× NICE uses cookies to make the site better.  Learn more
A-Z
Topics
Latest

Urinary incontinence in women overview

history control tooltip

divider handle tooltip

Urinary incontinence in women

About

What is covered

This pathway covers the management of urinary incontinence in women.
Urinary incontinence (UI) is a common symptom that can affect women of all ages, with a wide range of severity and nature. While rarely life-threatening, incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals. The impact on the families and carers of women with UI may be profound, and the resource implications for the health service considerable.
UI is defined by the International Continence Society as 'the complaint of any involuntary leakage of urine'. UI may occur as a result of a number of abnormalities of function of the lower urinary tract or as a result of other illnesses, which tend to cause leakage in different situations.
  • Stress UI is involuntary urine leakage on effort or exertion or on sneezing or coughing.
  • Urgency UI is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay).
  • Mixed UI is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing.
  • Overactive bladder (OAB) is defined as urgency that occurs with or without urgency UI and usually with frequency and nocturia. OAB that occurs with incontinence is known as 'OAB wet'. OAB that occurs without incontinence is known as 'OAB dry'. These combinations of symptoms are suggestive of the urodynamic finding of detrusor overactivity, but can be the result of other forms of urethrovesical dysfunction.
Within this pathway neurostimulation covers transcutaneous sacral nerve stimulation (surface electrodes placed above the sacrum), transcutaneous posterior tibial nerve stimulation (surface electrodes placed above the posterior tibial nerve) and percutaneous posterior tibial nerve stimulation (needles inserted close to the posterior tibial nerve).

Updates

Updates to this pathway

11 November 2015 Link added to the NICE pathway on suspected cancer recognition and referral in the node on urgent referral and specialist intervention.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
7 July 2015 Minor maintenance updates.
22 June 2015 Minor maintenance updates.
10 June 2015 Urinary tract infections in adults (NICE quality standard 90) added to this pathway.
21 January 2015 Urinary incontinence in women (NICE quality standard 77) added to this pathway.
3 September 2014 Minor maintenance updates.
26 November 2013 Corrected a minor error in the botulinum toxin A node.
01 October 2013 A minor amend has been made to the botulinum toxin A footnote to accurately reflect the licence for the BOTOX, Allergan preparation.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

The management of urinary incontinence in women

What is covered

This pathway covers the management of urinary incontinence in women.
Urinary incontinence (UI) is a common symptom that can affect women of all ages, with a wide range of severity and nature. While rarely life-threatening, incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals. The impact on the families and carers of women with UI may be profound, and the resource implications for the health service considerable.
UI is defined by the International Continence Society as 'the complaint of any involuntary leakage of urine'. UI may occur as a result of a number of abnormalities of function of the lower urinary tract or as a result of other illnesses, which tend to cause leakage in different situations.
  • Stress UI is involuntary urine leakage on effort or exertion or on sneezing or coughing.
  • Urgency UI is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay).
  • Mixed UI is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing.
  • Overactive bladder (OAB) is defined as urgency that occurs with or without urgency UI and usually with frequency and nocturia. OAB that occurs with incontinence is known as 'OAB wet'. OAB that occurs without incontinence is known as 'OAB dry'. These combinations of symptoms are suggestive of the urodynamic finding of detrusor overactivity, but can be the result of other forms of urethrovesical dysfunction.
Within this pathway neurostimulation covers transcutaneous sacral nerve stimulation (surface electrodes placed above the sacrum), transcutaneous posterior tibial nerve stimulation (surface electrodes placed above the posterior tibial nerve) and percutaneous posterior tibial nerve stimulation (needles inserted close to the posterior tibial nerve).

Updates

Updates to this pathway

11 November 2015 Link added to the NICE pathway on suspected cancer recognition and referral in the node on urgent referral and specialist intervention.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
7 July 2015 Minor maintenance updates.
22 June 2015 Minor maintenance updates.
10 June 2015 Urinary tract infections in adults (NICE quality standard 90) added to this pathway.
21 January 2015 Urinary incontinence in women (NICE quality standard 77) added to this pathway.
3 September 2014 Minor maintenance updates.
26 November 2013 Corrected a minor error in the botulinum toxin A node.
01 October 2013 A minor amend has been made to the botulinum toxin A footnote to accurately reflect the licence for the BOTOX, Allergan preparation.

Sources

NICE guidance and other sources used to create this pathway.
Mirabegron for treating symptoms of overactive bladder (2013) NICE technology appraisal guidance 290
Laparoscopic augmentation cystoplasty (including clam cystoplasty) (2009) NICE interventional procedure guidance 326
Retrograde urethral sphincterometry (2006) NICE interventional procedure guidance 167
Insertion of biological slings for stress urinary incontinence (2006) NICE interventional procedure guidance 154
Intramural urethral bulking procedures for stress urinary incontinence (2005) NICE interventional procedure guidance 138
Sacral nerve stimulation for urge incontinence and urgency-frequency (2004) NICE interventional procedure guidance 64
Bone-anchored cystourethropexy (2003) NICE interventional procedure guidance 18
Urinary tract infections in adults (2015) NICE quality standard 90
Urinary incontinence in women (2015) NICE quality standard 77

Quality standards

Urinary incontinence in women

These quality statements are taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice for urinary incontinence in women care and should be read in full.

Quality statements

Initial assessment

This quality statement is taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice in urinary incontinence in women care and should be read in full.

Quality statement

Women first presenting with urinary incontinence have a physical examination, recording of the type and duration of symptoms, and categorisation of the urinary incontinence.

Rationale

Physical assessment and recording of the type and duration of symptoms help to categorise the urinary incontinence and enable referral for the correct treatment. Categorising urinary incontinence is important because different types of incontinence need different treatments.

Quality measures

Structure
Evidence of local arrangements to ensure that women first presenting with urinary incontinence have a physical examination, recording of the type and duration of symptoms, and categorisation of urinary incontinence.
Data source: Local data collection.
Process
Proportion of women first presenting with urinary incontinence who receive a physical examination, recording of the type and duration of symptoms, and categorisation of urinary incontinence.
Numerator – the number in the denominator who receive a physical examination, recording of type and duration of symptoms, and categorisation of urinary incontinence.
Denominator – the number of women first presenting with urinary incontinence.
Data source: Local data collection and National Audit of Continence Care.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community continence services and hospitals) ensure that women first presenting with urinary incontinence receive a physical examination, recording of the type and duration of symptoms, and categorisation of urinary incontinence.
Healthcare professionals ensure that when women first present with urinary incontinence they carry out a physical examination, record the type and duration of symptoms, and categorise the incontinence.
Commissioners (such as clinical commissioning groups and NHS England local area teams) ensure that they commission services that offer women first presenting with urinary incontinence a physical examination, recording of the type and duration of symptoms, and categorisation of urinary incontinence.

What the quality statement means for patients, service users and carers

Women first going to their doctor with leakage of urine have an examination, with recording of the types of symptom and how long they have had them. This helps the healthcare professional to identify the type of problem and decide whether referral to a specialist is needed.

Source guidance

  • Urinary incontinence (NICE guideline CG171), recommendation 1.1.1 (key priority for implementation).

Definitions of terms used in this quality statement

Categorisation of urinary incontinence
Urinary incontinence can be categorised into stress urinary incontinence, urgency, urinary incontinence due to overactive bladder, or mixed urinary incontinence. [Expert opinion]
Physical examination
As a minimum, physical examination should include palpation of the abdomen to look for gross abnormalities and inspection of the external genitalia. [Expert opinion]

Equality and diversity considerations

Women with physical disabilities may have difficulty accessing the service so provision needs to be made for a home visit if necessary.
Women with learning disabilities may need to be escorted by a support worker or family member and may need to receive information about the condition in a way that is easy for them to understand.
Some women, including those from certain ethnic groups, religious or cultural backgrounds, may prefer to be examined by a female healthcare professional. Provision for this should be made, if possible.

Bladder diaries and lifestyle changes

This quality statement is taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice in urinary incontinence in women care and should be read in full.

Quality statement

Women first presenting with urinary incontinence are asked to complete a bladder diary for a minimum of 3 days and given advice about the impact that lifestyle changes can have.

Rationale

Bladder diaries can provide a variety of information about urinary incontinence and may also be used for monitoring the effects of treatment. A bladder diary can help healthcare professionals and the woman to understand when urgency or leakage occurs, which is important when considering the management options.
Lifestyle changes can improve symptoms in women with urinary incontinence or overactive bladder. Giving lifestyle advice to women when they first present means they can benefit from these improvements as soon as possible.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women first presenting with symptoms of urinary incontinence are asked to complete a bladder diary for a minimum of 3 days.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that women first presenting with urinary incontinence are given lifestyle advice.
Data source: Local data collection.
Process
a) Proportion of women first presenting with urinary incontinence who are asked to complete a bladder diary for a minimum of 3 days.
Numerator – The number in the denominator who are asked to complete a bladder diary for a minimum of 3 days.
Denominator – The number of women first presenting with urinary incontinence.
Data source: Local data collection and National Audit of Continence Care.
b) Proportion of women first presenting with urinary incontinence who are given advice about lifestyle changes.
Numerator – The number in the denominator who are given advice about lifestyle changes.
Denominator – The number of women first presenting with urinary incontinence.
Data source: Local data collection

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices and community continence services) ensure that staff are trained to ask women first presenting with urinary incontinence to complete a bladder diary for a minimum of 3 days and give advice about the impact that lifestyle changes can have.
Healthcare professionals ensure that they ask women first presenting with urinary incontinence to complete a bladder diary for a minimum of 3 days and give them advice about the impact that lifestyle changes can have.
Commissioners (such as clinical commissioning groups and NHS England local area teams) ensure that they commission services in which staff are trained to ask women first presenting with urinary incontinence to complete a bladder diary for a minimum of 3 days and give them advice about the impact that lifestyle changes can have.

What the quality statement means for patients, service users and carers

Women first going to their doctor with leakage of urine are asked to fill in a bladder diary for at least 3 days and given advice about how lifestyle changes can help. A bladder diary is used to record how much liquid they drink, how often they need to urinate and how much urine they pass. This diary is important to help understand patterns when considering options for management. Making lifestyle changes can improve symptoms.

Source guidance

  • Urinary incontinence (NICE guideline CG171), recommendations 1.1.17 (key priority for implementation), 1.2.1, 1.2.2 and 1.2.3.

Definitions of terms used in this quality statement

Bladder diary
A diary that records times and amounts of urine passed, leakage episodes, pad usage and other information such as fluid intake, degree of urgency and degree of incontinence. A bladder diary should cover variations in the usual activities, such as both working and leisure days. [Adapted from urinary incontinence (NICE guideline CG171)]
Lifestyle changes
These are part of conservative management and include weight loss, fluid management and caffeine reduction. [Adapted from urinary incontinence (NICE guideline CG171)]

Equality and diversity considerations

Women with physical disabilities may have difficulty accessing the service so provision needs to be made for a home visit if necessary.
Women with learning disabilities may need to be escorted by a support worker or family member and may need to receive information about the condition in a way that is easy for them to understand. They may also need support to complete the bladder diary.
Some women, including those from certain ethnic groups, religious or cultural backgrounds, may prefer to discuss urinary incontinence with a female healthcare professional. Provision for this should be made, if possible.
Different versions of bladder diaries should be available for women who do not speak or read English. These women may also need support to complete the diary.

Containment products

This quality statement is taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice in urinary incontinence in women care and should be read in full.

Quality statement

Women with urinary incontinence are only offered containment products as a temporary coping strategy, or as long term management if treatment is unsuccessful.

Rationale

Containment products such as absorbent products, hand held urinals and toileting aids can offer security and comfort for women with urinary incontinence. The products can help women to continue their normal daily activities and therefore improve quality of life. However, they are costly, can affect the woman’s dignity and do not offer a long term solution. Therefore they should not be offered in the long term unless other treatments have failed.

Quality measures

Structure
Evidence of local arrangements to ensure that containment products are offered only as a temporary coping strategy for urinary incontinence in women or as long term management if treatment is unsuccessful.
Data source: Local data collection.
Process
Proportion of women with urinary incontinence who are offered containment products as a temporary coping strategy or as long term management if treatment is unsuccessful.
Numerator – the number in the denominator offered containment products as a temporary coping strategy or as long term management if treatment is unsuccessful.
Denominator – the number of women with urinary incontinence who are offered containment products.
Data source: Local data collection and National Audit of Continence Care.

What the quality statement means for service providers, health and social care professionals, and commissioners

Service providers (such as GP practices, community continence services and hospitals) ensure that services offer containment products (absorbent products, hand held urinals and toileting aids) to women with urinary incontinence only as a temporary coping strategy or as long term management if treatment is unsuccessful.
Health and social care professionals ensure that they offer containment products (absorbent products, hand held urinals and toileting aids) to women with urinary incontinence only as a temporary coping strategy or as long term management if treatment is unsuccessful.
Commissioners (such as clinical commissioning groups) ensure that they commission services that offer women with urinary incontinence containment products (absorbent products, hand held urinals and toileting aids) only as a temporary coping strategy or as long term management if treatment is unsuccessful.

What the quality statement means for patients, service users and carers

Women with leakage of urine may be offered products such as pads, hand held urinals and toileting aids, but only as a temporary measure or in the longer term if treatment is unsuccessful. These products will help women to carry on with their normal daily activities.

Source guidance

Supervised pelvic floor muscle training

This quality statement is taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice in urinary incontinence in women care and should be read in full.

Quality statement

Women with stress or mixed urinary incontinence who are able to contract their pelvic floor muscles are offered a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first line treatment.

Rationale

Women with stress or mixed urinary incontinence are often given a leaflet on pelvic floor muscle training but are not given additional support. As a result, many women who attend for specialist treatment have been incorrectly performing pelvic floor muscle exercises for many years with no improvement in their symptoms. Supervised pelvic floor exercise programmes with trained healthcare professionals can improve symptoms significantly, avoiding surgery or other invasive treatment.
For women with mixed urinary incontinence, supervised pelvic floor training is first line treatment alongside bladder training.

Quality measures

Structure
Evidence of local arrangements to ensure that a trial of supervised pelvic floor muscle training of at least 3 months’ duration is available as first line treatment for women with stress or mixed urinary incontinence who are able to contract their pelvic floor muscles.
Data source: Local data collection.
Process
a) Proportion of women with stress or mixed urinary incontinence who can contract their pelvic floor muscles who have a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first line treatment.
Numerator – the number in the denominator who have a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first line treatment.
Denominator – the number of women with stress or mixed urinary incontinence who can contract their pelvic floor muscles.
Data source: Local data collection.
b) Proportion of women with urinary incontinence who have a digital vaginal assessment to confirm correct pelvic floor muscle contraction before referral for supervised pelvic floor muscle training.
Numerator – the number in the denominator who have a digital vaginal assessment to confirm correct pelvic floor muscle contraction before referral.
Denominator – the number of women with urinary incontinence who are referred for supervised pelvic floor muscle training.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community continence services and hospitals) ensure that supervised pelvic floor muscle training of at least 3 months’ duration is available as first line treatment for women with stress or mixed urinary incontinence who can contract their pelvic floor muscles. Those delivering the training should be suitably trained to do so.
Healthcare professionals ensure that they offer supervised pelvic floor muscle training of at least 3 months’ duration as first line treatment for women with stress or mixed urinary incontinence who can contract their pelvic floor muscles.
Commissioners (such as clinical commissioning groups) ensure that they commission services that offer women with stress or mixed urinary incontinence who can contract their pelvic floor muscles supervised pelvic floor muscle training of at least 3 months’ duration as first line treatment.

What the quality statement means for patients, service users and carers

Women with leakage of urine caused by conditions called stress or mixed urinary incontinence who can contract their pelvic floor muscles are offered at least 3 months of training in pelvic floor exercises with a healthcare professional as a first treatment. This can lead to big improvements in symptoms and can mean that surgery or other invasive treatment is avoided.

Source guidance

Definitions of terms used in this quality statement

Pelvic floor muscle training
Training in repetitive selective voluntary contraction and relaxation of specific pelvic floor muscles that is delivered and evaluated by a trained healthcare professional. [Adapted from urinary incontinence (NICE guideline CG171)]

Equality and diversity considerations

Women with physical disabilities may have difficulty accessing the service so provision needs to be made for a home visit if necessary.
Women with learning disabilities may need to be escorted by a support worker or family member and may need to receive information about the condition in a way that is easy for them to understand.
Some women, including those from certain ethnic groups, religious or cultural backgrounds, may prefer a female healthcare professional to supervise their pelvic floor exercises. Provision for this should be made, if possible.

Bladder training

This quality statement is taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice in urinary incontinence in women care and should be read in full.

Quality statement

Women with symptoms of urgency or mixed urinary incontinence are offered bladder training for a minimum of 6 weeks as first line treatment.

Rationale

Bladder training teaches a woman how to hold more urine in her bladder and so reduce the number of times she needs to pass urine. It also includes lifestyle advice on the amount and types of fluids to drink, and coping strategies to reduce urgency.
For women with mixed urinary incontinence, bladder training is first line treatment alongside supervised pelvic floor training.

Quality measures

Structure
Evidence of local arrangements to ensure that women with symptoms of urgency or mixed urinary incontinence are offered bladder training for a minimum of 6 weeks as first line treatment.
Data source: Local data collection.
Process
Proportion of women with symptoms of urgency or mixed urinary incontinence who have bladder training for a minimum of 6 weeks as first line treatment.
Numerator – The number in the denominator who have bladder training for a minimum of 6 weeks as first line treatment.
Denominator – The number of women having first line treatment for urgency or mixed urinary incontinence.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community continence services and hospitals) ensure that systems are in place for women with symptoms of urgency or mixed urinary incontinence to have bladder training for at least 6 weeks as first line treatment.
Healthcare professionals offer bladder training for at least 6 weeks as first line treatment to women with symptoms of urgency or mixed urinary incontinence.
Commissioners (such as clinical commissioning groups) ensure that they commission services that offer women with symptoms of urgency or mixed urinary incontinence bladder training for at least 6 weeks as first line treatment.

What the quality statement means for patients, service users and carers

Women with urine leakage caused by conditions called urgency or mixed urinary incontinence are offered bladder training (advice on reducing urine leakage) for at least 6 weeks as a first treatment. This can help reduce the number of times a woman needs to pass urine.

Source guidance

Definitions of terms used in this quality statement

Bladder training
Bladder training (also described as bladder retraining, bladder re education, bladder drill, bladder discipline) actively involves the woman in trying to increase the interval between the desire to pass urine and actually doing so. [Adapted from urinary incontinence (NICE guideline CG171)].

Equality and diversity considerations

Women with physical disabilities may have difficulty accessing the service so provision needs to be made for a home visit if necessary.
Women with learning disabilities may need to be escorted by a support worker or family member and may need to receive information about the condition in a way that is easy for them to understand.
Some women, including those from certain ethnic groups, religious or cultural backgrounds, may prefer a female healthcare professional to offer them bladder training. Provision for this should be made, if possible.

Indwelling catheters

This quality statement is taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice in urinary incontinence in women care and should be read in full.

Quality statement

Women with urinary incontinence have indwelling urethral catheters for long term treatment only if they have an assessment and discussion of the practicalities and potential urological complications.

Rationale

Long term use of indwelling urethral catheters can be associated with increased risk of urinary tract infections and urethral complications, and can affect daily life. Therefore, healthcare professionals should discuss with the woman (and her family or carer if appropriate) the practicalities, benefits and risks of this treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that healthcare professionals offer women with urinary incontinence long term treatment with indwelling urethral catheters only if they have had assessment and discussion about the practicalities and potential urological complications.
Data source: Local data collection.
Process
Proportion of women with urinary incontinence who had assessment and discussion of the practicalities and potential urological complications of the long term use of indwelling urethral catheters.
Numerator – the number in the denominator who had assessment and discussion of the practicalities and potential urological complications of long term use of indwelling urethral catheters before the fitting of the indwelling urethral catheter.
Denominator – the number of women with urinary incontinence who have indwelling urethral catheters for long term use.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community continence services and hospitals) ensure that systems are in place to assess and discuss the practicalities and potential urological complications of indwelling urethral catheters with women with urinary incontinence before these are fitted for long term use.
Healthcare professionals ensure that they assess women with urinary incontinence and discuss the practicalities and potential urological complications before they offer indwelling urethral catheters for long term use.
Commissioners (such as clinical commissioning groups) ensure that they commission services that assess and discuss the practicalities and potential urological complications of indwelling urethral catheters with women with urinary incontinence before these are fitted for long term use.

What the quality statement means for patients, service users and carers

Women with leakage of urine are offered an assessment and a discussion with their healthcare professional about the day to day use and possible complications of having a catheter before they are offered this for long term treatment. This will help the woman to decide whether a catheter is right for her.

Source guidance

Equality and diversity considerations

Women with physical disabilities may have difficulty accessing the service so provision needs to be made for a home visit if necessary.
Women with learning disabilities may need to be escorted by a support worker or family member and may need to receive information about the condition in a way that is easy for them to understand.
Some women, including those from certain ethnic groups, religious or cultural backgrounds, may prefer to have an assessment and discussion with a female healthcare professional. Provision for this should be made, if possible.

Multidisciplinary team review before surgery or invasive treatment

This quality statement is taken from the urinary incontinence in women quality standard. The quality standard defines clinical best practice in urinary incontinence in women care and should be read in full.

Quality statement

Women with overactive bladder or stress urinary incontinence symptoms have a multidisciplinary team review before they are offered surgery or other invasive treatment.

Rationale

Surgery or other invasive treatment should only be considered if conservative management and pharmacological treatment have been unsuccessful. Multidisciplinary team review can ensure that all other possible treatments have been considered before surgery and other invasive treatments. The whole team approach can also help the decision of whether invasive treatment is suitable for the woman.

Quality measures

Structure
Evidence of local arrangements to ensure that a multidisciplinary team reviews the treatment options before surgery or other invasive treatment are offered to women with overactive bladder or stress urinary incontinence.
Data source: Local data collection.
Process
Proportion of women with overactive bladder or stress urinary incontinence who have a multidisciplinary team review before they are offered surgery or other invasive treatment.
Numerator – The number in the denominator who had a multidisciplinary team review before they are offered surgery or other invasive treatment.
Denominator – The number of women with overactive bladder or stress urinary incontinence who have surgery or other invasive treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (such as community continence services and hospitals) ensure that multidisciplinary teams are in place to discuss management strategies before surgery or other invasive treatment are offered to women with overactive bladder or stress urinary incontinence.
Healthcare professionals ensure that women with overactive bladder or stress urinary incontinence have a multidisciplinary team review before they offer surgery or other invasive treatment.
Commissioners (such as clinical commissioning groups) ensure that they commission services that carry out a multidisciplinary team review before surgery or other invasive treatment are offered to women with overactive bladder or urinary incontinence.

What the quality statement means for patients, service users and carers

Women with leakage of urine caused by conditions called overactive bladder or stress urinary incontinence have a review of their condition by a team of healthcare professionals before surgery or other invasive treatment. This review will make sure that all other treatments have been considered and help with the decision of whether invasive treatment is right for the woman.

Source guidance

  • Urinary incontinence (NICE guideline CG171), recommendation 1.8.2 (key priority for implementation).

Definitions of terms used in this quality statement

Invasive treatments
  • Intravesical botulinum toxin
  • Percutaneous sacral nerve stimulation
  • Augmentation cystoplasty
  • Urinary diversion
  • Detrusor myectomy
  • Intravesical vanilloid receptor agonists.
[Adapted from urinary incontinence (NICE guideline CG171)]
Multidisciplinary team
The multidisciplinary team for urinary incontinence should include:
  • a urogynaecologist
  • a urologist with a sub specialist interest in female urology
  • a specialist nurse
  • a specialist physiotherapist
  • a colorectal surgeon with a sub specialist interest in functional bowel problems, for women with coexisting bowel problems
  • a member of the ‘care of the elderly team’ and/or occupational therapist, for women with functional impairment. [Urinary incontinence (NICE guideline CG171)]

Diagnosing urinary tract infections in adults aged 65 years and over

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Adults aged 65 years and over have a full clinical assessment before a diagnosis of urinary tract infection is made.

Rationale

The accuracy of dipstick testing in adults aged 65 years and over can vary. It is therefore important that factors other than the results of dipstick testing are taken into consideration when diagnosing urinary tract infections in older people to ensure appropriate management and avoid unnecessary use of antibiotics.

Quality measures

Structure
Evidence of local arrangements to ensure a full clinical assessment is undertaken before a diagnosis of urinary tract infection is made in adults aged 65 years and over.
Data source: Local data collection.
Process
Proportion of adults aged 65 years and over who received a full clinical assessment before being diagnosed with a urinary tract infection.
Numerator – the number in the denominator diagnosed with a urinary tract infection based on a full clinical assessment.
Denominator – the number of adults aged 65 years and over diagnosed with a urinary tract infection.
Data source: Local data collection.
Outcome
Antibiotic prescription rates for urinary tract infections.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services and GPs) ensure that adults aged 65 years and over receive a full clinical assessment before being diagnosed with a urinary tract infection.
Healthcare professionals ensure they perform a full clinical assessment before diagnosing urinary tract infections in adults aged 65 years and over.
Commissioners (such as clinical commissioning groups and NHS England area teams) ensure that all providers are aware that adults aged 65 years and over with a suspected urinary tract infection are diagnosed based on a full clinical assessment. NHS England area teams should be aware that achieving this quality statement could be incorporated into GP surgeries ‘Avoiding Unplanned Admissions’ Enhanced Service, as per local arrangements.

What the quality statement means for patients, service users and carers

Adults aged 65 years and over who have symptoms that are typical of a urinary tract infection have a full clinical assessment before a diagnosis of a urinary tract infection is made.

Source guidance

Definitions of terms used in this quality statement

Symptoms of urinary tract infection
These include dysuria, increased frequency of urination, suprapubic tenderness, urgency and polyuria (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).
Clinical assessment
A full clinical assessment should be a face to face review of the person’s medical history, physical examination, assessment of pulse, blood pressure, temperature and recording of symptoms (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).

Diagnosing urinary tract infections in adults with catheters

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters.

Rationale

Dipstick testing is not an effective method for detecting urinary tract infections in catheterised adults. This is because there is no relationship between the level of pyuria and infection in people with indwelling catheters (the presence of the catheter invariably induces pyuria without the presence of infection). To ensure that urinary tract infections are diagnosed accurately and to avoid false positive results, dipstick testing should not be used.

Quality measures

Structure
Evidence of local arrangements to ensure healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters.
Data source: Local data collection.
Process
Proportion of episodes of suspected urinary tract infection in adults with urinary catheters that are investigated using dipstick testing.
Numerator – the number in the denominator assessed using dipstick testing.
Denominator – the number of episodes of suspected urinary tract infection in adults with urinary catheters.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services, care homes and GPs) ensure that training and education programmes are kept up to date so that healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters.
Healthcare professionals ensure that dipstick testing is not used to diagnose urinary tract infections in adults with urinary catheters.
Commissioners (such as clinical commissioning groups, NHS England area teams) ensure that providers are aware that adults with urinary catheters should not have urinary tract infections diagnosed by dipstick testing.

What the quality statement means for patients, service users and carers

Adults with urinary catheters do not have urinary tract infections diagnosed by dipstick testing.

Source guidance

Referring men with upper urinary tract infections

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Men who have symptoms of an upper urinary tract infection are referred for urological investigation.

Rationale

Upper urinary tract infections can indicate the presence of lower urinary tract abnormalities. It is important that men with symptoms of an upper urinary tract infection have urological investigations to ensure that any possible abnormalities are diagnosed and treated.

Quality measures

Structure
Evidence of local arrangements to ensure that men with symptoms of an upper urinary tract infection are referred for urological investigations.
Data source: Local data collection.
Process
Proportion of episodes of suspected upper urinary tract infection in men that are referred for urological investigations.
Numerator – the number in the denominator referred for urological investigations.
Denominator – the number of episodes of suspected upper urinary tract infection in men.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services and GPs) ensure that they have processes in place so that men with symptoms of an upper urinary tract infection are referred for urological investigation.
Health and social care practitioners ensure that they are aware of local referral pathways for urological investigations so that men with symptoms of an upper urinary tract infection can be referred for urological investigation.
Commissioners (such as clinical commissioning groups and NHS England area teams) should seek evidence of practice from providers that men with symptoms of an upper urinary tract infection are referred for urological investigation. This can be achieved through carrying out local audits.

What the quality statement means for patients, service users and carers

Men with symptoms of an upper urinary tract infection are referred to a specialist for urological tests.

Source guidance

Definitions of terms used in this quality statement

Upper urinary tract infection
Characterised by evidence of urinary tract infection with symptoms suggestive of pyelonephritis (loin pain, flank tenderness, fever, rigors or other manifestations of systemic inflammatory response (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).

Urological investigations

These include urodynamic techniques such as pressure/flow cystography to detect lower urinary tract abnormalities (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012], recommendation 5.3).

Urine culture for adults with a urinary tract infection that does not respond to initial antibiotic treatment

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture.

Rationale

Some urinary tract infections are resistant to initial antibiotic treatment and a urine culture is needed (or a repeat where an initial urine culture was taken) to determine which antibiotic will work against the specific strain of bacteria causing the urinary tract infection. A urine culture is needed to guide a change in antibiotic treatment in people who do not respond to initial treatment with antibiotics.

Quality measures

Structure
Evidence of local arrangements to ensure adults with urinary tract infections who do not respond to initial antibiotic treatment have a urine culture.
Data source: Local data collection.
Process
Proportion of episodes of a urinary tract infection not responding to initial antibiotic treatment investigated with a urine culture.
Numerator – the number in the denominator investigated with a urine culture.
Denominator – the number of episodes of a urinary tract infection not responding to initial antibiotic treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services and GPs) ensure that processes and referral pathways are in place so that adults with a urinary tract infection not responding to treatment with initial antibiotic treatment have a urine culture.
Healthcare professionals ensure that adults with a urinary tract infection not responding to treatment with initial antibiotic treatment have a urine culture.
Commissioners (such as clinical commissioning groups) ensure that service specifications with local providers indicate that adults with a urinary tract infection not responding to treatment with initial antibiotic treatment have a urine culture.

What the quality statement means for patients, service users and carers

Adults with a urinary tract infection that is not responding to initial antibiotic treatment have their urine tested to see if other antibiotics should be tried.

Source guidance

Definitions of terms used in this quality statement

Urine culture
A sample of urine is taken to identify bacteria and their sensitivity to antibiotics (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).
Not responding
There is no response to treatment within the follow-up period as agreed with the healthcare professional (expert consensus).

Antibiotic treatment for asymptomatic adults with catheters and non-pregnant women

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.

Rationale

Antibiotics are not effective for treating asymptomatic bacteriuria in adults with catheters or non-pregnant women. Unnecessary treatment with antibiotics can also increase the resistance of bacteria that cause urinary tract infections, making antibiotics less effective for future use.

Quality measures

Structure
a) Evidence of local arrangements to ensure healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.
Data source: Local data collection.
b) Evidence of local arrangements to ensure healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.
Data source: Local data collection.
Process
a) Proportion of episodes of asymptomatic bacteriuria in adults with catheters treated with antibiotics.
Numerator – the number in the denominator treated with antibiotics.
Denominator – the number of episodes of asymptomatic bacteriuria in adults with a catheter.
Data source: Local data collection.
b) Proportion of episodes of asymptomatic bacteriuria in non-pregnant women treated with antibiotics.
Numerator – the number in the denominator treated with antibiotics.
Denominator – the number of episodes of asymptomatic bacteriuria in non-pregnant women.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services, care homes, GPs) ensure that processes are in place so that healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women. Internal training and education may be required, according to local need.
Healthcare professionals ensure that antibiotics are not prescribed to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.
Commissioners (such as clinical commissioning groups, local authorities and NHS England area teams) ensure that providers are aware that antibiotic treatment should not be prescribed to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women. This could be included in local service specifications and pathways.

What the quality statement means for patients, service users and carers

Adults with catheters and non-pregnant women who have bacteria in their urine but no symptoms of urinary tract infection are not prescribed antibiotics.

Source guidance

Definitions of terms used in this quality statement

Asymptomatic bacteriuria
Bacteria in a urine sample taken from a person who does not have any of the typical symptoms of lower or upper urinary tract infection. Asymptomatic bacteriuria should be confirmed by 2 consecutive urine samples (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).

Treatment of recurrent urinary tract infection: placeholder statement

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence‑based guidance to be developed in this area.

Rationale

Recurrent urinary tract infections are common and it is important that they are managed and prevented effectively.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

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 UI.
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 UI.
Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day.
Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training.
Continue an exercise programme if pelvic floor muscle training is beneficial.
Offer pelvic floor muscle training to women in their first pregnancy as a preventive strategy for UI.

Electrical stimulation

Do not routinely use electrical stimulation in the treatment of women with OAB.
Do not routinely use electrical stimulation in combination with pelvic floor muscle training.
Electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy.

Fluid intake

Consider advising modification of high or low fluid intake in women with UI or OAB.

Weight

Advise women with UI or OAB who have a BMI greater than 30 to lose weight. See also the diet pathway.

Oestrogens

Do not offer systemic hormone replacement therapy for the treatment of UI.

Complementary therapies

Do not recommend complementary therapies for the treatment of UI or OAB.

Offering invasive therapy

Inform any woman wishing to consider surgical treatment for UI about:
  • the benefits and risks of surgical and non-surgical options
  • their provisional treatment plan.
Include consideration of the woman's child-bearing wishes in the counselling.
Offer invasive therapy for OAB and/or SUI symptoms only after an MDT review.
When recommending optimal management the MDT should take into account:
  • the woman's preference
  • past management
  • comorbidities
  • treatment options (including further conservative management such as OAB drug therapy).
Inform the woman of the outcome of the MDT review if it alters the provisional treatment plan.

Organisation of the multidisciplinary team

The MDT for urinary incontinence should include:
  • a urogynaecologist
  • a urologist with a sub-specialist interest in female urology
  • a specialist nurse
  • a specialist physiotherapist
  • a colorectal surgeon with a sub-specialist interest in functional bowel problems, for women with coexisting bowel problems
  • a member of the care of the elderly team and/or occupational therapist, for women with functional impairment.
All MDTs should work within an established regional clinical network to ensure all women are offered the appropriate treatment options and high quality care.

Maintaining and measuring expertise and standards for practice

Surgery for UI should be undertaken only by surgeons who have received appropriate training in the management of UI and associated disorders or who work within an MDT with this training, and who regularly carry out surgery for UI in women.
Training should be sufficient to develop the knowledge and generic skills documented below. Knowledge should include the:
  • specific indications for surgery
  • required preparation for surgery including preoperative investigations
  • outcomes and complications of proposed procedure
  • anatomy relevant to procedure
  • steps involved in procedure
  • alternative management options
  • likely postoperative progress.
Generic skills should include:
  • the ability to explain procedures and possible outcomes to patients and family and to obtain informed consent
  • the necessary hand–eye dexterity to complete the procedure safely and efficiently, with appropriate use of assistance
  • the ability to communicate with and manage the operative team effectively
  • the ability to prioritise interventions
  • the ability to recognise when to ask for advice from others
  • a commitment to MDT working.
Training should include competence in cystourethroscopy.
Operative competence of surgeons undertaking surgical procedures to treat UI or OAB in women should be formally assessed by trainers through a structured process.
Surgeons who are already carrying out procedures for UI should be able to demonstrate that their training, experience and current practice equates to the standards laid out for newly trained surgeons.
Only surgeons who carry out a sufficient case load to maintain their skills should undertake surgery for UI or OAB in women. An annual workload of at least 20 cases of each primary procedure for stress UI is recommended. Surgeons undertaking fewer than 5 cases of any procedure annually should do so only with the support of their clinical governance committee; otherwise referral pathways should be in place within clinical networks.
There should be a nominated clinical lead within each surgical unit with responsibility for continence and prolapse surgery. The clinical lead should work within the context of an integrated continence service.
A national audit of continence surgery should be undertaken.
Surgeons undertaking continence surgery should maintain careful audit data and submit their outcomes to national registries such as those held by the British Society of Urogynaecology (BSUG) and British Association of Urological Surgeons Section of Female and Reconstructive Urology (BAUS-SFRU).

Urodynamic tests

After undertaking a detailed clinical history and examination, perform multi-channel filling and voiding cystometry before surgery in women who have:
  • symptoms of OAB leading to a clinical suspicion of detrusor overactivity, or
  • symptoms suggestive of voiding dysfunction or anterior compartment prolapse, or
  • had previous surgery for stress incontinence.
Consider ambulatory urodynamics or videourodynamics if the diagnosis is unclear after conventional urodynamics.
Do not perform multi-channel cystometry, ambulatory urodynamics or videourodynamics before starting conservative management.
Do not perform multi-channel filling and voiding cystometry in the small group of women where pure SUI is diagnosed based on a detailed clinical history and examination.

Other tests of urethral competence

Do not use the Q-tip, Bonney, Marshall and Fluid-Bridge tests in the assessment of women with UI.

Cystoscopy

Do not use cystoscopy in the initial assessment of women with UI alone.

Imaging

Do not use imaging (MRI, CT, X-ray) for the routine assessment of women with UI. Do not use ultrasound other than for the assessment of residual urine volume.

If a woman chooses not to have further treatment

If a woman chooses not to have further treatment for urinary incontinence:
  • offer her advice about managing urinary symptoms, and
  • explain that if she changes her mind at a later date she can book a review appointment to discuss past tests and interventions and reconsider her treatment options.

Glossary

Bristol Female Lower Urinary Tract Symptoms questionnaire.
International Consultation on Incontinence Questionnaire.
Incontinence Severity Index.
Incontinence Quality of Life questionnaire.
King's Health Questionnaire.
Stress-related leak, Emptying ability, Anatomy, Protection, Inhibition, Quality of life, Mobility and Mental status Incontinence Classification System.
Stress and Urge Incontinence and Quality-of-Life Questionnaire.
Urinary Incontinence Severity Score.

Paths in this pathway

Pathway created: September 2013 Last updated: November 2015

© NICE 2016

Recently viewed