Urinary Incontinence

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EAU GUIDELINES ON URINARY
INCONTINENCE

(Limited text update March 2017)

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

Introduction

This pocket version aims to synthesise the important clinical messages described in the full text and is presented as a series of ‘graded’ ‘action based recommendations’, which follow the standard for levels of evidence used by the EAU (see Introduction chapter of the EAU Guidelines book).

Diagnostic Evaluation

History and physical examination

The history should include details of the type, timing and severity of urinary incontinence (UI), associated voiding and other urinary symptoms. The history should allow UI to be categorised into stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI). It should also identify patients who need rapid referral to an appropriate specialist. These include patients with associated pain, haematuria, a history of recurrent urinary tract infection (UTI), pelvic surgery (particularly prostate surgery) or radiotherapy, constant leakage suggesting a fistula, voiding difficulty or suspected neurological disease. The patient should also be asked about other ill health and for the details of current medications, as these may impact on symptoms of UI.

Questionnaires

Recommendation

GR

Use a validated and appropriate questionnaire when standardised assessment is required.

B*

* Recommendation based on expert opinion.

Voiding diaries

Recommendations

GR

Ask patients with urinary incontinence to complete a voiding diary.

A

Use a diary duration of between three and seven days.

B

Urinalysis and urinary tract infection

Recommendations

GR

Perform urinalysis as a part of the initial assessment of a patient with urinary incontinence.

A*

If a symptomatic urinary tract infection is present with urinary incontinence, reassess the patient after treatment.

A*

Do not routinely treat asymptomatic bacteriuria in elderly patients to improve urinary incontinence.

B

* Recommendation based on expert opinion.

Post-voiding residual volume

Recommendations

GR

When measuring post-void residual urine volume, use ultrasound.

A

Measure post-void residual in patients with urinary incontinence who have voiding symptoms.

B

Measure post-void residual when assessing patients with complicated urinary incontinence.

C

Post-void residual should be monitored in patients receiving treatments that may cause or worsen voiding dysfunction, including surgery for stress urinary incontinence.

A*

* Recommendation based on expert opinion.

Urodynamics

Recommendations

GR

(NB: Concerning only neurologically intact adults with urinary incontinence)

Clinicians carrying out urodynamics in patients with urinary incontinence should:

nensure that the test replicates the patient’s
symptoms;

interpret results in the context of the clinical
problem;

check recordings for quality control;

remember there may be physiological variability within the same individual.

C

Advise patients that the results of urodynamics may be useful in discussing treatment options, although there is limited evidence that performing urodynamics will predict the outcome of treatment for uncomplicated urinary incontinence.

C

Do not routinely carry out urodynamics when offering treatment for uncomplicated urinary incontinence.

B

Perform urodynamics if the findings may change the choice of invasive treatment.

B

Do not use urethral pressure profilometry or leak point pressure to grade severity of incontinence or predict the outcome of treatment.

C

Urodynamic practitioners should adhere to standards defined by the International Continence Society.

C

Pad testing

Recommendations

GR

Have a standardised duration and activity protocol for pad test.

B

Use a pad test when quantification of urinary incontinence is required.

C

Use repeat pad test after treatment if an objective outcome measure is required.

C

Imaging

Recommendation

GR

Do not routinely carry out imaging of the upper or lower urinary tract as part of the assessment of urinary incontinence.

A

Disease Management

Conservative management

In clinical practice, it is a convention that non-surgical therapies are tried first because they usually carry the least risk of harm. Conventional medical practice encourages the use of simple, relatively harmless, interventions before resorting to those associated with higher risks.

Simple medical interventions

Correction of underlying disease/cognitive impairment

Urinary incontinence, especially in the elderly, can be caused or worsened by underlying diseases, especially conditions that cause polyuria, nocturia, increased abdominal pressure or central nervous system (CNS) disturbances. These conditions include:

cardiac failure;

chronic renal failure;

diabetes;

chronic obstructive pulmonary disease;

neurological disease including stroke and multiple sclerosis;

general cognitive impairment;

sleep disturbances, e.g. sleep apnoea;

depression;

metabolic syndrome.

Adjustment of medication

Although changing drug regimens for underlying disease may be considered as a possible early intervention for UI, there is very little evidence of benefit. There is also a risk that stopping or altering medication may result in more harm than benefit.

Recommendations

GR

Take a drug history from all patients with urinary incontinence.

A

Review any new medication associated with the development or worsening of urinary incontinence.

C

Constipation

Studies have shown strong associations between constipation and UI. Constipation can be improved by behavioural, physical and medical treatments.

Recommendation

GR

Adults with urinary incontinence who also suffer from constipation should be given advice about bowel management in line with good medical practice.

C

Containment (pads etc.)

Recommendations

GR

Ensure that adults with urinary incontinence and/or their carers are informed regarding available treatment options before deciding on containment alone.

A*

Suggest use of disposable insert pads for women and men with light urinary incontinence.

A*

In collaboration with other healthcare professionals with expertise in urinary incontinence, help adults with moderate/severe urinary incontinence to select the individually best containment regimen considering pads, external devices and catheters, balancing benefits and harms.

A*

The choice of pad, from the wide variety of different absorbent materials and designs available, should be made with consideration of the individual patient’s circumstance, degree of incontinence and preference.

B

* Recommendation based on expert opinion.

Lifestyle changes

Examples of lifestyle factors that may be associated with incontinence include obesity, smoking, level of physical activity and diet. Modification of these factors may improve UI.

Recommendations

GR

Encourage obese women with urinary incontinence to lose weight and maintain weight loss.

A

Advise adults with urinary incontinence that reducing caffeine intake may improve symptoms of urgency and frequency but not incontinence.

B

Patients with abnormally high or abnormally low fluid intake should be advised to modify their fluid intake appropriately in line with good medical practice.

C

Counsel female athletes experiencing urinary incontinence with intense physical activity that it will not predispose to urinary incontinence in later life.

C

Patients with urinary incontinence who smoke should be given smoking cessation advice in line with good medical practice.

A

Behavioural and physical therapies

Recommendations

GR

Offer bladder training as a first-line therapy to adults with urgency urinary incontinence or mixed urinary incontinence.

A

Offer prompted voiding for adults with incontinence, who are cognitively impaired.

A

Offer supervised intensive pelvic floor muscle training (PFMT), lasting at least three months, as a first-line therapy to women with stress urinary incontinence or mixed urinary incontinence.

A

Pelvic floor muscle training programmes should be as intensive as possible.

B

Offer PFMT to elderly women with urinary incontinence.

A

Offer PFMT to post-natal women with urinary incontinence.

A

Consider using biofeedback as an adjunct in women with stress urinary incontinence.

B

Offer PFMT to men undergoing radical prostatectomy to speed recovery of incontinence.

A

Do not offer electrical stimulation with surface electrodes (skin, vaginal, anal) alone for the treatment of stress urinary incontinence.

A

Consider offering electrical stimulation as an adjunct to behavioural therapy in patients with urgency urinary incontinence.

B

Do not offer magnetic stimulation for the treatment of incontinence or overactive bladder in adult women.

B

Offer, if available, percutaneous posterior tibial nerve stimulation as an option for improvement of urgency urinary incontinence in women who have not benefitted from antimuscarinic medication.

B

Support other healthcare professionals in use of rehabilitation programmes including prompted voiding for elderly care-dependent people with urinary incontinence.

A

Conservative therapy in mixed urinary incontinence

Recommendations

GR

Treat the most bothersome symptom first in patients with mixed urinary incontinence.

C

Warn patients with mixed urinary incontinence that the chance of success of pelvic floor muscle training is lower than for stress urinary incontinence alone.

B

Pharmacological Management

Antimuscarinics

Recommendations

GR

Offer antimuscarinic drugs to 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

Antimuscarinic drugs in the elderly

Recommendations

GR

In older people being treated for urinary incontinence, every effort should be made to employ non-pharmacological 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.

Mirabegron

Recommendation

GR

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

A

Drugs for stress urinary incontinence

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

Oestrogen

Recommendations

GR

Offer post-menopausal women with urinary incontinence vaginal oestrogen therapy, particularly if other symptoms of vulvovaginal atrophy are present.

A

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

For women taking oral conjugated equine oestrogen as hormone replacement therapy who develop or experience worsening urinary incontinence, discuss alternative hormone replacement therapies.

A

Advise women who are taking systemic oestradiol who suffer from urinary incontinence that stopping the oestradiol is unlikely to improve their incontinence.

A

Desmopressin

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*

Do not use desmopressin for long-term control of urinary incontinence.

A

*Recommendation based on expert opinion.

Drug treatment in mixed urinary incontinence

Recommendations

GR

Treat the most bothersome symptom first in patients with mixed urinary incontinence.

C

Offer antimuscarinic drugs or beta 3 agonists to patients with urgency-predominant mixed urinary incontinence.

A*

Consider duloxetine for patients with mixed urinary incontinence unresponsive to other conservative treatments and who are not seeking cure.

B

* Recommendation based on expert opinion.

Surgical Management

The section considers surgical options for the following situations:

Women with uncomplicated SUI; this means no history of previous surgery, no neurological lower urinary tract dysfunction (LUTD), no bothersome genitourinary prolapse, and those not considering further pregnancy.

Women with complicated SUI. Neurogenic LUTD is reviewed in the EAU Guidelines on Neuro-Urology.

Associated genitourinary prolapse has been included in these Guidelines in terms of treating the incontinence, but no attempt has been made to comment on treatment of prolapse itself.

Men with SUI, mainly those with post-prostatectomy incontinence without neurological disease affecting the lower urinary tract.

Patients with refractory DO incontinence.

Women with uncomplicated stress urinary incontinence

Recommendations

GR

Offer the mid-urethral sling to women with uncomplicated stress urinary incontinence as the preferred surgical intervention whenever available.

A

Warn women who are being offered a retropubic insertion of mid-urethral sling about the relatively higher risk of peri-operative complications compared to transobturator insertion.

A

Warn women who are being offered transobturator insertion of mid-urethral sling about the higher risk of pain and dyspareunia in the longer term.

A

Warn women who are being offered a single-incision sling that long-term efficacy remains uncertain.

A

Do a cystourethroscopy as part of the insertion of a mid-urethral sling.

C

Offer colposuspension (open or laparoscopic) or autologous fascial sling to women with stress urinary incontinence if mid-urethral sling cannot be considered.

A

Warn women undergoing autologous fascial sling that there is a high risk of voiding difficulty and the need to perform clean intermittent self-catheterisation; ensure they are willing and able to do so.

C

Inform older women with stress urinary incontinence about the increased risks associated with surgery, including the lower probability of success.

B

Inform women that any vaginal surgery may have an impact on sexual function.

B

Only offer new devices, for which there is no level 1 evidence base, as part of a structured research programme.

A*

Only offer adjustable mid-urethral sling as a primary surgical treatment for stress urinary incontinence as part of a structured research programme.

A*

Do not offer bulking agents to women who are seeking a permanent cure for stress urinary incontinence.

A*

* Recommendation based on expert opinion.

Women with complicated stress urinary incontinence

Recommendations

GR

Management of complicated stress urinary incontinence should only be offered in expert** centres.

A*

The choice of surgery for recurrent stress urinary incontinence should be based on careful evaluation of the individual patient including multichannel urodynamics and imaging as appropriate.

C

Warn women with recurrent stress urinary incontinence that the outcome of a surgical procedure, when used as a second-line treatment, is generally inferior to its use as a first-line treatment, both in terms of reduced efficacy and increased risk of complications.

C

Consider secondary synthetic sling, colposuspension or autologous sling as first options for women with complicated stress urinary incontinence.

C

Warn women receiving artificial urinary sphincter or ACT device that, even in expert centres, there is a high risk of complications, mechanical failure or a need for explantation.

C

* Recommendation based on expert opinion.

** See comments on surgeon volume in the full Guidelines for further information.

Women with both stress urinary incontinence and pelvic organ prolapse

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

GR

Offer simultaneous surgery for POP and stress urinary incontinence.

A

Warn women of the increased risk of adverse events with combined surgery compared to prolapse surgery alone.

A

Recommendations for women requiring surgery for bothersome POP without symptomatic or unmasked stress urinary incontinence

Warn women that there is a risk of developing de novo stress urinary incontinence after prolapse surgery.

A

Inform women that the benefit of prophylactic stress urinary incontinence surgery is uncertain.

C

Warn women that the benefit of surgery for stress urinary incontinence may be outweighed by the increased risk of adverse events with combined surgery compared to prolapse surgery alone.

A

* Recommendation based on expert opinion.

Urethral diverticulum

Recommendation

GR

Symptomatic urethral diverticula should be completely surgically removed.

A*

*Recommendation based on expert opinion.

Men with stress urinary incontinence

Recommendations

GR

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

B

Only offer bulking agents to men with mild post-prostatectomy incontinence who desire temporary relief of incontinence symptoms.

C

Do not offer bulking agents to men with severe post-prostatectomy incontinence.

C

Offer fixed slings to men with mild-to-moderate* post-prostatectomy incontinence.

B

Warn men that severe incontinence, prior pelvic radiotherapy or urethral stricture surgery, may worsen the outcome of fixed male sling surgery.

C

Offer artificial urinary sphincter (AUS) to men with moderate-to-severe post-prostatectomy incontinence.

B

Implantation of AUS or artificial compression device (ACT) for men should only be offered in expert centres.

C

Warn men receiving AUS or ACT that, even in expert centres, there is a high risk of complications, mechanical failure or a need for explantation.

C

Do not offer non-circumferential compression device (ProACT®) to men who have had pelvic radiotherapy.

C

* The terms mild and moderate post-prostatectomy incontinence remain undefined.

Surgical interventions for refractory detrusor overactivity

Intravesical injection of botulinumtoxin A

Recommendations

GR

Offer bladder wall injections of onabotulinum toxin A (100 U) to patients with urgency urinary incontinence refractory to conservative therapy (such as pelvic floor muscle training and/or transdermal drug treatment).

A

Warn patients of the limited duration of response, risk of urinary tract infection and the possible prolonged need to self-catheterise (ensure that they are willing and able to do so).

A

Sacral nerve stimulation (neuromodulation)

Recommendation

GR

Offer sacral nerve modulation to patients who have urgency urinary incontinence refractory to antimuscarinic therapy.

A

Cystoplasty/urinary diversion

Recommendations

GR

Only offer augmentation cystoplasty to patients with detrusor overactivity incontinence who have failed conservative therapy, in whom the possibility of botulinum toxin and sacral nerve stimulation has been discussed.

C

Warn 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.

C

Do not offer detrusor myectomy as a treatment for urinary incontinence.

C

Only offer urinary diversion to patients who have failed less invasive therapies for the treatment of urinary incontinence and who will accept a stoma.

C

Warn patients undergoing augmentation cystoplasty or urinary diversion of the high risk of short-term and long-term complications, and the possible small risk of malignancy.

C

Life-long follow-up is mandatory in patients who have undergone augmentation cystoplasty or urinary diversion.

C

Surgery in patients with mixed urinary incontinence

Recommendations

GR

Treat the most bothersome symptom first in patients with mixed urinary incontinence.

C

Warn patients with mixed urinary incontinence that surgery is less likely to be successful than surgery in patients with stress urinary incontinence alone.

A

Warn patients with mixed urinary incontinence that one single treatment may not cure urinary incontinence; it may be necessary to treat other components of the incontinence problem as well as the most bothersome symptom.

A*

* Upgraded following panel consensus.

Surgery for urinary incontinence in the elderly

Recommendation

GR

Inform older women with urinary incontinence about the increased risks associated with surgery (including onabotA injection), together with the lower probability of benefit.

B

Non Obstetric Urinary Fistula*

Recommendations

GR

General

Surgeons undertaking complex pelvic surgery should be competent at identifying, preserving and repairing the ureter.

C

Do not routinely use ureteric stents as prophylaxis against injury during routine gynaecological surgery.

B

Suspect ureteric injury or fistula in patients following pelvic surgery if a fluid leak or pelvicalyceal dilatation occurs post-operatively or if drainage fluid contains high levels of creatinine.

C

Suspect uretero-arterial fistula in patients presenting with haematuria with a history of relevant surgery.

C

Use three dimensional imaging techniques to diagnose and localise urinary fistulae.

C

Manage upper urinary tract fistulae by conservative or endoluminal technique where such expertise and facilities exists.

B

Surgical principles

Surgeons involved in fistula surgery should have appropriate training, skills, and experience to select an appropriate procedure for each patient.

C

Attention should be given as appropriate to skin care, nutrition, rehabilitation, counselling and support prior to and following fistula repair.

C

If a vesicovaginal fistula is diagnosed within six weeks of surgery, consider indwelling catheterisation for a period of up to twelve weeks after the causative event.

C

Tailor the timing of fistula repair to the individual patient and surgeon requirements once any oedema, inflammation, tissue necrosis, or infection, are resolved.

B

Where concurrent ureteric re-implantation or augmentation cystoplasty are required, the abdominal approach is necessary.

C

Ensure that the bladder is continuously drained following fistula repair until healing is confirmed (expert opinion suggests: 10-14 days for simple and/or post-surgical fistulae; 14-21 days for complex and/or post-radiation fistulae).

C

Where urinary and/or faecal diversions are required, avoid using irradiated tissue for repair.

C

Use interposition grafts when repair of radiation-associated fistulae is undertaken.

C

In patients with intractable urinary incontinence from radiation-associated fistula, where life expectancy is very short, consider performing ureteric occlusion.

C

Repair persistent ureterovaginal fistula by an abdominal approach using open, laparoscopic or robotic techniques according to availability and competence.

C

Consider palliation by nephrostomy tube diversion and endoluminal distal ureteric occlusion for patients with ureteric fistula associated with advanced pelvic cancer and poor performance status.

C

Urethrovaginal fistulae should preferably be repaired by a vaginal approach.

C

* These recommendations are derived from summarisation of the ICUD 2013 review and have not been fully validated by the EAU guidelines panel methodology.

This short booklet text is based on the more comprehensive EAU Guidelines (ISBN 978-90-79754-91-5), available to all members of the European Association of Urology at their website, http://www.uroweb.org/guidelines/.

Figure 1: Management and treatment of women presenting with urinary incontinence.

Figure 2: Management and treatment of men presenting with urinary incontinence.

* Based on expert opinion

* Available evidence on onabotulinumtoxin A and sacral nerve stimulation refers mainly to women.

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