Evidence
Overview of 2019 surveillance methods
Overview of 2019 surveillance methods
NICE's surveillance team checked whether recommendations in urinary incontinence in neurological disease (NICE guideline CG148) remain up to date. The 2019 surveillance followed the static list review process, consisting of:
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Feedback from topic experts via a questionnaire.
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A search for new or updated Cochrane reviews.
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Examining related NICE guidance and quality standards and NIHR signals.
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A search for ongoing research.
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Examining the NICE event tracker for relevant ongoing and published events.
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Consulting on the proposal with stakeholders.
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Considering comments received during consultation and making any necessary changes to the proposal.
For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
Evidence considered in surveillance
Cochrane reviews
We searched for new Cochrane reviews related to the whole guideline. We found 2 that were relevant, published between September 2013 and September 2018.
One review (Utomo et al. 2014) assessed different surgical therapies and botulinum A toxin injections for the treatment of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction. Five studies were identified but due to low quality and mixed findings no conclusions could be drawn. The second review (Jamison et al. 2013) planned to examine different types of catheter for managing the neurogenic bladder incontinence but no relevant studies were found.
Ongoing research
We checked for relevant ongoing research; of the 10 ongoing studies identified, 7 studies were assessed as having the potential to change recommendations; therefore we plan to check the publication status regularly, and evaluate the impact of the results on current recommendations as quickly as possible after results become available. These studies are:
Intelligence gathered during surveillance
Views of topic experts
We considered the views of topic experts, including those who helped to develop the guideline. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the NICE guideline on urinary incontinence in neurological disease.
We sent questionnaires to 15 topic experts and received 6 responses.
The main area suggested for updating the guideline included the following:
Electrical nerve stimulation
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No new evidence was identified through intelligence gathering on electrical stimulation targeting neurological incontinence at the current surveillance review. NICE published interventional procedures guidance on percutaneous posterior tibial nerve stimulation for overactive bladder syndrome in 2010 but the targeted population is not specific to the population with neurological disease.
Urethral tape and sling surgery
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Recommendation 1.4.2 currently states 'consider autologous fascial sling surgery for people with neurogenic stress incontinence' and recommendation 1.4.3 states 'do not routinely use synthetic tapes and slings in people with neurogenic stress incontinence because of the risk of urethral erosion'. However on 10 July 2018, Clinical Advisory Group, NHS England and NHS Improvement announced that a process of high vigilance scrutiny should apply to the use of a group of procedures, including a pause on the use of vaginally inserted mesh and tape 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 understand that the pause applies to the current recommendations. We will add an alert note to the NICE guideline to address the government's announcement on the use of vaginally inserted mesh and tape to treat stress urinary incontinence. NICE will also work with NHS England to produce a shared decision making tool, to be available when NICE's guideline on urinary incontinence and pelvic organ prolapse publishes. This is currently planned for April 2019.
Topic experts identified 4 published studies relevant to this guideline. However, none of these studies impact on the guideline as they either support current recommendations or the new evidence is insufficient to change recommendations at present. One study (Hoen et al. 2017) supports the recommendations to consider bladder augmentation in patients with neurogenic bladder dysfunction. Three further studies (Krhut et al. 2018, Chen et al. 2018 and Welk et al. 2018) assessed the effectiveness of beta-3 agonist mirabegron for treatment of neurogenic detrusor overactivity and overactive bladder. Mirabegron may improve some urodynamic variables of overactive bladder but the evidence was based on small scale studies and was considered to be insufficient to have an impact on the guideline. The use of beta-3 agonists is not covered by the current guideline. NICE has published technology appraisal guidance on mirabegron for treating symptoms of overactive bladder.
Implementation of the guideline
One topic expert indicated that there is a lack of community based services for children with bladder and bowel problems, which results in an inability to implement relevant NICE guidelines and recommendations at a local level. A commissioning guide prepared by the Paediatric Continence Forum addresses service provision and has been accredited by NICE. It provides support for the local implementation of NICE guidance through commissioning and should be read together with NICE's guidelines on urinary incontinence.
Views of stakeholders
Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal was to not update the guideline, we consulted with stakeholders.
Overall, 7 stakeholders commented (including representation from royal colleges, charities, NHS health board and pharmaceutical industry). Five stakeholders provided comments on the surveillance review proposal and the remaining 2 stakeholders stated that they had no substantive comments to make.
Four of the 7 stakeholders disagreed with the decision to not update the guideline, however 2 of these gave no reasons for disagreeing. We considered the suggestions for why the guideline is out of date but decided it did not need updating for the following reasons.
One stakeholder expressed concern about safety warnings on quinolones. However the NICE guideline does not recommend the use of a specific antibiotic. Recommendation 1.8.1 currently states 'do not routinely use antibiotic prophylaxis for urinary tract infections in people with neurogenic lower urinary tract dysfunction' and recommendation 1.8.2 states 'consider antibiotic prophylaxis for people who have a recent history of frequent or severe urinary tract infections'. NICE has published a treatment summary for quinolones and recently updated its guideline on urinary tract infection in under 16s. The stakeholder also expressed concern about use of prophylactic antibiotics and antimicrobial resistance. NICE produces antimicrobial prescribing guidelines for the management of common infections. This new group of guidance seeks to provide evidence-based advice on how common infections can be managed, with the purpose of tackling antibiotic resistance.
One stakeholder stated that the management of nocturia is missing from the guideline. NICE has published a guideline on bedwetting in under 19s, which has recommendations on assessment and investigation/or referral when nocturia is associated with neurological problems.
The stakeholder indicated that recommendations about management of infants with spina bifida should place emphasis on the early assessment and regular surveillance of those infants. However, infants with spina bifida are all managed in highly specialised units where early and regular assessment should be standard practice. This is reflected in recommendation 1.9.5, which states 'consider urodynamic investigations as part of a surveillance regimen for people at high risk of urinary tract complications (for example, people with spina bifida, spinal cord injury or anorectal abnormalities)'. In addition, recommendations 1.1.11 and 1.1.17 draw attention to patients with spina bifida having a high risk of renal problems and requiring more intensive investigation.
See appendix A for full details of stakeholders' comments and our responses.
See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.
Editorial amendments
During surveillance of the guideline we identified the following points in the guideline that should be amended.
Recommendation 1.1 contains a hyperlinked cross reference to an old version of the guideline on urinary incontinence in neurological disease. Because this guideline has been updated, this page simply contains text about the update with a link to the new guidance. The hyperlink should be updated to take the reader directly to the updated guideline.
Recommendation 1.11.4, a cross referral should be added to NICE's guideline on transition from children's to adults' services for young people using health or social care services.
Footnote 6 contains a hyperlinked cross reference to an old version of the guideline on chronic kidney disease. Because this guideline has been updated, this page simply contains text about the update with a link to the new guidance. The hyperlink should be updated to take the reader directly to the updated guideline on chronic kidney disease.
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