A summary of recommendations is shown below. Definitions for the grades of recommendations (A, B, C, D) and the levels of evidence (1++ to 4) are provided at the end of the "Major Recommendations" field.
Assessment
History-Taking
Take a history from the person identified to have urinary incontinence (UI). (D/4 - Fantl et al., 1996)
Physical Examination
Conduct systematic physical examination to identify abnormalities that have a bearing on the incontinence. (D/4 - Fantl et al., 1996)
Assess skin condition around the genital-perineal region and check for excoriation. (D/4– Fantl et al., 1996)
Assess functional state. Examine and determine patient's mobility, cognition, and manual dexterity. (D/4 - Fantl et al., 1996)
Direct Observation of Leakage
Instruct patient to cough forcefully when the bladder is full and observe for urine leakage. (D/4 - Fantl et al., 1996)
Urinalysis
Send a sample of urine for urinalysis and culture. (D/4 - Fantl et al., 1996)
Measurement of Residual Volume
Measure Post Voided Residual (PVR) volume by in-out catheterisation or bladder scanning within a few minutes after voiding. (D/4 - Fantl et al., 1996)
Bladder Chart/Intake-and-Output Chart
Record frequency, timing, and amount of fluid intake and voiding for a few days. (D/4 - Fantl et al., 1996)
Behavioural Intervention
Toileting Assistance
Timed Voiding/Scheduled Toileting
Timed voiding/scheduled toileting is recommended throughout the whole day for patient who needs assistance in toileting. (D/4 - Fantl et al., 1996)
Habit Training
Habit training is recommended for patient in whom a natural voiding pattern can be determined. (D/4 - Fantl et al., 1996)
Prompted Voiding
Prompted voiding is recommended for patients who can learn to recognize some degree of bladder fullness or the need to void, or who can ask for assistance or respond when prompted to void. Patient is asked at regular intervals regardless whether voiding is required and is assisted to the toilet if the response is positive. (A/1+ - Fantl et al., 1996)
When toileting is successful, reward with praise and words of encouragement. (D/4 - Fantl et al., 1996)
Bladder Training/Bladder Re-education
Bladder training is strongly recommended for management of urge UI. (A/1+)
Bladder training is recommended for management of stress UI. (D/4 - Fantl et al., 1996)
Pelvic Floor Muscle Exercise
Pelvic floor muscle exercise is beneficial to women with stress incontinence. It also enhances the benefits of other therapy. (A++/1)
Sustain a contraction of the perivaginal muscles or anal sphincter for at least 10 seconds followed by equal periods of relaxation. Perform this 30 to 80 times a day for at least 8 weeks or until desired muscle tone is achieved. (D/4 - Fantl et al., 1996)
Other Measures and Supportive Care
Intermittent Urinary Catheterisation
Intermittent catheterisation is recommended as a supportive measure for patients with spinal cord injury, persistent UI, chronic urinary retention due to under-active or partially obstructed bladder. (D/4 -- Fantl et al., 1996)
Indwelling Urinary Catheterisation
Indwelling catheter is recommended for patient with obstructive cause where other interventions are not feasible. It is also useful for the terminally ill; or patient with pressure ulcers, or for severely impaired individual in whom alternative interventions are not suitable. It may also be used when a caregiver is not available to provide other supportive measures. (D/4 - Fantl et al., 1996)
The patient is assessed periodically for voiding trials or bladder training. (D/4 - Fantl et al., 1996)
External Collection Systems
Uro-sheaths are recommended for incontinent men who have adequate bladder emptying and intact genital skin, and in whom other therapies have failed or are not appropriate. (D/4 - Fantl et al., 1996)
Absorbent Products
Absorbent products are recommended during evaluation, as an adjunct to other therapies, and for long term care of patients with chronic, intractable UI. (D/4 - Fantl et al., 1996)
Skin Care
Inspect genital-perineal area daily. Identify signs of contact dermatitis and skin excoriation. (D/4 - Fantl et al., 1996)
Cleanse skin immediately after urine leakage. (D/4 - Fantl et al., 1996)
Use appropriate skin cleansers and barrier creams. (D/4 - Fantl et al., 1996)
Dietary and Fluid Management
Encourage adequate fluid and fibre intake. Reduce caffeine intake (e.g. coffee, tea, colas). (D/4 - Fantl et al., 1996)
Education
Patient and Caregiver Education
The public should be informed that UI is not inevitable or shameful. UI is treatable, and, if not, it is manageable. Patient education should be individualised, involving caregivers and others. (D/4 - Fantl et al., 1996)
Nursing Education
Education and continuing education programmes on UI evaluation and management should be given to nurses. (D/4 - Fantl et al., 1996)
Physical and Environmental Alterations
Assess the environment in which the patient is in. Perform simple alterations, such as providing toileting or ambulation devices. (D/4 - Fantl et al., 1996)
Definitions:
Individual Study Validity Ratings
++
All or most of the criteria have been fulfilled. Where they have not been fulfilled the conclusions of the study or review are thought very unlikely to alter.
+
Some of the criteria have been fulfilled. Those criteria that have not been fulfilled or not adequately described are thought unlikely to alter the conclusions.
-
Few or no criteria fulfilled. The conclusions of the study are thought likely or very likely to alter.
Study Design Designation
The study design is designated by a numerical prefix:
"1" for systematic reviews or meta-analyses or randomised controlled trials (RCTs)
"2" for cohort and case-control studies
"3" for case reports/series
"4" for expert opinion/logical arguments/"common" sense
Hierarchy of the Levels of Scientific Evidence
Each study is assigned a level of evidence by combining the design designation (1, 2, 3 or 4) and its validity rating (++, + or -). The meanings of the various "levels of evidence" are given below:
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, or RCTs with a low risk of bias
1-
Meta-analyses, systematic reviews, 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
Categories of the Strength of Evidence Associated with the Recommendations
A
At least one meta-analysis, systematic review, 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+
Interpretation of the D/4 Grading
The grading system emphasises the quality of the experimental support underpinning each recommendation. The grading D/4 was assigned in cases where:
- It would be unreasonable to conduct a RCT because the correct practice is logically obvious
- Recommendations were derived from existing high quality evidence-based guidelines. The guideline developers alert the user to this special case by appending the initials of the source in the original guideline document. e.g. (D/4 - Fantl et al., 1996)
