Conservative management of urinary incontinence/overactive bladder (OAB)/stress incontinence in women

Conservative management

• lifestyle interventions (1)
  • trial of caffeine reduction is recommended for the treatment of women with overactive bladder syndrome (OAB)
  • consider advising modification of high or low fluid intake in women with urine incontinence (UI) or OAB
  • if body mass index greater than 30 then should be advised to lose weight
    
    
• physical therapies
  • trial of supervised pelvic floor muscle training of at least 3 months' duration - this should be offered as first-line treatment to women with stress or mixed UI
  • pelvic floor exercises may be effective in up to 50% of cases providing there is no serious degree of uterine prolapse (2)
    • critical factor is usually the woman's motivation to do the exercises
      
      
• behavioural therapies
  • bladder training lasting for a minimum of 6 weeks should be offered as first-line treatment to women with urge or mixed UI
    • if women do not achieve satisfactory benefit from bladder training programmes, the combination of an antimuscarinic agent with bladder training should be considered if frequency is a troublesome symptom
  • in women with UI who also have cognitive impairment, prompted and timed voiding toileting programmes are recommended as strategies for reducing leakage episodes
    
    
• drug therapies
  • choosing OAB drugs
    • do not use flavoxate, propantheline and imipramine for the treatment of UI or OAB in women
    • do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health
      
      
      • one of the following choices should be offered first to women with OAB or mixed UI:
        • oxybutynin (immediate release), or
        • tolterodine (immediate release), or
        • darifenacin (once daily preparation)
      • if the first treatment for OAB or mixed UI is not effective or well-tolerated, offer another drug with the lowest acquisition cost
        
        
    • offer a transdermal OAB drug to women unable to tolerate oral medication
      
      
    • Mirabegron is recommended as an option for treating symptoms of overactive bladder
      • only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects (1)
        
• Reviewing OAB drug treatment
  • offer a face-to-face or telephone review 4 weeks after the start of each new OAB drug treatment. Ask the woman if she is satisfied with the therapy:
    • If improvement is optimal, continue treatment
• If there is no or suboptimal improvement or intolerable adverse effects change the dose, or try an alternative OAB drug, and review again 4 weeks later

• offer review before 4 weeks if the adverse events of OAB drug treatment are intolerable

• offer referral to secondary care if the woman does not want to try another drug, but would like to consider further treatment

• offer a further face-to-face or telephone review if a woman's condition stops responding optimally to treatment after an initial successful 4-week review

• review women who remain on long-term drug treatment for UI or OAB annually in primary care (or every 6 months for women over 75)

• offer referral to secondary care if OAB drug treatment is not successful

• if the woman wishes to discuss the options for further management (non-therapeutic interventions and invasive therapy) refer to the MDT and arrange urodynamic investigation to determine whether detrusor overactivity is present and responsible for her OAB symptoms:
  • if detrusor overactivity is present and responsible for the OAB symptoms offer invasive therapy
  • if detrusor overactivity is present but the woman does not wish to have invasive therapy, offer advice as described in recommendation
  • if detrusor overactivity is not present refer back to the MDT for further discussion concerning future management
    
    

• Desmopressin

• the use of desmopressin may be considered specifically to reduce nocturia 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 (1)
  
  

• Duloxetine

• do not use duloxetine as a first-line treatment for women with predominant stress UI. Do not routinely offer duloxetine as a second-line treatment for women with stress UI, although it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects

• there is evidence that duloxetine is effective and safe in controlling the symptoms of female stress urinary incontinence, independent of the severity of incontinence (3)
  
  

• hormone replacement therapy (3)
  • systemic hormone replacement therapy is not recommended for the treatment of UI
  • intravaginal oestrogens are recommended for the treatment of OAB symptoms in postmenopausal women with vaginal atrophy

Notes:

• further treatment options
  • for women with OAB that has not responded to non-surgical management or treatment with medicine and who wish to discuss further treatment options:
    • urodynamic investigation should be offered to determine whether detrusor overactivity (involuntary bladder contractions seen during a cystometry test; they can be the cause of overactive bladder symptoms) is causing her OAB symptoms
    • and if detrusor overactivity is causing her OAB symptoms, an invasive procedure should be offered for management of symptoms
    • or if there is no detrusor overactivity, seek advice on further management from the local MDT

Reference:

1. NICE (April 2019). Urinary incontinence - The management of urinary incontinence in women
2. Drug and Therapeutics Bulletin (2003); 41 (6): 46-8.
3. Cardozo L. New developments in the management of stress urinary incontinence L. BJU Int 2004; 94 (s1):1-3.