Guidelines on urinary incontinence continued

Urodynamics

• These refer only to neurologically intact adults with urinary incontinence
• Clinicians carrying out urodynamics in patients with urinary incontinence should:
  • ensure that the test replicates the patient’s symptoms
  • interpret results in context of the clinical problem
  • check recordings for quality control
  • remember there may be physiological variability within the same individual
• Advise patients that the results of urodynamics may be useful in discussing treatment options, although there is limited evidence that performing urodynamics will alter the outcome of treatment for urinary incontinence
• Do not routinely carry out urodynamics when offering conservative treatment for urinary incontinence
• Perform urodynamics if the findings may change the choice of invasive treatment
• Do not routinely carry out urethral pressure profilometry

Pad testing

• A well-designed continence pad will contain any urine leaked within a period of time and this has therefore been used as a way of quantifying leakage. Although the International Continence Society has attempted to standardise pad testing, there remain differences in the way patients are instructed to undertake activity during the test
• Use a pad test when quantification of urinary incontinence is required
• Use repeat pad test after treatment if an objective outcome measure is required

Imaging

• Do not routinely carry out imaging of the upper or lower urinary tract as part of the assessment of uncomplicated stress urinary incontinence in women

Conservative treatment

• Conventional medical practice encourages the use of simple, relatively harmless, interventions before resort to those associated with higher risks

Simple medical interventions

• Correction of underlying disease/cognitive impairment. Numerous conditions exacerbate urinary incontinence or make it more likely to occur, whether or not they play any part in the pathophysiology of leakage. These conditions include:
  • cardiac failure
  • chronic renal failure
  • diabetes
  • chronic obstructive pulmonary disease
  • neurological disorders
  • stroke
  • dementia
  • multiple sclerosis
  • general cognitive impairment
  • sleep disturbances e.g. sleep apnoea

Adjustment of medication

• There is very little evidence of benefit from the adjustment of medication. There is also a theoretical risk, at least, that stopping or altering medication may bring with it more harm than good
• Take a drug history from all patients with urinary incontinence
• Inform women with urinary incontinence that begins or worsens after starting systemic oestrogen replacement therapy that it may cause urinary incontinence
• Review any new medication associated with the development or worsening of urinary incontinence

Guidelines on urinary incontinence continued

Constipation

• Several studies have shown strong associations between constipation, urinary incontinence and overactive bladder. Constipation can be improved by behavioural and medical treatments
• For adults with urinary incontinence, treat co-existing constipation

Containment (pads etc)

• Offer pads when containment of urinary incontinence is needed
• Adapt the choice of pad to the type and severity of urinary incontinence and the patient’s needs
• Offer catheterisation to manage urinary incontinence when no other treatments can be considered
• Offer condom catheters to men with urinary incontinence without significant residual urine
• Offer to teach intermittent catheterisation to manage urinary incontinence associated with retention of urine
• Do not routinely offer intravaginal devices as treatment for incontinence
• Do not use penile clamps for control of urinary incontinence in men

Lifestyle changes

• Examples of lifestyle factors that may be associated with incontinence include obesity, smoking, level of physical activity and diet. It may therefore be possible to improve urinary incontinence by beginning lifestyle interventions, such as weight loss, fluid restriction, reduction of caffeine or alcohol intake, limiting heavy activity and stopping smoking
• Encourage obese women suffering from any urinary incontinence to lose weight (>5%)
• Advise adults with urinary incontinence that reducing caffeine intake may improve symptoms of urgency and frequency but not incontinence
• Patients with abnormally high or abnormally low fluid intake should be advised to modify their fluid intake appropriately
• Counsel female athletes experiencing urinary incontinence with intense physical activity that it will not predispose to urinary incontinence in later life
• Patients with urinary incontinence who smoke should be given smoking cessation advice in line with good medical practice although there is no definite effect on urinary incontinence

Behavioural and physical therapies

• Offer supervised pelvic floor muscle training, lasting at least 3 months, as a first-line therapy to women with stress or mixed urinary incontinence
• Pelvic floor muscle training programmes should be as intensive as possible
• Offer pelvic floor muscle training to elderly women with urinary incontinence
• Consider using biofeedback as an adjunct in women with stress urinary incontinence
• Offer supervised pelvic floor muscle training to continent women in their first pregnancy to help prevent incontinence in the postnatal period
• Offer instruction on pelvic floor exercises to men undergoing radical prostatectomy to speed recovery of urinary incontinence
• Offer bladder training as a first-line therapy to adults with urge urinary incontinence or mixed urinary incontinence
• Offer timed voiding to adults with urinary incontinence, who are cognitively impaired
• Do not offer electrical stimulation with surface electrodes (skin, vaginal, anal) alone for the treatment of urinary incontinence
• Do not offer magnetic stimulation for the treatment of urinary incontinence or overactive bladder in adult women
• Do not offer posterior tibial nerve stimulation to women or men who are seeking a cure for urge urinary incontinence
• Offer, if available, posterior tibial nerve stimulation as an option for improvement of urge urinary incontinence in women, but not men, who have not benefited from antimuscarinic medication
• Support other healthcare professionals in use of rehabilitation programmes including prompted voiding for care of elderly care-dependent people with urinary incontinence

Guidelines on urinary incontinence continued

Drug treatment of urinary incontinence

Antimuscarinics

• Offer immediate release or extended release formulations of antimuscarinic drugs as initial drug therapy for adults with urge urinary incontinence
• If immediate release formulations of antimuscarinic drugs are unsuccessful for adults with urge urinary incontinence, offer extended release formulations or longer-acting antimuscarinic agents
• Consider using transdermal oxybutynin if oral antimuscarinic agents cannot be tolerated due to dry mouth
• Offer and encourage early review (of efficacy and side-effects) of patients on antimuscarinic medication for urge urinary incontinence (<30 days)
• When prescribing antimuscarinic drugs to elderly patients, be aware of the risk of cognitive side-effects, especially in those receiving cholinesterase inhibitors
• Avoid using oxybutynin immediate release in patients who are at risk of cognitive dysfunction
• Consider use of trospium chloride in patients known to have cognitive dysfunction
• Use antimuscarinic drugs with caution in patients with cognitive dysfunction
• Do an objective assessment of mental function before treating patients whose cognitive function may be at risk
• Check mental function in patients on antimuscarinic medication if they are at risk of cognitive dysfunction

Adrenergic drugs

• Offer mirabegron extended release to people with urge urinary incontinence depending on local licensing arrangements

Duloxetine

• Duloxetine should not be offered to women or men who are seeking a cure for their urinary incontinence
• Duloxetine can be offered to women or men who are seeking temporary improvement in incontinence symptoms
• Duloxetine should be initiated using dose titration because of high adverse effect rates

Intravaginal oestrogen

• Offer post-menopausal women with urinary incontinence local oestrogen therapy, although the ideal duration of therapy and best delivery method are unknown

Desmopressin

• Offer desmopressin to patients requiring occasional short-term relief from urinary incontinence and inform them that this drug is not licensed for this indication
• Do not use desmopressin for long-term control of urinary incontinence

Guidelines on urinary incontinence continued

Woman presenting with urinary incontinence

Guidelines on urinary incontinence continued

Man presenting with urinary incontinence

full guidelines available from…

Guidelines on Urinary Incontinence 2013. M.G. Lucas, D. Bedretdinova, J.L.H.R. Bosch, F. Burkhard, F. Cruz, A.K. Nambiar, D.J.M.K. de Ridder, A. Tubaro, R.S. Pickard. Available at: www.uroweb.org/guidelines/online-guidelines. March 2013.

First included: Oct 13.