Female Urinary Incontinence

Overview

Urinary incontinence (UI) is any involuntary leakage of urine.

The patient may present with symptoms of different types of UI, such as:

• stress urinary incontinence (SUI) - when coughing, sneezing, exertion
• urge urinary incontinence (UUI) -  accompanied or preceded by urgency 
• mixed urinary incontinence (MUI) - when associated with urgency and also with exertion, coughing or sneezing

Patient may present with symptoms suggesting overactive bladder syndrome (OAB):

• presents as urgency that occurs with UUI (‘OAB wet’) or without UUI (‘OAB dry’)
• usually occurs with frequency and nocturia
• coughing can elicit an overactive bladder contraction, indirectly causing incontinence 

Patient may present with voiding dysfunction or retention with or without incontinence

UI is highly prevalent in the population but often is not reported by patients. Women are often embarrassed about continence problems and may be reluctant to raise the issue. Clinicians should be aware of this and be proactive in raising the issue during consultations if appropriate.

Who to refer

Refer to physiotherapy or continence services for supervised pelvic floor exercises.

Refer to an appropriate specialist (urologist, urogynaecologist, or nephrologist), using clinical judgement to determine urgency, if there is: 

• Voiding difficulty.
• Persistent bladder or urethral pain (refer urgently if cancer is suspected).
• A pelvic mass that is clinically benign.
• Associated faecal incontinence.
• Suspected neurological disease.
• A history of previous incontinence surgery (including urethral endoscopic bulking injections), pelvic cancer surgery, or radiation therapy.
• Recurrent urinary tract infection 
• Suspected urogenital fistulae.

Red Flags

Patients < 45 years with unexplained visible haematuria should be referred Urgently to Urology.

 Those ≥ 45 years should be referred via Urology 2WW pathway.

Unexplained haematuria refers to patients where UTI and urinary stone disease have been excluded.

Refer via the Urology 2WW pathway

• Non-visible haematuria (age ≥ 60 years) with either dysuria or a raised white cell count (WCC) on a blood test.
• A soft tissue mass identified on imaging that appears to arise from the urinary tract.

Before referral

Consider Urinary Tract Infection and treat as appropriate. Please see Diagnosing and Treating Lower UTIs in Adult, Non-Pregnant, Non-Catheterised Patients guidelines and Recurrent UTIs in Women in the Formulary Local guidelines.

Assess with a minimum of 3 days bladder diary

Guidelines conclude that a 3-day period allows variation in day-to-day activities to be captured while securing reasonable compliance. Bladder diaries are useful in quantifying symptoms:

• frequency
• urgency
• stress incontinence episodes
• voided volume
• 24-hour or nocturnal total volume

Please see CKS guideline on managing urinary incontinence

• Give lifestyle advice on:
  • Reducing caffeine intake, fizzy drinks and energy drinks — this may improve symptoms of urgency and frequency but not incontinence. 
  • Fluid intake — advise the woman to avoid drinking either excessive amounts, or reduced amounts, of fluid each day.
  • Weight loss if the woman's body mass index is 30 kg/m² or greater. 
  • Smoking cessation if this is appropriate
  • Exclude or manage treatable causes of overactive bladder syndrome if possible.
• Provide information about self-help resources:
  • Refer to the Pelvic Floor Exercises leaflet (PDF) issued by the Bladder & Bowel Foundation.
  • Consider recommending the Bladder & Bowel self-care CONfidence App
  • The NHS provides online information for people with urinary incontinence, available at www.nhs.uk

Consider prescribing medication as per Chapter 7 of the BNSSG Formulary, particularly to treat overactive bladder symptoms . Antimuscarinic medication and mirabegron should not be used if patient experiencing any symptoms of voiding difficulties. If using an Antimuscarinic medication, patients should be advised to monitor for signs of constipation as this is the most common side effect.

Referral

Referral options are:

Sirona Bladder & Bowel service - the nurse-led, specialist service are trained and experienced in assessing and treating bladder and bowel problems. The service works to promote healthy bladder and bowel function.

Pelvic Health Physiotherapy - is available for treating urinary incontinence at St Michaels, Weston General, Southmead and Cossham Hospitals.

Gynaecology Advice & Guidance - is available for UHBW and NBT

If referral to secondary care is required this can be to Gynaecology or Urology (GP Care / NBT) via eRS. If the patient has previously had stress incontinence surgery or bulking injection, i.e. they present with recurrent or persistent stress urinary incontinence, refer to urology at NBT, not to GP Care.

PURSUIT - Clinical trial

There is currently no good evidence about which is the most effective treatment for recurrent or persistent stress urinary incontinence (SUI) in women. PURSUIT is a new NIHR-HTA funded clinical trial randomising women with recurrent or persistent SUI to endoscopic urethral bulking injections or a surgical operation. The study will help us to identify which treatment is better for improving symptoms and quality of life for women with this condition. We plan to recruit 250 women from 20+ NHS hospitals throughout the UK and are currently open to recruitment at NBT. The study will run for 6 years, with 2 years of recruitment and 3 years of follow-up.

See the study website for further information pursuit.blogs.bristol.ac.uk. Please refer any potential/interested patients to Urology at NBT for eligibility assessment.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance 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, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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