Urinary Incontinence and Pelvic Organ Prolapse in Women: Management (NICE NG123)
Overview
This guideline provides evidence-based recommendations for the assessment and management of urinary incontinence (UI) and pelvic organ prolapse (POP) in women. It includes advice on lifestyle interventions, non-surgical management, surgical options, and post-treatment care.
Who is it for?
- Healthcare professionals managing UI and POP.
- Commissioners and providers ensuring access to appropriate care.
- Women experiencing urinary incontinence or pelvic organ prolapse.
General Principles of Care
- Use a patient-centered approach that considers the woman’s preferences and goals.
- Provide clear information about treatment options, including benefits, risks, and potential side effects.
- Ensure shared decision-making between the healthcare provider and the patient.
- Consider psychological and emotional impact of UI and POP, offering support or referral if needed.
- Discuss lifestyle modifications alongside clinical management.
Assessment of Urinary Incontinence (UI)
Initial Evaluation
- Take a detailed history covering:
- Type of incontinence (stress, urgency, mixed, overflow).
- Frequency and severity of symptoms.
- Impact on quality of life.
- Red flag symptoms (hematuria, recurrent UTIs, pelvic pain, neurological symptoms).
- Obstetric history: Parity, mode of delivery, perineal trauma.
- Menopausal status and hormonal influence.
- Previous UI treatments or surgeries.
Physical Examination
- Abdominal examination to assess for bladder distension or masses.
- Pelvic examination to check for prolapse, atrophic changes, or tissue integrity.
- Digital vaginal examination to assess pelvic floor muscle function and screen for levator ani avulsion.
- Neurological assessment in case of suspected neurogenic bladder dysfunction.
Diagnostic Tests
| Test |
Indication |
| Urinalysis |
Exclude infection, hematuria, or glycosuria |
| Bladder diary (3 days) |
Assess voiding patterns, frequency, urgency, and leakage episodes |
| Urodynamic testing |
Consider in refractory cases or prior to invasive treatment |
| Pad test |
Quantifies urine leakage over time |
| Post-void residual volume measurement |
Detects incomplete bladder emptying |
| Cystoscopy |
Consider if there is persistent hematuria or bladder pain |
Conservative Management of UI
Lifestyle Interventions
- Encourage weight loss in women with BMI >30 kg/m².
- Advise on fluid management (reducing caffeine, alcohol, and excessive fluid intake).
- Encourage smoking cessation, as smoking is a risk factor for UI.
- Manage constipation, as chronic straining worsens UI and POP.
Pelvic Floor Muscle Training (PFMT)
- First-line treatment for stress UI.
- Minimum duration: 3 months.
- Supervised sessions improve adherence and outcomes.
- Consider adjunctive biofeedback if no improvement after 3 months.
Bladder Training
- First-line treatment for urgency UI (overactive bladder).
- Encourage scheduled voiding intervals and gradually increase the time between voids.
- Can be combined with pharmacological therapy.
Pharmacological Treatment
| Drug Class |
Indication |
Examples |
Considerations |
| Anticholinergics |
Overactive bladder |
Oxybutynin, Tolterodine, Solifenacin |
Avoid in older adults due to cognitive side effects |
| Beta-3 agonists |
Overactive bladder |
Mirabegron |
Preferred for elderly patients |
| Duloxetine |
Stress UI |
Consider if surgery is not an option |
May cause nausea, fatigue |
Surgical Management of UI
Surgical Options for Stress UI
| Procedure |
Mechanism |
Considerations |
| Mid-urethral sling (MUS) |
Supports urethra to prevent leakage |
Standard procedure, high success rate |
| Colposuspension |
Elevates the bladder neck |
More invasive but effective |
| Autologous fascial sling |
Uses patient’s own tissue for support |
Consider if MUS is unsuitable |
| Urethral bulking agents |
Increases urethral resistance |
Less durable, may require repeat injections |
Surgical Options for Urgency UI
| Procedure |
Mechanism |
Considerations |
| Botulinum toxin injection |
Inhibits detrusor overactivity |
Requires repeat injections every 6–12 months |
| Sacral nerve stimulation |
Modulates bladder nerve activity |
Consider if refractory to medications |
| Bladder augmentation surgery |
Expands bladder capacity |
Reserved for severe cases |
Assessment of Pelvic Organ Prolapse (POP)
Initial Evaluation
- History:
- Symptoms: Vaginal bulging, pressure, urinary issues, defecatory dysfunction.
- Impact on daily activities and sexual function.
- Risk factors: Age, parity, obesity, chronic constipation, prior pelvic surgery.
- Physical Examination:
- Pelvic exam in both supine and standing positions to assess prolapse severity.
- POP-Q (Pelvic Organ Prolapse Quantification) system for standardized grading.
- Neurological examination if symptoms suggest nerve involvement.
Diagnostic Tests
| Test |
Indication |
| Urinalysis |
To exclude infection |
| Bladder diary |
To assess associated UI |
| Urodynamics |
If considering surgery |
| MRI or ultrasound |
For complex or recurrent prolapse |
Post-Treatment Care
- Monitor for symptom recurrence and complications.
- Encourage ongoing pelvic floor exercises.
- Regular follow-up after pessary fitting or surgery to assess effectiveness and adverse effects.
- Monitor post-surgical recovery and assess for complications such as mesh erosion or voiding dysfunction.
Future Research Directions
- Effectiveness of PFMT for preventing prolapse progression.
- Long-term outcomes of surgical procedures.
- Patient-reported outcomes following conservative vs. surgical treatment.
- Development of safer and more effective mesh materials.
Key Takeaways
- Lifestyle interventions and pelvic floor therapy are first-line treatments for UI and POP.
- Bladder training and pharmacological therapy help manage urgency UI.
- Surgery is reserved for moderate to severe cases impacting quality of life.
- Pessary use provides a non-surgical option for POP.
- Shared decision-making is crucial in selecting the most appropriate treatment.