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A direct comparison of guidelines developed by the Hartford Institute for Geriatric Nursing (HIGN) and the Scottish Intercollegiate Guidelines Network (SIGN) for assessment and management of urinary incontinence (UI) is provided in the tables, below. The HIGN guideline applies to the acute care setting, while the SIGN guideline applies to the primary care setting.
Following the content comparison tables, the areas of agreement and areas of differences among the guidelines are identified.
Related Guideline
Registered Nurses Association of Ontario (RNAO). Promoting continence using prompted voiding. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 48 p. [42 references]
Abbreviations
TABLE 1: COMPARISON OF INTERVENTIONS AND PRACTICES CONSIDERED ("" indicates topic is addressed) |
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HIGN (2008) |
SIGN (2004) |
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Assessment | ||||
Management | ||||
Non-Pharmacological Interventions |
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Pharmacotherapy |
|
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Referral |
TABLE 3: COMPARISON OF RECOMMENDATIONS FOR MANAGEMENT OF PRESSURE ULCERS | |
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ASSESSMENT | |
HIGN (2008) |
Parameters of Assessment
|
SIGN (2004) |
Assessment of Urinary Incontinence Risk Factors for Developing Urinary Incontinence 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 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 Clinical history taking is an essential part of the initial assessment. GPP - A routine clinical history of urinary incontinence should cover:
A clinical history may be supplemented by appropriate use of the following tools:
Assessment Tool Recommendations D - Initial assessment of a male patient with UI should include completion of a voiding diary, urinalysis, estimation of PVR volume, and DRE. D - Initial assessment of a female patient with UI should include completion of a voiding diary, urinalysis, and, where symptoms of voiding dysfunction or repeated UTIs are present, estimation of PVR volume. |
MANAGEMENT | |
Non-Pharmacologic Interventions | |
HIGN (2008) |
Nursing Care Strategies General Principles That Apply to Prevention and Management of All Forms of UI
Strategies for Specific Problems Stress UI
Urge UI
Overflow UI
Functional UI
|
SIGN (2004) |
Physical Therapies Pelvic Floor Muscle Exercises PFMEs are effective in the treatment of stress and mixed urinary incontinence, but there is insufficient evidence to assess their efficacy in the treatment of urge incontinence. Expert opinion suggests that PFMEs may have a role in treatment of urge incontinence in combination with bladder training. A - PFME 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 - PFME 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 PFME treatment. GPP - Digital assessment of pelvic floor muscle function should only be carried out by an appropriately trained clinician. A - Where group physiotherapy is available patients should be offered the choice of attending or being seen individually. GPP - Where group physiotherapy is offered individual assessment and monitoring should be carried out. Pelvic Floor Muscle Exercises in Men Undergoing Radical Prostatectomy B - PFME treatment should be considered for patients following radical prostate surgery. Bladder Retraining C - Bladder retraining should be offered to patients with urge urinary incontinence. Lifestyle Interventions GPP - As excessively small or large urine output can contribute to urinary incontinence, patients should be encouraged to adjust their fluid intake to produce a 24 hour urinary output of between 1,000 mL and 2,000 mL. Containment Product Evaluation Containment products are an essential component in the management of incontinence, but they should only be issued after an initial assessment or when a management plan has been completed and reviewed. Offering disposable pads prematurely can lead to psychosocial dependence upon them and reluctance to accept active treatment. Patients starting physical or medical therapies may require containment products in the short term; this will depend upon their symptoms, leakage incidence, personal choice and lifestyle. Patients with intractable urinary incontinence will require products long term. A number of factors may influence choice of product including patient preference, level of disability, gender, skin integrity, history of allergy, incidence of infection, availability of carers and history of failure with previous products. D - All patients should undergo a continence assessment before product issue. Issue of products should not take the place of therapeutic interventions. GPP - Professionals should be vigilant to the proper use of products with regard to application, fitting and tissue viability. Where products appear not to have been effective, the patient should be reassessed for product suitability. |
Pharmacotherapy | |
HIGN (2008) |
No specific recommendations offered. |
SIGN (2004) |
Stress Incontinence Combined Noradrenaline and Serotonin Reuptake Inhibitors A - Duloxetine should be used only as part of an overall management strategy in addition to PFMEs 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. GPP - Antimuscarinic therapy should be tried for a period of six weeks to enable an assessment of the benefits and side effects. Treatment should be reviewed after six months to ascertain continuing need. |
Referral | |
HIGN (2008) |
Stress UI Consider referral to other team members if pharmacologic or surgical therapies are warranted. Urge UI Collaborate with prescribing team members if pharmacologic therapy is warranted. Overflow UI Initiate referrals to other team members for those patients requiring pharmacologic or surgical intervention. Functional UI Refer for physical and occupational therapy as needed. |
SIGN (2004) |
Referral to Secondary Care All Patients D - Patients should be referred to secondary care if previous surgical or non-surgical treatments for UI 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 prolapsed should be referred to secondary care. |
TABLE 4: BENEFITS AND HARMS | |
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Benefits | |
HIGN (2008) |
Patient
Nurse
Institution
|
SIGN (2004) |
Effective treatment and management of UI resulting in reduced incontinence episode frequency, reduced urgency, increased patient satisfaction, improved quality of life, and reduced incidence of potential harms (e.g., falls and fractures). |
Harms | |
HIGN (2008) |
Indwelling urinary catheters are associated with the risk of UTI. |
SIGN (2004) |
|
TABLE 5: EVIDENCE RATING SCHEMES AND REFERENCES | |
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HIGN (2008) |
Levels of Evidence Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews) Level II: Single experimental study (randomized controlled trials [RCTs]) Level III: Quasi-experimental studies Level IV: Non-experimental studies Level V: Care report/program evaluation/narrative literature reviews Level VI: Opinions of respected authorities/Consensus panels Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocls for Best Practice, (3rd ed). New York: Springer Publishing Company. |
SIGN (2004) |
Levels of Evidence: 1++: High quality meta-analyses, systematic reviews of randomized controlled trials (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 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+ |
The Hartford Institute for Geriatric Nursing (HIGN) and the Scottish Intercollegiate Guidelines Network (SIGN) present recommendations for the assessment and management of urinary incontinence. The groups provide explicit reasoning behind their judgments, ranking the level of evidence for each major recommendation.
The guidelines generally recommend similar components for the assessment of UI: medical and UI history; physical examination; ruling out transient or underlying causes of UI (such as infection and atrophic vaginitis); and distinguishing between the different types of incontinence.
SIGN recommends that initial assessment of all patients with UI should include completion of a voiding diary and urinalysis. They also recommend DRE and estimation of PVR volume be performed in all men, and estimation of PVR be performed in women with symptoms of voiding dysfunction or a history of repeated UTIs. SIGN also recommends a pelvic floor assessment be performed and that symptom severity be evaluated using a standardized questionnaire. HIGN recommends assessing and documenting the presence/absence of an indwelling catheter and its use.
Both guidelines agree that PFME should be used for stress incontinence. HIGN also recommends PFME, in conjunction with bladder training, for urge incontinence. SIGN similarly notes that expert opinion suggests that PFMEs may have a role in treatment of urge incontinence in combination with bladder training.
Both groups agree that bladder training should be used for urge incontinence. HIGN also notes that bladder training should be provided as needed for the management of stress UI.
Only SIGN addresses drug treatment for UI, recommending a 4-week trial of duloxetine for female patients with moderate to severe stress incontinence. They also recommend a trial of oxybutynin, propiverine, tolterodine, or trospium be given to patients with significant urgency with or without urge incontinence.
This synthesis was prepared by ECRI on June 20, 2006. The information was verified by John A. Hartford Institute of Geriatric Nursing on July 27, 2006. The information was updated most recently on October 26, 2007 to remove BWH recommendations. This synthesis was revised in December 2008 to update HIGN recommendations. This synthesis was revised most recently in January 2009 to remove FMSD recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Evaluation and Management of Urinary Incontinence. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2006 Aug (revised 2009 Feb). [cited YYYY Mon DD]. Available: http://www.guideline.gov.