Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

History‑taking and physical examination

  • At the initial clinical assessment, categorise the woman's urinary incontinence (UI) as stress UI (SUI), mixed UI, or urgency UI/overactive bladder (OAB). Start initial treatment on this basis. In mixed UI, direct treatment towards the predominant symptom. [2006]

Assessment of pelvic floor muscles

  • Undertake routine digital assessment to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of UI. [2006, amended 2013]

Bladder diaries

  • Use bladder diaries in the initial assessment of women with UI or OAB. Encourage women to complete a minimum of 3 days of the diary covering variations in their usual activities, such as both working and leisure days. [2006]

Percutaneous posterior tibial nerve stimulation

  • Do not offer percutaneous posterior tibial nerve stimulation for OAB unless:

    • there has been a multidisciplinary team (MDT) review, and

    • conservative management including OAB drug treatment has not worked adequately, and

    • the woman does not want botulinum toxin A[1] or percutaneous sacral nerve stimulation. [new 2013]

Absorbent products, urinals and toileting aids

  • Absorbent products, hand held urinals and toileting aids should not be considered as a treatment for UI. Use them only as:

    • a coping strategy pending definitive treatment

    • an adjunct to ongoing therapy

    • long‑term management of UI only after treatment options have been explored. [2006]

General principles when using OAB drugs

  • Before OAB drug treatment starts, discuss with women:

    • the likelihood of success and associated common adverse effects, and

    • the frequency and route of administration, and

    • that some adverse effects such as dry mouth and constipation may indicate that treatment is starting to have an effect, and

    • that they may not see the full benefits until they have been taking the treatment for 4 weeks. [new 2013]

Choosing OAB drugs

  • Offer one of the following choices first to women with OAB or mixed UI:

    • oxybutynin (immediate release), or

    • tolterodine (immediate release), or

    • darifenacin (once daily preparation). [new 2013]

  • If the first treatment for OAB or mixed UI is not effective or well‑tolerated, offer another drug with the lowest acquisition cost[2]. [new 2013]

The multidisciplinary team (MDT)

  • Offer invasive therapy for OAB and/or SUI symptoms only after an MDT review. [new 2013]

Surgical approaches for SUI

[1] At the time of publication (September 2013), most Botulinum toxin type A preparations did not have a UK marketing authorisation for this indication. Evidence was only available for the licensed Botulinum toxin A (BOTOX, Allergan) preparation.

[2] This could be any drug with the lowest acquisition cost from any of the drugs reviewed, including an untried drug from recommendation 1.7.7. The evidence review considered the following drugs: darifenacin, fesoterodine, oxybutynin (immediate release), oxybutynin (extended release), oxybutynin (transdermal), oxybutynin (topical gel), propiverine, propiverine (extended release), solifenacin, tolterodine (immediate release), tolterodine (extended release), trospium and trospium (extended release). See chapter 6 of the full guideline.

  • National Institute for Health and Care Excellence (NICE)