• Treat any conditions that may be causing or contributing to the symptoms, including:
• Lower urinary tract conditions (such as urinary tract infection).
• Neurological conditions (such as Parkinson's disease and multiple sclerosis).
• Systemic conditions (such as congestive heart failure and diabetes mellitus).
• Functional and behavioural disorders (such as impaired mobility and excess alcohol use).
• Adverse effects of medication (such as rapid-acting diuretics).
• Recommend caffeine reduction if appropriate.
• Refer women with an overactive bladder with or without urgency incontinence, and those with mixed urinary incontinence, to an appropriate practitioner for a full assessment and consideration of bladder training for a minimum of 6 weeks.
• If bladder training is ineffective, offer to add in immediate-release oxybutynin with upward dose titration from an initial low dose.
• Encourage the woman to persist with bladder training.
• If immediate-release oxybutynin is not tolerated, consider other antimuscarinic drugs (darifenacin, fesoterodine, solifenacin, tolterodine, and trospium) or an alternative formulation of oxybutynin (modified-release tablets or transdermal patches).
• If antimuscarinic drugs are prescribed:
• Counsel the person regarding the adverse effects of these drugs — particularly elderly people, who are more prone to the antimuscarinic adverse effects (see below).
• Review after 6 weeks' treatment to assess the balance between beneficial and adverse effects.
• If beneficial, review treatment after 6 months to assess whether it is still needed.
• Continue treatment for as long as benefit is maintained and the woman wishes for it to be continued.
• Consider:
• Propiverine to treat frequency in women with an overactive bladder without incontinence.
• Intravaginal oestrogen therapy (but not systemic hormone replacement therapy) with PFMT or other treatments in postmenopausal women with vaginal atrophy, urethral pain, or dysuria.
• Long-term treatment may be required.
• Review at least annually to re-assess the need for continued treatment and to monitor for symptoms of endometrial hyperplasia or carcinoma in women with a uterus.
• Consider seeking specialist advice if uncertain how long to prescribe intravaginal oestrogen therapy.
• Desmopressin (unlicensed use) if the woman has troublesome nocturia and is younger than 65 years of age without cardiovascular disease. Advise restriction of night-time intake of fluid to reduce the risk of fluid retention and water intoxication. With desmopressin, measure serum sodium (particularly in elderly people and in people at risk of hyponatraemia):
• Before starting treatment.
• 72 hours after starting treatment.
• If unwell.
• If medications change.
• If hyponatraemia is suspected.
• If conservative measures fail, refer to a urologist for urodynamic investigations and consideration of sacral nerve stimulation, treatment with botulinum toxin, or surgery. See Secondary care treatments for urgency incontinence.
• In frail elderly people:
• Take into account cognitive function, mobility, dexterity, desire for treatment, and expectation.
• Where appropriate, refer for a full assessment and consideration for bladder training.
• Review current medication.
• Consider adding an antimuscarinic; start at the lowest dose, as adverse effects, particularly confusion, are more common in elderly people. Be aware that antimuscarinic drugs may affect cognitive function in elderly people (particularly if cognitive impairment is already present — for example dementia) and monitor regularly for this.
• Refer where appropriate to a continence adviser, the district nursing team, or elderly care team for specialist assessment for the management of incontinence.
• For some women with urgency incontinence who have cognitive impairment, limited mobility, or both, the use of toilet-assisted protocols, such as prompted or timed voiding, can be helpful.
• The following treatments are not recommended:
• Propantheline, flavoxate, or imipramine.
• Diuretics. However, these are needed if there is nocturnal polyuria secondary to cardiac failure.
• Complementary therapies (acupuncture, hypnosis, herbal medicines).

Appropriate practitioner

• An appropriate practitioner will depend on local continence services and may be:
• A continence adviser.
• A continence 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.

Symptoms of hyponatraemia

• Symptoms of hyponatraemia include [Baylis, 2003]:
• Mild hyponatraemia: anorexia, headache, nausea, vomiting, lethargy, oedema.
• Moderate hyponatraemia: personality change, muscle cramps, muscle weakness, confusion, ataxia.
• Severe hyponatraemia: drowsiness, convulsions, coma, death.
• For more information regarding desmopressin and hyponatraemia, see Cautions and contraindications.

Reducing caffeine

• Limited evidence indicates that reducing caffeine intake reduces frequency and urgency in women who have an overactive bladder with or without urinary incontinence [National Collaborating Centre for Women's and Children's Health, 2006].

Bladder training

• There is good evidence from randomized controlled trials (RCTs) that bladder training is effective in women with urgency or mixed urinary incontinence. The combination of bladder training with either oxybutynin or tolterodine results in a greater reduction in frequency of micturition but has not been shown to lead to further improvements in incontinence [National Collaborating Centre for Women's and Children's Health, 2006].

Antimuscarinic drugs

• Good evidence from RCTs indicates that all antimuscarinic drugs are more effective than placebo.
• There is no evidence of any clinically important difference among different antimuscarinics; all are equally effective in improving frequency, incontinence episodes, and quality of life in women with an overactive bladder.
• Most of the trials comparing drugs studied oxybutynin and tolterodine.
• A dry mouth is more common with immediate-release oxybutynin than with tolterodine, trospium, extended-release oxybutynin, or transdermal oxybutynin.
• The National Institute for Health and Clinical Excellence (NICE) adopted a cost minimization approach and therefore recommends immediate-release oxybutynin as first choice.
• However, NICE advised that if immediate release oxybutynin is not well tolerated, darifenacin, solifenacin, tolterodine, trospium, or a modified-release or transdermal formulation of oxybutynin should be considered as an alternative.
• Fesoterodine was not available when the NICE guideline was developed. Fesoterodine is a prodrug which is converted in the body to its active metabolite, tolterodine. Two trials have been identified: one study compared fesoterodine to placebo and found it to be more effective than placebo, and the other study compared it with tolterodine [Chapple et al, 2007; Nitti et al, 2007]. Both studies had high dropout rates, and the second study was not powered to detect a difference between fesoterodine and tolterodine [NHS Scotland, 2008; Regional Drug and Therapeutics Centre, 2008]. Fesoterodine is currently a 'black triangle' drug (it is under intensive monitoring by the Medicines and Healthcare products Regulatory Agency [MHRA]). Many CKS expert reviewers recommend its use.

Antimuscarinic drugs and cognitive adverse effects in elderly people

• Although antimuscarinic drugs may affect cognitive function in elderly people [Wagg, 2008; BNF 57, 2009], CKS found little evidence to support one antimuscarinic drug over another in minimizing cognitive adverse effects in elderly people.
• A literature review on urinary incontinence in older women examined the impact of newer antimuscarinic drugs on cognitive function, in people without cognitive problems and in artificial environments, with increasing dose titration [Wagg, 2008]. The review found no studies investigating the effect of long-term dosing on cognitive function (particularly elderly people) [Wagg, 2008].
• A systematic review found that antimuscarinics were not significantly associated with serious adverse events [Chapple et al, 2008].
• Some CKS expert reviewers recommended that antimuscarinic drugs with higher potential to cross the blood-brain barrier (for example oxybutynin) should not be used in elderly people.
• Given that all antimuscarinic drugs are known to cause cognitive adverse effects, CKS recommends regular monitoring of these drugs when used in elderly people, and to consider substituting for an alternative drug if cognitive adverse effects are an issue.

Follow up

• The recommendations on when to review after starting an antimuscarinic drug are based on expert opinion in national guidance [SIGN, 2004] and from CKS expert reviewers.

Propiverine

• A randomized study (n = 185) evaluated four different daily doses of propiverine (15 mg, 30 mg, 45 mg, and 60 mg) and found a reduction in urinary frequency in all dosage groups. Blurred vision and dry mouth were the most common adverse effects. The optimum dose for subjective efficacy and tolerability was 30 mg daily [National Collaborating Centre for Women's and Children's Health, 2006].

Short-term topical rather than systemic oestrogens

• There is good evidence from RCTs that the short-term use of intravaginal oestrogens may improve incontinence and frequency in postmenopausal women with vaginal atrophy. There is no evidence of benefit for systemic oestrogens alone, or combined with progesterone, in postmenopausal women with urinary incontinence [National Collaborating Centre for Women's and Children's Health, 2006].
• Most CKS expert reviewers advised that intravaginal oestrogens may be used in women with vaginal atrophy at the same time as other treatment, including bladder training.
• CKS recommends that healthcare professionals should consider seeking specialist advice before prescribing intravaginal oestrogens long term or repeatedly because the benefits and safety of long-term or repeated use of topical intravaginal oestrogen are uncertain.
• The British National Formulary recommends treatment should be reviewed at least annually to monitor for symptoms of endometrial hyperplasia or carcinoma [BNF 57, 2009].
• Some CKS expert reviewers suggested prescribing long term, whereas others suggested a break after 3 months before repeating the course in women with a uterus.

Desmopressin

• There is good evidence from RCTs that desmopressin significantly reduces nocturia but insufficient evidence that it reduces incontinence in women. It acts by reducing urinary output and is not a specific treatment for urgency. It can be used in addition to other treatments.
• Hyponatraemia is common. NICE warns that hyponatraemia may be more common in elderly women. As hyponatraemia is also more likely to occur soon after starting treatment, NICE recommends pretreatment and early post-treatment monitoring of serum sodium [National Collaborating Centre for Women's and Children's Health, 2006].
• The symptoms of hyponatraemia are standard clinical advice in the Oxford Textbook of Medicine [Baylis, 2003].
• Several CKS expert reviewers advised that for women younger than 65 years of age, desmopressin:
• Can be used in addition to other treatments if the woman has troublesome nocturia.
• Should be used cautiously long term.
• CKS recommends seeking specialist advice if more than 3 months of treatment is planned.

Treatments not recommended

• Flavoxate, propantheline, and imipramine in women with urinary incontinence or overactive bladder are not recommended, as there is no evidence for their effectiveness [National Collaborating Centre for Women's and Children's Health, 2006].
• No good RCTs are available to support the use of imipramine, and its cardiotoxic adverse effects limit its use [SIGN, 2004].
• The evidence is insufficient to support the use of diuretics for the treatment of nocturia [National Collaborating Centre for Women's and Children's Health, 2006].
• The use of complementary therapies is not recommended, as evidence on their use is insufficient [National Collaborating Centre for Women's and Children's Health, 2006].

Referral if conservative treatments fail

• This recommendation reflects expert advice [National Collaborating Centre for Women's and Children's Health, 2006].

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]. Elderly people may be taking several different medications, all with antimuscarinic adverse effects, and this may lead to antimuscarinic overload [Josephson and Ginsberg, 2004].

Timed voiding and prompted voiding

• There is limited evidence that prompted voiding and timed voiding reduces the number of incontinence episodes in cognitively impaired men and women [National Collaborating Centre for Women's and Children's Health, 2006].