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Urinary incontinence: the management of urinary incontinence in women
NICE National Institute for Health and Clinical Excellence
NICE Clinical Guidelines 171; 2013
All NICE Guidelines are designed and funded to support the NHS in the UK and have no formal jurisdiction outside of this territory
Last September (2013), the National Institute for Health and Care Excellence (NICE) produced the new Guideline on “Urinary Incontinence: the Management of urinary incontinence in women”, which updates and replaces the previous NICE clinical guideline published in October 2006.
This new clinical guideline represents the fruit of a rigorous process that was based on using the best available evidence and knowledge on urinary incontinence in women, and includes the opinions of experts, patients and caregivers. The need to produce an updated clinical guideline on this topic derives from the fact that new methods of managing urinary incontinence have become available since 2006. Particularly, Botulinum toxin A and sacral nerve stimulation have been recently introduced and are commonly used today for treating Overactive Bladder Syndrome (OAB). Synthetic tape procedures are increasingly common for the treatment of stress urinary incontinence and many advances in the types of procedure developed since 2006. Urinary incontinence in neurological disease has not been reported in this guideline but is covered in Urinary incontinence in neurological disease (NICE clinical guideline 148). In the new Guideline particular attention has been devoted to behavioral therapies, neurostimulation, alternative conservative management options and pharmacological treatment for urinary incontinence in women. With regards to surgical treatment for stress urinary incontinence, best advice is offered for all the available procedures, from the use of synthetic tapes to the positioning of artificial urinary sphincter. Pharmacological treatment: the Nice Guideline precisely assesses general principles when using OAB drugs. It is considered particularly important to take into account “woman's coexisting conditions (for example, poor bladder emptying), the use of other existing medication affecting the total anticholinergic load, and risk of adverse effects”. In addition, when discussing the effects of a particular anticholinergic drug, “women should be informed that they may not see the full benefits until they have been taking the treatment for 4 weeks”. Importantly, the Guideline recommends to avoid the use of oxybutynin in frail older women, especially those with multiple comorbidities, functional impairments, such as walking or dressing difficulties and any degree of cognitive impairment. With regards to the treatment of Nocturia, the guideline suggests to “consider the use of desmopressin in women with urinary incontinence or OAB who find nocturia as troublesome symptom”. Nevertheless, “caution should be used in women with cystic fibrosis, and desmopressin should be avoided in patients over 65 years with hypertension or cardiovascular pathologies”. As at the time of publication (September 2013), desmopressin did not have a marketing authorization for this indication in many countries. The prescriber should take full responsibility for the decision and informed consent should be obtained and documented from treated patients.
Diagnostic procedures. Some concepts have been amended in the new guideline regarding the use of urodynamics in the clinical practice to study urinary incontinence. In particular, it recommends to not perform multi-channel filling and voiding cystometry in women where pure SUI is diagnosed based on a detailed clinical history and examination. Indeed, the guidelines suggest that “after detailed history and examination, multi-channel filling and voiding cystometry should be performed 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”. One important concept showed by the new Nice guideline is the need to have a multidisciplinary team (MDT) in decision making on pharmacological and particularly, on surgical treatment of urinary incontinence in women. The MDT for urinary incontinence should include a uro-gynaecologist, a urologist with a sub-specialist interest in female urology, a specialist nurse, a specialist physiotherapist and a colorectal surgeon with a sub-specialist interest in functional bowel problems, for women with coexisting bowel problems.
Overall, the Nice Guideline 2013 on “Urinary Incontinence: the Management of urinary incontinence in women”, provides clear and comprehensive up-date of recommendations for all physicians involved in the care of women affected by urinary incontinence.