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.A. Bedretdinova, F. Farag, R. Lombardo, M.P. Schneider

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 current Guidelines provide:

  • A clear pathway (algorithm) for common clinical problems. This can provide the basis for thinking through a patient’s management and also for planning and designing clinical services.
  • A brief but authoritative summary of the current state of evidence on clinical topics, complete with references to the original sources.
  • Clear guidance on what to do or not to do, in most clinical circumstances. This should be particularly helpful in those areas of practice for which there is little or no high-quality evidence.

In this edition the Panel has continued to focus, largely, on the management of a ‘standard’ patient. The Panel has referred in places to patients with ‘complicated incontinence’, by which we mean patients with associated morbidity, a history of previous pelvic surgery, surgery for UI, radiotherapy and women with associated genitourinary prolapse. An appendix is included on non-obstetric genitourinary fistulae. The subject of prevention of UI has not been addressed. A systematic review (SR) on nocturnal incontinence found no studies on the topic. The Panel are of the opinion that nocturnal incontinence should be considered in future research studies.

1.1.1.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 as an app for iOS and Android 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. Section 4.3 Surgical Management has been completely updated in this 2018 publication.

1.4.1.Summary of changes.

Changed evidence summaries and recommendations can be found in sections:

4.3.1.1.3 Summary of evidence for mid-urethral slings

Summary of evidence

LE

Mid-urethral synthetic sling inserted by either the transobturator or retropubic route provides equivalent patient-reported outcome at five years.

1a

Mid-urethral synthetic sling inserted by the retropublic routes has higher objective patient-reported cure rates at 8 years.

1b

Long-term analysis of TVT cohorts showed a sustained response up to 17 years.

2b

The transobturator route of insertion is associated with a higher risk of groin pain than the retropubic route.

1a

Long-term analysis showed no difference in terms of efficacy for the skin-to-vagina compared to vagina-to-skin directions up to nine years.

2a

The top-to-bottom direction in the retropubic approach is associated with a higher risk of post-operative voiding dysfunction.

1b

Incontinence surgery has similar outcomes in older patients (≥ 65 years).

2a

Incontinence surgery may be safely performed in obese women, however, outcomes may be inferior.

2b

Improvement in sexual life is higher with single incision slings than with standard MUS.

1a

SUI=stress urinary incontinence; TVT=tension-free vaginal tape.

NB: Most evidence on single-incision slings is from studies using the tension-free vaginal tape secure (TVT-S) device and although this device is no longer available, many women still have the device in place.

4.3.1.4.3 Summary of evidence for open and laparoscopic surgery for stress urinary incontinence

Summary of evidence

LE

Laparoscopic colposuspension has a shorter hospital stay and may be more cost-effective than open colposuspension.

1a

4.3.1.5.3 Summary of evidence for bulking agents

Summary of evidence

LE

Peri-urethral injection of a bulking agent may provide short-term improvement and cure (twelve months), in women with SUI.

1b

Autologous fat and hyaluronic acid as bulking agents have a higher risk of adverse events.

1a

Peri-urethral route of injection of bulking agents may be associated with a higher risk of urinary retention compared to the transurethral route.

2b

SUI=stress urinary incontinence.

4.2.5.2.13 Additional recommendations for antimuscarinic drugs in the elderly

Recommendations

Strength rating

Inform women about the higher risk of groin pain following a transobturator approach when compared to a retropubic approach.

Strong

Inform women that any vaginal surgery may have an impact on sexual function, which is generally positive.

Weak

Offer bulking agents to women with SUI who request a low-risk procedure with the understanding that repeat injections are likely and long-term durability is not established.

Strong

SUI=stress urinary incontinence.

4.3.2.1.3 Summary of evidence for colposuspension or sling following failed surgery

Summary of evidence

LE

TVT and TOT have similar outcomes in patients with recurrent SUI.

1a

Burch colposuspension has similar patient reported or objective cure rates when compared to TVT.

1b

TOT=trans-obturator tape; TVT=tension-free vaginal tape.

4.3.3.4 Recommendations for women with both stress urinary incontinence and pelvic organ prolapse

Recommendations for women requiring surgery for bothersome pelvic organ prolapse who have symptomatic or unmasked stress urinary incontinence

Strength rating

Inform women of the increased risk of adverse events with combined surgery compared to prolapse surgery alone, as well as the risk of UI progression if UI is untreated at the time of POP repair.

Strong

POP=pelvic organ prolapse; UI=urinary incontinence.

4.3.5.1.1 Summary of evidence for drug therapy in men with stress urinary incontinence

Summary of evidence

LE

Duloxetine, either alone or combined with conservative treatment, can hasten recovery but does not improve continence rate following prostate surgery. However, it can be associated with significant, albeit often transient, side effects.

1b

4.3.5.3.3 Summary of evidence for fixed male sling

Summary of evidence

LE

There is no evidence that intraoperative placement of an autologous sling during RARP improves return of continence at 6 months.

1b

RARP=robotic assisted radical prostatectomy.

4.3.5.6 Recommendations for men with stress urinary incontinence

Recommendation

Strength rating

Offer duloxetine only to hasten recovery of continence after prostate surgery but inform the patient about the possible adverse events and that its use is off label for this indication in most European countries.

Weak

4.3.6.2.3 Summary of evidence for sacral nerve stimulation

Recommendations

LE

Sacral nerve neuromodulation is not more effective than OnabotulinumA toxin 200 U injection at 6 months.

1b

4.3.6.3.4 Recommendations for cystoplasty/urinary diversion

Recommendations

Strength rating

Offer augmentation cystoplasty to patients with UI who have failed all other treatment options.

Weak

Inform patients undergoing augmentation cystoplasty of the high risk of having to perform clean intermittent self-catheterisation (ensure they are willing and able to do so) and that they need lifelong surveillance.

Weak

UI=urinary incontinence.

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