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Incontinence - urinary, in women - Management
What treatment might be offered in secondary care to a woman with urgency incontinence associated with overactive bladder syndrome in whom conservative measures have failed?

  • The following treatments are recommended by the National Institute for Health and Clinical Excellence for women who have not responded to conservative treatments:
    • Sacral nerve stimulation in women with urgency incontinence due to detrusor overactivity.
      • Adverse effects include pain and discomfort.
      • Up to two-thirds of women achieve continence or substantial improvement in symptoms, and beneficial effects appear to persist for 3–5 years after implantation.
      • Life-long follow up is necessary.
    • Augmentation cystoplasty in women with urinary incontinence due to detrusor overactivity who are willing to self catheterize.
      • About half of women report improvement.
      • Postoperative complications are common and include bowel disturbance, metabolic acidosis, urine retention, and mucus production.
      • Many people will need to self catheterize, and the incidence of urinary tract infection is high.
      • Rarely, cancer may occur in the bowel segment.
      • Life-long follow up is recommended.
    • Urinary diversion should be considered only if sacral nerve stimulation or augmentation cystoplasty is not appropriate. Explain that:
      • Bladder infection, stoma problems, and upper urinary tract dilation are common subsequently.
      • The need for surgical revision is common.
      • Life-long follow up is recommended.
    • The place of detrusor myomectomy is unclear.
      • In one small case series, most women reported some improvement.
      • One-third of women required intermittent self catheterization.
    • Botulinum toxin type A. Explain that:
      • Self-catheterization may be necessary afterwards.
      • There are no long-term data.
      • The use of botulinum toxin type A for idiopathic detrusor overactivity is outside its UK licence.
Clarification / Additional information
  • These treatments for an overactive bladder aim to alter or modulate the nerve supply to the bladder and contractility, increase its capacity, or bypass the lower urinary tract completely. As a result, detrusor contractility is reduced in several of these procedures, and difficulty voiding is therefore a very common adverse effect. Women should be considered for these procedures only if they are willing and able to self catheterize.
  • Sacral nerve stimulation:
    • Appropriate electrical stimulation of the sacral reflex pathway inhibits the reflex behaviour of the bladder.
      • Permanently implantable sacral root stimulators provide chronic stimulation to the S3 nerve roots.
      • A percutaneous nerve evaluation is done initially by inserting a needle under local anaesthetic through the sacral foramina and connecting it to an external stimulation source.
      • After a few days, people who show a satisfactory response then have a permanent implant [National Collaborating Centre for Women's and Children's Health, 2006].
  • Augmentation cystoplasty:
    • The bladder wall is bivalved and a segment of bowel (usually ileum) incorporated into the defect.
  • Urinary diversion:
    • The ureters are transported to an isolated segment of ileum which is used to create an ileal conduit (a permanent cutaneous stoma) into which urine drains continuously into a stoma bad attached to the abdominal wall.
  • Detrusor myomectomy:
    • Detrusor muscle is excised from the fundus of the bladder, leaving the bladder mucosa intact and thus creating a permanent wide diverticulum.
Basis for recommendation
  • These recommendations are from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2006].
    • After considering the evidence from randomized controlled trials (RCTs), NICE concluded that there was a stronger body of evidence to support the use of sacral nerve stimulation than augmentation cystoplasty, urinary diversion, or botulinum toxin.
    • Data on augmentation cystoplasty used to treat overactive bladder or urgency incontinence are limited to case series.
    • Data on the outcomes of urinary diversion in women with urgency incontinence are limited.
    • The role of detrusor myomectomy is unclear, as all of the case series included people with both neurogenic bladder function and idiopathic detrusor overactivity.
    • Despite the limited evidence on the use of botulinum toxin, NICE recognizes that this is rapidly becoming accepted clinical practice.
  • The Women's Health Specialist Library (part of the National Library for Health) has reviewed the evidence from 2006–2008 on sacral nerve stimulation in the management of overactive bladder syndrome and concluded that recent evidence supports this as an effective long-term treatment with a good safety profile and that a stronger body of evidence exists for its use than for augmentation cystoplasty, urinary diversion, or botulinum toxin type A [Women's Health Specialist Library, 2009].

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