Alternatives to try are desmopressin for nocturia, duloxetine in women with stress incontinence who wish to avoid surgery and topical vaginal oestrogen in postmenopausal women with vaginal atrophy.

For a quick revision of NICE guidance how to manage urinary incontinence more generally, read on...

History

Classify the problem as 'Stress Incontinence (SUI)', 'Urge Incontinence ', 'Mixed Incontinence' or Overactive Bladder (OAB).

Examination

  • Dipstix
  • Vaginal examination to assess for pelvic tone and for prolapse (which is considered significant if it is to the level of the introitus or beyond - though local consultants have advised that they do not want patients referring if they are not symptomatic of prolapse)

Further assessment

  • Bladder Diary - ask the lady to do a bladder diary for 3d (available from PIP)
  • Bladder Scan - if she has symptoms of incomplete voiding, or if there is recurrent UTI

Red flags

  • Microscopic haematuria - if over 50
  • Visible haematuria - at any age
  • Recurrent or persistent UTI with haematuria - if over 40
  • Suspected Malignant Mass

Lifestyle measures to advise

  • Caffeine - reduce consumption in OAB (the incontinence teams advise to avoid citrus and blackcurrent juice too)
  • Fluid intake - ensure this is not too much, nor too little (concentrated urine will irritate the bladder and cause symptoms).
  • BMI - if the BMI is over 30, advise weight loss

First-line management

Generally drugs are used second-line, but can be used alongside first-line measures if wanted. The local continence services in Southampton andPortsmouth can supervise the below

  • Sress Incontinence - Supervised Pelvic Floor Exercises - At least 8 contractions, 3 times a day for at least 3/12.
  • Urge Incontinence or OAB - Bladder Retraining for at least 6/52

Secondary care management

There are all sorts options for secondary care management, including Transvaginal Tapes for SUI, botulinum A for OAB and nerve stimulation for OAB.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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