Urinary incontinence and pelvic organ prolapse in primary care

Urinary incontinence (UI) is thought to affect up to 70% of women at some point in their life (Milsom, 2019). According to Smith et al (2010), 50% of parous women will develop a pelvic organ prolapse (POP) in their lifetime. The prevalence for both of these problems increases with age and represents a significant problem in healthcare as the population ages.

The National Institute for Health and Care Excellence (NICE) (2006; 2013) guidelines have previously made practice recommendations for the management of female UI in primary and secondary care; however, there has never been a guideline related to POP. Given that a significant number of women will experience either UI, POP or both in their lifetime, NG123 was published in April 2019 (NICE, 2019) to not only update the UI guidelines, but to also provide the first ever guidance on the assessment and management of POP.

A significant proportion of this guideline is directed at specialist services, surgical management and or management of complications. However, this article aims to update the changes to recommendations regarding UI and present an overview to the recommendations for POP that will be relevant to initial assessment and management in primary care.

Urinary incontinence

Assessing urinary incontinence

In line with previous guidelines, an initial assessment of UI should include a full medical history, including gynaecological, obstetric and nitrites. It is advised to send a midstream urine specimen for culture and analysis of antibiotic sensitivities, and to prescribe an appropriate course of antibiotic treatment pending culture results. This is in line with the NICE (2018) guideline on lower urinary tract infection (UTI) and antimicrobial prescribing. Note that due to regional variations in antibiotic resistance, local policies should be consulted for prescribing recommendations.

Indications for referral to a specialist service

In women with UI, indications for referral to a specialist service (without initial management in primary care) remain unchanged. However, for all women with haematuria (visable and non-visable) or recurrent or persistent unexplained UTI it is now recommended to follow the referral guidelines from the NICE (2017) urinary tract cancer guideline.

Non-surgical management of urinary incontinence

Conservative or non-surgical management of UI is still recommended as the first-line treatment. Firstly, women with an overactive bladder (OAB) should be advised to trial a reduction in caffeine. For all women with a particularly high or low fluid intake, modification to intake should be advised, with a recommended daily fluid intake based on 25 ml/kg of body weight per 24 hours (NICE, 2015). All women presenting with UI who have a BMI greater than 30 kg/m² should be advised to lose weight as this may help to improve incontinence.

Pelvic floor muscle training

A new recommendation this year is for all women with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) to be offered at least 3 months of supervised pelvic floor muscle training (PFMT) as first-line treatment. This programme should include at least eight contractions performed at least three times per day and a suitably qualified health professional should assess pelvic floor contract to ensure that women are performing the exercises correctly and to assess changes in strength over the course of treatment.

It is often necessary to refer into a specialist women's health physiotherapist or community continence specialist nurse to provide this service. If PFMT is beneficial it is recommended to continue in the long term. An NHS-approved app called Squeezy (Ryan, 2014) has been developed to help prompt and motivate women with their exercises as well as assisting in monitoring progression.

Electrical stimulation/biofeedback/gadgets

Women often buy devices to help stimulate their pelvic floor, often with the misconception that this will do the work for them and improve their pelvic floor without any of their own effort. However, this is not the case and the recommendation is that biofeedback and electrical stimulation should not be used routinely in combination with PFMT. Electrical stimulation and/or biofeedback should only be considered for women who cannot actively contract pelvic floor muscles to aid motivation and adherence to therapy.

Behavioural therapies

In line with both previous guidelines, bladder retraining should be offered for a minimum of 6 weeks as a first-line treatment for all women with OAB, UUI and MUI. This involves trying to defer voiding, initially for a short time (eg 30 seconds) and building up to minutes/hours depending on baseline frequency. This is achieved through a combination of urge suppression techniques and lifestyle changes, such as modifying fluid intake. For some women, bladder retraining alone may not provide significant benefit and medication may also be required.

Absorbent containment products, urinals and toileting aids

Due to escalating costs in primary care for pads and aids, and concerns that these were being prescribed without appropriate initial assessment or reassessment, it was included in this new guideline. This is particularly relevant to district nurses or community continence nurses who are generally providing these in primary care. It has been advised that we should not routinely offer absorbent containment products, hand-held urinals or toileting aids to treat urinary incontinence. They should only be offered:

• As a coping strategy pending definitive treatment
• As an adjunct to ongoing therapy
• For long-term management of urinary incontinence only after treatment options have been explored (NICE, 2019).

For those women who are using absorbent containment products for long-term management of urinary incontinence, it is recommended that they are reviewed at least annually. The review should cover:

• Routine assessment of continence
• Assessment of skin integrity
• Changes to symptoms, comorbidities, lifestyle, mobility, medication, BMI, and social and environmental factors
• The suitability of alternative treatment options
• The efficacy of the absorbent containment product the woman is using and the quantities used (NICE, 2019).

Practice recommendations have also been made to suggest who should be performing these reviews in recognition of the changing workforce in the community. It is advised that these reviews should be undertaken by either:

• A registered health professional trained in assessing continence and making referrals to specialist services
• A non-registered healthcare worker under the supervision of a registered health professional who is trained in assessing continence and making referrals to specialist services (NICE, 2019).

Pharmacological management of urinary incontinence

Medicines for overactive bladder

The main changes to the guidelines regarding medications for OAB is related to advice that women should be given before starting medication. It is recognised that managing expectations around medications is essential for compliance and the most common reason why women stop medication is that it did not work as expected (Basra, 2008). It is therefore recommended that before starting medication of OAB, women should be advised on:

• The likelihood of the medicine being successful
• The common adverse effects associated with the medicine
• That some adverse effects of anticholinergic medicines, such as dry mouth and constipation, may indicate that the medicine is starting to have an effect
• That they may not see substantial benefits until they has been taking the medicine for at least 4 weeks and that their symptoms may continue to improve over time
• That the long-term effects of anticholinergic medicines for overactive bladder on cognitive function are uncertain (NICE, 2019).

Another new recommendation is in line with concerns regarding cognitive function that was raised by Fox et al (2014). They reported that people with a high anticholinergic load are more likely to develop dementia/cognitive impairment and anticholinergic medications were recognised as one of the high-risk drugs.

Therefore, it now recommends that when offering anticholinergic medicines to treat OAB, take account of the woman's:

• Coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia)
• Use of other medicines that affect total anticholinergic load
• Risk of adverse effects, including cognitive impairment (NICE, 2019).

NICE (2019) further clarifies that for women who have a diagnosis of dementia and who may need an anticholinergic medicines to treat OAB, recommendations on medicines that may cause cognitive impairment in the NICE guideline on dementia should be followed.

Choosing anticholinergics medicines

The main difference in the new guideline is that there are now no recommendations for individual preparations as first- or second-line therapy. It is now recommended that for women with OAB and MUI, they should be offered medication based only on the lowest acquisition cost and if this is not effective or tolerated, then another drug with a low acquisition cost should be prescribed. Table 1 displays all the drugs available and their NHS drug tariff costs based on dosage.

Other drugs

There are no new recommendations related to alternative drugs for UI. For the use of Mirabegron to treat OAB symptoms, the guideline advises following the NICE (2013) technology appraisal where it can be used as a first-line therapy in women where anticholinergics are contraindicated or as a second-line therapy when anticholinergics have not been tolerated.

For women with nocturia and nocturnal polyuria, Desmopressin should be considered, however, caution should be taken and increased monitoring is required prior to and in the initial stages of therapy. For women with OAB, intravaginal oestrogens should be used to treat OAB symptoms in post-menopausal women with vaginal atrophy. However, systemic hormone replacement therapy should not be used to treat any form of UI. Finally for women with SUI, the only drug available is Duloxetine; however, this should not be offered as a first-line therapy and should only be offered if women do not want or are unsuitable for surgery.

Reviewing medicine

There are very few changes to the new guidelines with regards to reviewing medication with the guideline still recommending a face-to-face or telephone review after 4 weeks to assess treatment efficacy, tolerability and satisfaction. If changes are made to treatment a further 4-week review should be arranged. If women have been unsuccessful or unable to tolerate medication then referral to secondary care should be considered. The only new recommendation is related to long-term medication where it is now suggested that all women who remain on long-term medicine for OAB or UI should be offered a review in primary care every 12 months, or every 6 months if they are aged over 75 years.

Pelvic organ prolapse

Definitions and risk factors

POP is a definition of anatomical change, primarily the downward displacement of a pelvic organ (eg the uterus, and/or the different vaginal compartments) and their neighbouring organs such as the bladder, rectum or bowel (Haylen et al, 2016).

POP is associated with a number of different risk factors including:

• Pregnancy and childbirth
• Ageing and the menopause
• Lifestyle and exercise
• Constipation
• Smoking
• Obesity
• Continuous heavy lifting
• Strenuous exercise in the gym
• Chronic illnesses that result in constant stress and strain on the pelvic floor
• Previous pelvic surgery
• Genetic factors such as connective tissue weakness (hypermobility)
• Genetic collagen deficiency disorders (such as Marfan syndrome or Ehlers-Danlos syndrome).

POP is very common in women who have had children and many of these women are unaware that they have a POP and do not experience any symptoms of POP. In these cases it is only noted when women attend for routine gynaecological assessment (eg for smear tests). Women tend to seek help in primary care when they develop symptoms associated with their POP. POP is commonly noticed by a feeling of pelvic fullness, pressure or pain, a dragging sensation or a feeling of ‘something falling out’. Women may also present with bladder, bowel or sexual symptoms (Table 2).

Assessing pelvic organ prolapse

For women presenting in primary care with symptoms or an incidental finding of vaginal prolapse it is recommended to:

• Take a history to include symptoms of prolapse, urinary, bowel and sexual function
• Perform a vaginal and abdominal examination to rule out a pelvic mass or other pathology and to document the presence of prolapse
• Discuss the woman's treatment preferences with her, and refer if needed (NICE, 2019).

Routine imaging, such as transvaginal ultrasound scans, are not routinely recommended unless there is suspicion of a pelvic mass or the POP is not detected by a physical examination.

For women with symptoms of POP, but examination in the supine position does not demonstrate a POP, the woman should be examined in a standing or a squatting position, or at a different time (eg at the end of the day) as this may change examination findings (NICE, 2019). On referral to a specialist service (either in secondary care or a specialist community gynaecology clinic) an examination will be performed to assess the POP in line with an international quantification system (POP-Q), assess the activity of the pelvic floor muscles, assess and treat vaginal atrophy and rule out other pathology. Validated questionnaires will be used at this stage.

Investigations

For asymptomatic women, no routine investigations are recommended. For those who present with bladder or bowel symptoms it is recommended that investigations are considered when women have:

• Urinary symptoms that are bothersome
• Symptoms of obstructed defaecation or faecal incontinence (the NICE guideline on faecal incontinence in adults has recommendations on baseline assessment of faecal incontinence)
• Pain
• Symptoms that are not explained by examination findings (NICE, 2019).

Non-surgical management of pelvic organ prolapse

In standard practice, there are three treatment options available to manage POP. The first is to do nothing, the second is conservative management including lifestyle advice, pelvic floor muscle exercises and the use of intravaginal pessaries and the third is surgical management. Treatment options should be discussed with women taking into account their preferences, comorbidities, age, desire for childbearing, site of POP, previous abdominal or pelvic surgery and the benefits and risks of individual procedures (NICE, 2019).

Lifestyle modification

It is recommended to provide lifestyle advice to women with POP, including information on:

• Losing weight, if the woman has a BMI greater than 30 kg/m2
• Minimising heavy lifting
• Preventing or treating constipation
• Pelvic floor muscle training (NICE, 2019).

As with UI, PFMT is very effective in reducing symptoms associated with POP (although it is unlikely to put the walls of the vagina back to their original place). It is therefore recommended that all women with a stage 1 or 2 POP (ie coming down to the introitus) should be offered a 16-week supervised course of PFMT. For those who this is beneficial for they should be encouraged to continue this in the long-term.

Topical oestrogen

‘There may be considerable variation across CCGs and in primary and secondary care with regards to formulary restrictions. Dependent on formulary rules, some practices may restrict the number of drugs available, while others may allow the full range. As a minimum, all formularies should have an immediate release preparation, a modified release preparation, and an alternative mode of delivery’

Atrophy of the vulva, vagina, lower urinary tract and supporting pelvic structures can be caused by prolonged oestrogen deprivation and results in a range of genitourinary symptoms including discomfort, pain, prolapse, urinary incontinence and impairment of sexual function and has been shown to negatively impact on quality of life (Sousa et al, 2017). The prevalence of vaginal atrophy increases with age with one study suggesting it ranges from 64.7% to 84.2%, starting from 1 to 6 years after menopause (Palma et al, 2016).

Given the impact that atrophy may have on symptoms it is advised to consider vaginal oestrogens for women reporting POP with signs of atrophy. This should be prescribed in line with the section on managing short-term menopausal symptoms in the NICE guideline on menopause (NICE, 2019).

Women should be counselled that it can take 6–12 months of therapy to reverse the atrophic changes and if treatment is stopped then symptoms will recur after a period of time. In line with this, certain preparations such as Vagifem pessaries are licensed for life-long use.

Vaginal pessaries

According to Lamers et al (2011) a pessary is a device that is inserted into the vagina to provide structural support to one or more of the descending vaginal compartments. It can be used on its own or in conjunction with pelvic floor muscle training. Pessaries are recommended in women who:

• Choose to try a pessary
• Wanting symptomatic relief while waiting for or delaying surgery
• Are pregnant or wish to consider future pregnancies
• Are unfit or choose not to undergo surgery.

In primary care there is a lack of health professionals are trained and confident with pessary fitting and long-term management and it is generally only GPs with a special interest in gynaecology that provide this. For women who wish to try a pessary, but there is no local service available, onward referral to a urogynaecology service is recommended. This secondary care pessary service will generally be led by nurse specialists.

If a service is available in primary care it is recommended that before starting pessary treatment women should be advised to:

• Consider treating vaginal atrophy with topical oestrogen
• Explain that more than one pessary fitting may be needed to find a suitable pessary
• Discuss the effect of different types of pessary on sexual intercourse
• Describe complications including vaginal discharge, bleeding, difficulty removing pessary and pessary expulsion
• Explain that the pessary should be removed at least once every 6 months to prevent serious pessary complications (NICE, 2019).

Women can be taught how to self-manage their pessaries so that they can remove them for activities such as sexual intercourse (if they find it uncomfortable during sex) and it can be washed and replaced. Replacement pessaries can be provided on prescription. For those who are unable to self-manage or who are at risk of complications, they should be offered an appointment in a pessary clinic every 6 months for review.

Referral to secondary care

Referral to secondary care is recommended early for women with symptomatic POP or for those with a grade 3 or above POP (descending past the introitus). Referral to specialist services should also be offered to those with a mild POP whose symptoms have not improved with conservative management or for those who do not have appropriate access to PFMT or pessary services in primary care.

Impact on guidelines in secondary care

The main focus of this new guideline provides recommendations for surgical management of UI and POP in secondary care. Particular focus is given not only to when and what type of surgery should be offered, but on what investigations should be performed before surgery and that all surgery should be discussed by a multidisciplinary team (and who that team should include). In view of the controversies surrounding certain surgeries for UI and POP, a large part of the document relates to identification and management of mesh complications.

Alongside the guideline, patient decision aids have been developed to help women understand the outcomes and potential complications for all surgeries for UI and POP to encourage informed decision-making.

Relevance for practice nurses

There may be considerable variation across CCGs and in primary and secondary care with regards to formulary restrictions. Dependent on formulary rules, some practices may restrict the number of drugs available, while others may allow the full range. As a minimum, all formularies should have an immediate release preparation, a modified release preparation, and an alternative mode of delivery (ie patches). Formulary committees should also take into consideration variations in compliance with some of the older generic drugs compared to newer branded drugs which, despite increased monthly costs, may be more cost-effective in the longer term.

Conclusions

This review has discussed the sections of the new NICE guidelines for UI and POP that are pertinent to those providing care for women in primary care. The main new points related to UI are regarding assessment of UTI, drug choice for OAB and the provision of containment products and toileting aids. The POP guideline is the first of its kind and although is mainly focused on specialist care in does make recommendations for assessment and non-surgical management in primary care.

KEY POINTS

• Urinary incontinence (UI) and pelvic organ prolapse are very common complaints for women
• Initial assessment is key to rule out underlying pathologies
• For women with UI, conservative management should be the first-line therapy offered in primary care
• Referral to secondary care is recommended early for women with symptomatic prolapse or prolapse descending past the introitus

CPD reflective practice

• How does this new guideline fit in with your current practice?
• Can you think of a patient that you have seen recently that you would now treat differently
• Has this article highlighted any areas for further learning for you?