Clinical guidelines: an overview for primary care

Terminology

Under ICS/IUGA terminology, urinary incontinence is the complaint of any involuntary loss of urine.

• Stress (SUI) — on effort, exertion, coughing or sneezing.
• Urgency (UUI) — accompanied or immediately preceded by a sudden compelling desire to void.
• Mixed (MUI) — a combination of stress and urgency.
• Overactive bladder (OAB) — urgency, usually with frequency and nocturia, with or without incontinence, in the absence of infection or other obvious pathology.

Initial assessment

• Classify incontinence by history (SUI, UUI/OAB, MUI) and start treatment for the predominant type.
• Assess impact on quality of life with validated questionnaires (e.g. ICIQ-SF).
• Bladder diary for at least 3 days, covering working days and days off.
• Urine dipstick to exclude infection and haematuria; send for culture if infection is suspected.
• Physical examination: abdomen, perineum, vaginal examination assessing prolapse, atrophy and pelvic floor contraction.
• Post-void residual (preferably by ultrasound) if there are voiding symptoms or recurrent infections.
• Urodynamics are not needed before conservative treatment for clear SUI or OAB.

A detailed step-by-step pathway is in Initial assessment pathway.

Conservative treatment (first line)

Electrical stimulation and biofeedback are not recommended routinely but may help women who can't actively contract their pelvic floor.

Drug treatment of OAB

• Offered when bladder training hasn't been effective enough.
• Before prescribing antimuscarinics, consider anticholinergic burden, especially in older and frail patients (risk of cognitive impairment and falls).
• β3-agonists are an alternative when antimuscarinics are contraindicated, ineffective or not tolerated.
• Post-menopausal women with vaginal atrophy and OAB: local vaginal oestrogen.
• Review effect and tolerability 4 weeks after starting or changing a drug.

Specific drugs and doses follow current clinical protocols of the Ministry of Health of Kazakhstan and local formularies.

When to refer

• visible haematuria; microscopic haematuria in women aged 50 and over;
• recurrent or persistent urinary tract infection with haematuria in women aged 40 and over;
• suspected pelvic mass;
• bladder or urethral pain; suspected fistula;
• palpable bladder after voiding, significant residual urine;
• symptomatic prolapse visible at or beyond the vaginal introitus;
• suspected neurological cause;
• previous continence surgery, radical pelvic surgery or pelvic radiotherapy;
• failure of first-line treatment; the woman wishes to consider surgery.

Invasive treatment (specialist level)

For SUI after failed conservative treatment: synthetic mid-urethral slings, colposuspension, autologous fascial slings, bulking agents. For refractory OAB: botulinum toxin A injections, percutaneous tibial nerve stimulation, sacral neuromodulation. Decisions are made by a multidisciplinary team after urodynamic assessment and an informed discussion of risks.

Documentation

Record the leading symptom, diary and questionnaire results, examination findings, options discussed, the agreed plan and the follow-up date. This makes the pathway clear for the patient and the next specialist.

Sources

1. NICE guideline NG123. Urinary incontinence and pelvic organ prolapse in women: management. 2019. nice.org.uk
2. EAU Guidelines on Non-neurogenic Female LUTS. uroweb.org
3. AUA/SUFU Guideline on Surgical Treatment of Female Stress Urinary Incontinence (2023); Guideline on Idiopathic Overactive Bladder (2024). auanet.org
4. Haylen BT, et al. An IUGA/ICS joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4–20.