New guidelines to improve the care and treatment for millions of women suffering from a hidden and distressing condition are launched today (25 October).
The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Women's and Children's Health have published a clinical guideline on the best way to manage urinary incontinence (UI) in women. The recommendations advise on the diagnosis of UI, effective treatments for women with this condition, as well as expected competencies of surgeons performing procedures.
Urinary incontinence affects an estimated 5 million women in England and Wales aged over 20, yet the condition is largely a taboo subject. Urinary incontinence affects women at different ages - it can occur in women after pregnancy as well as in later years, often having a major impact on their day-to-day lives. Many women are too embarrassed to seek help from their GP, and often are not aware that effective treatments are available. Urinary incontinence is the unintentional leakage of urine. Stress incontinence is the most common form of urinary incontinence, and is caused by physical exertion, such as sneezing or exercise. Urge incontinence is another form where the woman feels a strong need to urinate and cannot stop herself.
The key recommendations include:
- Diagnosis – a history should be taken from the woman to help categorise the type of incontinence.
- Treatments: Lifestyle changes such as changing how much you drink and losing weight if the woman is very overweight are recommended to help improve all types of urinary incontinence. For stress incontinence or mixed urinary incontinence, the guideline recommends at least 3 months of pelvic floor muscle training should be the first treatment offered to all women, and should also be offered as a preventative measure for women in their first pregnancy. In treating urge incontinence, at least 6 weeks of bladder training should be offered first. Surgical options are available for treating the different types of urinary incontinence. Drug treatments are also options for treating urge incontinence, but should not normally be offered to treat stress urinary incontinence.
- Training: Surgery for urinary incontinence should only be performed by surgeons who are trained in the management of urinary incontinence or who work in a multidisciplinary team with this training, and who regularly perform surgery for urinary incontinence in women.
Andrea Sutcliffe, Deputy Chief Executive at NICE and Executive Lead for the guideline, said: "Urinary incontinence is a distressing condition affecting the lives of millions of women. This guideline will help improve the care and treatment of women affected by advising them on which treatments should be offered first, as well as explaining what further treatments may be needed. The guideline includes clear advice for health care professionals on the appropriate assessment of urinary incontinence and the treatment options for the different types. We are also issuing advice to support the implementation of our recommendations to ensure all women affected can benefit from a high-quality service wherever they live."
Paul Hilton, Consultant Gynaecologist and Chair of the Guideline Development Group, said: "Incontinence is one of the last taboo subjects in healthcare, which patients have often been reluctant to discuss, and the medical profession slow to address. I am therefore delighted to see the publication of this guideline on managing urinary incontinence in women by NICE. The guideline sets standards for all health care professionals on the best ways of assessing and treating the condition, and should help to limit variations in standards and access to care.
"I see perhaps 1500 women per year with urinary incontinence, and many are concerned that nothing can be done to help them. This guideline clearly sets out what the treatment options are for the main types of urinary incontinence, so that women can have an informed discussion with their health professional about their condition."
Malcolm Lucas, Consultant Urologist, and Guideline Development Group member, said: "Whilst most women with urinary incontinence will be improved following simple treatments there will always be a small number who will require help from a specialist and this will sometimes mean surgery. We have looked at all the options available and provided guidance for surgeons on those which are most suitable. For the first time we have also provided recommendations on surgeon competencies so that women can be confident that they are in the best hands wherever they are seen."
Dr Julian Spinks, Guideline Development Group member and GP said: "The guideline will help GPs and other primary care health professionals to provide the best possible care for women with urinary incontinence. The clear step-by-step advice for health professionals and treatment algorithms provide guidance on managing this condition effectively. We hope that women with urinary incontinence symptoms will now feel more comfortable about seeking help from their GP."
Joanne Townsend, Guideline Development Group member and Urogynaecology Nurse Specialist, said: "The need for a consistent approach to diagnosing urinary incontinence, offering lifestyle advice and appropriate treatment is highlighted in the guidance. Urinary incontinence can be a sensitive and difficult condition for women to discuss, but there's no need for women with urinary incontinence to suffer in silence. There are a range of different treatment options, some of which require specific training support from nurses, physiotherapists and occupational therapists, so this guideline will help health professionals to provide the most effective care for women with this condition."
Lynda Evans, Trainer for the Expert Patients Programme and GDG patient representative, said: "I'm delighted that we now have national standards of care and treatment for women with urinary incontinence. Women with urinary incontinence will have clear and consistent information about which therapies are most effective in treating their condition, and health staff will be better informed when women seek their help. It's important that women are offered treatments that are appropriate to their individual circumstances, so this guideline should help patients and clinicians explore the available options."
For more information call Dr Tonya Gillis on 020 7067 5937 or email firstname.lastname@example.org.
Notes to Editors
1. NICE is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
2. NICE produces guidance in three areas of health:
- public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
- health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
- clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
About the guidance
3. The guidance is available at http://www.nice.org.uk/CG40 (from 25 October)
4. Urinary incontinence affects an estimated 5 million women in England and Wales aged over 20. In women over 40 years old, around 1 in 3 is affected by this often distressing and demoralising condition.
5. UI is the unintentional leakage of urine. It may occur with physical exertion, for example sneezing or exercise (stress incontinence) or the where the woman feels a strong need to urinate and can't stop (urge incontinence). Overactive bladder is another type of UI where bladder muscles contract before the bladder is full. Mixed UI describes a person experiencing more than one type of UI
6. Some key guideline recommendations are:
- Diagnosis – a history should be taken from the woman to help categorise the type of incontinence. After checking for infections or any other conditions that may have caused the incontinence, the guideline recommends that women be asked to keep a 'bladder diary' for at least 3 days to help in assessing the condition.
- Treatments: Lifestyle changes such as adjusting fluid intake and losing weight if the woman is very overweight are recommended to help improve all types of urinary incontinence.
In treating stress incontinence or mixed UI, the guideline recommends at least 3 months of pelvic floor muscle training (PFMT) as a standard first line treatment for all women to train and strengthen the muscles that support the bladder and the urethra. Pelvic floor muscle training is also recommended as a preventative measure for women in the first pregnancy. Drug treatments should not normally be offered to treat stress UI.
Surgical options for stress UI include the insertion of a strip of tape or body tissue to support the urethra to help stop urine leaking out, a procedure to support the bladder, or the injection of a bulking agent in to the sides of the urethra to help stop urine leaking.
In treating urge incontinence the guideline recommends cutting down intake of caffeine, for example from coffee, tea or cola, along with at least 6 weeks of bladder training as a first line therapy to help increase the time between the urge to urinate and then passing urine. Oxybutynin should be offered if bladder training fails, but with counselling on the side effects of this type of drug. Botulinum Toxin A (commonly known as botox) is a relatively new treatment, and although further research is required, it may have a role in managing urge incontinence before surgical treatments are considered. Surgical options include sacral nerve stimulation, and urinary diversion, but urodynamic tests should be performed before surgery is carried out.
- Training: Surgery for UI should only be performed by surgeons who are trained in the management of UI or who work in a multidisciplinary team with this training, and who regularly perform surgery for UI in women
- The guidance states that absorbent products and toileting aids are not treatments, and recommends that they should only be used to cope whilst awaiting treatment, as an adjunct to ongoing therapy or for long-term management of UI if treatment has failed.
Dr Tonya Gillis
National Institute for Health and Clinical Excellence (NICE)
71 High Holborn
London WC1V 6NA
Tel: 020 7067 5937
Main switchboard : 020 7067 5800
The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.