1. 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:
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
Phase
Completed by:
Comments
Initial draft
Nov 2014
Initial stakeholder group workshop 25th Nov 2104
Review by FHAPC
Feb 2015
Rollout
Mar 2017
Review
Mar 2019

2. URINARY INCONTINENCE [UI] PATHWAY - WOMEN
Date issued :[insert]
Page Version: Draft v01
Author: [insert]
URINARY INCONTINENCE [UI] PATHWAY - WOMEN
INITIAL ASSESSMENT
Clinical history and physical examination
- Categorise UI as stress UI, urge UI/overactive bladder syndrome (OAB) or mixed UI.
- Start treatment on this basis.
Validated quality of life
Identify factors that may require referral.
Ask the woman to complete a bladder diary for at least 3 days, covering variations in usual activities (e.g. working and leisure days).
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.
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 Infection (UTI)
Symptoms
Send a mid-stream urine sample for culture and antibiotic sensitivity analysis
Prescribe appropriate antibiotics pending results
Consider antibiotics pending results
No symptoms
Do not prescribe antibiotics unless there is a positive urine culture result.
UTI unlikely. Do not send a urine sample for culture.
LIFESTYLE INTERVENTIONS
Advise patients with UI or OAB to:
Modify high or low fluid intake
Bladder retraining- at least for 6/52 Pelvic floor muscle re-education
Lose weight if their body mass index is over 30
Review caffeine intake
INDICATIONS FOR REFERRAL
Urgently refer patients with any of the following:
microscopic haematuria if >50 yo
visible haematuria
recurrent or persisting UTI if >40 yo
pelvic masses
suspected urogenital fistulae
Non-urgent referral of women with:
symptomatic prolapse visible at or below the vaginal introitus
palpable bladder on bimanual or physical examination after voiding.
Consider referring women with:
persisting bladder or urethral pain
associated faecal incontinence
suspected neurological disease
voiding difficulty
previous continence surgery
previous pelvic cancer surgery
previous pelvic radiation therapy.
MIXED UTI
Determine treatment according to whether stress or urge UI dominant symptom
Refer to physiotherapist
Go to OAB medicines pathway
URGE UTI
STRESS UTI
Pelvic floor muscle re-education- trial for at least 3 months’
TREATMENT SUCCESSFUL
Complete course / maintain
TREATMENT UNSUCCESSFUL
Refer to Urology or Gynaecology in secondary care

3. URINARY INCONTINENCE [UI] PATHWAY - MEN
Date issued :[insert]
Page Version: Draft v01
Author: [insert]
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 Infection (UTI)
Symptoms
Send a mid-stream urine sample for culture and antibiotic sensitivity analysis
Prescribe appropriate antibiotics pending results
Consider antibiotics pending results
No symptoms
Do not prescribe antibiotics unless there is a positive urine culture result.
UTI unlikely. Do not send a urine sample for culture.
INDICATIONS FOR REFERRAL
Urgently refer patients with any of the following:
Recurrent incontinence after failed previous surgery or ‘total’ incontinence associated with:
Pain
Haematuria
Recurrent infection
Voiding symptoms
Prostate irradiation
Radical pelvic surgery
Non-urgent referral of men with:
Any other abnormality detected e.g. significant PVR
Abnormal digital rectal examination
LIFESTYLE INTERVENTIONS
Advise patients with UI or OAB to:
Modify high or low fluid intake
Bladder retraining- at least for 6 weeks
Pelvic floor muscle re-education
Lose weight if their body mass index is > 30
Review caffeine intake
LUTS
Moderate to severe LUTS - alpha-blockers (alfuzosin or tamsulosin for men
For symptoms of OAB see OAB medicines pathway
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
Complete course / maintain
TREATMENT UNSUCCESSFUL
Refer to Urology in secondary care

4. OAB RECOMMENDED TREATMENTS
Date issued :[insert]
Page Version: Draft v01
Author: [insert]
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
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
TREATMENT SUCCESSFUL
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.