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2625 pages added, reviewed or updated during the last month (last updated: 15/4/2021)


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conservative management of urinary incontinence/overactive bladder (OAB)/stress incontinence in women

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Conservative management

  • lifestyle interventions (1)
    • trial of caffeine reduction is recommended for the treatment of women with overactive bladder syndrome (OAB)
    • consider advising modification of high or low fluid intake in women with urine incontinence (UI) or OAB
    • if body mass index greater than 30 then should be advised to lose weight

  • physical therapies
    • trial of supervised pelvic floor muscle training of at least 3 months' duration - this should be offered as first-line treatment to women with stress or mixed UI
    • pelvic floor exercises may be effective in up to 50% of cases providing there is no serious degree of uterine prolapse (2)
      • critical factor is usually the woman's motivation to do the exercises

  • behavioural therapies
    • bladder training lasting for a minimum of 6 weeks should be offered as first-line treatment to women with urge or mixed UI
      • if women do not achieve satisfactory benefit from bladder training programmes, the combination of an antimuscarinic agent with bladder training should be considered if frequency is a troublesome symptom
    • in women with UI who also have cognitive impairment, prompted and timed voiding toileting programmes are recommended as strategies for reducing leakage episodes

  • drug therapies
    • choosing OAB drugs
      • do not use flavoxate, propantheline and imipramine for the treatment of UI or OAB in women
      • do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health

        • one of the following choices should be offered first to women with OAB or mixed UI:
          • oxybutynin (immediate release), or
          • tolterodine (immediate release), or
          • darifenacin (once daily preparation)
        • if the first treatment for OAB or mixed UI is not effective or well-tolerated, offer another drug with the lowest acquisition cost

      • offer a transdermal OAB drug to women unable to tolerate oral medication

      • Mirabegron is recommended as an option for treating symptoms of overactive bladder
        • only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects (1)
    • Reviewing OAB drug treatment
      • offer a face-to-face or telephone review 4 weeks after the start of each new OAB drug treatment. Ask the woman if she is satisfied with the therapy:
        • If improvement is optimal, continue treatment
        • If there is no or suboptimal improvement or intolerable adverse effects change the dose, or try an alternative OAB drug, and review again 4 weeks later
      • offer review before 4 weeks if the adverse events of OAB drug treatment are intolerable
      • offer referral to secondary care if the woman does not want to try another drug, but would like to consider further treatment
      • offer a further face-to-face or telephone review if a woman's condition stops responding optimally to treatment after an initial successful 4-week review
      • review women who remain on long-term drug treatment for UI or OAB annually in primary care (or every 6 months for women over 75)
      • offer referral to secondary care if OAB drug treatment is not successful
      • if the woman wishes to discuss the options for further management (non-therapeutic interventions and invasive therapy) refer to the MDT and arrange urodynamic investigation to determine whether detrusor overactivity is present and responsible for her OAB symptoms:
        • if detrusor overactivity is present and responsible for the OAB symptoms offer invasive therapy
        • if detrusor overactivity is present but the woman does not wish to have invasive therapy, offer advice as described in recommendation
        • if detrusor overactivity is not present refer back to the MDT for further discussion concerning future management

    • Desmopressin
      • the use of desmopressin may be considered specifically to reduce nocturia in women with UI or OAB who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension (1)

    • Duloxetine
      • do not use duloxetine as a first-line treatment for women with predominant stress UI. Do not routinely offer duloxetine as a second-line treatment for women with stress UI, although it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects
      • there is evidence that duloxetine is effective and safe in controlling the symptoms of female stress urinary incontinence, independent of the severity of incontinence (3)

    • hormone replacement therapy (3)
      • systemic hormone replacement therapy is not recommended for the treatment of UI
      • intravaginal oestrogens are recommended for the treatment of OAB symptoms in postmenopausal women with vaginal atrophy

Notes:

  • further treatment options
    • for women with OAB that has not responded to non-surgical management or treatment with medicine and who wish to discuss further treatment options:
      • urodynamic investigation should be offered to determine whether detrusor overactivity (involuntary bladder contractions seen during a cystometry test; they can be the cause of overactive bladder symptoms) is causing her OAB symptoms
      • and if detrusor overactivity is causing her OAB symptoms, an invasive procedure should be offered for management of symptoms
      • or if there is no detrusor overactivity, seek advice on further management from the local MDT

Reference:

  1. NICE (April 2019). Urinary incontinence - The management of urinary incontinence in women
  2. Drug and Therapeutics Bulletin (2003); 41 (6): 46-8.
  3. Cardozo L. New developments in the management of stress urinary incontinence L. BJU Int 2004; 94 (s1):1-3.

Last edited 05/2019 and last reviewed 05/2019

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