Update information

November 2015: Deleted recommendation 1.1.14 and replaced with a link to updated advice in suspected cancer guideline (NG12), published in June 2015.

October 2015: Title changed from 'Urinary incontinence: The management of urinary incontinence in women' to 'Urinary incontinence in women: management' for clarity and consistency with other guidance on this topic.

September 2013: This guideline updates and replaces NICE guideline CG40 (published October 2006).

Recommendations are marked as [new 2013], [2013], [2006] or [2006, amended 2013]:

  • [new 2013] indicates that the evidence has been reviewed and the recommendation has been updated or added.

  • [2013] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2006] indicates that the evidence has not been updated and reviewed since 2006

  • [2006, amended 2013] indicates that the evidence has not been updated and reviewed since 2006, but changes have been made to the recommendation wording that change the meaning (see below).

Recommendations from NICE guideline CG40 that have been amended

Some recommendations had had minor editorial changes to so they are written in the direct, active style or to improve clarity and implementation.

Recommendations listed in the table below are those where the evidence has not been reviewed but changes have been made to the recommendation wording that change the meaning.

Recommendation in NICE guideline CG40

Recommendation in current guideline

Reason for change

Multi‑channel filling and voiding cystometry is recommended in women before surgery for UI if:

  • there is clinical suspicion of detrusor overactivity, or

  • there has been previous surgery for stress incontinence or anterior compartment prolapse, or

  • there are symptoms suggestive of voiding dysfunction.

Ambulatory urodynamics or videourodynamics may also be considered in these circumstances.

(Recommendation [1.1.10.3] in 2006 guideline).

1.1.20 After undertaking a detailed clinical history and examination, perform multi‑channel filling and voiding cystometry 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. [2006, amended 2013]

1.1.22 Consider ambulatory urodynamics or videourodynamics if the diagnosis is unclear after conventional urodynamics. [2006, amended 2013]

The criteria for multi‑channel filling and voiding cystometry has been updated to improve clarity and implementation.

The recommendation for ambulatory urodynamics has additional text to clarify that this procedure should take place following unclear outcomes from an initial urodynamic assessment.

For the small group of women with a clearly defined clinical diagnosis of pure stress UI, the use of multi‑channel cystometry is not routinely recommended.

(Recommendation [1.1.10.2] in 2006 guideline).

1.1.21 Do not perform multi‑channel filling and voiding cystometry in the small group of women where pure SUI is diagnosed based on a detailed clinical history and examination. [2006, amended 2013]

Explanatory text was added to the recommendation on multichannel filling and voiding cystometry particularly because establishing a diagnosis of pure SUI requires a detailed clinical history and examination. This has been added to the recommendation to avoid women being offered surgical treatment for SUI without the identification of any symptoms of OAB.

The use of desmopressin may be considered specifically to reduce nocturia in women with UI or OAB who find it a troublesome symptom. However, the use of desmopressin for nocturia in women with idiopathic UI is outside the UK marketing authorisation for the product. Informed consent to treatment should be obtained and documented.

(Recommendation [1.2.4.5] in 2006 guideline).

1.7.18 The use of desmopressin may be considered specifically to reduce nocturia[a] in women with UI or OAB who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension. [2006, amended 2013]

The cautionary note for the use of desmopressin has been updated to reflect current clinical practice. The updated caution is taken from the current BNF indications for use.

Augmentation cystoplasty for the management of idiopathic detrusor overactivity should be restricted to women who have not responded to conservative treatments and who are willing and able to self‑catheterise. Preoperative counselling should include common and serious complications: bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder, UTI and urinary retention. The small risk of malignancy occurring in the augmented bladder should also be discussed. Life‑long follow‑up is recommended.

(Recommendation [1.3.2.2] in 2006 guideline).

1.9.14 Restrict augmentation cystoplasty for the management of idiopathic detrusor overactivity to women whose condition has not responded to conservative management and who are willing and able to self‑catheterise. Preoperative counselling for the woman or her carer should include common and serious complications: bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder, UTI and urinary retention. Discuss the small risk of malignancy occurring in the augmented bladder. Provide life‑long follow‑up. [2006, amended 2013]

'for the woman or her carer' has been added to the recommendation. This update has been made to reflect the equality of treatment of some women who would be required to catheterise. 'Provide life‑long follow‑up' has been added to give a direct instruction and to match the recommendation for urinary diversion.

Urinary diversion should be considered for a woman with OAB only when conservative treatments have failed, and if sacral nerve stimulation and augmentation cystoplasty are not appropriate or are unacceptable to her. Life‑long follow‑up is recommended.

(Recommendation [1.3.2.3] in 2006 guideline).

1.9.15 Urinary diversion should be considered for a woman with OAB only when conservative management has failed, and if botulinum toxin A[b], percutaneous sacral nerve stimulation and augmentation cystoplasty are not appropriate or are unacceptable to her. Provide life‑long follow‑up. [2006, amended 2013]

'Provide life‑long follow‑up' has been added to give a direct instruction and to match the recommendation for augmentation cystoplasty.

Intramural bulking agents (glutaraldehyde cross‑linked collagen, silicone, carbon‑coated zirconium beads, or hyaluronic acid/dextran co‑polymer) should be considered for the management of stress UI if conservative management has failed. Women should be made aware that:

  • repeat injections may be required to achieve efficacy

  • efficacy diminishes with time

  • efficacy is inferior to that of retropubic suspension or sling.

(Recommendation [1.3.3.4] in 2006 guideline).

1.10.11 Consider intramural bulking agents (silicone, carbon‑coated zirconium beads or hyaluronic acid/dextran copolymer) for the management of stress UI if conservative management has failed. Women should be made aware that:

  • repeat injections may be needed to achieve efficacy

  • efficacy diminishes with time

  • efficacy is inferior to that of synthetic tapes or autologous rectus fascial slings. [2006, amended 2013]

Glutaraldehyde cross‑linked collagen has been removed from this recommendation. This update has been made because collagen is no longer used for this procedure in the UK.

[a] At the time of publication (September 2013), desmopressin did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[b] 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.

Minor changes since publication

October 2013: Minor amendment made to the botulinum toxin A footnote to accurately reflect the licence for the BOTOX, Allergan preparation.

  • National Institute for Health and Care Excellence (NICE)