Urinary Incontinence

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

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F.C. Burkhard (Chair), J.L.H.R. Bosch, F. Cruz, G.E. Lemack, A.K. Nambiar, N. Thiruchelvam, A. Tubaro
Guidelines Associates: D. Ambühl, D. Bedretdinova, F. Farag, B.B. Rozenberg

1.INTRODUCTION

Urinary incontinence (UI) is an extremely common complaint in every part of the world. It causes a great deal of distress and embarrassment, as well as significant costs, to both individuals and societies. Estimates of prevalence vary according to the definition of incontinence and the population studied. However, there is universal agreement about the importance of the problem in terms of human suffering and economic cost.

1.1.Aim and objectives

These Guidelines from the European Association of Urology (EAU) Working Panel on Urinary Incontinence are written by a multidisciplinary group, primarily for urologists, and are likely to be referred to by other professional groups. They aim to provide sensible and practical evidence-based guidance on the clinical problem of UI rather than an exhaustive narrative review. Such a review is already available from the International Consultation on Incontinence [1], and so the EAU Guidelines do not describe the causation, basic science, epidemiology and psychology of UI. The focus of these Guidelines is entirely on assessment and treatment reflecting clinical practice. The Guidelines also do not consider patients with UI caused by neurological disease, or in children, as this is covered by complementary EAU Guidelines [2,3].

The elderly

The Panel decided to include a separate but complimentary set of recommendations referring to the elderly population within each section. Older people with UI deserve special consideration for a number of reasons. Physiological changes with natural ageing mean that all types of UI become more common with increasing age. Urinary incontinence commonly co-exists with other comorbid conditions, reduced mobility, and impaired cognition and may require specific interventions, such as assisted toileting.

For the elderly person expectations of assessment and treatment may need to be modified to fit in with specific circumstances, needs, and preferences, while also taking into account any loss of capacity for consent. When the urologist is dealing with a frail elderly patient with urinary incontinence, collaboration with other healthcare professionals such as elderly care physicians is recommended.

It must be emphasised that clinical guidelines present the best evidence available to the experts. However, following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel composition

The EAU Urinary Incontinence Panel consists of a multidisciplinary group of experts, including urologists, a gynaecologist and a physiotherapist. All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website: http://www.uroweb.org/guideline/urinary-incontinence.

1.3.Available publications

A quick reference document (Pocket Guidelines) is available, both in print and in a number of versions for mobile devices. These are abridged versions which may require consultation together with the full text versions. Two scientific publications in the journal European Urology are also available [4,5]. All documents are accessible through the EAU website: http://www.uroweb.org/guideline/urinary-incontinence.

1.4.Publication history

The EAU published the first Urinary Incontinence Guidelines in 2001. This 2017 publication presents a limited update of the 2016 Urinary Incontinence Guidelines.

1.4.1.Summary of changes.

Section 4.2 Pharmacological management has been revised for this 2017 print, including the addition of a new section 4.3.5.1 on Drug therapy.

Changed evidence summaries and recommendations can be found in sections:

4.2.1 Antimuscarinic drugs

Summary of evidence

LE

There is limited evidence that one antimuscarinic drug is superior to an alternative antimuscarinic drug for cure or improvement of urgency urinary incontinence.

1b

Higher doses of antimuscarinic drugs are more effective to cure or improve urgency urinary incontinence, but with a higher risk of side effects.

1b

Once daily (extended release) formulations are associated with lower rates of adverse events compared to immediate release ones, although similar discontinuation rates are reported in clinical trials.

1b

Dose escalation of antimuscarinic drugs may be appropriate in selected patients to improve treatment effect although higher rates of adverse events can be expected.

1b

Transdermal oxybutynin (patch) is associated with lower rates of dry mouth than oral antimuscarinic drugs, but has a high rate of withdrawal due to skin reaction.

1b

4.2.3.3 Recommendations for antimuscarinic drugs

Recommendations

GR

Offer antimuscarinic drugs for adults with urgency urinary incontinence who failed conservative treatment.

A

Consider extended release formulations in patients who do not tolerate immediate release antimuscarinics.

A

If antimuscarinic treatment proves ineffective, consider dose escalation or offering an alternative treatment.

B

Consider using transdermal oxybutynin if oral antimuscarinic agents cannot be tolerated due to dry mouth.

B

Offer and encourage early review (of efficacy and side effects) of patients on antimuscarinic medication for urgency urinary incontinence.

C

4.2.4 Antimuscarinic agents: adherence and persistence

Summary of evidence

LE

Adherence to antimuscarinic treatment is low and decreases over time because of lack of efficacy, adverse events and/or cost.

2

Most patients will stop antimuscarinic agents within the first three months.

2

4.2.5 Antimuscarinic and beta3 agonist agents, the elderly and cognition

Summary of evidence

LE

Antimuscarinic drugs are effective in elderly patients.

1b

Mirabegron has been shown to efficacious and safe in elderly patients.

1b

In older people, the cognitive impact of drugs which have anticholinergic effects is cumulative and increases with length of exposure.

2

Oxybutynin may worsen cognitive function in elderly patients.

2

Solifenacin, darifenacin, fesoterodine and trospium have been shown not to cause cognitive dysfunction in elderly people in short-term studies.

1b

4.2.5.2.13 Additional recommendations for antimuscarinic drugs in the elderly

Recommendations

GR

In older people being treated for urinary incontinence, every effort should be made to employ nonpharmacological treatments first.

C

Long-term antimuscarinic treatment should be used with caution in elderly patients especially those who are at risk of, or have, cognitive dysfunction.

B*

When prescribing antimuscarinic for urgency urinary incontinence, consider the total antimuscarinic load in older people on multiple drugs.

C

Consider the use of Mirabegron in elderly patients if additional antimuscarinic load is to be avoided.

C

*Recommendation based on expert opinion.

4.2.6 Mirabegron

Summary of evidence

LE

Mirabegron is better than placebo and as efficacious as antimuscarinics for improvement of urgency urinary incontinence symptoms.

1a

Adverse event rates with mirabegron are similar to placebo.

1a

Patients inadequately treated with solifenacin 5 mg may benefit more from the addition of mirabegron than dose escalation of solifenacin.

1b

Recommendation

GR

In patients with urgency urinary incontinence and an inadequate response to conservative treatments, offer mirabegron unless they have uncontrolled hypertension.

A

4.2.7 Drugs for stress urinary incontinence

Summary of evidence

LE

Duloxetine, 40 mg twice daily improves stress urinary incontinence in women.

1a

Duloxetine causes significant gastrointestinal and central nervous system (CNS) side effects leading to a high rate of treatment discontinuation, although these symptoms are limited to the first weeks of treatment.

1a

Recommendations

GR

Duloxetine can be used with caution to treat women with symptoms of stress urinary incontinence.

A

Duloxetine should be initiated using dose titration because of high adverse event rates.

A

4.2.8 Oestrogen

Recommendation

GR

Vaginal oestrogen therapy for vulvovaginal atrophy should be prescribed long-term. In women with a history of breast cancer, the treating oncologist needs to be consulted.

C

4.2.9.2.2 Monitoring for hyponatraemia

Recommendations

GR

Consider offering desmopressin to patients requiring occasional short-term relief from daytime urinary incontinence and inform them that this drug is not licensed for this indication.

A

Monitor plasma sodium levels in patients on desmopressin.

A*

*Recommendation based on expert opinion.

4.2.10 Drug treatment in mixed urinary incontinence

Recommendation

GR

Offer antimuscarinic drugs or beta3 agonists to patients with urgency-predominant mixed urinary incontinence.

A*

*Recommendation based on expert opinion.

4.3.5.1 Drug therapy

Summary of evidence

LE

Duloxetine, either alone or combined with conservative treatment, can hasten recovery of continence but does not improve continence rate following prostate surgery.

1b

4.3.5.5 Compression devices in males

Recommendation

GR

Consider offering duloxetine to hasten recovery of continence after prostate surgery but inform the patient about the possible adverse events.

B

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