Guideline Gyn 7
Division of Surgery
Directorate of Obstetrics and Gynaecology
Guidelines for the initial management of women with lower
urinary tract symptoms
Compiled by Jennifer Davies, June 2001.Amended August 2002. Updated August 2005.
Updated August 2008. Updated by Shatha Attarbashi August 2011
Ratified by SIT:
Latest date for review:
17th August 2011
August 2014
Definition
Lower urinary tract symptoms are those which are related to control of
micturition and incontinence. Also included in lower urinary tract problems
are recurrent urinary tract infections (excluding pyelonephritis) and bladder
pain.
Introduction
In this Trust we are extremely fortunate in that we have an Integrated
Continence Service between the PCT and our own Trust. Within the PCT
there is an excellent Continence Advisory Service comprising a team of 4
specialist nurses led by Rose Moran who work in the Community in various
clinics. Rose Moran also attends the bladder assessment clinic at Leigh
Infirmary. Chris Eaves and Rachel Hurst are specialist physiotherapists in
Women’s Health and work in both primary and secondary care with clinics at
Chandler House, Worsley Mesnes Health Centre, Wrightington and Leigh
Infirmary. Direct referrals to either service can be made. Please make a
referral by sending a copy of the clinic letter; this is preferable to completing
a referral form as it will contain more information.
Contact details;
Mrs Rose Moran, Hindley Health Centre, Liverpool Road, Hindley WN2 3HG
Tel 01942 482497 Fax 01942 482527
Mrs Chris Eaves, Chandler House, Worsley Mesnes Health Centre,
Poolstock Lane, Wigan WN3 5HL. Tel 01942481462
or
Physiotherapy department, Leigh Infirmary ext 4160 (01942 264160)
Rachel Hurst,
It is intended that women with lower urinary tract symptoms which do not
require surgery should be managed as far as possible in primary care.
Inevitably, women will still on occasions be seen in a general gynaecology
clinic for management of urinary symptoms but they should be referred to the
continence advisory service or physiotherapy for further management as
often as possible. If this is done further hospital appointments should
not be made as they will be made if necessary at a later date as both
teams can refer directly into the bladder assessment clinic or for
urodynamics without a further referral from a GP. If further hospital
management is required this will usually be in the bladder assessment clinic
at Leigh Infirmary.
Guidelines
A. General
Action
1. 1An abdominal and pelvic
examination should be performed
Rationale
To exclude the presence of
masses
To exclude an overdistended
bladder
To establish whether there is any
tenderness of the urethra and
bladder
To identify any concomitant
prolapse (remembering this may
be coincidental and not the cause
of the urinary tract symptoms)
2. 2Neurological abnormalities which
may be contributing to the
symptoms should be excluded as
far as possible by history with or
without a brief neurological
examination.
Neurological abnormalities are
commonly associated with bladder
symptoms as a result of
neurogenic detrusor overactivity
(previously detrusor hyperreflexia)
3. 3MSU should be sent for culture
prior to any investigations
Any infection should be adequately
treated and the urine re-tested
before proceeding with
investigations
Initial management urinary symptoms (Gyn 7)
Latest date for review August 2014
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4. 4Consider cystoscopy prior to other
investigations in cases of:
To exclude malignancy or other
pathology
a) frank haematuria without
infection
b) sterile pyuria on two
separate occasions (when not
taking antibiotics)
c) bladder pain and no other
urinary symptoms at all (UDS
may still be useful especially if
the cystoscopy is negative)
B. Specific Situations
1. Recurrent urinary tract infections
Action
1. 1Exclude glycosuria
Rationale
Sugar provides an excellent culture
medium for bacteria
2. 2Refer to bladder assessment clinic
to ascertain normal voiding
Long term residual urine promotes
UTIs
3. 3Commence treatment with 3
months rotating antibiotics e.g. 1
month each of 3 of the following:
If the bladder remains infection free
for some months the bladder
mucosa becomes less inflamed
and therefore less prone to
infection
Trimethoprim 200 mgs daily
Nitrofurantoin 50mg daily
Norfloxacin 400 mgs. daily
Cefalexin 250mg daily
Amoxycillin 250mg daily
Doxycycline 100mg daily
Ciprofloxacin 250mg daily
Ofloxacin 200mg daily
4. 4If voiding is abnormal try to
improve voiding (urethral dilatation,
intermittent self catheterisation )
+/- antibiotics as above
5. 5If there are further infections
despite this arrange cystoscopy
Initial management urinary symptoms (Gyn 7)
Latest date for review August 2014
Reduction of residual urine reduces
infection rates (retained urine can
provide an excellent culture
medium for infection even in the
absence of sugar)
To exclude other pathology within
the bladder
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6. 6If other urinary symptoms persist
when infection free, arrange full
urodynamics
Infection is clearly not the only
cause of urinary symptoms in this
situation
2. Symptoms suggestive of idiopathic detrusor overactivity (previously
detrusor instability)
Action
1. 1MSU
a) treat any infection and repeat
b) if negative proceed to 2
2. 2Treat with low dose antibiotics for
3 months (trimethoprim 200mg
nocte) if any of the following are
present
Rationale
Infections are the commonest
cause of all urinary symptoms
Chronic inflammation within the
bladder and urethra is a common
cause of lower urinary tract
symptoms
a) feeling of cystitis or bladder
discomfort
b) tender urethra or bladder base
c) voiding difficulties
d) symptoms provoked initially by
a UTI
Review after 2 months usually by
referring to the Continence
Advisory Service (copy the letter to
the GP to Rose Moran, Clinical
Nurse Specialist Continence by
way of a referral for follow up)
a) if no improvement try
alternative treatments as below
b) if improved continue for full 3
months then discontinue and
review 2-3 months after
stopping
Initial management urinary symptoms (Gyn 7)
Latest date for review August 2014
Benefit is usually experienced after
6 – 8 weeks
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3. 3If none of the above are present
prescribe trial of an anticholinergic
for at least 6 weeks. Available
anticholinergics are:
 Detrusitol XL 4mg od
(tolterodine)
 Lyrinel XL 10-15mg od
(oxybutynin)
 Vesicare 5mg od (solifenacin)
 Regurin 20mg bd (trospium)
 Detrunorm 15mg tds
(Propiverine) also available as
Detrunorm XL 30mg od
 Emselex 7.5mg od
(darifenacin)
 Toviaz 4mg and 8mg od
(Fesoterodine Fumarate)
Warn about side effects and give
patient information leaflet (tablets
used to treat bladder problems)
mentioning that they may reduce
with time but if they are intolerable
stopping the tablets will lead to a
resolution within a few days.
 Dry mouth
 Constipation
 Indigestion
 Dry eyes
 Blurred vision
Request review by the Continence
Advisory Service (send a copy of
the letter to the GP to Rose Moran,
Clinical Nurse Specialist
Continence).
4.
If anticholinergics have been
commenced and are effective then
continue for 6 months but also
refer to Continence Advisory
Service as above for bladder
retraining.
Initial management urinary symptoms (Gyn 7)
Latest date for review August 2014
If anticholinergic agents are
beneficial then it is likely that the
diagnosis is idiopathic detrusor
overactivity (previously detrusor
instability) and urodynamic studies
are not required if the patient is
cured.
Choose a once daily anticholinergic
as a first option as compliance with
these is better.
NOTE solifenacin and
darifenacin have longer half lives
than the others and if changing
from solifenacin or darfinacin to
another anticholinergic a one week
break from treatment is required
before starting the new medication.
Oxybutynin is also available as a
transdermal preparation 1 patch
twice a week delivering 3.9mg
daily, this preparation may reduce
side effects.
The team at the Continence
Advisory Service are experts in the
management of these problems
and can review patients in the
community.
If bladder retraining is effective the
anticholinergics may be able to be
reduced or even stopped.
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5. 4 If the above measures have not
resulted in a satisfactory
improvement, commence an
alternative anticholinergic and
refer to the bladder assessment
clinic.
 If the patient declines treatment
with tablets refer to the bladder
assessment clinic.
 If the patient has already had 3
months of empirical treatment
with at least 2 anticholinergics
refer for full urodynamic
studies.
In the bladder assessment clinic
the history can be reviewed with
the benefit of input/output charts.
Voiding can be investigated.
Urodynamics provide objective
evidence of the cause of bladder
symptoms.
6. 5The following issues will be
addressed in the bladder
assessment clinic
 if voiding is abnormal try to
improve voiding (urethral
dilatation, intermittent self
catheterisation) +/- antibiotics
as above
 if voiding is normal consider
 bladder and fluid intake
education
 bladder retraining
 low dose antibiotics if
appropriate
 trial of alternative
anticholinergics
The same measures as above will
be employed but review will take
place in a clinic dedicated to these
problems with more time to review
the entire history once again
3. Symptoms suggestive of pure stress incontinence
Action
1. 1MSU - treat any infection and
repeat
Rationale
Infection may cause symptoms
which masquerade as stress
incontinence
2. 2If MSU negative refer for
physiotherapy
Physiotherapy is the first treatment
of choice for stress incontinence
Initial management urinary symptoms (Gyn 7)
Latest date for review August 2014
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3.
Duloxetine may be offered as a
second line therapy if women
prefer pharmacological to surgical
treatment, or if not suitable for
surgery.
The full dose is 40mg bd but it can
be commenced at 20mg od to
reduce side effects, gradually
increasing to the full dose (20mg
od for 3 days, 20mg bd for 3 days,
20mg od and 40mg od for 3 days,
40mg bd).
If no beneficial effect after 3 weeks
on the full dose it is unlikely to be
effective. It probably works better
combined with physiotherapy.
Duloxetine is a Serotonin
Noradrenaline Reuptake inhibitor
which improves tone of external
urethral sphincter. It treats stress
incontinence with a 50% reduction
in episodes. It was introduced in
November 2004.
The data sheet initially suggested
starting at 40mg bd and reducing
as necessary but more recent
company advice has suggested the
approach outlined here.
Nausea is the most problematic
side effect.
If discontinuing after more than 1
week of therapy reduce slowly to
avoid rebound mood swings
Watch with SSRIs
Not with MAOIs
Not with fluvoxamine or
ciproflaxacin (inhibit CYP1A2)
4. 3Refer for full urodynamics prior
. to surgery if physiotherapy fails or
is refused. As physiotherapy
facilities are limited within the Trust
consider referring for urodynamics
if stress incontinence is very
severe i.e. demonstrable in clinic
with an empty bladder.
As the bladder is an “unreliable
witness” stress incontinence should
be proven to be urodynamic stress
incontinence (previously genuine
stress incontinence) by urodynamic
studies prior to surgery.
This is absolutely essential in
cases where repeat surgery is
planned
4. Symptoms suggestive of mixed incontinence
Action
1. 1 Manage as for idiopathic detrusor
overactivity (previously detrusor
instability) combined with
physiotherapy
Rationale
Detrusor overactivity should be
controlled if possible prior to
surgery.
Physiotherapy can treat idiopathic
detrusor overactivity as well as
stress incontinence
2. 2Refer for full urodynamics before
considering surgery
To establish the relative
contribution from both components
of the incontinence
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3. 3If the idiopathic detrusor
. overactivity (previously detrusor
instability) has been controlled with
medication then urodynamic
studies should be performed whilst
taking medication
Usually medication is discontinued
for urodynamics to evaluate the
extent of the detrusor overactivty
but in this case it is only the stress
incontinence component which is
being evaluated as medication can
be continued post operatively.
References:
Abrams P ( 2006. Urodynamics. 3rd edition. Springer.
Urinary incontinence: The management of urinary incontinence in women.
NICE Clinical Guideline No. 40 (October 2006).
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Latest date for review August 2014
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