A comparison of the National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) Guidelines for the Assessment and Management of Urinary Incontinence in Women
Introduction
Urinary incontinence (UI), the complaint of any involuntary leakage of urine (1), is a common and significant issue for health services worldwide. The British Association of Urological Surgeons (BAUS) suggest a conservative estimate of approximately 3 million sufferers in the UK(2). 95% of cases of urinary leakage are stress and / or urgency incontinence, with a plethora of treatment options available to the healthcare professional involved in their management. Here, we appraise and compare the guidelines most relevant to UK practice. These are provided by NICE (first published in 2006 with a significant update in 2013 and minor changes in 2015), and the EAU (first published in 2007, updated annually and most recently in 2016). These guidelines are aimed at providing high level evidence-based advice to a range of stakeholders in the treatment of urinary incontinence; namely, urologists, urogynaecologists, general practitioners, continence specialist nurses and therapists and patients themselves. We aim to provide clarity where there is high level evidence and accepted consensus, and identify where the two organisations differ in their recommendations, suggesting associated explanations and options for treatment.
Guideline Content
Both the NICE and EAU guidelines follow a similar stepwise management algorithm for their treatment recommendations. They build from lifestyle adjustment and conservative management through pharmacological therapies to surgical intervention. For the most part, similar clinical questions and management strategies are discussed in the two guidelines, the detail of which we will set out below. Of note, the EAU guidance includes a section on the management of post-prostatectomy UI in men, not discussed in the NICE guidelines. This is not within the scope of this review. Furthermore, the EAU guidelines consider specific recommendations for elderly women,the management of whom are not differentiated by NICE.
The NICE guidelines are being updated to include further advice on surgical management in stress UI, the management of mesh related complications and the holistic management of pelvic organ prolapse (POP). The currently expected publication date for this is February 2019, and thus, NICE recommendations regarding this are not included in this review.
Methods
We identified whether an intervention was recommended or not in each guideline and the level / grade of evidence behind the recommendation. If more than one different level of evidence is appropriate for each recommendation we have used the highest level. If no specific level has been provided by the guideline then the respective table entry has been left blank.
Assessment and Investigation
History & Examination
Both guidelines suggest taking a history as the first step in the assessment of UI with a view to categorising the incontinence as either stress UI, urgency UI or mixed UI and therefore guiding treatment. Further detail of an obstetric and gynaecological history, past surgical history and a note of current medications should be taken. NICE also recommend eliciting a history of bowel symptoms. The history should identify other causative factors, particularly those that are suggestive of a more sinister aetiology, e.g. malignancy or fistula.
Both guidelines advise abdominal and pelvic examination which includes digital examination of the vagina +/- rectum and identification of a pelvic organ prolapse. NICE also recommend cognitive assessment in the elderly with complex medical comorbidities.
Recommendation EAU Level /Grade NICE Level Comment
Detailed history to determine type of UI Yes Yes 4
Detailed Obstetric History Yes Yes
Exclude other disorders Yes Yes*
Physical Examination Yes Yes
Pelvic Examination Yes Yes 4
Examine for POP Yes Yes 3
SUI O/E No No
EGGS** No No
Questionnaires Yes B Yes 3 To monitor changes
3 day Bladder Diary Yes 2b/A Yes 3
7 Day Bladder Diary Yes 2b/A Yes 3
Table 1: Comparison of the recommendations for assessment (UI – urinary incontinence; POP – pelvic organ prolapse; SUI – stress urinary incontinence)
• Not a specific recommendation but is noted within the body of the guideline text
** Expetations, Goals, ?, Satisfaction
Questionnaires
EAU guidance suggests validated symptom / quality of life questionnaires can be used in the identification of UI, assessment of severity and measure the response to treatment. In contrast, the NICE guidelines only recommend their use for assessing the impact of treatment. Furthermore, NICE provide a list of specific questionnaires it recommends for use based on a good level of evidence. This contrasts with the EAU guidance, which suggests the decision as to which questionnaire to use, is at the discretion of the clinician. Of note, two tools recommended by NICE are not included in EAU guidance at all. These are the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) score (5) and SEAPI-QMM (6).
Bladder diaries
Both guidelines recommend the use of bladder diaries, NICE specifying for at least 3 days, EAU for 3-7 days. NICE also recommend including a variety of days i.e. both normal working and leisure days.
Diagnostic Tests
Recommendation EAU Level/Grade NICE Level Comment
Urinalysis Yes 1/A Yes 2
PVR Yes 2/B Yes 4 No consensus on abnormal PVR
Pad Testing to quantify UI Yes 2/C No 3
Pad Testing to monitor changes
Yes 2/C Yes 4
Routine Imaging No 2b/A No 3 Not recommended
Cystoscopy in uncomplicated UI No No 3 Not recommended
Table 2: Comparison of the recommendations for investigation. (PVR – post void residual)
Urine testing
Both guidelines recommend urinalysis as a first line test in all that present with urinary incontinence. As a consequence of its high specificity, a test that is negative for both leucocytes and nitrites can be used to rule out urinary tract infection. NICE guidelines, unlike the EAU, specify that asymptomatic women should not be treated for a UTI until the results of a mid-stream urine culture is known. There is no recommendation in either guideline relating to pregnant women and UI. The EAU highlight that asymptomatic bacteriuria in the elderly should not be treated as a means for improving UI, as up to 60% of older women have an asymptomatic bacteriuria (3). Furthermore, eradicating the bacteriuria does not improve incontinence (4).
Post-void residual (PVR) volumes
Both guidelines recommend the use of bladder scans (ultrasound) as first-line measurement of PVR. Urethral catheterisation is a more accurate but invasive 2nd line that also has a greater risk of adverse events. Both guidelines recommend measuring PVR when there are symptoms suggestive of voiding dysfunction. The EAU also suggest PVR measurements are indicated when there is complex incontinence (not defined further) and following interventions that may worsen voiding dysfunction. NICE guidelines highlight measurement in a woman that suffers with recurrent UTIs. There is no consensus amongst the two guidelines as to what is an abnormal PVR.
Pad Testing
NICE guidelines do not recommend the use of routine pad testing but their guideline development group suggest there may be a role in assessing treatment effect. Conversely, the EAU guidelines suggest pad testing can be used to diagnose UI, quantify the amount and as a measure of treatment outcome as has been demonstrated following TVT and colposuspension for SUI (7). Both guidelines suggest a 24 hour pad test has a greater sensitivity than a 1 hour test but cannot conclude on the best testing protocol to use. Pad testing is more commonly used in the research domain compared with clinical practice. As highlighted by the International Continence Society, protocols that can be used and reproduced in the clinical setting are required to improve the uptake of pad testing to an easy, cheap and non-invasive aid to the assessment of UI.
Imaging
Both guidelines agree no routine imaging or cystoscopy should be performed in the diagnostic work-up of urinary incontinence.
Urodynamics
Recommendation EAU Level/Grade NICE Level Comment
Required before conservative treatment No 1a/B No 1
Required before primary simple SUI surgery No 1b No 3
Counsel that may not predict outcome Yes 1a/C Yes 4
Required if previous SUI surgery Yes 4 No EAU comment
Perform if Outcome will affect Treatment and Management Yes 1a/B Yes 2
Perform if diagnosis Unclear Yes No EAU comment
Perform if Symptoms suggest DO Yes No EAU comment
Perform if Voiding Dysfunction Yes No EAU comment
Perform if Previous Failed UI Invasive Treatment Yes Yes C
Ambulatory / video urodynamics if diagnosis remains unclear No 2 Yes 3
Perform UPP or LPP to grade UI severity No 3/C No Not discussed in NICE
Other urethral competence tests* No 3 No EAU comment
Table 3: Comparison of the recommendations for use of urodynamics. (SUI – stress urinary incontinence; DO – detrusor overactivity; UI – urinary incontinence; UPP – urethral pressure profile; LPP – leak point pressure)
* Other tests: Q-tip, Bonney, Marshall, Fluid-Bridge
Both guidelines agree urodynamics does not need to be carried out before conservative management or primary surgery for uncomplicated stress urinary incontinence because it does not affect the outcome (8,9).
The NICE guidance provides very specific instances for when urodynamics should be performed, namely clinical suspicion of detrusor overactivity (DO), voiding dysfunction symptoms, prolapse and previous SUI surgery. It does not, however, provide clear high level evidence for any of these recommendations. Conversely, the EAU provide much broader advice for the indication for using urodynamics as: when it will change your invasive management. The lack of detail provides a less useful clinical tool, but perhaps, better reflects the current level of evidence for the best use of urodynamics in this setting.
NICE recommends ambulatory or video-urodynamics if standard urodynamics does not provide the answer. The EAU guideline group accept with level 2 evidence that ambulatory urodynamics is more sensitive but stop short of recommending when it should be used.
Mixed Urinary Incontinence
Both the EAU and NICE currently recommend treating the predominant symptom. The EAU suggest results of SUI surgery worse in patients with MUI
Recommendation EAU Level NICE Level
Treat predominant symptom 1st Yes C Yes 4
Success of SUI surgery worse in MUI Yes 1c/A
Table 4: Comparison of the recommendations for the management of mixed urinary incontinence (SUI – stress urinary incontinence; MUI – mixed urinary incontinence)
Conservative Management
Lifestyle Advice
Recommendation EAU Level/Grade NICE Level Comment
Treat associated medical conditions Yes 3/A
Review new medications Yes 3/C
Treatment of Constipation Yes 4/C No 2
Use of containment devices or disposable pads for light UI Yes 1b/A No 1+ No NICE comment
Pads/External Devices/Incontinence for Moderate to Severe UI Yes 1b/A No 1+
Modification of Fluid intake Yes 2/C Yes 1
Smoking Cessation Yes 4/A No 2
Avoidance of Caffeine Yes 2/B Yes 1 Reduces urgency and frequency but not UI
Weight Loss Yes 1b/A Yes 1
Table 5: Comparison of the recommendations for lifestyle adjustment measures. (UI – urinary incontinence)
High level evidence to support the role of lifestyle modification on UI is lacking. The EAU recommends treating other associated conditions that may affect UI including cardiac failure, renal failure, diabetes, depression and cognitive impairment although there is no evidence this will improve their UI. They also recommend reviewing medications and avoiding constipation, however, again the evidence for this is weak. Likewise the role of long term moderate exercise on female UI is unclear. These specific modifications are not recommended by NICE.
Where there is a greater body of evidence the two organisations agree in their endorsement. This includes weight loss, modification of fluid intake if required and avoidance of caffeine. Both the EAU and NICE recommend a trial of reducing caffeine intake to improve urgency and frequency, (although it will not improve UI). NICE interestingly discusses the significant improvements in incontinence noted in case series following bariatric surgery.
Catheterisation
EAU guidance recommends the use of catheters as one of a number of options for management when other pharmacological or surgical interventions are ineffective, contraindicated or not wanted by the patient. They do not specifically make recommendations regarding the type, site or material of the catheter other than to suggest suprapubic catheterisation is associated with less urethral complications when compared with a long-term indwelling urethral catheter.
NICE guidance provides further detail in its recommendations. They suggest that an indwelling urethral catheter may not result in continence in UUI as a result of increased detrusor over-activity and highlight the use of intermittent catheterisation when possible. NICE also give strong guidance against the use of intravaginal or intraurethral devices.
NICE guidance specifically advises healthcare workers to not recommend complimentary therapies for managing UI.
Recommendation EAU Level/Grade NICE Level Comment
Scheduled Voiding No Yes 1
Prompted Voiding in cognitive impairment Yes 1b/A Yes 1
Combination bladder training and OAB drug 1b Yes 1 Not a specific EAU recommendation
PFMT for at least 3 months Yes 1/A Yes 1
PFMT to post-natal women with UI Yes 1/A Not specified in NICE
Consider using biofeedback Yes 1/A No 1
P-PTNS for UUI if failed antimuscarinics Yes 2b/B Yes 1 2nd Line Treatment
T-PTNS No 2a No 1
T-SNS No No 1
Table 6: Comparison of the recommendations for non-pharmacological, non-surgical management.. (OAB – overactive bladder; PFMT – pelvic floor muscle training; UI – urinary incontinence; P-PTNS – percutaneous posterior tibial nerve stimulation; UUI – urgency urinary incontinence; T-PTNS – transcutaneous posterior tibial nerve stimulation; T-SNS – transcutaneous sacral nerve stimulation)
Behavioural Therapies
Prompting of the elderly cognitively impaired patient to void by carers is recommended by both guidelines to improve incontinence. Scheduled voiding, the regular pre-planned voiding of urine at specified times is recommended by NICE.
Bladder training is offered if a patient is suffering from UUI or MUI to alter voiding intervals. Evidence suggests it does help urgency urinary incontinence if sustained (10). Both sets of guidance suggest combination with antimuscarinic can improve frequency symptoms although not necessarily incontinence.(11).
Pelvic Floor Muscle Training (PFMT)
EAU guidance on PFMT refers to the UK NICE technology appraisal. PFMT does improve UI particularly in women with SUI. The efficacy is improved with greater intensity, supervision and biofeedback. Both organisations say PFMT should be offered first line in SUI and MUI for at least 3 months. It should also be offered in post-natal UI according to the EAU to increase the chances of continence at 12 months (12) and as primary prevention for women in their first pregnancy according to NICE. NICE do not recommend using biofeedback whilst the EAU recommend considering it despite explaining that the evidence is contradictory and therefore far from conclusive. Furthermore, NICE suggests digital examination to confirm pelvic floor contraction prior to referral, and they provide very specific guidance on the exercises required (i.e. “at least 8 contractions three times per day”).
Electrical Neurostimulation
NICE are very clear that transcutaneous nerve stimulation (of either sacral or posterior tibial nerves) should not be performed to treat OAB. The EAU echo this. In regards to percutaneous posterior tibial nerve stimulation in UUI, the EAU suggest recommending if no improvement with antimuscarinics. NICE suggests this should only be an option if the woman does not want Botulinum Toxin A or percutaneous Sacral Nerve Stimulation options AND has been discussed in MDT.
Pharmacological Management
Antimuscarinic Drugs
Antimuscarinic drugs are the mainstay of treatment for overactive bladder symptoms in both continent (OAB dry) and incontinent (OAB wet) women. Both NICE and the EAU evaluated the use of the same 13 drug preparations, namely oxybutynin immediate release (IR), extended release (ER) and transdermal (TD), solifenacin, tolterodine IR and ER, Fesoterodine, Propiverine IR and ER, Trospium IR and ER and Darifenacin. The two groups agree that all preparations demonstrate an improvement in symptoms compared with placebo. However, there is no significant difference in the efficacy between the different drugs.
As a consequence, the EAU guidelines do not make any specific recommendations as to which antimuscarinic should be used first line other than to say immediate release preparations should be used initially. In contrast, NICE provide a specific list of three first-line antimuscarinics: oxybutynin immediate release, tolterodine immediate release and darifenacin once daily preparation. To evaluate all of the 13 agents, NICE performed their own de novo network meta-analysis combining and comparing trials where individual drugs were compared to placebo, instead of using the evidence from the few randomised trials directly comparing more than one preparation in the same study. The quality of evidence of the included studies was of a high standard but the differences in study populations used across a number of trials means that this data may not be the full and final story. Of note, the 3 recommended first line agents by NICE are, therefore, the three with the lowest cost per QALY.
Both guidelines agree on the recommendation not to use oxybutynin in elderly patients as a result of the increased risk of cognitive impairment. They also suggest the assessment of a patient’s total anticholinergic load prior to prescribing new OAB drugs again particularly in the elderly.
Overall, the NICE guidelines provide a significant emphasis on the fact that the first part of the pathway for the management of women with UI can and should be carried out in the primary care setting. This is particularly emphasised in the initiation of 1st line pharmacological therapy. The EAU guidelines do not take this approach. NICE recommend a follow-up review at 4 weeks following the start of a new therapy (or sooner of significant side effects). The EAU recommend review within 30 days.
NICE recommends against the use of flavoxate, propantheline and imipramine. EAU guidance does not discuss these agents.
Mirabegron
Mirabegron is a Beta 3 agonist targeting receptors in the detrusor muscle causing smooth muscle relaxation..
NICE guidelines refer readers to the linked NICE Technology appraisal (TA290). NICE recommend use only if antimuscarinics are ineffective, contraindicated or produce intolerable side effects. EAU does not provide such a clear hierarchy for when Mirabegron can be prescribed but does support its use in UUI.
Duloxetine
Duloxetine is a Serotonin and Noradrenaline presynaptic Reuptake Inhibitor. Its mechanism of action is thought to involve increased serotonin and noradrenaline in the sacral spinal cord causing an increased stimulation of the pudendal motor nerves leading to increased urethral sphincter tone and closing pressure.
Both guidelines identify significant frequency of side effects including GI (nausea, vomiting and constipation) and dry mouth, insomnia, fatigue and dizziness.NICE recommend that it should not be offered first or second line for SUI or MUI unless surgery is not an option. The EAU suggest it can be used for temporary improvement (does not cure the UI).
Oestrogen
Both guidelines agree that we should offer topical vaginal oestrogens to post-menopausal women with vaginal atrophy but should not offer systemic oestrogens for UI.
Desmopressin
Desmopressin is a synthetic vasopressin. The evidence presented by both guidelines is that use helps incontinence in the very short term only (13). NICE only recommend its use to treat nocturia that is particularly affecting quality of life. In contrast, EAU guidance recommends the unlicensed use for short term daytime incontinence. More importantly, however, it causes significant side effects including hyponatraemia for which monitoring would be required, as well as headaches, nausea, dizziness, UTIs and peripheral oedema.
Diuretics
These are not discussed in the EAU guidelines. NICE suggest insufficient evidence and therefore not recommended for treatment of nocturia.
Recommendation EAU Level/Grade NICE Level Comment
Anti-Muscarinics 1st Line Yes 1a/A Yes 1
Anti-Muscarinics Iso-Effective Yes 1a/A Yes 1
IR 1st line/ER 2nd line Yes 1b/A Not specified by NICE
Dose modification/Alternate anti-muscarinic if failure or side effects Yes A Yes 1
Transdermal Oxybutynin if dry mouth Yes 1b/B Yes 1
Offer early review Yes A Yes 1
Do not use oxybutynin in elderly Yes 2/A Yes 1
Mirabegron as 2nd line for UUI Yes 1a/B Yes (2nd line) 1+
Duloxetine SUI and MUI Yes 1a/B No 1+ NICE: only if surgery not an option
Topical oestrogen in post menopausal women with vulvo-vaginal atrophy Yes 1a a/A Yes 1+
Oral HRT worsens pre-existing UI/increases risk of developing UI YesYes 1a/A1a A YesYes 1+1+
Desmospressin – short term daytime Yes 1ba /B No
Desmospressin – short term nocturia No Yes 1+
Desmopressin – long term No 1b/A No
Table 7: Comparison of the recommendations for pharmacological management. (IR – immediate release; ER – extended release; UUI – urgency urinary incontinence; SUI – stress urinary incontinence; MUI – mixed urinary incontinence; HRT – hormone replacement therapy; UI – urinary incontinence)
Surgical Management
MDT
The NICE recommend that every patient should undergo an MDT review before any invasive treatment is offered. Regional clinical networks should be in place to allow access to treatments that cannot be provided in smaller hospitals. They also specify exactly who should be at the MDT:both a urologist and urogynaecologist, functional bowel sub-specialist colorectal surgeon if rectum involvement, specialist nurse and specialist physiotherapist. For elderly patients a member of the elderly care team +/- occupational therapist should be present.
The EAU make no recommendations regarding MDT discussions.
Urgency Urinary Incontinence Procedures
Botulinum Toxin A
NICE recommend that Botulinum Toxin A should be offered only if urodynamic proven DO and failure of conservative management. Women must have been trained in clean intermittent self-catheterisation (CISC) and able to perform it regularly if required. EAU agrees with this.
Importantly, NICE advise giving 200 units, as backed by meta-analysis (14) unless women wish to reduce their chances of having to catheterise, in which case 100 units can be used. If effective, follow-up at least 6 monthly and earlier if symptoms reoccur. They suggest that if treatment is ineffective the patient should be listed for repeat MDT discussion.
In contrast, the EAU recommends 100 IU only (as use at 200U not licenced) and specifies injecting at 20 sites. This is a significant divergence between the guidelines. Common accepted UK practice is in fact to give 100 IU at each application with 200IU the dosage used for neuropathic bladders.
NICE specify that one should not use Botulinum Toxin B. The EAU guidelines do not mention this, although they do clearly describe the use of Botulinum Toxin A only.
Percutaneous sacral nerve modulation (P-SNM)
NICE recommend P-SNM should be offered to those where conservative, pharmacological and botulinum toxin A treatment has failed and only before botulinum toxin A if they cannot perform CISC . Efficacy is backed by a Cochrane review, although, of note, in none of the RCTs analysed were participants blinded because a successful 1st stage was an entry requirement. (15). In contrast, the EAU do not give any guidance regarding a difference in the sequence to be used for these treatments. In other words, either intradetrusor botulinum toxin A injection or P-SNM can be used once conservative therapy has failed.
Of note, the EAU recommend that as part of the 2-stage approach a permanent tined lead rather than a temporary wire electrode should be used for the 1st stage (level of evidence = 4). NICE do not make any recommendation for this, although it is widely acknowledged that this is a superior approach, primarily because it ensures no movement of the lead position between test and full treatment. (16)
Augmentation Cystoplasty
The EAU suggests offering in cases of idiopathic DO only if unsuccessful with non-surgical management and botulinum toxin / P-SNM have been either unsuccessful or discussed and cannot be provided. NICE do not comment on where augmentation cystoplasty sits in the management algorithm compared to botulinum toxin or P-SNM. Both bodies highlight the importance of counselling patients on the key risks, namely needing to CISC and the small chance of malignancy. They also recommend lifelong follow-up. Neither guideline provides advice on what surveillance techniques should be used. Indeed, as suggested in a recent systematic review, this remains uncertain (17).
Urinary Diversion
Both guidelines suggest this is the final option in management of OAB. There is very little evidence for the use of urinary diversion techniques in idiopathic detrusor overactivity alone. Therefore, neither guideline provides further detail on the diversion technique to be used. Lifelong follow-up is recommended but no detail is provided for what surveillance is needed and in particular of the defunctioned bladder. Patients must be able to live with and manage a stoma.
Other Interventions
There is currently unclear evidence for the use of detrusor myectomy. Only case series have been reported and all patients had additional neurogenic bladder dysfunction (18). Neither guideline recommends this treatment.
Vanilloid receptor agonists (Resiniferatoxin) that act as capsaisin analogues to desensitise afferent neurons are discussed but not recommended by NICE. They are not discussed by the EAU. There is minimal evidence at present for use in various population groups (19,20), but no definitive RCT evidence in women with simple drug-resistant urge UI.
Recommendation EAU Level/Grade NICE Level Comment
Botulinum Toxin A for refractory UUI Yes 1a/A Yes 1
Councel re repeat injection, UTI, CISC Yes 3/A Yes
Able to do CISC first Yes A Yes
Start at 200U No Yes 1
Start at 100U Yes 1a/A No 1
Botulinum Toxin B No 1 No EAU comment
SNM for refractory UUI Yes 1b/A Yes 1
Councel re longterm failure/complications No Yes 4
Augmentation cystoplasty only for refractory DO not interested in Botox or SNM Yes C Yes 3
Councel re CISC, short and long term complications Yes 3/C Yes 3
Councel re small risk of malignancy Yes 3/C Yes 4
Urinary diversion if all other options unsuitable or fail Yes 3/C Yes 3
Detrusor Myectomy No 3/C No 3
Vanilloid Receptor Agonists No No
Table 8: Comparison of the recommendations for urgency urinary incontinence procedures. (UTI – urinary tract infection; CISC – clean intermittent self-catheterisation; SNM – sacral neural modulation; UUI – urgency urinary incontinence; DO – detrusor overactivity)
Primary Stress Urinary Incontinence Procedures
Mid-urethral Slings / Colposuspension / Autologous Fascial Slings
The EAU suggest there is no significant difference between the efficacy of treatment of SUI with a synthetic mid-urethral sling compared with open colposuspension, but colposuspension has more adverse events including urgency and voiding dysfunction. Consequently they recommend mid-urethral sling’s to be used first line. Colposuspension (open or laparoscopic – they do not recommend one surgical approach over the other) or autologous fascial sling are to be advised only if a mid-urethral sling is not appropriate. Unlike NICE, the EAU suggest AFS is more effective than colposuspension. This also contradicts a Cochrane systematic review where no significant difference in efficacy is noted (21). This disparity is, as they themselves suggest, a result of their use of a single RCT for this evidence (22). Of note, they, do not go further and make this a formal recommendation. In contrast, NICE recommend mid-urethral sling, open colposuspension or autologous rectus facial sling with no clear preference. They also suggest laparoscopic colposuspension should not be performed except by surgeons experienced in the procedure.
With regards to the mid-urethral sling approach, both panels suggest similar efficacy of the retropubic vs transobturator technique. Transobturator provides less risk of intra-operative complications, namely bladder perforation but greater risk of longer term complications including vaginal erosion and chronic pain. They do not specify whether one approach or the other should be used preferentially, nor what should influence that decision. The EAU recommend an vagina to skin approach should be used for both retropubic and transobturator operations. (23). This is echoed by NICE. Furthermore, neither organisation recommends the use of single-incision slings. Whilst the single-incision operation is quicker and has less peri-operative adverse events, there remains no evidence of any benefit over the more conventional approaches (24). This may be a reflection of inter-operative variability for a relatively new procedure or the variability in the slings themselves. In addition, the material that should be used for a synthetic mid-urethral sling remains a constantly evolving debate. Current NICE guidelines recommend using the well established and tested type 1 macroporous polypropylene tape. This should be coloured to aid both primary insertion and the revision surgeon. The EAU do not make any recommendations regarding tape material or colour.
Finally, the EAU recommend a cystoscopy on all women having a mid-urethral sling inserted.
Bulking Agents
Both guidelines recommend that bulking agents can be used for short term management of SUI if conservative management has failed. The evidence suggests they are less effective than colposuspension or AFS but have significantly less adverse effects. There is a range of patient satisfaction reports compared to more invasive options that suggest both lower (25) and higher levels of satisfaction (26). The EAU highlight that bulking agents should not be offered if a permanent cure is required and both panels emphasise that multiple injections will be required. There is no consensus on the best route of injection i.e. transurethral or transperineal, although as both guidelines highlight a transperineal approach may increase the risk of urinary retention (25, 27).
Recommendation EAU Level/Grade NICE Level
Recommend MUS only as 1st Surgical option Yes 1a/A No
Retropubic = Transobturator cure Yes 1a Yes 1
Counsel higher risk dyspareunia, vaginal erosion and chronic pelvic pain with transobturator MUS and higher risk bladder perforation and voiding dysfunction with RP Yes 1a/A Yes 1
Recommend single-incision slings over conventional No 1c/A No
Cystoscopy for all MUS procedures Yes C No
Open=Laparoscopic Colposuspension Yes 1a No
Recommend Open NOT laparoscopic routinely No 1a/A Yes 1
AFS better than colposuspension for SUI Yes 1b No
If AFS must be able to CISC Yes 1b/C No
Colposuspension (open or lap) or AFS second line to MUS Yes A No
Bulking agent short term improvement in SUI only Yes 2a/A Yes 3
Do not offer to women seeking cure for SUI Yes 2a/A Yes 3
Table 9: Comparison of the recommendations for primary stress urinary incontinence procedures. (MUS – mid-urethral sling; RP – retropubic; AFS – autologous fascial sling; CISC – clean intermittent self-catheterisation; SUI – stress urinary incontinence)
Complex Stress UI Procedures
This is generally defined as patients who have had previous unsuccessful SUI surgery, concomitant POP or radiotherapy to the pelvis / perineum. NICE guidelines recommend referral to a tertiary service that has a case load of at least 20 complex SUI patients per year for further investigation and management. The EAU also recommend tertiary referral and further detailed patient evaluation. There is insufficient evidence to identify exactly what secondary procedures should be performed. As a result, neither guideline provides a clear treatment algorithm. Decisions are best assessed on a case by case basis. Of note, the EAU suggests AFS is better than colposuspension if the patient has had more than 2 previous surgeries. (28)
Artificial Urinary Sphincter (AUS)
Both panels recommend AUS only to be used if previous surgery has failed as a final option due to the high risk of adverse events. NICE recommend that patient undergoing AUS implantation should have lifelong follow-up.
Pelvic Organ Prolapse (POP)
Only discussed by EAU. They recommend offering simultaneous surgery for POP and SUI, but that combined surgery has an increased risk of adverse events. For patients with POP but no SUI patients should be counselled that there is an increased risk of developing UI post-operatively. Moreover, any benefits from prophylactic incontinence surgery at the same time as the primary POP procedure remain uncertain. As mentioned previously, the current NICE guidelines do not cover POP with UI.
Urethral Diverticulum
This is only covered by the EAU. They recommend excision if the patient is symptomatic.
Recommendation EAU Level NICE Level Comment
Refer to a tertiary centre Yes A Yes
Base surgery on evaluation of patient and their UDS Yes C Yes
SUI secondary surgery less effective than primary surgery Yes 2/C Yes
No evidence for superiority of 1 surgical technique for recurrent SUI Yes 3 Yes
AFS > open colposuspension if >2 previous SUI surgeries Yes 2 No
AUS last line SUI therapy Yes 3/C Yes
Concomitant SUI and POP surgery ok Yes 1a/A No NICE comment
Combined POP & SUI surgery increases risks Yes 1b/A No NICE comment
Benefit of prophylactic SUI surgery during POP Surgery uncertain Yes 1b/C No NICE comment
Counsel increased risk of SUI after POP surgery Yes 1a/A No NICE comment
Table 10: Comparison of the recommendations for complex stress urinary incontinence procedures. (UDS – urodynamics; SUI – stress urinary incontinence; AFS – autologous fascial sling; AUS – artificial urinary sphincter; POP – pelvic organ prolapse
Surgical Competance
The NICE guidelines finish with a section on the appropriate training and standards expected of surgeons performing incontinence procedures. Apart from the generic transferable skills generally expected of a fully trained and competent surgeon, NICE suggest that a surgeon should be performing a minimum of 20 cases of each primary incontinence operation per year with no real evidence upon which to base this recommendation. They also say that if performing less than 5 cases/year clear local governance policies should be in place otherwise patients should be referred to a larger volume centre – suggesting it is acceptable for a surgeon performing < 5 cases per year to continue providing they audit their data and are subject to regular clinical governance review.. It is unclear what should be happening with surgeons and their patients who perform 5-19 cases per year but we assume a similar situation to those performing less than 5 cases per year. The EAU guidance follows the NICE criteria for the description of a competent surgeon but does not put a number on the volume of cases that should be completed.
Conclusions
Key differences:
• The EAU recommends pad testing in the initial work up of urinary incontinence, NICE does not (recommends only useful to assess treatment response)
• NICE recommend the use of urodynamics in all that have had failed SUI surgery and video and/or ambulatory urodynamics if the diagnosis remains unclear. The EAU does not give such strict criteria for performing a cystometrogram (CMG).
• The EAU recommend the use of biofeedback with PFMT. NICE do not.
• The EAU recommend the use of duloxetine as a second line agent in the management of UI. Conversely, NICE recommend its use only if surgery is not an option and further pharmacological therapies are required.
• They disagree on the use of desmopressin – EAU for short term daytime use, NICE for short term use to improve nocturia.
• The EAU recommend starting botulinum toxin A therapy at 100 units, NICE at 200 units.
• The EAU clearly state a mid-urethral tape is first line surgical management for primary SUI. NICE also recommend that open colposuspension or autologous rectus fascial sling can be used.
• The EAU recommend a cystoscopy as part of every MUS procedure, NICE do not have this specific recommendation.