The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on intramural urethral bulking procedures for stress urinary incontinence.

 October 2018: Following advice from its Clinical Advisory Group, NHS England and NHS Improvement have announced that a process of high vigilance scrutiny should apply to the use of a group of procedures, including this procedure, that are used to treat stress urinary incontinence and pelvic organ prolapse in England. For details, see the letter from NHS England and NHS Improvement to trust medical directors. We will work with NHS England to produce a shared decision making tool, to be available when our guideline on urinary incontinence and pelvic organ prolapse publishes early next year.


Stress urinary incontinence is the involuntary leakage of urine during exercise or movements such as coughing, sneezing and laughing. It is usually caused by weak or damaged muscles and connective tissues in the pelvic floor, compromising urethral support, or by weakness of the urethral sphincter itself.

Typically, first-line treatment is conservative and includes pelvic floor muscle training, electrical stimulation, and biofeedback. If the condition does not improve, surgical alternatives in women may include colposuspension, tension-free vaginal tape (TVT), transobturator tape, and traditional suburethral slings.

The injection of bulking agents into the wall of the urethra is usually performed under local anaesthesia. A cystoscope is inserted into the urethra to locate the areas where the bulking agent should be introduced. After injection of local anaesthetic, several millilitres of bulking agent are injected into the submucosal tissue at the level of the proximal urethra just distal to the bladder neck. The injections may be administered transurethrally through the cystoscope or paraurethrally via small perineal incisions.

Coding recommendations

M56.3 Endoscopic injection of inert substance into outlet of female bladder

Guidance development process

How we develop NICE interventional procedures guidance

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the 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.

Commissioners and/or providers have a responsibility to implement the guidance, 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 guidance 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.