Clinical Practice Guidelines for Adults:

Introduction
Recommended Steps in Assesment and Management
Guidelines
References
Appendix

Description of the flow charts

The flow charts provide a visual representation of the recommended steps in the assessment and management of urinary incontinence, and the order in which they should be considered. They are not algorithms mandating decisions, but allow the health professional and client to make their own decisions in a logical way. After feedback from the reactor panels it was decided that a single flow chart for the initial management of incontinence, and 3 separate flowcharts for specialized management in men, women, and the frail elderly respectively, could best guide professionals and clients through these steps. By the frail elderly we do not mean the fit older person, and in the absence of evidence of frailty the same approach should be used in older and younger people. The definition of frail elderly persons is "those in whom the assets maintaining health and the deficits threatening it are in precarious balance." In practical terms, this definition takes in those who depend on others for the activities of daily living or who are at high risk of becoming dependent (Rockwood et al, 1994). Examples include people with impaired mobility, who do not leave their residence without assistance of others, or with cognitive impairment. Most such people will be over 75 years of age, although some younger people with disabilities may respond to similar management.

An essential part of initial management is assessment, to establish a presumed etiology and to identify complex cases or serious conditions. It includes conservative methods using lifestyle modifications and behavioural interventions. They can be (but do not have to be) taught and implemented by primary-care professionals, as suggested in the recommended models of continence care developed in parallel with the guidelines. Conservative measures can be taught to and implemented by most people with incontinence. Time for thorough education in lifestyle modification and behavioural techniques is essential if they are to have any impact on the symptoms. These measures alone may completely resolve urinary incontinence or significantly improve it and the person's quality of life. Consistent with the non-prescriptive nature of the guidelines, however, the measures actually implemented will depend on the wishes of the client/consumer and the opinion of the health-care professional consulted. Specialized management is usually offered by a continence specialist from one of a number of disciplines. It may include more invasive urologic and urodynamic investigations. Management options include further trials of medication, devices, bulking agents such as periurethral collagen, or surgery.

As shown at the top of the flow chart for initial management, most patients or clients present with one of three or four common types of symptoms. A focused history is taken, and as one of the first steps it is important that the health professional discusses with the patient or client their expectations, to determine whether they want treatment, and what realistic outcomes would reflect a meaningful improvement in their quality of life. In some there may be a complex history, and they should be referred for specialized management. In the majority, the history, a physical examination, and simple tests lead to a presumed etiology. These steps (history, physical and listed tests) should be followed whether the professional is a physician or is acting under the guidance of a physician, because they may suggest the presence of serious conditions which require onward referral. Based on the presumed etiology, the professional should discuss with the patient the possible steps in management, beginning with conservative lifestyle and behavioural interventions (AHCPR, 1996; Abrams, Khoury, et al, 1998). These are reversible and do not have side effects. If indicated (and respecting the boundaries of professional standards of practice), drug therapy or various devices may be considered. They may cause side effects but are reversible. The use of incontinence products, which includes a large variety of pads and devices for effective containment of urine, may be implemented at any point in the management.

Throughout the process and follow-up, it is important for the professional to continue to review with the individual their expectations, levels of improvement or worsening of symptoms, and their quality of life.

After thorough evaluation of the results of initial management, failure to satisfy expectations may lead to specialized management. Specialized clinical assessment provides a diagnosis of the etiology and the underlying pathophysiology. On the basis of this new diagnosis, the possible efficacy of first-line management options is re-evaluated. Incontinence containment products may be considered again. Surgical interventions - which may cause side effects and are not reversible - may be instituted. After treatment, expectations, improvement, and quality of life are again evaluated.

Flow Charts

The flow chart for initial management and the 3 flow charts for specialized management of men, women and frail elderly are shown in Figures 1 - 4. Their general structure is based on the recommendations of the 1st International Consultation on Incontinence (Abrams, Khoury, et al, 1998), together with statements II-1, II-2, II-4, II-5, II-5a, II-5b, and II-5c in the list of guidelines.

Figure 1 • Figure 2 • Figure 3 • Figure 4