OAB LUTS Urology Pathway for Primary Care within

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 25 th Nov 2104 Review by FHAPC Feb 2015 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

Date issued : [insert] Page Version: Draft v 01 Author: [insert] 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 Urinary Tract Infection (UTI) Send a mid-stream urine sample for culture and antibiotic sensitivity analysis Symptoms No symptoms Prescribe appropriate antibiotics pending results Consider antibiotics pending results 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 MIXED UTI • Determine treatment according to whether stress or urge UI dominant symptom • Refer to physiotherapist • Go to OAB medicines pathway URGE UTI • Go to OAB medicines pathway STRESS UTI • Pelvic floor muscle re-education- trial for at least 3 months’ TREATMENT SUCCESSFUL • Complete course / maintain Negative for either leucocytes or nitrates 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. TREATMENT UNSUCCESSFUL • Refer to Urology or Gynaecology in secondary care

Date issued : [insert] Page Version: Draft v 01 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 Urinary Tract Infection (UTI) Send a mid-stream urine sample for culture and antibiotic sensitivity analysis Symptoms No symptoms Prescribe appropriate antibiotics pending results Consider antibiotics pending results 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 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 CG 97 (for example, tamsulosin / solifenacin in combination) TREATMENT SUCCESSFUL • Complete course / maintain Negative for either leucocytes or nitrates 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 TREATMENT UNSUCCESSFUL • Refer to Urology in secondary care

Date issued : [insert] Page Version: Draft v 01 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 2 mg BD Reduce to 1 mg BD if necessary to minimise side effects TREATMENT UNSUCCESSFUL Which could include side effects or ineffective action. Use 2 nd line antimuscarinic (Trospium M/R 60 mg or Solifenacin 5 mg od) or Mirabegron 50 mg OD Review after eight weeks TREATMENT UNSUCCESSFUL Refer to secondary care Patient to keep urine diary prior to appt ANTIMUSCARINICS CONTRAINDICATED Mirabegron M/R 50 mg OD 25 mg OD if there is renal or hepatic impairment. 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.