OAB / LUTS Urology Pathway for Primary Care within

Frimley Health locality

Developed with key local stakeholders including Urologists, Gynaecologists, GP

specialist leads, Pharmacists & Commissioners

Phases of development:

Phase Completed by: Comments

Initial draft Nov 2014 Initial stakeholder group

workshop 25th Nov 2104
Review by Feb 2015
FHAPC
Rollout Mar 2017

Review Mar 2019

Information about development

Project supported by a non-promotional educational grant from Astellas
Project management by Res Consortium (independent NHS support agency)

Project contact:

Dr Mark Davies
01264 366622
07815750502
mdavies@resconsortium.com
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URINARY INCONTINENCE [UI] PATHWAY - WOMEN

INITIAL ASSESSMENT
1. Clinical history and physical examination
2. - Categorise UI as stress UI, urge UI/overactive bladder syndrome (OAB) or mixed UI.
3. - Start treatment on this basis.
4. Validated quality of life
5. Identify factors that may require referral.
6. Ask the woman to complete a bladder diary for at least 3 days, covering variations in usual
activities (e.g. working and leisure days).
7. Measure post-void residual urine in women with symptoms of voiding dysfunction or recurrent UTI.
If available, use a bladder scan in preference to catheterisation.
8. Use urine dipstick tests to detect blood, glucose, protein, leucocytes and nitrites.

Dipstick test results Positive for leucocytes and nitrates Negative for either
leucocytes or nitrates

Urinary Tract Symptoms Send a mid-stream urine sample for culture and antibiotic sensitivity analysis
Infection
(UTI) Prescribe appropriate antibiotics pending results Consider antibiotics
pending results

No Do not prescribe antibiotics unless there is a UTI unlikely. Do not send

symptoms positive urine culture result. a urine sample for
culture.

LIFESTYLE INTERVENTIONS INDICATIONS FOR REFERRAL

Advise patients with UI or OAB to: Urgently refer patients with any of the
Modify high or low fluid intake following:
Bladder retraining- at least for 6/52 microscopic haematuria if >50 yo
Pelvic floor muscle re-education visible haematuria
Lose weight if their body mass recurrent or persisting UTI if >40 yo
index is over 30 pelvic masses
Review caffeine intake suspected urogenital fistulae
Non-urgent referral of women with:
symptomatic prolapse visible at or below
the vaginal introitus
MIXED UTI palpable bladder on bimanual or physical
Determine treatment according to whether examination after voiding.
stress or urge UI dominant symptom Consider referring women with:
Refer to physiotherapist persisting bladder or urethral pain
Go to OAB medicines pathway associated faecal incontinence
URGE UTI suspected neurological disease
Go to OAB medicines pathway voiding difficulty
previous continence surgery
STRESS UTI previous pelvic cancer surgery
Pelvic floor muscle re-education- trial for at previous pelvic radiation therapy.
least 3 months

TREATMENT SUCCESSFUL TREATMENT UNSUCCESSFUL

Complete course / maintain Refer to Urology or Gynaecology in
secondary care
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URINARY INCONTINENCE [UI] PATHWAY - MEN

INITIAL ASSESSMENT
Clinical history and physical examination: abdominal, rectal, sacral neurological
Categorise patient into the following four categories according to symptoms; post-micturition dribble,
incontinence on physical activity, incontinence with mixed stress and urgency symptoms and
urgency or frequency either or without incontinence.
Start treatment on this basis.
Validated quality of life
Identify factors that may require referral.
U&Es; PSA testing
Measure post-void residual (PVR) urine in men. If available, use a bladder scan in preference to
catheterisation.
Use urine dipstick tests to detect blood, glucose, protein, leucocytes and nitrites.

Dipstick test results Positive for leucocytes and nitrates Negative for either
leucocytes or nitrates

Urinary Tract Symptoms Send a mid-stream urine sample for culture and antibiotic sensitivity analysis
Infection
(UTI) Prescribe appropriate antibiotics pending results Consider antibiotics
pending results

No Do not prescribe antibiotics unless there is a UTI unlikely. Do not send

symptoms positive urine culture result. a urine sample for
culture.

INDICATIONS FOR REFERRAL

LIFESTYLE INTERVENTIONS Urgently refer patients with any of the
Advise patients with UI or OAB to: following:
Modify high or low fluid intake Recurrent incontinence after failed
Bladder retraining- at least for 6 weeks previous surgery or total incontinence
Pelvic floor muscle re-education associated with:
Lose weight if their body mass index is > 30 Pain
Review caffeine intake Haematuria
Recurrent infection
Voiding symptoms
Prostate irradiation
Radical pelvic surgery
LUTS
Moderate to severe LUTS - alpha-blockers Non-urgent referral of men with:
(alfuzosin or tamsulosin for men Any other abnormality detected e.g.
For symptoms of OAB see OAB medicines significant PVR
pathway Abnormal digital rectal examination
If storage symptoms persist after
treatment with an alpha-blocker alone add
an anticholinergic & review after four
weeks as per NICE CG97 (for example,
tamsulosin / solifenacin in combination)

TREATMENT SUCCESSFUL TREATMENT UNSUCCESSFUL

Complete course / maintain Refer to Urology in secondary care
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OAB RECOMMENDED TREATMENTS

Encourage pelvic floor exercises, bladder retraining and lifestyle interventions where appropriate as
stated in the Urinary Incontinence Pathway.

ANTIMUSCARINICS NOT CONTRAINDICATED

Tolterodine IR 2mg BD
Reduce to 1mg BD if necessary to minimise side effects

TREATMENT UNSUCCESSFUL TREATMENT SUCCESSFUL

Which could include side effects or
ineffective action. Use 2nd line
antimuscarinic (Trospium M/R 60mg
or Solifenacin 5mg od) or Mirabegron
50mg OD
Review after eight weeks
Continue treatment as the
patient has responded.
Review every 6-12 months.
Try to withdraw treatment after
12 months
Restart treatment if symptoms
return.

TREATMENT UNSUCCESSFUL
Refer to secondary care
Patient to keep urine diary prior to appt

ANTIMUSCARINICS CONTRAINDICATED
Mirabegron M/R 50mg OD
25 mg OD if there is renal or hepatic impairment.