Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
The strength of recommendation grading (A-D) and level of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Quality of Life, Patient Information, and Health Promotion
Quality of Life
Objective Assessment
B - Health care practitioners should consider using a validated quality of life and incontinence severity questionnaire to evaluate the impact of urinary symptoms and to audit the effectiveness of any management strategy.
Patient Information, Advice, and Support
D - 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 health care 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 in primary care without general practitioner (GP) referral.
Health Promotion
C - 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.
Assessment of Urinary Incontinence
Risk Factors for Developing Urinary Incontinence
Risk Factors for Women
B - Health professional 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 body mass index (BMI), and experience of continence problems in childhood.
Initiating an Assessment of Urinary Incontinence
C - Health care professionals should recognize the difficulty that some patients have in raising concerns about continence and should be proactive in questioning patients about continence during consultations.
C - Health professional should have a positive attitude to continence problems.
B - Assessment, treatment, and referral, as appropriate, should be offered to all patients with urinary continence problems.
Primary Care Assessment Tools
Assessment Tool Recommendations
D - 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 with urinary incontinence should include completion of a voiding diary, urinalysis, and, where symptoms of voiding dysfunction or repeated urinary tract infections (UTIs) are present, estimation of post void residual volume.
Physical Therapies
Pelvic Floor Muscle Exercises
A - 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.
D - Pelvic floor muscle exercises should be considered as part of a treatment plan for patients with urge urinary incontinence.
D - Digital assessment of pelvic floor muscle function should be undertaken prior to initiating any pelvic floor muscle exercise treatment.
A - Where group physiotherapy is available patients should be offered the choice of attending or being seen individually.
Pelvic Floor Muscle Exercises in Men Undergoing Radical Prostatectomy
B - Pelvic floor muscle exercise treatment should be considered for patients following radical prostate surgery.
Bladder Retraining
C - Bladder retraining should be offered to patients with urge urinary incontinence.
Pharmacotherapy
Stress Incontinence
Combined Noradrenaline and Serotonin Reuptake Inhibitors
A - Duloxetine should be used only as part of an overall management strategy in addition to pelvic floor muscle 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.
Detrusor Overactivity and Urge Incontinence
Antimuscarinics
A - 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.
Containment
Product Evaluation
D - All patients should undergo a continence assessment before product issue. Issue of products should not take the place of therapeutic interventions.
Referral
Referral to Secondary Care
All Patients
D - 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.
Female Patients
D - Female patients with suspected voiding dysfunction should be referred to secondary care.
D - Female patients with symptomatic pelvic organ prolapse should be referred to secondary care.
Male Patients
D - Male patients with reduced urinary flow rates or elevated post void residual volumes should be referred to secondary care.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion
Grades of Recommendation
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
