• Refer to a gynaecologist or urogynaecologist if there is associated prolapse that is symptomatic or visible at or below the introitus.
• Otherwise, refer to an appropriate practitioner for full assessment and consideration for a programme of supervised pelvic floor muscle training (PFMT) that should ideally last for at least 3 months. Women require an individualized programme based on assessment.
• Digital assessment of pelvic floor muscle contraction should be done before implementation of a PFMT programme.
• At a minimum, eight pelvic floor muscle contractions should be performed at least three times a day.
• The woman should be reviewed after 12 weeks or as required to assess response.
• The woman should be advised to continue taught PFMT exercises if she is experiencing sufficient benefit.
• The use of weighted vaginal cones or multicomponent behavioural therapy (bladder training plus PFMT) may improve the outcome of PFMT but requires specialist provision and high levels of motivation in the woman.
• Biofeedback may assist motivation, and electrical stimulation may be of help to women who cannot initiate a pelvic floor muscle contraction.
• If initial conservative treatments fail or if the woman expresses a preference, consider:
• Referring to a urologist, urogynaecologist, or gynaecologist for urodynamic investigations and surgery. See Secondary care treatments for stress urinary incontinence.
• Offering duloxetine as a second-line treatment, but only if the woman prefers pharmacological to surgical treatment or is not suitable for surgical treatment.
• Drug treatment with alpha 1A-adrenoreceptor agonists (for example, pseudoephedrine) is not recommended.
• In frail elderly people:
• Treat any reversible causes or contributing factors to stress urinary incontinence (such as cognitive impairment, urinary tract infection, excess fluid intake, restricted mobility, constipation, or adverse effects of medications).
• Take into account desire and suitability for treatment. Where appropriate, refer for full assessment and consideration of PFMT.
• Refer where appropriate to a continence adviser, the district nursing team, or elderly care team for specialist assessment for the management of incontinence.

• An appropriate practitioner will depend on local continence services and may be:
• A continence adviser/nurse specialist.
• A nurse specialist in urogynaecology.
• A physiotherapist specialising in women's health.
• The practitioner may be based in the community or in secondary care.
• Some GP practices may have a specially trained practice nurse.

Referral for symptomatic prolapse

• This is based on expert advice in guidance from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2006].

Supervised pelvic floor muscle training (PFMT)

• NICE [National Collaborating Centre for Women's and Children's Health, 2006] reviewed the evidence for PFMT and concluded that:
• There is good evidence from well-conducted randomized controlled trials (RCTs) that daily PFMT is an effective first-line treatment in women with stress and mixed urinary incontinence. The only adverse effects are occasional pain and discomfort.
• Clear evidence on an optimal training regimen is lacking. NICE therefore adopted the minimum number of pelvic floor exercises advised across the studies (that is, 24; eight contractions three times a day). As most studies evaluated 3 months of treatment, NICE considered this an appropriate duration of PFMT to recommend.
• Good evidence from RCTs indicates that there is no benefit from combining PFMT with either biofeedback or electrical stimulation. Therefore, NICE has not routinely recommended the use of biofeedback or electrical stimulation with PFMT. However, NICE concluded that the support generated by biofeedback may help to motivate some women, and electrical stimulation may be of value for women who cannot initiate a pelvic floor muscle contraction.
• CKS expert reviewers stressed the importance of:
• An individualized exercise programme.
• Digital assessment of pelvic musculature, as not all women are suitable for PFMT.

Weighted vaginal cones

• Although good evidence from RCTs indicates that weighted vaginal cones may be as effective as PFMT in the short term, they are not suitable for all women and there are compliance problems. NICE has therefore not recommended the use of vaginal cones. Several CKS expert reviewers commented that they may be useful in some women.

Multicomponent behaviour therapy

• Some evidence from RCTs indicates that multicomponent behavioural therapy reduces leakage episodes, but research on direct comparisons with single-component therapies is needed. NICE has not recommended multicomponent behavioural therapy.

Follow up

• As most studies evaluated the effect of PFMT after 12 weeks, NICE [National Collaborating Centre for Women's and Children's Health, 2006] recommended that this is an appropriate duration of PFMT before assessing its effectiveness and also advised continuing the exercises if they have been found to be beneficial.

Use of duloxetine

• NICE recommends that duloxetine be prescribed second line only to women who would not consider or are not suitable for surgical treatment.
• Although good evidence from RCTs indicates that short-term use of duloxetine in women with stress incontinence can reduce incontinence, increase the interval between voids, and improve quality of life, there is a lack of long-term effectiveness data for both PFMT and duloxetine and a lack of long-term safety data for duloxetine. Adverse effects, particularly nausea, are common.
• In addition, NICE does not recommend duloxetine as a first-line treatment for stress urinary incontinence because results from a NICE economic model suggested that PFMT is more cost effective than duloxetine alone. NICE does not recommend duloxetine as second-line treatment routinely — only if a woman prefers pharmacological to surgical treatment or is unsuitable for surgical treatment. This is based on a second economic model that suggested surgery was cost effective relative to duloxetine as a second-line treatment to PFMT.

Referral for surgery

• Surgery is an option if conservative treatments have failed. NICE recommends that urodynamic investigations are necessary for most women before surgery [National Collaborating Centre for Women's and Children's Health, 2006].

Alpha 1 A-adrenoreceptor agonists (such as pseudoephedrine)

• The Scottish Intercollegiate Guidelines Network (SIGN) does not recommend the use of alpha-adrenoreceptor agonists [SIGN, 2004]. Although weak evidence supports the use of adrenoceptor drugs in women with stress urinary incontinence compared with placebo, further trials are needed to determine their place in treatment. They have the potential for serious, although rare, adverse effects (such as cardiac arrhythmias and hypertension), as they are not selective for urethral adrenoreceptors. They are not licensed for the treatment of stress urinary incontinence in the UK.

Management of frail elderly people

• The recommendations are based on expert advice in guidelines from the European Association of Urologists [European Association of Urology, 2006] and a review article [Josephson and Ginsberg, 2004].