NICE guidelines on urinary incontinence in women

NICE has just produced a guideline on the treatment of urinary incontinence in women. Urinary Incontinence is defined by the International Continence Society as ‘the complaint of any involuntary leakage of urine’. It may occur as a result of a number of abnormalities of function of the lower urinary tract or as a result of other illnesses, which tend to cause leakage in different situations.

Stress incontinence is involuntary urine leakage on effort or exertion or on sneezing or coughing. Urge incontinence is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to defer).

Mixed incontinence is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing.

Overactive bladder syndrome (OAB) is defined as urgency that occurs with or without urge UI and usually with frequency and nocturia. OAB that occurs with urge incontinence is known as ‘OAB wet’. OAB that occurs without urge UI is known as ‘OAB dry’. These combinations of symptoms are suggestive of the urodynamic finding of detrusor overactivity, but can be the result of other forms of urethrovesical dysfunction.

Among a large number of other recommendations the guideline suggests that at the initial clinical assessment, the woman’s urinary incontinence (UI) should be categorised as stress UI, mixed UI, or urge UI/overactive bladder syndrome (OAB). Initial treatment should be started on this basis. In mixed UI, treatment should be directed towards the predominant symptom.

Bladder diaries should be used in the initial assessment of women with UI or OAB. Women should be encouraged to complete a minimum of 3 days of the diary covering variations in their usual activities, such as both working and leisure days.

The use of multi-channel cystometry, ambulatory urodynamics or videourodynamics is not recommended before starting conservative treatment. For the small group of women with a clearly defined clinical diagnosis of pure stress UI, the of multi-channel cystometry is not routinely recommended. Multi-channel filling and voiding cystometry is recommended in women before surgery for UI if there is clinical suspicion of detrusor overactivity, or there has been previous surgery for stress incontinence or anterior compartment prolapse, or there are symptoms suggestive of voiding dysfunction.

Ambulatory urodynamics or videourodynamics may also be considered in these circumstances.

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NICE Public Health Intervention Guidance

The NICE Public Health Intervention Guidelines are increasingly appearing on the NICE web pages. There follows the first four recommendations for smoking cessation guidance as examples of what can be found.

Recommendation 1

Everyone who smokes should be advised to quit, unless there are exceptional circumstances. People who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future. If an individual who smokes presents with a smoking-related disease, the cessation advice may be linked to their medical condition.

Recommendation 2

People who smoke should be asked how interested they are in quitting. Advice to stop smoking should be sensitive to the individual’s preferences, needs and circumstances: there is no evidence that the ‘stages of change’ model  is more effective than any other approach.

Recommendation 3

GPs should take the opportunity to advise all patients who smoke to quit when they attend a consultation.

Those who want to stop should be offered a referral to an intensive support service (for example, NHS Stop Smoking Services). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy, in line with NICE technology appraisal guidance no. 39, and additional support. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year.

Recommendation 4

Nurses in primary and community care should advise everyone who smokes to stop and refer them to an intensive support service (for example, NHS Stop Smoking Services). If they are unwilling or unable to accept this referral, they should be offered pharmacotherapy by practitioners with suitable training, in line with NICE technology appraisal guidance no. 39, and additional support.

Nurses who are trained NHS stop smoking counsellors may ‘refer’ to themselves, where appropriate. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.

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Physical activity and obesity in  children

Obesity in children has increased dramatically in recent years. Systematic reviews have reported a dearth of high quality evidence from randomised controlled trials. More recent interventions have usually been unsuccessful. Only a single long term randomised controlled trial reported as being of high quality in systematic reviews found benefits to the intervention (attributed to reduced time spent watching television). Despite the need for trials in obesity prevention in children, a systematic review to the end of 2003 identified only six ongoing trials, most of which were focused on adolescent girls from minority groups in the United States

A recent BMJ study was set up to assess whether a physical activity intervention reduces body mass index in young children. It was a cluster randomised controlled single blinded trial over 12 months in thirty six nurseries in Glasgow. There were 545 children in their preschool year.

An enhanced physical activity programme was carried out in the nurseries plus home based health education aimed at increasing physical activity through play and reducing sedentary behaviour. The body mass index, physical activity and sedentary behaviour; fundamental movement skills were measured. Children in the intervention group had significantly higher performance in movement skills tests than control children at six month follow-up after adjustment for sex and baseline performance.

It is concluded that physical activity can significantly improve motor skills but did not reduce body mass index in young children in this trial.

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