Clinical Practice Guidelines for Adults:

Introduction
Recommended Steps in Assesment and Management
Guidelines
References
Appendix

Part I: Introduction

The following is the list of guideline statements on which the flow charts are based. The list is divided into 4 parts, numbered II to V in accordance with the AHCPR handbook (1996). Part II (Identifying and evaluating urinary incontinence) is mainly relevant to the initial clinical assessment and the re-evaluation of treatment/management. Part III (Treatment of urinary incontinence) provides the scientific basis for the treatments suggested in the flowcharts. Part IV (Chronic intractable urinary incontinence) states or reiterates some of the issues relevant to this type of incontinence. Part V (Education) contains statements that are particularly relevant to the proposed models of continence care.

The guideline statements extracted from the AHCPR handbook (1996) are shown in regular type, and throughout the document the statement numbers and page numbers refer to that handbook.

Revisions, additions, and references to new evidence, based on the core committee's review of the recent literature, are shown in bold type. Levels of evidence 1-3 are approximately equivalent to AHCPR strengths of evidence A-C (see Tables 1 and 2).

The guideline statements are followed by a list of the new literature references (1995 - January 2000) identified by the core committee. For the literature references on which the unchanged AHCPR guideline statements are based, the AHCPR handbook (1996) should be consulted. Finally, in an appendix two issues particularly relevant to the elderly are discussed.

Part II: Identifying and evaluating urinary incontinence

1. General Principles of Diagnostic Evaluation

Health care providers are encouraged to be knowledgeable about and initiate the basic evaluation of patients with UI. (Strength of Evidence = C) AHCPR p 18

2. Basic Evaluation

All patients with UI should undergo a basic evaluation that includes a history, physical examination, measurement of post void residual volume, and urinalysis.
(Strength of Evidence = B) AHCPR p 19

Risk factors that are associated with UI should be identified and attempts made to modify them.
(Strength of Evidence = B) AHCPR p 19

2.a. Quality of Life

A number of quality of life measures are available and can measure subjective and objective improvement. These measurements reflect outcomes that are important to the person with UI and should be established at baseline. (Level of Evidence = 1) (Fonda et al, 1995)

2.b. Assessment of Residual Urine in the Bladder

A bladder ultrasound scan is a non-invasive alternative to in/out catheterization to rule out clinically significant urinary retention. (Level of Evidence = 2) (Resnick, 1995; Simforoosh et al, 1997)

3. Supplementary Assessments

Blood testing (Blood, urea, nitrogen (BUN), creatinine, glucose, and calcium) is recommended if compromised renal function is suspected or if polyuria (in the absence of diuretics) is present.
(Strength of Evidence = C) AHCPR

Urine cytology is not recommended in the routine evaluation of the incontinent patient.
(Strength of Evidence = B) AHCPR

4. Further Evaluation

After the basic evaluation, treatment for the presumed type of urinary incontinence should be initiated unless there is an indication for further evaluation. (Strength of Evidence = B) AHCPR

After the basic evaluation and initial treatment, patients who fail or those who are not appropriate for treatment based on presumptive diagnosis should undergo further evaluation. (Strength of Evidence = C) AHCPR

5. Specialized Tests

Specialized tests are not intended to be part of the basic evaluation of UI. (Strength of Evidence = B) AHCPR

5.a. Urodynamic Tests

In the further evaluation of UI, simple cystometry is appropriate for detecting abnormalities of detrusor compliance and contractility, measuring post void residual (PVR), and determining capacity.
(Strength of Evidence = A) AHCPR

In some instances of complicated diagnostic situations or involved therapeutic plans, multichannel cystometric tests are appropriate. (Strength of Evidence = B) AHCPR

When performing urodynamic studies, the health care provider should attempt to reproduce the patient's symptoms.
(Strength of Evidence = C) AHCPR

5.b. Endoscopic Tests

Cystoscopy is not recommended in the basic evaluation of UI. (Strength of Evidence = B), AHCPR. However, cystoscopy may be indicated in the further evaluation when the following situations are present:

(a) sterile pyuria or hematuria (Strength of Evidence = B) AHCPR
(b) when urodynamics fail to duplicate symptoms
(Strength of Evidence = C) AHCPR
(c) new onset of irritative voiding symptoms, bladder pain, recurrent cystitis, or suspected foreign body. (Strength of Evidence = B) AHCPR

5.c. Imaging Tests

Radiographic, ultrasonographic, and other imaging tests should be used for the evaluation of anatomic conditions associated with UI when clinically needed.
(Strength of Evidence = C) AHCPR

Part III: Treatment of urinary incontinence

Behavioural Technique

1a. Lifestyle Adjustment:

Fluid increase/decrease - intake of adequate fluid (approximately 30 ml/kg or 1.5 to 2 litres a day) may improve symptoms of urinary incontinence (Level of Evidence = 3) (Griffiths et al, 1996; Dowd et al, 1996)

Caffeine reduction or elimination may improve lower urinary tract symptoms (Level of Evidence = 1) (Tomlinson et al, 1999)

Smoking - not engaging in smoking or quitting smoking may prevent or reduce the onset of lower urinary symptoms (Level of Evidence = 2) (Koskimaki et al, 1998)

Weight loss may reduce urine loss in obese women (Level of Evidence = 3) (Bump et al, 1992)
Moderate physical activity - exercise may prevent or reduce lower urinary symptoms (Level of Evidence = 3) (Platz et al, 1998)

Constipation - bowel regularity may improve continence (Level of Evidence = 3) (MacDonald et al, 1991)

Women with stress, urge or mixed urinary incontinence may have long term persisting improvement from conservative measures (Level of Evidence = 2) (Seim et al, 1998; Weinberger et al, 1999; Bear et al, 1997)

1. Toileting Assistance

Routine or scheduled toileting should be offered to incontinent patients on a consistent schedule. This technique is recommended for patients who cannot participate in independent toileting.
(Strength of Evidence = C)

Habit training is recommended for patients for whom a natural voiding pattern can be determined. (Strength of Evidence = B)

Prompted voiding is recommended in patients who can learn to recognize some degree of bladder fullness or the need to void, or who can ask for assistance or respond when prompted to toilet. Patients who are appropriate for prompted voiding may not have sufficient cognitive ability to participate in other, more complex behavioural therapies. (Strength of Evidence = A)

2. Bladder Training

Bladder training is recommended for management of urge (DI) and mixed incontinence.
(Strength of Evidence = A) . (Level of Evidence = 1) (Roe, Williams, Palmer, 1999)

3. Pelvic Muscle Rehabilitation

3.a. Pelvic Muscle Exercise (PME)

Teaching women PMEs may prevent UI. (Strength of Evidence = C)

Teaching exercises to strengthen pelvic muscles may decrease the incidene of UI. (Strength of Evidence = C)

PMEs are strongly recommended for women with SUI. (Strength of Evidence = A) (Level of Evidence = 1) (Bø, 1999)

PMEs are recommended in conjunction with bladder training for urge incontinence. (Strength of Evidence = B)

PMEs may benefit men who develop urinary incontinence following prostatectomy. (Strength of Evidence = C)

PMEs in combination with electrical stimulation, biofeedback, or bladder retraining may improve incontinence following radical prostatectomy (Level of Evidence = 2) (Van Kampen, 2000)

Bulbous urethral massage or PMEs are useful for post micturition dribble. (Level of Evidence = 2) (Paterson et al, 1997)

3.b. PME and Bladder Inhibition Augmented by Biofeedback Therapy

Pelvic muscle rehabilitation and bladder inhibition using biofeedback therapy are recommended for patients with stress UI, urge UI, and mixed UI.
(Strength of Evidence = A)

Biofeedback-assisted behavioural treatment is safe and more effective than oxybutynin or placebo in women with urge and mixed incontinence. (Level of Evidence = 1) (Burgio et al, 1998)

Biofeedback-assisted pelvic floor muscle training in homebound older women can reduce urine loss. (Level of Evidence = 1) (McDowell et al, 1999)

Electrical stimulation may reduce the symptoms of urgency and frequency (Level of Evidence = 2) (Bower et al, 1998; Hasan et al, 1996)

3.c. Pelvic Muscle Exercises Augmented with Vaginal Weight Training

Vaginal weight training may be recommended for SUI in premenopausal women, but is no more effective than pelvic muscle exercises. (Level of evidence = 2) (Bø? 1999)

3.d. Pelvic Floor Electrical Stimulation

Pelvic floor electrical stimulation may decrease incontinence in women with SUI. (Strength of Evidence = B)

Pelvic floor electrical stimulation may be useful for urge and mixed incontinence. (Strength of Evidence = B)

Pelvic floor exercises, electrical stimulation and estrogen may reduce urinary incontinence in older women with stress, urge, or mixed UI. (Level of Evidence = 1) (Holtedahl et al, 1998)

4. Pharmacologic Treatment

4.a. Urge Incontinence: Detrusor Instability (DI)

The following pharmacologic agents are reported to be useful in DI as observed in clinical practice. (Strength of Evidence = B)
Anticholinergic agents: oxybutynin, dicyclomine hydrochloride, propantheline, tolterodine.
Tricyclic antidepressants: imipramine, doxepin, desipramine, and nortriptyline.
Direct smooth muscle relaxant: flavoxate.

4.b. Anticholinergic Agents

Anticholinergic agents are the first-line pharmacologic therapy for patients with DI. (Strength of Evidence = A)

When pharmacologic therapy is to be used for patients with DI, oxybutynin is the anticholinergic agent of choice. The recommended dosage is 2.5-5mg taken orally two to four times per day. (Strength of Evidence = A)

Once a day controlled release oxybutynin is as efficacious as immediate release oxybutynin. Higher doses may be better tolerated using controlled release. (Level of Evidence = 1) (Anderson et al, 1999) (Level of Evidence = 2) (Gleason et al, 1999)

Low dose oxybutynin combined with bladder retraining may reduce urinary frequency in elderly women with detrusor instability. (Level of Evidence = 2) (Szonyi et al, 1995)

Tolterodine is an anticholinergic agent with selectivity for urinary bladder receptors over salivary receptors. It has comparable efficacy to oxybutynin. It is the drug of choice if oxybutynin use is limited by excessive dry mouth. The optimum dose is 2 mg BID. (Level of Evidence = 1) (Drutz et al, 1999; Abrams and Wein, 1997)

Propantheline is the second-line anticholinergic agent in the treatment of patients with DI who can tolerate the full dosage. The recommended dosages are 7.5-30mg administered three to five times per day; higher dosages (15-60mg qid) may be required. (Strength of Evidence = B)

Flavoxate at higher doses (800 mg-1200 mg) in divided dose 3 times/day may be of benefit in people with urinary urgency or urge incontinence (Level of Evidence = 2) (Fehrmann-Zumpe et al, 1999; Guarneri et al, 1994).

4.c. Tricyclic Agents

The use of tricyclic agents (TCAs) should be reserved for carefully evaluated patients. The usual oral dosages are 10-25mg, initially one to three times per day, but less frequent administration is usually possible because of the long half-life. The daily total dosage is usually 25-100mg. (Strength of Evidence = B)

Strongly anticholinergic TCAs including Amitriptyline and Doxepin are contra-indicated in the frail elderly. (Level of evidence = 3) (McLeod et al 1997; Pollock BG 1999)

4.d. Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for the primary treatment of DI. (Strength of Evidence = C)

5. Stress Urinary Incontinence (SUI): Urethral Sphincter Insufficiency

5.a. Estrogen Therapy

Estrogen (oral or vaginal) may be considered as an adjunctive pharmacologic agent for postmenopausal women with SUI or mixed incontinence. Conjugated estrogen is usually administered either orally (0.3-1.25mg/day) or vaginally (2g or fraction/day). Progestin (e.g., medroxyprogesterone 2.5-10 mg/day) may be given continuously or intermittently. (Strength of Evidence = B) (Level of Evidence = 2) (Fantl et al, 1996) Results from existing randomized controlled trials are disparate. The best study (Fantl et al, 1996) showed no effect of estrogen on continence status. There are potentially other reasons to consider estrogen in post-menopausal women with stress incontinence.

5.b. Other Drugs of Possible Benefit

Imipramine (10-75 mg qhs) is recommended as an alternative pharmacologic therapy for SUI when first-line agents have proven unsatisfactory. Although there are no studies regarding the safety of the long term use of imipramine for stress urinary incontinence, inferences from the psychiatric literature are reassuring. (Strength of Evidence = C)

The use of propranolol or other beta-blockers cannot be recommended for treatment of SUI because of lack of clinical experience and clinical studies.
(Strength of Evidence = C)

6. Surgical Treatment

Surgery is recommended for treatment of stress incontinence in men and women and may be recommended as first-line treatment for appropriately selected patients who are unable to comply with other lifestyle modifications and behavioural interventions. (Strength of Evidence = B)

7. Stress Incontinence in Women

Hypermobility or Intrinsic Sphincter Deficiency (ISD)

7.a. Procedures for Hypermobility

Retropubic suspension is recommended for women with hypermobility when SUI is the primary indication for surgery. On the basis of greater efficacy, this procedure is recommended over anterior vaginal repair for hypermobility. (Strength of Evidence = B) . All retropubic suspension techniques have equal efficacy short and long term. Long-term results of needle suspensions are not as good. (Level of evidence = 2) (Leach et al, 1997)

7.b. Procedure for Intrinsic Sphincter Deficiency (ISD)

Sling procedures are recommended for women who have ISD with coexisting hypermobility or as first-line treatment for ISD. (Strength of Evidence = B)

Urethral bulking injections are recommended as first-line treatment for women with ISD. (Strength of Evidence = B). Coexisting hypermobility is not necessarily a contra-indication (Level of evidence = 2) (Herschorn et al 1996)

Tension-free vaginal tape is a new minimally invasive technique for treating genuine stress urinary incontinence in women. This procedure by trained operators is an alternative to sling procedures. Its short- to medium-term success rate is comparable and the incidence of post-operative complications may be lower. Further longer term follow-up data (more than 3 years) are needed for a complete comparison. (Level of evidence = 2) (Ulmsten et al, 1995, 1998, 1999; Wang & Lo, 1998; Olsson & Kroon, 1999).

Artificial sphincter is recommended for ISD patients who have severe SUI that is unresponsive to other surgical treatments. Because of the high complication rate, this treatment is rarely used as primary therapy. (Strength of Evidence = B)

8. Stress Incontinence in Men

Intrinsic Sphincter Deficiency

Lifestyle adjustments may improve lower urinary tract symptoms. (Level of Evidence = 3) (Kondo et al, 1999).

8.a. Periurethral Bulking Injections

Periurethral bulking injections may be recommended as a first-line surgical treatment for men with ISD. (Strength of Evidence = B)

8.b. Placement of an Artificial Sphincter

Artificial sphincter may be elected for ISD 6 months after prostatectomy. Behavioural intervention should also be tried during this period.
(Strength of Evidence = B) (Level of Evidence = 2) (Schettini et al, 1998)

9. Urge Incontinence: Overactive Bladder

Neuromodulation is a minimally invasive surgical treatment for detrusor instability offered in specialized centres and may be considered after failure of non-invasive treatments. (Level of evidence = 2) (Weil et al, 1998; Shaker and Hassouna, 1998).

Augmentation intestinocystoplasty is recommended for individuals with intractable, severe bladder instability or poor bladder compliance that is unresponsive to nonsurgical therapies (Strength of Evidence = B)

Urinary diversion is recommended in severe intractable cases of detrusor instability or poor bladder compliance that is unresponsive to other therapies.
(Strength of Evidence = B)

10. Incomplete Emptying

10.a Bladder Neck or Urethral Obstruction or Poorly Contractile Bladder

Symptoms of overflow or incontinence secondary to bladder neck obstruction, prostatic enlargement or urethral stricture can be addressed with surgical procedure(s) to relieve the obstruction. (Strength of Evidence = B)

Intermittent catheterization or an indwelling catheter may be considered as a temporary or permanent measure for individuals who have urinary incontinence due to incomplete emptying secondary to underactive or obstructed bladder, and who are not candidates for surgery or who are awaiting surgery. (Strength of Evidence = C)
There is no evidence to support the use of urethral dilation for the treatment of incontinence in women, although it may be useful in the extremely rare cases of primary obstruction. (Strength of Evidence = C)

Internal urethrotomy is not recommended for treating urethral obstruction in women. (Strength of Evidence = C)

Bladder neck electrical stimulation in men and women with acontractile or hypocontractile bladder may enhance bladder emptying. (Level of Evidence = 3) (Primus et al, 1996)

Surgical management

In cases of anatomic obstruction in men, surgery can be selected when other forms of therapies have failed. Benign prostatic hyperplasia (BPH) is the most common cause of infravesical obstruction in males. The treatment of BPH is multifaceted and is addressed in other published clinical practice guidelines. (Level of Evidence = 3) (Jepsen and Bruskewitz, 1998)

11. Other Measures and Supportive Devices

Protective garments and external collecting devices have a major part in the management of chronic incontinence. The most absorbent and skin-friendly products should always be utilized. However, no scientific literature is available to guide selection of the most effective product. (Strength of Evidence = C)

11.a. Intermittent Catheterization (IC)

IC is recommended as a supportive measure for patients with spinal cord injury, persistent UI, or chronic urinary retention secondary to underactive or partially obstructed bladder. (Strength of Evidence = B)

Clean technique for IC is recommended for all except immunocompromised individuals. (Strength of Evidence = B)

Sterile technique for IC is recommended for elderly patients and patients with compromised immune system. (Strength of Evidence = C)

Routine use of long-term suppressive therapy with antibiotics in patients with chronic, clean IC is not recommended. (Strength of Evidence = B)

In high-risk populations, for example, those with an internal prosthesis or those who are immunosuppressed because of age or disease, the use of antibiotic therapy for asymptomatic bacteriuria must be individually reviewed. (Strength of Evidence = C)

11.b. Indwelling Urethral Catheters

Indwelling catheters are recommended for selected incontinent patients who are terminally ill or for patients with pressure ulcers as short-term treatment.
(Strength of Evidence = B)

Indwelling catheters are recommended in severely impaired individuals in whom alternative interventions are not an option and when a patient lives alone and a caregiver is unavailable to provide other supportive measures. (Strength of Evidence = C)

11.c. Suprapubic Catheters

Suprapubic catheters are for short-term use following gynecologic, urologic, and other surgery, or as an alternative to long-term catheter use. Suprapubic catheterization is contraindicated as a long-term management option in persons with chronic unstable bladder (detrusor instability, detrusor hyperactivity) and ISD. (Strength of Evidence = B)

11.d. External Collection Systems

External collection systems are recommended for incontinent men and women who have adequate bladder emptying, who have intact genital skin, and in whom other therapies have failed or are not appropriate. (Strength of Evidence = C)

11.e. Penile Compression Devices

Penile compression devices are known to be used in clinical practice in the treatment of UI. No scientific literature was found to support the use of these devices. The panel recognizes the temporary use of penile compression devices in males in selected circumstances under the supervision of a health care provider.
(Strength of Evidence = C)

11.f. Pelvic Organ Support Devices

There are no comparison studies with other treatments to recommend or discourage the use of pessaries for the treatment of UI in women. (Level of Evidence = 3)

Pessaries are recommended for women who have symptomatic pelvic organ prolapse. (Strength of Evidence = C)

11.g. Vaginal Devices for Urge Incontinence

Vaginal devices for urge incontinence may reduce urine loss. (Level of Evidence = 2) (Thyssen et al, 1999, Versi et al, 1997)

Part IV: Chronic Intractable Urinary Incontinence

1. Prevalence and Incidence

1.a. Interventions for Chronic UI

Care of people with chronic UI should include attention to toileting schedules, fluid and dietary intake, strategies to decrease urine loss at night, use of the most absorbent and skin-friendly protective garments possible, and prevention and early treatment of skin breakdown. (Strength of Evidence = B)

1.b. Physical and Environmental Alterations

All caregivers for elderly or disabled individuals must assess the environment in which the patient resides. Simple alterations, or the addition of toileting or ambulation devices, can often eliminate or reduce episodes of involuntary urine loss. (Strength of Evidence = C)

Strategies that maintain or improve mobility are likely to prevent or reduce incontinent episodes in the frail elderly. (Strength of Evidence = B)

1.c. Fluid and Dietary Management

Constipation is a common problem for patients with chronic UI. Establishing a bowel regimen based on adequate fibre and fluid intake is often helpful. Elimination of bowel impaction and consequent pressure on the bladder and urethra are often necessary first steps in the treatment of chronic UI. (Strength of Evidence = C)

1.d. Management of Nocturia

Night-time voiding and incontinence are major problems for adults of all ages. Prevention measures to decrease night-time voids are recommended. The use of simple electronic urine detection devices should be encouraged for more efficient and effective patient monitoring of night-time urine loss. (Strength of Evidence = B)

2. Other Measures and Supportive Care

2.a. Absorbent products

Absorbent products are recommended during evaluation, as an adjunct to other therapy, and for long-term care of patients with chronic, intractable urinary incontinence. (Strength of Evidence = C). There is limited information on the relative merit of the many different products available. (Level of Evidence = 3) (Baker and Norton, 1996; McClish et al, 1999)

2.b. Suprapubic Catheters

Suprapubic catheters may be an acceptable alternative for indwelling urethral catheters when patient choice or circumstances require the use of a bladder drainage device. (Strength of Evidence = B)

2.c. Skin Care

Recommended measures of cleansing the skin before and immediately after urine loss are helpful in preserving skin integrity. (Strength of Evidence = B)

Some pads and garments may provide some protection from skin damage. (Strength of Evidence = C)

Part V: Education

1. Public Education

Urinary incontinence has the stigma of a socially unacceptable condition because of public lack of knowledge, misconceptions and intolerance. This leads to personal isolation, social embarrassment, and delays in seeking medical advice. The public needs to know that many therapy and management problems surround urinary incontinence. Since the 1998 NIH Consensus Conference, public knowledge has increased somewhat through publication of the 1992 AHCPR Guideline document and efforts of the two self-help groups in the United States, the Simon Foundation for Continence and the National Association for Continence (NAFC, formerly Help for Incontinent People, HIP). In Canada, The Canadian Continence Foundation has raised public awareness through its many publications, surveys and Incontinence Awareness Month (November).

Increased efforts to inform and educate the public about incontinence are essential. (Strength of Evidence = C)

The public should be aware that incontinence is not inevitable or shameful but is treatable or at least manageable. (Strength of Evidence = C)

Patient education needs to be comprehensive and multidisciplinary so as to explain all management alternatives. (Strength of Evidence = C)

More research is needed to test the effectiveness of patient education activities. (Strength of Evidence = C)

2. Professional Education

Education about urinary incontinence for professionals, paraprofessionals and survey teams continues to be urgently needed. Information about urinary incontinence should be included and enhanced in the curricula of undergraduate and graduate health care professional schools. Schools of nursing and physiotherapy should consider educating professionals on incontinence care who can then serve as expert advisors (continence advisors) to other health care providers, regionally, on the provincial level in academic health sciences, community care access centres/home care and in long term care facilities.

Nurse continence advisor training has been formalized with the lead being taken at McMaster University, spearheaded by Jennifer Skelly, RN, PhD.. Distance education for nurses is available through this program. There are opportunities for similar programs to develop across the country for nurses. Formalized physiotherapy programs are evolving and would likewise be offered across Canada. In Canada, identifying sites that can provide the clinical component of education in a wide variety of settings, acute care hospitals, long term care facilities and the community will be important for nurses and physiotherapists and other health professionals seeking higher levels of training.

Education about UI evaluation and treatment should be included in the basic curricula of undergraduate and graduate training programs of all health care providers. Continuing education programs on UI should be offered to all health care providers. (Strength of Evidence = C)

Continuing education programs on UI should be offered to all health care providers. Training programs that provide didactic and broad clinical experience need to be available for nurses , physiotherapists and other health care professionals to become experts within their discipline for the management of continence in adults.