Lifestyle Interventions

• Manage any reversible causes or contributing factors (See NICE CKS).
• Provide advice on:
  • Caffeine intake (reducing intake may improve symptoms of urgency).
  • Fluid intake (avoid excessive or restricted amounts).
  • Weight loss if BMI is >30kg/m²
  • Smoking cessation.
• Offer information on self-help resources e.g., The NHS website.

Conservative Management

• Consider referral to Bladder and Bowel Care Services and Continence Advisory Teams
  • South Devon & Torbay
  • Western locality

• Containment products should only be considered:
  • As an interim measure whilst awaiting assessment or response to ongoing treatment.
  • For long term management where other treatment options are ineffective or not suitable.

The prescriber should review the use of containment products annually.

Absorbent pads or pants

• Thin absorbent pads or pants are commercially available at pharmacies or supermarkets for mild to moderate incontinence.
• Incontinence pads for severe intractable urinary incontinence can be obtained (where appropriate) from a continence service (Western locality and South Devon and Torbay)

Urinals, toileting aids, and intravaginal / intraurethral devices

• Seek advice from continence service.
• Intravaginal / intraurethral devices should not be used for the routine management of urinary incontinence. They should only be considered for occasional use when necessary to prevent leakage (e.g., during physical exercise).

Catheters

• Seek advice from continence service.
• Only indicated for persistent urinary retention which is causing incontinence, symptomatic infections, or renal dysfunction and cannot be otherwise corrected.

Delivered by continence services (Western locality and South Devon and Torbay)

Women with urinary urgency (overactive bladder) or mixed urinary incontinence:

• Offer bladder training for a trial period of at least 6 weeks.
• If a satisfactory benefit is not achieved after 6 weeks, consider adding pharmacological treatment (see below).

Women with stress incontinence or mixed urinary incontinence:

• Offer pelvic floor muscle training for a trial period of at least 3 months.
• If no improvement in symptoms after 3 months, consider referral to urology (urogynaecology if significant pelvic organ prolapse). Please note, local specialists indicate that surgery is not typically offered if BMI>35kg/m².

Drug treatment is indicated where lifestyle interventions and physical or behavioural therapies are unsuccessful.

Chronic retention can present with frequency (particularly in the elderly). If there is doubt, arrange a bladder scan prior to initiating drug treatment.

In post-menopausal women with vaginal atrophy, symptoms may be linked to oestrogen deficiency; consider intravaginal oestrogen (See 7.2.1 Preparations for vaginal and vulval changes).

Offer an anticholinergic drug:

• Solifenacin tablets; 5 mg once daily, increased if necessary to 10 mg once daily (see 7.4.2 Drugs for urinary frequency).
• If the patient is at risk of cognitive impairment (e.g., dementia) consider trospium tablets (immediate release); 20mg twice daily, before food (see 7.4.2 Drugs for urinary frequency). Where trospium is ineffective or not tolerated, consider mirabegron (see below).

If symptoms persist (after 4 weeks) or solifenacin not tolerated:

• Switch to tolterodine tablets (immediate release); 2mg twice daily, reduced to 1mg twice daily if not tolerated (see 7.4.2 Drugs for urinary frequency).
  • Modified release tablets (4mg once daily) are only indicated where tolterodine immediate release tablets are effective but not tolerated.

If the above options are effective but not tolerated:

• Switch to fesoterodine; 4 mg once daily, increased if necessary up to 8 mg once daily (see 7.4.2 Drugs for urinary frequency).

If the above anticholinergic drugs are contraindicated, not tolerated, or not effective:

• Switch to mirabegron tablets modified release; 50mg once daily (see 7.4.2 Drugs for urinary frequency).

Darifenacin and oxybutynin are not routinely recommended for initiation in primary care without advice and guidance from urology; treatment may be continued in established patients (See 7.4.2 Drugs for urinary frequency for further details).

For all anticholinergic drugs / mirabegron:

Review after 4 weeks (or sooner if unable to tolerate adverse effects) consider assessing anticholinergic burden (e.g., acbcalc.com). If effective and tolerated schedule further reviews on an annual basis (every 6 months for women over 75 years of age).

If symptoms do not improve following a trial of two or more anticholinergics and/or mirabegron (as above), consider a referral to urology. Management options may include specialist drug treatment (e.g., botulinum toxin type A for urinary incontinence due to detrusor overactivity; See 4.9.3) or surgery.

Duloxetine may be considered following specialist advice for moderate to severe stress urinary incontinence where pelvic floor muscle training fails and surgery is not suitable or the patient prefers drug therapy.

• See 4.3.4 Other antidepressant drugs.

Manage according to the most predominant symptom (urgency incontinence or stress incontinence, see above).

Drug treatment is indicated where nocturnal polyuria remains bothersome despite attempts to exclude or manage treatable causes and the use of lifestyle interventions (see above) are unsuccessful or not appropriate.

Local specialists advise considering a loop diuretic.

• Furosemide tablets; 20mg to 40mg once daily in the late afternoon (off-label).
• If already prescribed a diuretic, consider moving a morning dose to a mid-afternoon dose.

If furosemide is ineffective or not appropriate:

• Consider specialist advice and guidance or a referral to urology.
• Desmopressin may be appropriate if recommended by a specialist (continence service or urology); sublingual tablets 25 micrograms once daily, one hour before bedtime (See 6.5.2 Posterior pituitary hormones and antagonists).