Initial Management:
- Eliminate caffeine
- Stop smoking
- Lose weight: aim for a BMI below 30
- Manage constipation
- Advise patient to keep well hydrated (concentrated urine causes bladder irritation)
- Limit fluid intake 2 to 4 hours before bed if patient has bothersome nocturia
- Pelvic floor physiotherapy for at least 3 months
- If pelvic organ prolapse present and causing prolapse symptoms → refer to Physiotherapy for 3 to 6 months as above.
If symptoms persist → refer to Gynaecology pelvic floor clinic.
Pelvic floor physiotherapists can also directly refer the patient to the clinic after their assessment and treatment if more input is required to save primary care appointment and re-referral.
- If patient is post-menopausal and has vulvo-vaginal atrophy:
Prescribe estradiol vaginal tablets (10 microgram) or topical oestrogen: estriol cream (Ovestin 0.1%). Commence nightly for 2 weeks, reduce to alternate nights for 2 weeks followed by twice weekly application for maintenance. If there are physical issues using the vaginal tablet or cream, the 3 monthly estradiol ring (Estring) could be an alternative.
- Non-hormonal alternatives on the Highland Formulary include Hyalofemme, Replens and Sylk vaginal moisturisers. Alternative, non-formulary preparations available to be bought are Regelle and YES vaginal moisturisers.
New in NICE 2019
- Only offer absorbent containment products, urinals and toileting aids
- 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.
If all conservative management does not improve symptoms, offer a trial of medication in addition to ongoing conservative measures. Medication should be commenced at the lowest possible dose and may be increased. Side effects can limit tolerance and should be monitored.
1st Line: Trial for 4 to 6 weeks then review:
- Solifenacin
- 5mg, oral, once daily. Dose can be increased to 10mg once daily after 3 to 4 weeks.
Cautions and contraindiations: see 
Or, if antimuscarinics contra-indicated, alternative first line treatment:
- Mirabegron 50mg, oral, once daily
- if patient has renal or hepatic impairment, use reduced dose of 25mg once daily
Cautions and contraindiations: see
Renal and hepatic impairment: See sections 4.2 and 4.4 in the Summary of Product Characteristics for dosing information.
2nd Line: Trial for 4 to 6 weeks then review:
- Mirabegron 50mg, oral, once daily
- if patient has renal or hepatic impairment, use reduced dose of 25mg once daily
Cautions and contraindiations: see
Renal and hepatic impairment: See sections 4.2 and 4.4 in the Summary of Product Characteristics for dosing information.
Review and Follow Up in Primary Care:
- If stable and symptoms improved, review in primary care annually (or every 6 months if aged over 75)
- If no improvement after trial of 2 medications or intolerant to medication refer to urology incontinence clinic
New in NICE 2019
When offering anticholinergic medicines to treat overactive bladder, take account of:
- Coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia)
- Current use of other medicines that affect total anticholinergic load
Anticholinergic burden calculator: http://www.acbcalc.com
- Risk of adverse effects, including cognitive impairment
Patients using absorbent containment products for long-term management of urinary incontinence should have an annual review by the district nurse including:
- Routine assessment of continence
- Assessment of skin integrity
- Changes to symptoms, co-morbidities, lifestyle, mobility, medication, BMI, and social and environmental factors
- The suitability of alternative treatment options
- The efficacy of the absorbent containment product the patient is currently using and the quantities used
