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1、Urinary incontinence in womenOctober 2006Changing clinical practice NICE guidelines are based on the best available evidenceThe Department of Health asks NHS organisations to work towards implementing guidelines Compliance will be monitored by the Healthcare Commission Need for this guidelineUrinary
2、 incontinence (UI) commonly affects women of all agesIt can seriously affect physical, psychological and social wellbeingThe impact on families and carers may be profoundEstimated current cost to the NHS is 233 million annuallyUI is common but hiddenEstimated 4 million women over 40 years regularly
3、incontinent in UKUrinary incontinenceDefined as involuntary urinary leakageMay occur as a result of:functional abnormalities of the lower urinary tractother illnessesThese tend to cause leakage in different situations How UI presentsClassificationSymptomsStress UIon effort, exertion, or sneezing or
4、coughingMixed UIwith urgency and exertion, effort, sneezing or coughingUrge UI or overactive bladder syndrome (OAB)with or immediately preceded by a sensation of urgent need to urinate, with or without frequencySpot the risk factorsAssociations and possible risk factors include:ageobstetric factors
5、such as pregnancy and paritymenopause and hysterectomylower urinary tract symptomsfamily history and geneticssmoking, diet and obesitycognitive or functional impairmentTreatment pathwayLifestyle interventionsReferMixed UIOAB with or without urge UIStress UIOAB with or without urge UIStress UI Urodyn
6、amics if appropriate, not routinely for pure stress UIAssess and categoriseAssessmentConservative managementSurgical managementWhat the guideline coversInitial assessment and investigation Conservative management, including: bladder training supervised pelvic floor muscle training pharmacological th
7、erapyMulti-channel cystometrySurgical treatment optionsCompetencies for surgeons performing operationsAssess and investigateAssess using:bladder diariesurine dipstick testpost void residual volumeConsider:fluid intake caffeine consumptionweight lossCategorise and treat according to type of UI Suppor
8、t initial assessmentRaise awareness of NICE recommendations and develop training opportunities to focus on key aspects Review and update local referral and care pathwaysUse local multidisciplinary and specialist teams, such as integrated continence servicesUse tools and questionnaires to support sym
9、ptom scoring and quality of life assessment Manage conservativelyStress UIMixedUIUrge UI or OABFirst pregnancyPelvic floor muscle training*Bladder training*Antimuscarinic treatment*Offer training and drugsPelvic floor muscle trainingEight contractions, three times a day, 3 months minimumBladder trai
10、ning 6 weeks minimumAntimuscarinic drugs Immediate-release oxybutynin as first choice Offer support and advice for side effectsMulti-channel cystometry, ambulatory urodynamics or videourodynamics are not recommended before starting conservative treatmentSupport conservative choicesReview who is offe
11、ring supervised pelvic floor muscle training and bladder training locally Update prescribing policies and formularies in line with the guidelineUnderline the importance of support and advice about side effects when prescribing medication for UIUse cystometry if appropriate Multi-channel filling and
12、voiding cystometry is recommended before surgery if:detrusor overactivity suspectedprevious surgery has been done for stress UI or anterior compartment prolapsesymptoms suggest voiding dysfunctionAlso consider ambulatory urodynamics or videourodynamicsOffer surgical managementIf conservative treatme
13、nts have failed for: overactive bladder with or without urge UI offer - sacral nerve stimulation stress UI offer- retropubic mid-urethral procedures -alternatively colposuspension or rectus fascial sling Skills for surgeonsSurgeons undertaking surgery should: receive appropriate training in the mana
14、gement of UI and associated disorders, orwork within a multidisciplinary team with this trainingregularly carry out surgery for UI in womenSupport surgical optionsReview local access, consider use of regional servicesFormally assess current practice for surgeonsMaintain skills with a minimum annual
15、workload - 20 cases per year per primary procedure Nominate a clinical lead within each surgical unitEncourage surgeons to submit outcomes to national registriesTreatment pathwayLifestyle interventionsReferMixed UIOAB with or without urge UIStress UIOAB with or without urge UIStress UI Urodynamics i
16、f appropriate, not routinely for pure stress UIAssess and categoriseAssessmentConservative managementSurgical managementTarget resourcesRecommendations with significant resource impactAnnual cost000sUrodynamic investigations before conservative treatment-3,019Urodynamic investigations before primary
17、 surgery-321Sacral nerve stimulation 307Total net saving of implementing the UI guideline -3,033Access tools onlineCosting toolscosting reportcosting templateAudit criteriaImplementation adviceAvailable from: www.nice.org.uk/CG040Access the guideline onlineQuick reference guide a summary www.nice.org.uk/CG040quickrefguideNICE guideline all of the recommendations www.nice.org.uk/CG040niceguidelineFull guideline all of the evidence and rationale www.nice.org.uk/CG040fullguidelineUnderstanding NICE guidance a plain English version www.nice.org.uk/CG040publicinfo
