Frequency Volume Chart: Pt to complete 3 day frequency volume chart covering variations in usual activities: Frequency volume chart should be used in the initial assessment of women with UI or OAB. Women should be encouraged to complete a minimum of 3 days of the frequency volume chart, covering variations in their usual activities, such as both working and leisure days. The volume voided at each void should be measured, to include both day & night

Urine dipstick: Urine dipstick should be undertaken to exclude infection, diabetes & haematuria. A urine dipstick test should be undertaken in all women presenting with UI to detect the presence of blood, glucose, protein, leucocytes & nitrites in the urine. Women with symptoms of UTI whose urine tests are negative for both leucocytes & nitrites should have a midstream urine specimen sent for culture & analysis of antibiotic sensitivities. An appropriate course of antibiotic treatment should be prescribed pending culture results.Women with symptoms of UTI whose urine tests negative for either leucocytes or nitrites should have a midstream urine specimen sent for culture & analysis of antibiotic sensitivities. The healthcare professional should consider the prescription of antibiotics pending culture results.Women who do not have symptoms of UTI, but whose urine tests positive for both leucocytes and nitrites, should not be offered antibiotics without the results of midstream urine culture.
Women who do not have symptoms of UTI and whose urine tests negative for either leucocytes or nitrites are unlikely to have UTI and should not have a urine sample sent for culture

Bladder Ultrasound: The measurement of post-void residual volume by bladder scan or catheterisation should be performed in women with symptoms suggestive of voiding dysfunction or recurrent UTI. A bladder scan should be used in preference to catheterisation on the grounds of acceptability and lower incidence of adverse events. Women who are found to have a palpable bladder on bimanual or abdominal examination after voiding should be referred to a specialist

WORKFORCE FUNCTIONS
2.2 Request investigations to provide information on an individuals health status and needs

2.2.1 Refer individuals to specialist services for treatment and care

2.2.2 Perform a specialist clinical measurement investigation
- Assess system/organ function using specialised procedures
- Interpret and report on the findings of investigations

2.2.3 Perform a specialist clinical measurement investigation
- Obtain specimens non invasively

2.2.4 Obtain images of organs and tissues using ultrasound
- Assess system/organ function using specialised procedures
- Maintain health care equipment and devices

2.3 Undertake a risk assessment in relation to a defined health need
- Assess an individuals needs arising from their health status
- Assess an individuals suitability to undergo planned actions
- Assess the need for and provision of environmental and social support
- Determine a diagnosis and prognosis for an individual
- Refer individuals to specialist services for treatment and care

SERVICE IMPROVEMENT
A summary of service improvement knowledge for UK Radiologists is available. See the hyperlink or website for information

COMMISSIONING AND CONTRACTING
Generic Patient Reported Outcome Measures exist for this pathway (EQ5D). Currently clinical consensus has not been reached for a condition specific measure.

Commissioning a World Class Imaging Service tool has been developed to support commissioners of imaging services. It aims to bring together a number of valuable resources about diagnostic imaging in one easy and convenient reference tool. For more information see the web page.

Clinical Guidelines: NICE has proposed that a subset of patients should not be offered Urodynamics this be a local clinician / commissioner led decision.

Urodynamics: If failed conservative therapy urodynamics may help to clarify diagnosis: The use of multichannel cystometry, ambulatory urodynamics or videourodynamics is not recommended before starting conservative Tx. For the small group of women with a clearly defined clinical diagnosis of pure stress Urinary Incontinence, the use of multichannel cystometry is not routinely recommended. Multichannel filling and voiding cystometry is recommended in women before surgery for multichanel filling urinary incontinence if:
- there is clinical suspicion of detrusor overactivity,
- there has been previous surgery for stress incontinence,
- there are symptoms suggestive of voiding dysfunction.
Ambulatory urodynamics or videourodynamics may also be considered in these circumstances.

Frequency volume charts, dipsticks and bladder scanning may also be used as part of specialist assessemnt diagnostics especialy if not used in the primary assessment diagnostic stage

WORKFORCE FUNCTIONS
3.2.2 Maintain health care equipment and devices
- Perform a specialist clinical measurement investigation
- Prepare environments for use in health care delivery
- Assess system/organ function using specialised procedures
- Interpret and report on the findings of investigations

3.3 Undertake a risk assessment in relation to a defined health need
- Assess an individuals needs arising from their health status
- Assess an individuals suitability to undergo planned actions
- Assess the need for and provision of environmental and social support
- Determine a diagnosis and prognosis for an individual
- Refer individuals to specialist services for treatment and care

Urgent exits onto Haematuria pathway : Women with UI who have any of the following - microscopic haematuria in women aged 50 years and older, recurrent or persisting UTI associated with haematuria in women aged 40 years & older.

Conditions treated on this pathway: visible prolapse below the introitus, congenital abnormalities, young nulliparous stress incontinent women, severe prolapse, neurological disease to include stroke, MS & spinal injury

Urgent exits onto Haematuria pathway : Women with UI who have any of the following - microscopic haematuria in women aged 50 years and older, recurrent or persisting UTI associated with haematuria in women aged 40 years & older.

Conditions treated on this pathway include: symptomatic prolapse that is visible at or below the vaginal introitus, the finding of a palpable bladder on bimanual or abdominal ex after voiding. In women with UI, further indications for consideration for referral to a specialist service include:
persisting bladder or urethral pain, clinically benign pelvic masses, associated faecal incontinence, suspected neurological disease, symptoms of voiding difficulty, suspected urogenital fistulae, previous continence surgery, previous pelvic cancer surgery, previous pelvic radiation Tx.

Overactive bladder characterised by frequency, urgency of micturitation or urgency leakage

WORKFORCE FUNCTIONS
- Plan and prepare health screening programmes
- Screen populations for specific health characteristics
- Communicate and disseminate information about health and stressors to health
- Advise others on data and information relating to health and stressors to health

Prevalence estimates vary from 5 - 69% though symptoms severe enough to require help estimated up to 17% of women over 65

There are booklets on incontinence such as those provided by the Continence Foundation and NHS Direct, which contain some self help measures

WORKFORCE FUNCTIONS
- Support individuals to undertake and monitor their own healthcare
- Provide expert advice
- Obtain information from individuals to support assessment of their health status and needs (History Taking)

WORKFORCE FUNCTIONS
- Receive and direct requests for health care assistance using protocols and guidelines
- Prioritise treatment and care for individuals according to their health status and needs
- Refer individuals to specialist services for treatment and care
- Advise and support others pending the attendance of a healthcare practitioner

WORKFORCE FUNCTIONS
- Receive and direct requests for health care assistance using protocols and guidelines
- Prioritise treatment and care for individuals according to their health status and needs
- Refer individuals to specialist services for treatment and care
- Advise and support others pending the attendance of a healthcare practitioner

TECHNOLOGY
Oldham Community PAS system for recording 18 week journeys through ICATs or other intermediate services.

COMMISSIONING AND CONTRACTING
Can the quality of primary care be improved to help referrals?

Failed conservative Tx, prolapse at introitus or palpable bladder after voiding. Failed previous surgery - referral to subspecialist assessment

Referral Thresholds: Failure of previous operation for stress incontinence. Failure of Botulinum Toxin therapy. Suspected fistula. Concomitant genitourinary prolapse.

Decision Aids: The following incontinence-specific quality of life scales are recommended when therapies are being evaluated: ICIQ, BFLUTS, I-QOL, SUIQQ, UISS, SEAPI-QMM, ISI and KHQ

WORKFORCE FUNCTIONS
- Receive and direct requests for health care assistance using protocols and guidelines
- Prioritise treatment and care for individuals according to their health status and needs
- Refer individuals to specialist services for treatment and care
- Advise and support others pending the attendance of a healthcare practitioner

Urodynamics: May need to be repeated:
The use of multichannel cystometry, ambulatory urodynamics or videourodynamics is not recommended before starting conservative treatment.
For the small group of women with a clearly defined clinical diagnosis of pure stress UI, the use of multichannel cystometry is not routinely recommended.
Multichannel filling and voiding cystometry is recommended in women before surgery for UI if:
- there is clinical suspicion of detrusor overactivity, or
- there has been previous surgery for stress incontinence, or
- there are symptoms suggestive of voiding dysfunction.
Ambulatory urodynamics or videourodynamics may also be considered in these circumstances

Videourodynamics: Especially for neuropaths: See above

Ambulatory Urodynamics: Where conventional urodynamics fail to confirm cause of incontinence: See above

WORKFORCE FUNCTIONS
4.2.2 Maintain health care equipment and devices
- Perform a specialist clinical measurement investigation
- Prepare environments for use in health care delivery
- Assess system/organ function using specialised procedures
- Interpret and report on the findings of investigations

4.2.3 Prepare environments for use in health care delivery
- Assess system/organ function using specialised procedures
- Obtain images of organs and tissues using plain film radiography
- Obtain images of organs and tissues using light sensitive film and digital imaging equipment
- Obtain specimens invasively
- Administer contrast media to increase information provided by diagnostic imaging

4.2.4 Assess system/organ function using specialised procedures
- Refer individuals to specialist services for treatment and care
- Maintain health care equipment and devices
- Perform a specialist clinical measurement investigation
- Prepare environments for use in health care delivery
- Interpret and report on the findings of investigations

4.3 Undertake a risk assessment in relation to a defined health need
- Assess an individuals needs arising from their health status
- Assess an individuals suitability to undergo planned actions
- Assess the need for and provision of environmental and social support
- Determine a diagnosis and prognosis for an individual
- Refer individuals to specialist services for treatment and care

WORKFORCE FUNCTIONS
- Assess an individuals needs arising from their health status
- Arrange access to resources needed to support planned health care/lifestyle programmes
- Evaluate treatment plans with individuals and those involved in their care

WORKFORCE FUNCTIONS
- Assess an individuals needs arising from their health status
- Arrange access to resources needed to support planned health care/lifestyle programmes
- Evaluate treatment plans with individuals and those involved in their care

WORKFORCE FUNCTIONS
- Assess an individuals needs arising from their health status
- Arrange access to resources needed to support planned health care/lifestyle programmes
- Evaluate treatment plans with individuals and those involved in their care

Hx: At the initial clinical assessment, the womans Urinary Incontinence (UI) should be categorised as stress UI, mixed UI, or urgency UI/OAB (Overactive bladder). Initial treatment should be started on this basis. In mixed UI, treatment should be directed towards the predominant symptom

Ex: Routine digital assessment of pelvic floor muscle contraction should be undertaken before the use of supervised pelvic floor muscle training for the treatment of UI. (Women with UI who have symptomatic prolapse that is visible at or below the vaginal introitus should be referred to a specialist)

WORKFORCE FUNCTIONS
- Obtain information from individuals to support assessment of their health status and needs (History Taking)
- Undertake routine clinical measurements
- Determine an individuals state of physical health and fitness
- Assess an individual with a suspected health condition

2.1 Agree the nature and purpose of assessment and investigation into an individuals health status
- Plan assessment and investigation into an individuals health status
- Plan inter-disciplinary assessment and investigation into an individuals health status
- Select assessment and investigative techniques/ procedures for use
- Request investigations to provide information on an individuals health status and needs
- Agree courses of action following assessment

COMMISSIONING AND CONTRACTING
See the Contractual Levers for 18 week Pathways for more detailed directions and guidance that underpin primary care contracting.- Before starting commissioning consider existing primary care medical contracts. Are you already paying for this work? Is it more appropriate to commission this stage of the pathway from primary care contractors? Have your Practice Based Commissioning (PBC) groups considered this pathway for any service redesign? Have you considered the contractual options to commission the pathway at primary care level?
Is the current primary care contract fully utilised? Is there capacity to commission additional activity under additional or enhanced service arrangements?

Hist: Categorise UI as stress UI, urgency UI/OAB or mixed UI

Exam: Abdominal and pelvic examination to exclude pelvic mass and identify enlarged bladder. Assess prolapse and pelvic floor contraction

WORKFORCE FUNCTIONS
- Obtain information from individuals to support assessment of their health status and needs (History Taking)
- Undertake routine clinical measurements
- Determine an individuals state of physical health and fitness
- Assess an individual with a suspected health condition

3.1 Agree the nature and purpose of assessment and investigation into an individuals health status
- Plan assessment and investigation into an individuals health status
- Plan inter-disciplinary assessment and investigation into an individuals health status
- Select assessment and investigative techniques/procedures for use
- Request investigations to provide information on an individuals health status and needs
- Agree courses of action following assessment

Hist: Categorise UI as stress UI, urgency UI/OAB or mixed UI

Exam: Abdominal and pelvic examination to exclude pelvic mass and identify enlarged bladder. Assess prolapse and pelvic floor contraction

WORKFORCE FUNCTIONS
- Obtain information from individuals to support assessment of their health status and needs (History Taking)
- Undertake routine clinical measurements
- Determine an individuals state of physical health and fitness
- Assess an individual with a suspected health condition

4.1 Agree the nature and purpose of assessment and investigation into an individuals health status
- Plan assessment and investigation into an individuals health status
- Plan inter-disciplinary assessment and investigation into an individuals health status
- Select assessment and investigative techniques/procedures for use
- Request investigations to provide information on an individuals health status and needs
- Agree courses of action following assessment

Includes overactive bladder syndrome (OAB), without incontinence

Medication: If the pts Symptoms are bothersome they should be counselled about the adverse effects of antimuscarinic drugs. Immediate release non-proprietary Oxybutynin should be offered to women with OAB or mixed UI as first-line antimuscarinic drug treatment if bladder training has been ineffective. If immediate release Oxybutynin is not well tolerated, darifenacin, solifenacin, tolterodine, trospium or an extended release or transdermal formulation of oxybutynin should be considered as alternatives. An early tx review should be undertaken following any change in antimuscarinic drug therapy. Duloxetine is not recommended as a first-line tx for women with predominant stress UI. Medication should also consider topical oestrogens for associated symptoms such as overactive bladder, prolapse, vaginal discomfort & recurrent urinary infections

Behavioural Modification / Pelvic Floor Therapy also reffered to as pelvic floor mucle training or rehabilitation: A trial of caffeine reduction is recommended for the treatment of women with OAB. Consider advising modification of high or low fluid intake for the treatment of women with UI or OAB. Women with UI or OAB who have a body mass index greater than 30 should be advised to lose weight. A trial of supervised pelvic floor muscle training of at least 3 months duration should be offered as first-line tx to women with stress or mixed UI. Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 x per day. If pelvic floor muscle training is beneficial, an exercise programme should be maintained. Bladder training for overactive bladder should also be considered. The role of a specialist physio or continence advisor should be used where available throughout this pathway

WORKFORCE FUNCTIONS
2.4.1 Provide information and advice to individuals/carers on managing health care needs
- Support individuals with their personal care needs
- Determine a diagnosis and prognosis for an individual

2.4.2 Discharge individuals
- Support individuals to access and use services and facilities

2.4.3 Co-ordinate the implementation and delivery of treatment plans
- Agree courses of action following assessment
- Support individuals with their personal care needs
- Deliver therapeutic activties
- Plan activities, interventions and treatments to achieve specific goals

2.4.4 Provide expert advice
- Manage an individuals medication to achieve optimum outcomes
- Administer medication to individuals
- Support individuals to self medicate

2.4.5 Assess an individuals suitability to undergo planned actions

SERVICE IMPROVEMENT
2.4.5 - For good practice pre-operative assessment guidance, use the hyperlink above or see the website

Behavioural Modification / Pelvic Floor Therapy: Pelvic floor muscle training (PFMT). Perineometry or pelvic floor electromyography as biofeedback should not be used as a routine part of pelvic floor muscle training.
Electrical stimulation should not routinely be used in the treatment of women with OAB. Electrical stimulation should not routinely be used in combination with pelvic floor muscle training. Electrical stimulation &/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation & adherence to therapy. Bladder training lasting for a min of 6 wks should be offered as first-line tx to women with urge or mixed UI. If women do not achieve satisfactory benefit from bladder training programmes, the combination of an antimuscarinic agent with bladder training should be considered if frequency is a troublesome symptom. In women with UI who also have cognitive impairment, prompted and timed voiding toileting programmes are recommended as strategies for reducing leakage episodes.
Consider the role of specialist physiotherapists

Medication: Immediate release non-proprietary oxybutynin should be offered to women with OAB or mixed UI as first-line antimuscarinic drug Tx if bladder training has been ineffective. If immediate release oxybutynin is not well tolerated, darifenacin, solifenacin, tolterodine, trospium or an extended release or transdermal formulation of oxybutynin should be considered as alternatives. Women should be counselled about the adverse effects of antimuscarinic drugs.
An early Tx review should be undertaken following any change in antimuscarinic drug therapy. Duloxetine is not recommended as a 1st-line Tx for women with predominant stress UI. Duloxetine should not routinely be used as a second-line tx for women with stress UI, although it may be offered as second-line therapy if women prefer harmacological to surgical Tx or are not suitable for surgical tx. If duloxetine is prescribed, women should be counselled about its adverse effects

Invasive Tx: Surgery detailed under Specialist Ax may also be undertaken by a Subspecialist - a listing from specialist Ax (where sub-specialists may also be working.) Surgery should be undertaken as part of good clinical practice as detailed in the Nice Guidelines on Urinary Incontinence in Women

WORKFORCE FUNCTIONS
3.4.1Provide information and advice to individuals/carers on managing health care needs
- Support individuals with their personal care needs
- Determine a diagnosis and prognosis for an individual

3.4.2 Discharge individuals
- Support individuals to access and use services and facilities

3.4.3 Co-ordinate the implementation and delivery of treatment plans
- Agree courses of action following assessment
- Support individuals with their personal care needs
- Deliver therapeutic activties
- Plan activities, interventions and treatments to achieve specific goals

3.4.4 Provide expert advice
- Manage an individuals medication to achieve optimum outcomes
- Administer medication to individuals
- Support individuals to self medicate

3.4.5 Assess an individuals suitability to undergo planned actions

3.4.6 Administer medication to individuals
- GAP - All aspects of invasive surgery are still subject to development

SERVICE IMPROVEMENT
3.4.5 - For good practice pre-operative assessment guidance, use the hyperlink above or see the website

Behavioural Modification / Pelvic Floor Therapy: Pelvic floor muscle training (PFMT). Perineometry or pelvic floor electromyography as biofeedback should not be used as a routine part of pelvic floor muscle training.
Electrical stimulation should not routinely be used in the treatment of women with OAB. Electrical stimulation should not routinely be used in combination with pelvic floor muscle training. Electrical stimulation &/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation & adherence to therapy.
Bladder training lasting for a minimum of 6 wks should be offered as first-line tx to women with urge or mixed UI. If women do not achieve satisfactory benefit from bladder training programmes, the combination of an antimuscarinic agent with bladder training should be considered if frequency is a troublesome symptom.
In women with UI who also have cognitive impairment, prompted & timed voiding toileting programmes are recommended as strategies for reducing leakage episodes.
Consider the role of specialist physiotherapists.

Invasive Tx: Includes full range of surgical interventions for recurrent & complex incontinence & this includes botulinum toxin for refractory urgency or urge incontinence.
NICE have recommended that for patients who require surgery for urge incontinence i.e. those who have failed to respond to conservative therapy & whose symptoms are severe, that sacral nerve root stimulation should be considered. This is a costly procedure & expert opinion suggests that this should be performed by subspecialists in tertiary centres. NICE have suggested that approximately 118 such procedures will be required in England per year. Therefore to maintain competence & achieve good results it is important that subspecialty-trained surgeons are performing this procedure on a regular basis. This is not compatible with the procedure being done in secondary care (i.e. specialist axt). Intravesical botulinum toxin is an alternative Tx but not yet recommended by NICE. While this could be done in sec. care we would not advocate its use until there are data from good quality clinical trials. In the meantime these procedures should be performed by subspecialists

WORKFORCE FUNCTIONS
4.4.3 Co-ordinate the implementation and delivery of treatment plans
- Agree courses of action following assessment
- Support individuals with their personal care needs
- Deliver therapeutic activties
- Plan activities, interventions and treatments to achieve specific goals

4.4.4Provide expert advice
- Manage an individuals medication to achieve optimum outcomes
- Administer medication to individuals
- Support individuals to self medicate

4.4.5 Assess an individuals suitability to undergo planned actions

4.4.6 Administer medication to individuals
- GAP - All aspects of invasive surgery are still subject to development

SERVICE IMPROVEMENT
4.4.5 - For good practice pre-operative assessment guidance, use the hyperlink above or see the website