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SIGN advocates team approach to managing incontinent patients

Evidence-based recommendations on the primary care management of urinary incontinence should help to improve patients’ quality of life, says Dr Paul Dewart

Urinary incontinence, defined as the involuntary leakage of urine, is consistently associated with adverse effects on quality of life;1 even mild incontinence can have a serious effect.2 In older women, there is an association between urge incontinence and falls, increasing the risk of hip and wrist fractures.3

Given the serious impact of the condition on quality of life, it is unfortunate that many people, including some healthcare professionals, consider urinary incontinence simply as an untreatable consequence of ageing.

Estimates suggest that between 210 000 and 335 000 Scottish adults suffer from urinary incontinence.4 This represents 5-9% of the adult population, rising to 46% of women and 34% of men in the over-80s.5,6 This probably underestimates the true extent of the problem,as surveys suggest that less than half of adults with moderate to severe urinary incontinence seek help for this potentially treatable condition.

The SIGN guideline, Management of urinary incontinence in primary care, was developed to meet this need and to encourage patients to gain access to healthcare, as well as to improve primary care management by raising awareness of the potential of physical and pharmacological therapies.7

Recommendations are graded to indicate the strength of supporting evidence (Figure 1, below).

Figure 1: Key to evidence statements and grades of recommendations

Patients’ quality of life

Urinary incontinence can cause embarrassment, social isolation, loneliness, depression, adverse effects on sexual relationships and sleep disturbance resulting in chronic fatigue.

It is important to ascertain the patient’s view of how the condition affects his or her quality of life, and the guideline recommends using a validated questionnaire to assess both quality of life and symptom severity. It identifies several suitable questionnaires with shortened versions for use in primary care, and these can be useful in measuring treatment outcomes as well as in audit or research projects.

A proactive approach in consultations with patients who are at greatest risk is to be commended. Many will not volunteer the information that they are experiencing problems with urinary incontinence, often feeling too embarrassed or not realising that effective treatments are available. These patients can be encouraged to refer themselves to a continence adviser or other healthcare professional with expertise in the condition.

Recommendations relating to quality of life and health promotion are given in Box 1 (below).

Box 1: Recommendations on quality of life and health promotion
  • Healthcare practitioners should consider a validated quality of life and incontinence severity questionnaire to evaluate and audit the impact of urinary symptoms and to audit the effectiveness of any management strategy (B)
  • Patients with urinary incontinence should be offered information and advice on the treatment options available to them in both primary and secondary care (D)
  • Patients with urinary incontinence should have access to trained healthcare professionals who have the relevant knowledge and skills to offer appropriate advice and information (D)
  • Patients with urinary incontinence should be made aware that they are able to access specially trained staff without GP referral (D)
  • Effective communication within the primary care team and across the community/ hospital interface is essential if the optimal standard of care is to be achieved ()
  • Strategies using a number of different approaches and delivery media should be employed to raise awareness of urinary continence and promote incontinence services to a range of target audiences (C)

Risk factors and assessment

Healthcare professionals should be aware of the factors most commonly associated with urinary incontinence, namely pregnancy and childbearing, 8 prostate surgery, and ageing in both sexes. A high body mass index also predisposes women to develop the condition.

A multidisciplinary team approach is needed to identify patients with urinary incontinence and ensure optimal management. Nurses in the community (health visitors, district nurses and practice nurses) are often the first point of contact, particularly for elderly patients.

However, all healthcare professionals should be aware of the risk factors and how to deal with the problem.They should encourage the patient to express his or her concerns and to describe how it is affecting quality of life before deciding on the most appropriate healthcare professional to help.

Patients should also be offered information on where to obtain help and advice, including support groups, and be given information on investigation and treatment options.

Following identification, the next step is to undertake an initial assessment. This should be carried out by the continence adviser, physiotherapist, nurse or GP, depending on the patient’s needs.

The assessment should include a clinical history, which should cover:

  • medication
  • bowel habit
  • functional status and toilet access
  • sexual dysfunction
  • quality of life.

As well as a questionnaire, the assessment should include a voiding diary and urinalysis. In addition, for men, a post-void residual volume and digital rectal examination should be performed. Residual volume is necessary only in women who are experiencing voiding difficulties or recurrent urinary infection. Box 2 (below) gives the recommendations on risk factors and assessment.

Box 2: Recommendations on risk factors and assessment
  • Health professionals should be vigilant and adopt a proactive approach in consultations with patients who are at greatest risk of developing urinary incontinence through factors including age, the menopause, pregnancy and childbirth, high BMI and experience of continence problems in childhood (B)
  • Health professionals should recognise the difficulty that some patients have in raising concerns about continence and should be proactive in questioning patients about continence during consultations (C)
  • Health professionals should have a positive attitude to continence problems (C)
  • Assessment, treatment and referral, as appropriate, should be offered to all patients with urinary continence problems (B)
  • Initial assessment of a male patient with urinary incontinence should include completion of a voiding diary, urinalysis, estimation of post void residual volume and digital rectal examination (D)
  • Initial assessment of a female patient presenting with urinary incontinence should include completion of a voiding diary, urinalysis and, where symptoms of voiding dysfunction or repeated UTIs are present, estimation of post void residual volume (D)

Physical therapies

The guideline divides the types of urinary incontinence considered for treatment with physical or pharmacological therapies into three categories:

  • Stress urinary incontinence, defined as involuntary leakage of urine on effort or exertion, such as coughing or sneezing;
  • Urge urinary incontinence, defined as involuntary leakage preceded by an uncontrollable urge to pass urine;
  • Mixed urinary incontinence, a combination of stress and urge incontinence.

Pelvic floor muscle exercises are effective in treating both stress and mixed urinary incontinence in women 9 and should be the first line treatment for these conditions. The role of physical therapies for urge incontinence is less clear, but may have a role in combination with bladder retraining.10

In men, pelvic floor exercises should be considered for those undergoing radical prostate surgery.11 Recommendations on physical therapies are given in Box 3 (below).

Box 3: Recommendations on physical therapies
  • Pelvic floor muscle exercises should be the first choice of treatment offered to patients suffering from stress or mixed incontinence. Exercise programmes should be tailored to be achievable by the individual patient (A)
  • Digital assessment of pelvic floor muscle function should be undertaken prior to initiating any pelvic floor muscle exercise treatment (D)
  • Digital assessment of pelvic floor muscle function should only be carried out by an appropriately trained clinician ()
  • Pelvic floor muscle exercise treatment should be considered for patients following radical prostate surgery (B)
  • Bladder retraining should be offered to patients with urge urinary incontinence (C)

Pharmacotherapy

Detrusor overactivity and urge incontinence

Antimuscarinics such as oxybutynin, tolterodine, trospium and propiverine are of proven and equal efficacy in reducing bladder overactivity and hence urgency and urge incontinence.12

Side-effects of these antimuscarinic agents are common and include dry mouth, blurred vision, abdominal discomfort, drowsiness, nausea and dizziness.

The guideline recommends that the dose of these drugs should be titrated to the needs of the individual patient so as to minimise side-effects. Sustained release preparations of these drugs are associated with reduced side-effects and should therefore be the preferred option for most patients.

Stress incontinence

Duloxetine, a combined noradrenaline and selective serotonin reuptake inhibitor, has been shown to reduce urinary stress incontinence episodes by 50%.13 It is therefore recommended as part of a management strategy that includes pelvic floor exercises for women with moderate to severe stress incontinence.

Side-effects are generally mild. Nausea, the most commonly reported side-effect, usually settles quite quickly.

Recommendations relating to pharmacotherapies are given in Box 4 (below).

Box 4: Recommendations on pharmacotherapies
  • A trial of oxybutynin, propiverine, tolterodine, or trospium should be given to patients with significant urgency with or without urge incontinence. The dose should be titrated to combat adverse effects — see British National Formulary for dose ranges (A)
  • Antimuscarinic therapy should be tried for a period of 6 weeks to enable an assessment of the benefits and side-effects.Treatment should be reviewed after 6 months to ascertain continuing need ()
  • Duloxetine should be used only as part of an overall management strategy in addition to pelvic floor exercises and not in isolation. A 4-week trial of duloxetine is recommended for female patients with moderate to severe stress incontinence. Patients should be reviewed again after 12 weeks of therapy to assess progress and determine whether it is appropriate to continue treatment (A)

Containment

Containment products, such as pads, sheaths and catheters, have an important role in the management of urinary incontinence, but should be considered only after an initial assessment has been made and a management plan formulated.

Appropriately trained healthcare professionals must consider the active therapies that are available – cure of urinary incontinence, where this is achievable, is preferable to containment.

When selecting a containment product, care must be taken to ensure that the patient’s individual needs and comfort are considered. Offering disposable pads prematurely can lead to psychological dependence upon them and reluctance to accept active treatment.

Recommendations on containment are given in Box 5 (below).

Box 5: Recommendations on pharmacotherapies
  • All patients should undergo a continence assessment before product issue. issue of products should not take the place of therapeutic interventions (D)
  • Professionals should be vigilant to the proper use of products with regard application, fitting and tissue viability. Where products appear not to have effective, the patient should be reassessed for product suitability ()

Patient care pathway and referral to secondary care

Figure 1 (below) shows the recommended assessment and treatment options for stress, urge and mixed urinary incontinence, to support clinical decision making in men and women.

Figure 2: Sample care pathways for men and women with urinary incontinence

Some patients may need to be referred to a urologist or uro-gynaecologist for specialist investigation or treatment (Box 6, below);however, it is envisaged that most patients will be investigated and treated in primary care.

Box 6: Recommendations on referral
  • Patients should be referred to secondary care if previous surgical or non-surgical treatments for urinary incontinence have failed or if surgical treatments are being considered (D)
  • Male patients with reduced urinary flow rates or elevated post void residual volumes should be referred to secondary care (D)
  • Female patients with symptomatic pelvic organ prolapse or suspected voiding dysfunction should be referred to secondary care (D)

The suggested pathways cannot take the place of clinical judgement in the assessment of each individual patient.

Promoting best practice

The key to success in implementing this guideline is good communication within a well-informed multidisciplinary primary healthcare team. The recommendations are not complex, and the potential benefit in terms of improved quality of life for patients is considerable.

The content of the guideline lends itself to multidisciplinary learning opportunities.There are many highly trained and enthusiastic individuals working in primary care with expertise in the assessment and management of urinary incontinence who could help to meet their organisation’s learning needs.

Continence advisers, support groups and secondary care practitioners could contribute to learning sessions. Posters and leaflets are also available to educate patients. The Continence Foundation (www.continence-foundation.org.uk) is a useful source of information.

Implementing these recommendations should:

  • Heighten awareness of the prevalence and severity of this condition;
  • Educate members of the primary healthcare team;
  • Encourage timely and appropriate communication between members; and
  • Provide tools to measure the effectiveness of interventions.

The suggested care pathways could be used as templates to develop local algorithms.

SIGN Guideline 79. Management of urinary incontinence in primary care can be downloaded from the SIGN website: www.sign.ac.uk

References

  1. Fonda D, Woodward M, D'Astoli M, Chin WF. Sustained improvement of subjective quality of life in older community-dwelling people after treatment of urinary incontinence. Age Ageing 1995; 24: 283-6.
  2. Brittain K, Perry S, Williams K. Triggers that prompt people with urinary symptoms to seek help. Br J Nurs 2001; 10: 74-80.
  3. Brown JS,Vittinghoff E, Wyman JF et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc 2000; 48: 721-5.
  4. Royal College of Physicians of London. Incontinence: causes management and provision of services. London: RCP, 1995.
  5. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000; 107: 1460-70.
  6. Stoddart H, Donovan J, Whitley E et al. Urinary incontinence in older people in the community: a neglected problem? Br J Gen Pract 2001; 51: 548-52.
  7. Burnet C, Carter H, Gorman D. Urinary incontinence: a survey of knowledge working practice and training needs of nursing staff in Fife. Health Bull (Edinb) 1992; 50: 448-51.
  8. Viktrup L, Lose G.The risk of stress incontinence 5 years after first delivery. Am J Obstet Gynecol 2001; 185: 82-7.
  9. Hay-Smith EJC, Bø K, Berghmans LCM et al. Pelvic floor muscle training for urinary incontinence in women (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester UK: John Wiley & Sons.
  10. Wilson PD, Bo K, Hay-Smith J et al. Conservative treatment in women. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence: 2nd International Consultation on Incontinence, Paris, July 1-3, 2001. Plymouth: Health Publications 2002.
  11. Hunter KF, Moore KN, Cody DJ, Glazener CMA. Conservative management for postprostatectomy urinary incontinence (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.
  12. Hay-Smith J, Herbison P, Ellis G, Moore K. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.
  13. Dmochowski RR, Miklos JR, Norton PA et al. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol 2003; 170: 1259-63.

Dr Paul Dewart is consultant obstetrician/gynaecologist, St John’s Hospital, Livingston, and a member of the guideline development group

Guidelines in Practice, March 2005, Volume 8(3)
© 2005 MGP Ltd
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