Management of Urinary incontinence and pelvic organ prolapse in women: 2019 NICE Guidelines
National Institute for Health and Care Excellence (NICE) has released 2019 Guideline on management of Urinary incontinence and pelvic organ prolapse in women.
Following are the major recommendations:
1. Non-surgical management of urinary incontinence
Lifestyle interventions
- Recommend a trial of caffeine reduction to women with overactive bladder. [2006]
- Consider advising women with urinary incontinence or overactive bladder and a high or low fluid intake to modify their fluid intake. [2006]
- Advise women with urinary incontinence or overactive bladder who have a BMI greater than 30 to lose weight. [2006]
Physical therapies
Pelvic floor muscle training
- Offer a trial of supervised pelvic floor muscle training of at least 3 months' duration as first-line treatment to women with stress or mixed urinary incontinence. [2019]
- Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day. [2006]
- Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training. [2006]
- Continue an exercise programme if pelvic floor muscle training is beneficial. [2006]
Electrical stimulation
- Do not routinely use electrical stimulation in the treatment of women with overactive bladder. [2006]
- Do not routinely use electrical stimulation in combination with pelvic floor muscle training. [2006]
- Electrical stimulation and/or biofeedback should be considered for women who cannot actively contract pelvic floor muscles to aid motivation and adherence to therapy. [2006]
Behavioral therapies
- Offer bladder training lasting for a minimum of 6 weeks as first-line treatment to women with urgency or mixed urinary incontinence. [2006]
- If women do not achieve satisfactory benefit from bladder training programmes, the combination of an overactive bladder medicine with bladder training should be considered if frequency is a troublesome symptom. [2006]
Neurostimulation
- Do not offer transcutaneous sacral nerve stimulation (surface electrodes placed above the sacrum, often known as transcutaneous electrical nerve stimulation [TENS]) to treat overactive bladder in women. [2013]
- Do not offer transcutaneous posterior tibial nerve stimulation for overactive bladder. [2013]
- Do not offer percutaneous posterior tibial nerve stimulation (needles inserted close to the posterior tibial nerve) for overactive bladder unless:
- there has been a local MDT review and
- non-surgical management including overactive bladder medicine treatment has not worked adequately and
- the woman does not want botulinum toxin type A or percutaneous sacral nerve stimulation. [2013, amended 2019]
Absorbent containment products, urinals and toileting aids
- Do not offer absorbent containment products, hand-held urinals or toileting aids to treat urinary incontinence. Offer them only:
- as a coping strategy pending definitive treatment
- as an adjunct to ongoing therapy
- for long-term management of urinary incontinence only after treatment options have been explored. [2019]
- Offer a review at least once a year to women who are using absorbent containment products for long-term management of urinary incontinence. The review should cover:
- routine assessment of continence
- assessment of skin integrity
- changes to symptoms, comorbidities, lifestyle, mobility, medication, BMI, and social and environmental factors
- the suitability of alternative treatment options
- the efficacy of the absorbent containment product the woman is currently using and the quantities used. [2019]
- Reviews for women who are using absorbent containment products for long-term management of urinary incontinence should be carried out by either:
- a registered healthcare professional who is trained in assessing continence and making referrals to specialist services or
- a non-registered healthcare worker, under the supervision of a registered healthcare professional who is trained in assessing continence and making referrals to specialist services.See indications for referral to a specialist service in this guideline. [2019]
Catheters
- Bladder catheterisation (intermittent or indwelling urethral or suprapubic) should be considered for women in whom persistent urinary retention is causing incontinence, symptomatic infections or renal dysfunction, and in whom this cannot otherwise be corrected. Healthcare professionals should be aware, and explain to women, that the use of indwelling catheters in urgency urinary incontinence may not result in continence. [2006]
- Offer intermittent urethral catheterisation to women with urinary retention who can be taught to self-catheterise or who have a carer who can perform the technique. [2006]
- Give careful consideration to the impact of long-term indwelling urethral catheterisation. Discuss the practicalities, benefits and risks with the woman or, if appropriate, her carer. Indications for the use of long-term indwelling urethral catheters for women with urinary incontinence include:
- chronic urinary retention in women who are unable to manage intermittent self-catheterisation
- skin wounds, pressure ulcers or irritations that are being contaminated by urine
- distress or disruption caused by bed and clothing changes
- where a woman expresses a preference for this form of management. [2006]
- Indwelling suprapubic catheters should be considered as an alternative to long-term urethral catheters. Be aware, and explain to women, that they may be associated with lower rates of symptomatic UTI, 'bypassing', and urethral complications than indwelling urethral catheters. [2006]
Products to prevent leakage
- Do not use intravaginal and intraurethral devices for the routine management of urinary incontinence in women. Do not advise women to consider such devices other than for occasional use when necessary to prevent leakage, for example during physical exercise. [2006]
Complementary therapies
- Do not recommend complementary therapies for the treatment of urinary incontinence or overactive bladder. [2006]
Choosing Medicines for overactive bladder
- Do not offer women flavoxate, propantheline or imipramine to treat urinary incontinence or overactive bladder. [2013]
- 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. [2013, amended 2019]
- Offer the anticholinergic medicine with the lowest acquisition cost to treat overactive bladder or mixed urinary incontinence in women. [2019]
- If the first medicine for overactive bladder or mixed urinary incontinence is not effective or well-tolerated, offer another medicine with a low acquisition cost. [2013]
- Offer a transdermal overactive bladder treatment to women unable to tolerate oral medicines. [2013]
- For guidance on mirabegron, see the NICE technology appraisal guidance on mirabegron for treating symptoms of overactive bladder. [2013]
- The use of desmopressin may be considered specifically to reduce nocturia in women with urinary incontinence or overactive bladder 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. [2013]
- Do not use duloxetine as a first-line treatment for women with predominant stress urinary incontinence. Do not routinely offer duloxetine as a second-line treatment for women with stress urinary incontinence, 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. [2006]
- Do not offer systemic hormone replacement therapy to treat urinary incontinence. [2006]
- Offer intravaginal oestrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy. [2006]
Invasive procedures for overactive bladder
- For women with overactive bladder that has not responded to non-surgical management or treatment with medicine and who wish to discuss further treatment options:
- offer urodynamic investigation to determine whether detrusor overactivity is causing her overactive bladder symptoms and
- if detrusor overactivity is causing her overactive bladder symptoms, offer an invasive procedure in line with recommendations 1.4.44 to 1.4.56 or
- if there is no detrusor overactivity, seek advice on further management from the local MDT in line with recommendation 1.4.45. [2013, amended 2019]
Botulinum toxin type A injection
- After a local MDT review, offer bladder wall injection with botulinum toxin type A to women with overactive bladder caused by detrusor overactivity that has not responded to non-surgical management, including pharmacological treatments. [2019]
- Consider treatment with botulinum toxin type A after a local MDT review for women with symptoms of overactive bladder in whom urodynamic investigation has not demonstrated detrusor overactivity, if the symptoms have not responded to non-surgical management and the woman does not wish to have other invasive treatments. [2019]
- After a local MDT review, discuss the benefits and risks of treatment with botulinum toxin type A with the woman and explain:
- the likelihood of complete or partial symptom relief
- the process of clean intermittent catheterisation, the risks, and how long it might need to be continued
- the risk of adverse effects, including an increased risk of urinary tract infection
- that there is not much evidence about how long the injections work for, how well they work in the long term and their long-term risks. [2019]
- Start treatment with botulinum toxin type A only if the woman is willing, in the event of developing significant voiding dysfunction:
- to perform clean intermittent catheterisation on a regular basis for as long as needed or
- to accept a temporary indwelling catheter if she is unable to perform clean intermittent catheterisation. [2013, amended 2019]
- Use 100 units as the initial dose of botulinum toxin type A to treat overactive bladder in women. [2019]
- Offer a face-to-face or telephone review within 12 weeks of the first treatment with botulinum toxin type A to assess the response to treatment and adverse effects, and:
- if there is good symptom relief, tell the woman how to self-refer for prompt specialist review if symptoms return, and offer repeat treatment as necessary
- if there is inadequate symptom relief, consider increasing subsequent doses of botulinum toxin type A to 200 units and review within 12 weeks
- if there was no effect, discuss with the local MDT. [2019]
- If symptom relief has been adequate after injection of 100 units of botulinum toxin type A but has lasted for less than 6 months, consider increasing subsequent doses of botulinum toxin type A to 200 units and review within 12 weeks. [2019]
- Do not offer botulinum toxin type B to women with overactive bladder. [2019]
Percutaneous sacral nerve stimulation
- Offer percutaneous sacral nerve stimulation to women after local or regional MDT review if their overactive bladder has not responded to non-surgical management including medicines and:
- their symptoms have not responded to botulinum toxin type A or
- they are not prepared to accept the risks of needing catheterisation associated with botulinum toxin type A. [2013, amended 2019]
- Discuss the long-term implications of percutaneous sacral nerve stimulation with women including:
- the need for test stimulation and the probability of the test's success
- the risk of failure
- the long-term commitment
- the need for surgical revision
- the adverse effects. [2013]
- Tell women how to self-refer for prompt specialist review if symptoms return following a percutaneous sacral nerve stimulation procedure. [2013]
Augmentation cystoplasty
- Restrict augmentation cystoplasty for the management of idiopathic detrusor overactivity to women whose condition has not responded to non-surgical management and who are willing and able to self-catheterise. Preoperative counselling for the woman or her carer should include common and serious complications: bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder, UTI and urinary retention. Discuss the small risk of malignancy occurring in the augmented bladder. Provide life-long follow‑up. [2006, amended 2013]
Urinary diversion
- Urinary diversion should be considered for a woman with overactive bladder only when non-surgical management has failed, and if botulinum toxin type A[2], percutaneous sacral nerve stimulation and augmentation cystoplasty are not appropriate or are unacceptable to her. Provide life-long follow‑up. [2006, amended 2013]
2. Surgical management of stress urinary incontinence
There is public concern about the use of mesh procedures. For all of the procedures recommended in this section, including mesh procedures, there is evidence of benefit but limited evidence on the long-term adverse effects. In particular, the true prevalence of long-term complications is unknown.
- If a woman is thinking about a surgical procedure for stress urinary incontinence, use the NICE patient decision aid on surgery for stress urinary incontinence to promote informed preference and shared decision making. Discussion with the woman should include:
- the benefits and risks of all surgical treatment options for stress urinary incontinence that NICE recommends, whether or not they are available locally
- the uncertainties about the long-term adverse effects for all procedures, particularly those involving the implantation of mesh materials
- differences between procedures in the type of anaesthesia, expected length of hospital stay, surgical incisions and expected recovery period
- any social or psychological factors that may affect the woman's decision. [2013, amended 2019]
- If non-surgical management for stress urinary incontinence has failed, and the woman wishes to think about a surgical procedure, offer her the choice of:
- colposuspension (open or laparoscopic) or
- an autologous rectus fascial sling.Also include the option of a retropubic mid-urethral mesh sling in this choice but see recommendations 1.5.7 to 1.5.11 for additional guidance on the use of mid-urethral mesh sling procedures for stress urinary incontinence. [2019]
- Consider intramural bulking agents to manage stress urinary incontinence if alternative surgical procedures are not suitable for or acceptable to the woman. Explain to the woman that:
- these are permanent injectable materials
- repeat injections may be needed to achieve effectiveness
- limited evidence suggests that they are less effective than the surgical procedures listed in recommendation 1.5.2 and the effects wear off over time
- there is limited evidence on long-term effectiveness and adverse events. [2019]
- If an intramural bulking agent is injected, give the woman written information about the bulking agent, including its name, manufacturer, date of injection, and the injecting surgeon's name and contact details. [2019]
- If the woman's chosen procedure for stress urinary incontinence is not available from the consulting surgeon, refer her to an alternative surgeon. [2019]
- Providers must ensure that data on surgical procedures for stress urinary incontinence are recorded in a national registry, as outlined in the section on collecting data on surgery and surgical complications in this guideline. [2019]
Mid-urethral mesh sling procedures
- When offering a retropubic mid-urethral mesh sling, advise the woman that it is a permanent implant and complete removal might not be possible. [2019]
- If a retropubic mid-urethral mesh sling is inserted, give the woman written information about the implant, including its name, manufacturer, date of insertion, and the implanting surgeon's name and contact details. [2019]
- When planning a retropubic mid-urethral mesh sling procedure, surgeons should:
- use a device manufactured from type 1 macroporous polypropylene mesh
- consider using a retropubic mid-urethral mesh sling coloured for high visibility, for ease of insertion and revision. [2013, amended 2019]
- Do not offer a transobturator approach unless there are specific clinical circumstances (for example, previous pelvic procedures) in which the retropubic approach should be avoided. [2019]
- Do not 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. [2019]
Artificial urinary sphincters
- Do not offer women an artificial urinary sphincter to manage stress urinary incontinence unless previous surgery has failed. [2006, amended 2019]
- For women who have had an artificial urinary sphincter inserted:
- offer postoperative follow‑up and
- ensure access to review if needed. [2006, amended 2019]
3.Non-surgical management of pelvic organ prolapse
- Discuss management options with women who have pelvic organ prolapse, including no treatment, non-surgical treatment and surgical options, taking into account:
- the woman's preferences
- site of prolapse
- lifestyle factors
- comorbidities, including cognitive or physical impairments
- age
- desire for childbearing
- previous abdominal or pelvic floor surgery
- benefits and risks of individual procedures. [2019]
Lifestyle modification
- Consider giving advice on lifestyle to women with pelvic organ prolapse, including information on:
- losing weight, if the woman has a BMI greater than 30 kg/m2
- minimising heavy lifting
- preventing or treating constipation. [2019]
Topical oestrogen
- Consider vaginal oestrogen for women with pelvic organ prolapse and signs of vaginal atrophy. For recommendations on managing urogenital atrophy, see managing short-term menopausal symptoms in the NICE guideline on menopause. [2019]
- Consider an oestrogen-releasing ring for women with pelvic organ prolapse and signs of vaginal atrophy who have cognitive or physical impairments that might make vaginal oestrogen pessaries or creams difficult to use. [2019]
Pelvic floor muscle training
- Consider a programme of supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP‑Q (Pelvic Organ Prolapse Quantification) stage 1 or stage 2 pelvic organ prolapse. If the programme is beneficial, advise women to continue pelvic floor muscle training afterwards. [2019]
Pessaries
- Consider a vaginal pessary for women with symptomatic pelvic organ prolapse, alone or in conjunction with supervised pelvic floor muscle training. [2019]
- Refer women who have chosen a pessary to a urogynaecology service if pessary care is not available locally. [2019]
- Before starting pessary treatment:
- consider treating vaginal atrophy with topical oestrogen
- explain that more than 1 pessary fitting may be needed to find a suitable pessary
- discuss the effect of different types of pessary on sexual intercourse
- describe complications including vaginal discharge, bleeding, difficulty removing pessary and pessary expulsion
- explain that the pessary should be removed at least once every 6 months to prevent serious pessary complications. [2019]
- Offer women using pessaries an appointment in a pessary clinic every 6 months if they are at risk of complications, for example because of a physical or cognitive impairment that might make it difficult for them to manage their ongoing pessary care. [2019]
4.Surgical management of pelvic organ prolapse
There is public concern about the use of mesh procedures. For all of the procedures recommended in this section, including mesh procedures, there is some evidence of benefit, but limited evidence on long-term effectiveness and adverse effects. In particular, the true prevalence of long-term complications is unknown.
- Offer surgery for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment. [2019]
- If a woman is thinking about a surgical procedure for pelvic organ prolapse, use a decision aid (use the NICE patient decision aids on surgery for uterine prolapse and surgery for vaginal vault prolapse where they apply) to promote informed preference and shared decision making. Discussion with the woman should include:
- the different treatment options for pelvic organ prolapse, including no treatment or continued non-surgical management
- the benefits and risks of each surgical procedure, including changes in urinary, bowel and sexual function
- the risk of recurrent prolapse
- the uncertainties about the long-term adverse effects for all procedures, particularly those involving the implantation of mesh materials
- differences between procedures in the type of anaesthesia, expected length of hospital stay, surgical incisions and expected recovery period
- the role of intraoperative prolapse assessment in deciding the most appropriate surgical procedure. [2019]
- Do not offer surgery to prevent incontinence in women having surgery for prolapse who do not have incontinence. [2019]
- Explain to women considering surgery for anterior or apical prolapse who do not have incontinence that there is a risk of developing postoperative urinary incontinence and further treatment may be needed. [2019]
- If the woman's chosen procedure for pelvic organ prolapse is not available from the consulting surgeon, refer her to an alternative surgeon. [2019]
- If mesh is to be used in prolapse surgery:
- explain to the woman about the type of mesh that will be used and whether or not it is permanent
- ensure that details of the procedure and its subsequent short- and long-term outcomes are recorded in a national registry (see collecting data on surgery and surgical complications in this guideline)
- give the woman written information about the implant, including its name, manufacturer, date of insertion, and the implanting surgeon's name and contact details. [2019]
- Providers must ensure that data on surgical procedures for pelvic organ prolapse are recorded in a national registry, as outlined in the section on collecting data on surgery and surgical complications in this guideline. [2019]
Surgery for uterine prolapse
- Discuss the options for treatment (see recommendation 1.8.2), including non-surgical options, hysterectomy and surgery that will preserve the uterus, with women who have uterine prolapse. [2019]
- For women considering surgery for uterine prolapse:
- discuss the possible complications and the lack of long-term evidence on the effectiveness of the procedures
- use the NICE patient decision aid on surgery for uterine prolapse to discuss the benefits and risks of treatment, including non-surgical options. [2019]
- For women with uterine prolapse who have no preference about preserving their uterus, offer a choice of:
- vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures or
- vaginal sacrospinous hysteropexy with sutures or
- Manchester repair. Also include the option of sacro-hysteropexy with mesh (abdominal or laparoscopic) in this choice but see recommendation 1.8.6 for specific guidance on the use of mesh in prolapse surgery. [2019]
- For women with uterine prolapse who wish to preserve their uterus, offer a choice of:
- vaginal sacrospinous hysteropexy with sutures or
- Manchester repair, unless the woman may wish to have children in the future.Also include the option of sacro-hysteropexy with mesh (abdominal or laparoscopic) in this choice but see recommendation 1.8.6 for specific guidance on the use of mesh in prolapse surgery. [2019]
- If a synthetic polypropylene mesh is inserted, the details of the procedure and its subsequent short- and long-term outcomes must be collected in a national registry (see collecting data on surgery and surgical complications in this guideline). [2019]
- Ensure the proposed treatment is reviewed by a regional MDT (see recommendation 1.1.4) if the woman wishes to have children in the future. [2019]
Surgery for vault prolapse
- Discuss the options for treatment (see recommendation 1.8.2), including non-surgical and surgical options, with women who have vault prolapse. [2019]
- For women considering surgery for vault prolapse:
- discuss the possible complications and the lack of long-term evidence on the effectiveness of the procedures
- use the NICE patient decision aid on surgery for vaginal vault prolapse to discuss the benefits and risks of treatment, including non-surgical options. [2019]
- Offer women with vault prolapse a choice of:
- vaginal sacrospinous fixation with sutures or
- sacrocolpopexy (abdominal or laparoscopic) with mesh.See recommendation 1.8.6 for specific guidance on the use of mesh in prolapse surgery. [2019]
- If a synthetic polypropylene mesh is inserted, the details of the procedure and its subsequent short- and long-term outcomes must be collected in a national registry (see collecting data on surgery and surgical complications in this guideline). [2019]
Colpocleisis for vault or uterine prolapse
- Consider colpocleisis for women with vault or uterine prolapse who do not intend to have penetrative vaginal sex and who have a physical condition that may put them at increased risk of operative and postoperative complications. [2019]
Surgery for anterior prolapse
- Discuss the options for treatment (see recommendation 1.8.2), including non-surgical and surgical options, with women who have anterior prolapse. [2019]
- Offer anterior repair without mesh to women with anterior vaginal wall prolapse. [2019]
- Consider synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse only after:
- regional MDT review and
- discussion with the woman about the risks of mesh insertion (see recommendation 1.8.2)and if:
- apical support is adequate or
- an abdominal approach is contraindicated.See recommendation 1.8.6 for specific guidance on the use of mesh in prolapse surgery. [2019]
- If a synthetic polypropylene or biological mesh is inserted, the details of the procedure and its subsequent short- and long-term outcomes must be collected in a national registry (see collecting data on surgery and surgical complications in this guideline). [2019]
Surgery for posterior prolapse
- Offer posterior vaginal repair without mesh to women with a posterior vaginal wall prolapse. [2019]
5.Surgery for women with both stress urinary incontinence and pelvic organ prolapse
- Consider concurrent surgery for stress urinary incontinence and pelvic organ prolapse in women with anterior and/or apical prolapse and stress urinary incontinence. [2019]
- When considering concurrent surgery for stress urinary incontinence and pelvic organ prolapse, discuss the options for treatment (see recommendations 1.5.1 and 1.8.2) and explain to the woman:
- that there is uncertainty about whether the combined procedure is effective for treating stress urinary incontinence beyond 1 year, and that stress urinary incontinence might persist despite surgery
- the risk of complications related to having surgery for stress urinary incontinence at the same time as prolapse surgery compared with the risk of complications related to having sequential surgery.[2019]
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