A-Z
Topics
Latest

Urinary incontinence and pelvic organ prolapse in women

About

What is covered

This interactive flowchart covers assessing and managing urinary incontinence and pelvic organ prolapse in women aged 18 and over. It also covers complications associated with mesh surgery for these conditions.
In July 2018, the Government announced a period of `high vigilance restriction' on the use of on the use of a group of procedures, including vaginally inserted mesh and tape to treat stress urinary incontinence and pelvic organ prolapse, in England. This followed a recommendation by Baroness Cumberlege, who is chairing an independent review of surgical mesh procedures and has heard from women and families affected by them. For details, see the letter from NHS England and NHS Improvement to trust medical directors. At the time of publication of this updated NICE guideline, the high vigilance restriction period had been extended and, until it ends, professionals should continue to follow its requirements.

Updates

Updates to this interactive flowchart

21 June 2019 Withdrew recommendations on the use of synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse.
1 April 2019 Updated on publication of urinary incontinence and pelvic organ prolapse in women: management (NICE guideline NG123).
21 March 2017 Extraurethral (non-circumferential) retropubic adjustable compression devices for stress urinary incontinence in women (NICE interventional procedures guidance 576) added.
28 February 2017 Structure revised, and summarised recommendations replaced with full recommendations.
11 October 2016 Single-incision short sling mesh insertion for stress urinary incontinence in women (NICE interventional procedures guidance 566) added.
10 June 2015 Urinary tract infections in adults (NICE quality standard 90) added.
21 January 2015 Urinary incontinence in women (NICE quality standard 77) added.
01 October 2013 Amendment made to the botulinum toxin A footnote to accurately reflect the licence for the BOTOX, Allergan preparation.

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said about managing urinary incontinence and pelvic organ prolapse in women in an interactive flowchart

What is covered

This interactive flowchart covers assessing and managing urinary incontinence and pelvic organ prolapse in women aged 18 and over. It also covers complications associated with mesh surgery for these conditions.
In July 2018, the Government announced a period of `high vigilance restriction' on the use of on the use of a group of procedures, including vaginally inserted mesh and tape to treat stress urinary incontinence and pelvic organ prolapse, in England. This followed a recommendation by Baroness Cumberlege, who is chairing an independent review of surgical mesh procedures and has heard from women and families affected by them. For details, see the letter from NHS England and NHS Improvement to trust medical directors. At the time of publication of this updated NICE guideline, the high vigilance restriction period had been extended and, until it ends, professionals should continue to follow its requirements.

Updates

Updates to this interactive flowchart

21 June 2019 Withdrew recommendations on the use of synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse.
1 April 2019 Updated on publication of urinary incontinence and pelvic organ prolapse in women: management (NICE guideline NG123).
21 March 2017 Extraurethral (non-circumferential) retropubic adjustable compression devices for stress urinary incontinence in women (NICE interventional procedures guidance 576) added.
28 February 2017 Structure revised, and summarised recommendations replaced with full recommendations.
11 October 2016 Single-incision short sling mesh insertion for stress urinary incontinence in women (NICE interventional procedures guidance 566) added.
10 June 2015 Urinary tract infections in adults (NICE quality standard 90) added.
21 January 2015 Urinary incontinence in women (NICE quality standard 77) added.
01 October 2013 Amendment 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 interactive flowchart.
Mirabegron for treating symptoms of overactive bladder (2013) NICE technology appraisal guidance 290
Laparoscopic mesh pectopexy for apical prolapse of the uterus or vagina (2018) NICE interventional procedures guidance 608
Transvaginal mesh repair of anterior or posterior vaginal wall prolapse (2017) NICE interventional procedures guidance 599
Sacrocolpopexy using mesh to repair vaginal vault prolapse (2017) NICE interventional procedures guidance 583
Infracoccygeal sacropexy using mesh to repair uterine prolapse (2017) NICE interventional procedures guidance 582
Infracoccygeal sacropexy using mesh to repair vaginal vault prolapse (2017) NICE interventional procedures guidance 581
Sacrocolpopexy with hysterectomy using mesh to repair uterine prolapse (2017) NICE interventional procedures guidance 577
Laparoscopic augmentation cystoplasty (including clam cystoplasty) (2009) NICE interventional procedures guidance 326
Retrograde urethral sphincterometry (2006) NICE interventional procedures guidance 167
Sacral nerve stimulation for urge incontinence and urgency-frequency (2004) NICE interventional procedures guidance 64
Bone-anchored cystourethropexy (2003) NICE interventional procedures guidance 18
Urinary tract infections in adults (2015) NICE quality standard 90
Urinary incontinence in women (2015) NICE quality standard 77
Peezy Midstream for urine collection (2019) NICE medtech innovation briefing 183

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 for urinary incontinence in women 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 different audiences

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.
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 and pelvic organ prolapse in women (2019) NICE guideline NG123, recommendation 1.3.1

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 for urinary incontinence in women 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 different audiences

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.
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 and pelvic organ prolapse in women (2019) NICE guideline NG123, recommendations 1.3.13, 1.4.1, 1.4.2 and 1.4.3

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.
Lifestyle changes
These are part of conservative management and include weight loss, fluid management and caffeine reduction.

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 for urinary incontinence in women 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 different audiences

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.
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

Urinary incontinence and pelvic organ prolapse in women (2019) NICE guideline NG123, recommendation 1.4.16

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 for urinary incontinence in women 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 different audiences

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.
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

Urinary incontinence and pelvic organ prolapse in women (2019) NICE guideline NG123, recommendation 1.4.4

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.

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 for urinary incontinence in women 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 different audiences

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.
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

Urinary incontinence and pelvic organ prolapse in women (2019) NICE guideline NG123, recommendation 1.4.11

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.

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 for urinary incontinence in women 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 different audiences

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.
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

Urinary incontinence and pelvic organ prolapse in women (2019) NICE guideline NG123, recommendation 1.4.21

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 for urinary incontinence in women and should be read in full.

Quality statement

Women with overactive bladder or stress urinary incontinence symptoms have a local multidisciplinary team review before 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 local multidisciplinary team reviews the treatment options before surgery or other invasive treatment for 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 local multidisciplinary team review before surgery or other invasive treatment.
Numerator – The number in the denominator who had a local multidisciplinary team review before 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 different audiences

Service providers (such as community continence services and hospitals) ensure that local multidisciplinary teams are in place to discuss management strategies before surgery or other invasive treatment for women with overactive bladder or stress urinary incontinence.
Healthcare professionals ensure that women with overactive bladder or stress urinary incontinence have a local multidisciplinary team review before surgery or other invasive treatment.
Commissioners (such as clinical commissioning groups) ensure that they commission services that carry out a local multidisciplinary team review before surgery or other invasive treatment for women with overactive bladder or urinary incontinence.
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 and pelvic organ prolapse in women (2019) NICE guideline NG123, recommendation 1.1.1

Definitions of terms used in this quality statement

Invasive treatments
These include:
  • botulinum toxin type A injection
  • percutaneous sacral nerve stimulation
  • augmentation cystoplasty
  • urinary diversion.
[Adapted from NICE's guideline on urinary incontinence and pelvic prolapse in women]
Local multidisciplinary team
A multidisciplinary team for urinary incontinence that should include:
  • 2 consultants with expertise in managing urinary incontinence in women and/or pelvic organ prolapse
  • a urogynaecology, urology or continence specialist nurse
  • a pelvic floor specialist physiotherapist
and may also include:
  • a member of the care of the elderly team
  • an occupational therapist
  • a colorectal surgeon.

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

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

BFLUTS = Bristol Female Lower Urinary Tract Symptoms questionnaire
ICIQ = International Consultation on Incontinence questionnaire
I-QOL = Incontinence Quality of Life questionnaire
ISI = Incontinence Severity Index
KHQ = King's Health QuestionnaireSee full guideline for details.
SEAPI-QMM = Stress-related leak, Emptying ability, Anatomy, Protection, Inhibition, Quality of life, Mobility and Mental status incontinence classification system
SUIQQ = Stress and Urge Incontinence and Quality-of-life Questionnaire
UISS = Urinary Incontinence Severity Score
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.
NICE has published guidance that laparoscopic mesh pectopexy for apical prolapse of the uterus or vagina should only be used in the context of research.

Local

Local MDTs for women with primary SUI, OAB or primary prolapse should:
Local MDTs for women with primary SUI, OAB or primary prolapse should include:
  • 2 consultants with expertise in managing UI in women and/or POP
  • a urogynaecology, urology or continence specialist nurse
  • a pelvic floor specialist physiotherapist
and may also include:
  • a member of the care of the elderly team
  • an occupational therapist
  • a colorectal surgeon.
Members of the local MDT should attend all local MDT meetings.

Regional

Regional MDTs that deal with complex pelvic floor dysfunction and mesh-related problems should review the proposed treatment for women if:
  • they are having repeat continence surgery
  • they are having repeat, same-site prolapse surgery
  • their preferred treatment option is not available in the referring hospital
  • they have coexisting bowel problems that may need additional colorectal intervention
  • vaginal mesh for prolapse is a treatment option for them
  • they have mesh complications or unexplained symptoms after mesh surgery for UI or prolapse
  • they are considering surgery and may wish to have children in the future.
Regional MDTs that deal with complex pelvic floor dysfunction and mesh-related problems should include:
  • a subspecialist in urogynaecology
  • a urologist with expertise in female urology
  • a urogynaecology, urology or continence specialist nurse
  • a pelvic floor specialist physiotherapist
  • a radiologist with expertise in pelvic floor imaging
  • a colorectal surgeon with expertise in pelvic floor problems
  • a pain specialist with expertise in managing pelvic pain
and may also include:
  • a healthcare professional trained in bowel biofeedback and trans-anal irrigation
  • a clinical psychologist
  • a member of the care of the elderly team
  • an occupational therapist
  • a surgeon skilled at operating in the obturator region
  • a plastic surgeon.
Regional MDTs that deal with complex pelvic floor dysfunction and mesh-related problems should have ready access to the following services:
  • psychology
  • psychosexual counselling
  • chronic pain management
  • bowel symptom management
  • neurology.
Members of the regional MDT should attend regional MDT meetings when their specific expertise is needed.
NICE has published interventional procedures guidance that transvaginal mesh repair of anterior or posterior vaginal wall prolapse should only be used in the context of research.
There is public concern about the use of mesh procedures. For all of the procedures recommended in this flowchart, including mesh procedures, there is evidence of benefit, but limited evidence on long-term adverse effects. In particular, the true prevalence of long-term complications is unknown.
There is public concern about the use of mesh procedures. For all of the procedures recommended in this flowchart, including mesh procedures, there is evidence of benefit, but limited evidence on long-term adverse effects. In particular, the true prevalence of long-term complications is unknown.

Glossary

(a type of medicine used to treat overactive bladder; it reduces the activity of the bladder muscle by blocking chemical messengers to the nerves that control muscle movements)
(a type of medicine used to treat overactive bladder; it reduces the activity of the bladder muscle by blocking chemical messengers to the nerves that control muscle movements)
(a procedure to treat overactive bladder; the bladder is made larger by adding a piece of tissue from the intestines to the bladder wall)
(a type of sling used to treat stress urinary incontinence: it is made out of tissue from the woman's abdomen; the sling supports the tube that carries urine out of the body (the urethra))
British Association of Urological Surgeons Section of Female and Reconstructive Urology
British Society of Urogynaecology
(a treatment used for overactive bladder; it is injected into the wall of the bladder)
(an operation to treat pelvic organ prolapse by closing the vagina)
(a type of surgery used to treat stress urinary incontinence; the neck of the bladder is lifted up and stitched in this position)
(involuntary bladder contractions seen during a cystometry test; they can be the cause of overactive bladder symptoms)
General Medical Council's
hormone replacement therapy
(materials used to treat stress urinary incontinence: they are injected into the sides of the tube that carries urine out of the body (the urethra); this helps it remain closed so that urine is less likely to leak out)
(an operation used to treat uterine prolapse: the neck of the womb (the cervix) is shortened; it involves shortening the cervix (neck of the womb) and supporting the womb in its natural position)
(an operation to insert plastic mesh to support tissues: mesh procedures are used to treat stress urinary incontinence and pelvic organ prolapse in women)
multidisciplinary teams
multidisciplinary team
overactive bladder
(a procedure used to treat overactive bladder: a mild electric current is passed through a fine needle to stimulate a nerve in the leg; this nerve controls bladder function)
(a procedure used to treat overactive bladder: a device is implanted in the back to stimulate the nerves at the base of the spine; these nerves affect the bladder and surrounding muscles)
pelvic organ prolapse
Pelvic Organ Prolapse Quantification
(a type of sling used to treat stress urinary incontinence: a strip of plastic is placed behind the tube that carries urine out of the body (the urethra) to support it in a sling)
(a type of surgery used to treat vaginal vault prolapse; plastic mesh is used to attach the vagina to a bone at the bottom of the spine)
(an operation to treat uterine prolapse; plastic mesh is used to attach the womb (the uterus) to a bone at the bottom of the spine)
stress urinary incontinence
transcutaneous electrical nerve stimulation
urinary incontinence
(a type of surgery used to treat stress urinary incontinence; it causes urine to flow through an opening in the abdomen into an external bag, instead of into the bladder)
urinary tract infection
(a type of surgery used to treat vaginal vault or uterine prolapse: the top of the vagina is stitched to a ligament in the pelvis; it is done through a cut on the inside of the vagina)
(an operation used to treat uterine prolapse: the cervix is stitched to a ligament in the pelvis; it is done through a cut on the inside of the vagina)

Paths in this pathway

Pathway created: September 2013 Last updated: July 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

Recently viewed