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2aManaging Acute and Chronic Urinary Incontinence

Quick Reference Guide for Clinicians Number 2 (1996 Update)

Created: .

Attention Clinicians:

The Clinical Practice Guideline Update on which this Quick Reference Guide for Clinicians is based was developed by an interdisciplinary, private-sector panel comprising health care professionals and consumers sponsored by the Agency for Health Care Policy and Research (AHCPR). Panel members were:

  • J. Andrew Fantl, MD (Co-Chair)
  • Diane Kaschak Newman, RNC, MSN, FAAN (Co-Chair)
  • Joyce Colling, PhD, RN, FAAN
  • John O.L. DeLancey, MD
  • Christopher Keeys, PharmD
  • Richard Loughery, FACHA
  • B. Joan McDowell, PhD, RN, FAAN
  • Peggy Norton, MD
  • Joseph Ouslander, MD
  • Jack Schnelle, PhD
  • David Staskin, MD
  • Jeannette Tries, MS, OTR
  • Vernon Urich, MD
  • Sharon H. Vitousek, MD
  • Barry D. Weiss, MD
  • Kristene Whitmore, MD

Consultants to the panel were: Patricia Burns, PhD, RN, FAAN; Ananias Diokno, MD; The-Wei Hu, PhD; Donna Katzman McClish, PhD; Thelma Joan Wells, PhD, RN, FAAN; and Matthew Zack, MD, MPH.

An explicit, science-based methodology was employed along with expert clinical judgment to develop specific statements on patient assessment, treatment, and management of urinary incontinence in adults. Extensive literature searches were conducted, and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review was undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice.

This Quick Reference Guide for Clinicians presents summary points from the Clinical Practice Guideline Update . The latter provides a description of the guideline development process, thorough analysis and discussion of the available research, critical evaluation of the assumptions and knowledge of the field, more complete information for health care decisionmaking, consideration for patients with special needs, and references. Decisions to adopt particular recommendations from either publication must be made by practitioners in light of available resources and circumstances presented by the individual patient.

AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to: Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Willco Building, Suite 310, 6000 Executive Boulevard, Rockville, MD 20852

Abstract

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline Update on Urinary Incontinence in Adults: Acute and Chronic Management, which was developed by a multidisciplinary panel of health care providers and a consumer representative. Findings and recommendations are presented for identification and evaluation of urinary incontinence (UI); use of behavioral, pharmacologic, and surgical treatment as well as supportive devices; long-term management of chronic intractable UI; and education of health care providers and the public. An algorithm is included to show the sequence of events related to the overall management of UI. Tables and forms are included to outline assessment and treatment options.

Suggested Citation

This document is in the public domain and may be used and reprinted without special permission except for those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. AHCPR appreciates citation as to source, and the suggested format is provided below:

Fantl JA, Newman DK, Colling J, et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 96-0686. January 1996.

Abbreviations Used in this Guideline

  • BUN: Blood urea nitrogen
  • DHIC: Detrusor hyperactivity with impaired bladder contractility
  • DI: Detrusor instability
  • ISD: Intrinsic sphincter deficiency
  • NSAID: Nonsteroidal anti-inflammatory drug
  • PME: Pelvic muscle exercise
  • PPA: Phenylpropanolamine
  • PVR: Post-void residual volume
  • SUI: Stress urinary incontinence
  • TCA: Tricyclic antidepressant
  • UI: Urinary incontinence
  • UTI: Urinary tract infection

Purpose and Scope

Urinary incontinence (UI) affects approximately 13 million Americans or about 10-35 percent of adults and at least half of the 1.5 million nursing home residents. Among the population between 15 and 64 years of age, the prevalence of UI in men ranges from 1.5 to 5 percent and in women from 10 to 30 percent. For noninstitutionalized persons older than 60 years of age, prevalence ranges from 15 to 35 percent, with women having twice the prevalence of men. Survey data from caregivers of the elderly show that approximately 53 percent of the homebound elderly are incontinent. A random sampling of hospitalized elderly patients identified 11 percent as having persistent UI at admission and 23 percent at discharge. A recent estimate of the direct costs of caring for persons of all ages with incontinence is more than $15 billion annually. Despite the high prevalence and considerable cost burden of the condition, most affected individuals do not seek help for incontinence. Studies indicate, however, that treatment is effective in most people with UI.

UI is defined as involuntary loss of urine that is sufficient to be a problem. UI can be caused by factors affecting either the anatomy or the physiology of the lower urinary tract, or both, as well as other factors. The symptoms and subtypes of UI are outlined in Table 1. Documented risk factors associated with incontinence are wide-ranging and include:

  • Immobility commonly associated with chronic degenerative disease.
  • Diminished cognitive status and delirium.
  • Medications, including diuretics.
  • Smoking.
  • Fecal impaction.
  • Low fluid intake.
  • Environmental barriers.
  • High-impact physical activities.
  • Diabetes.
  • Stroke.
  • Estrogen depletion.
  • Pelvic muscle weakness.
  • Pregnancy, vaginal delivery, and episiotomy.

Table 1. Symptoms and subtypes of urinary incontinence.

Table

Table 1. Symptoms and subtypes of urinary incontinence.

Specific risk factors for incontinence can be both identified and remediated with targeted intervention. Examples of possible preventive maneuvers include teaching women about gestational and postpartum pelvic muscle exercises, and teaching both men and women about scheduled voiding and proper bladder-emptying techniques. Other health promotion models describe education programs regarding estrogen use to treat atrophic vaginitis, postmenopausal changes of the genitourinary tract, and elimination of fluids with diuretic effects.

The findings and recommendations included in the Clinical Practice Guideline Update define a comprehensive program for managing UI in adults. This Quick Reference Guide is intended for health care providers who examine and treat adults with this condition. The guide does not address involuntary loss of urine through channels other than the urethra (extraurethral UI), UI in children, or UI due to neuropathic conditions.

Highlights of Patient Management

Effective management of UI in primary care should focus on:

  • Assessment of the patient and the incontinence.
  • Identification of risk factors and reversible causative conditions.
  • Treatment of reversible conditions.
  • Discussion of UI treatment options.
  • Implementation of an effective plan of management consistent with the patient's condition, goals, and wishes.
  • Education and quality-of-life improvement.

Figure 1 is an overview of the evaluation and management of UI in primary care and displays the decision points and preferred management pathways outlined in this guide.

Figure 1: Evaluation and management of urinary incontinence in primary care.

Figure

Figure 1: Evaluation and management of urinary incontinence in primary care.

Basic Evaluation Checklist

History

The history should include a focused medical, neurologic, and genitourinary history that includes an assessment of risk factors, a review of medications, and a detailed exploration of the symptoms of the UI and associated symptoms and factors, including the following:

  • Duration and characteristics of UI (see Incontinence Profile).
  • Most bothersome symptom(s) to the patient.
  • Frequency, timing, and amount of continent voids and incontinent episodes.
  • Precipitants of incontinence (e.g., situational antecedents, such as cough, laugh, or exercises "on way to bathroom"; surgery; injury/trauma; recent illness; new medications).
  • Other urinary tract symptoms (e.g., nocturia, dysuria, hesitancy, enuresis, straining, poor or interrupted stream, pain).
  • Daily fluid intake.
  • Bowel habits.
  • Alteration in sexual function due to UI.
  • Amount and type of perineal pads or protective devices.
  • Previous treatments and effects on UI.
  • Expectations of treatment.

Incontinence Profile

Questions such as those listed below are useful in the initial identification and assessment of UI.

  • Can you tell me about the problems you are having with your bladder?
or
  • Can you tell me about the trouble you are having holding your urine (water)?
  • How often do you lose urine when you don't want to?
  • When do you lose urine when you don't want to? What activities or situation are linked with leakage? Is it associated with laughing, coughing, or getting to the bathroom?
  • How often do you wear a pad for protection?
  • Do you use other protective devices to collect your urine?
  • How long have you been having a problem with urine leakage?

Mental Status Evaluation

  • Cognition.
  • Motivation to self toilet.

Functional Assessment

  • Manual dexterity.
  • Mobility: Observe patient toileting; Can patient toilet unaided? Are physical or chemical restraints being used?

Environmental Assessment

  • Access and distance to toilets or toilet substitutes.
  • Chair/bed allows ease when rising.

Social Factors

  • Relationship of UI to work.
  • Living arrangements.
  • Identified caregiver and degree of caregiver involvement.
  • Lives alone.

Bladder Records

See Figure 2.

  • Frequency, timing, and amount of voids.
  • Amount of incontinent episodes.
  • Activities associated with UI.
  • Fluid intake.

Figure 2. Sample bladder record.

Table

Figure 2. Sample bladder record.

Physical Examination

Guided by the medical history, the physical examination includes:

  • General examination: Edema; Neurologic abnormalities.
  • Abdominal examination: Diastasis rectii (separation of the rectus muscles of the abdominal wall); Organomegaly; Masses; Peritoneal irritation; Fluid collections.
  • Rectal examination: Perineal sensation; Resting and active sphincter tone; Fecal impaction; Masses; Consistency and contour of the prostate (men).
  • Genital examination in men: Skin condition; Abnormalities of the foreskin, penis, and perineum.
  • Pelvic examination in women: Skin condition; Genital atrophy; Pelvic organ prolapse; Pelvic masses; Perivaginal muscle tone; Other abnormalities.
  • Direct observation of urine loss: Urine loss with full bladder using cough stress test.
  • Estimation of post-void residual (PVR) volume.
  • Urinalysis.

Supplementary Assessments

Supplementary assessments may be necessary or helpful in some patients, including:

  • Blood testing (BUN, creatinine, calcium): Suspected compromised renal function; Polyuria.

Initial Care

After the basic evaluation, treatment for the presumed type of UI (see Table 1) should be initiated unless further evaluation by a specialist is indicated. All incontinent patients with identified reversible conditions that cause or contribute to UI should be managed appropriately. Table 2 lists reversible conditions and their management.

Table 2. Identification and management of reversible conditions that cause or contribute to urinary incontinence.

Table

Table 2. Identification and management of reversible conditions that cause or contribute to urinary incontinence.

Further Evaluation

Patients requiring further evaluation include those who meet any of the criteria listed in Table 3.

Box Icon

Box

Table 3. Criteria for further evaluation[a]. Uncertain diagnosis and inability to develop a reasonable management plan based on the basic diagnostic evaluation. Uncertainty in (more...)

Please note that specialized testing, including urodynamic, endoscopic, and imaging tests, is not detailed here. Although primary health care providers are not expected to be experts in these techniques, they should be familiar with the diagnostic test options for evaluating the symptoms of UI. The tests are performed by qualified professionals trained in the specific definitions and procedures. The specialized diagnostic tests are reviewed in the Clinical Practice Guideline Update.

Treatment Options

The three major categories of treatment are behavioral, pharmacologic, and surgical. Treatment options, including their risks, benefits, and outcomes, should be discussed with the patient so that informed choices can be made. As a general rule, the first choice should be the least invasive treatment with the fewest potential adverse effects that is appropriate for the patient. For many forms of UI, behavioral techniques meet these criteria. Tables 4a, 4b, and 4c outline the major treatment options.

Table 4a. Management options: behavioral interventions.

Table

Table 4a. Management options: behavioral interventions.

Table 4b. Management options: pharmacologic interventions.

Table

Table 4b. Management options: pharmacologic interventions.

Table 4c. Management options: surgical management.

Table

Table 4c. Management options: surgical management.

Other Measures and Supportive Devices

Other measures and supportive devices in the management of UI include intermittent catheterization, indwelling urethral catheterization, suprapubic catheters, external collection systems, penile compression devices, pelvic organ support devices, and protective pads and garments. Recommendations for the use of these measures and devices are included in Table 5.

Table 5. Summary of guideline recommendations.

Table

Table 5. Summary of guideline recommendations.

Management of Chronic Intractable UI

Although many persons can benefit from behavioral, pharmacologic, or surgical interventions for UI, many others cannot. Typically, these persons reside in long-term care facilities or are homebound and have cognitive or physical impairments that prevent them from learning or performing behavioral methods. In addition, these individuals often cannot tolerate or would not benefit from pharmacologic or surgical interventions.

The care of persons with chronic UI should include attention to toileting schedules, fluid and dietary intake, strategies to decrease urine loss at night, use of the most absorbent and skin-friendly protective garments, and prevention and early treatment of skin breakdown.

Continence status can be categorized as follows:

  • Independent continence describes those who are able to maintain continence without assistance.
  • Dependent continence applies to persons who are physically or mentally impaired and are kept dry through the efforts of others.
  • Social continence applies to those incapable of maintaining continence independently or through regular toileting by caregivers and who depend on absorbent products and other measures to contain or collect urine leakage.

Assessment

The basic evaluation checklist should be followed for the assessment of patients with suspected chronic UI.

In addition, the Health Care Financing Administration requires standardized comprehensive assessment and screening of nursing home residents using the instrument known as the Minimum Data Set on admission and quarterly during their stay in a facility. When a patient is incontinent or has an indwelling catheter, a Resident Assessment Profile is also performed to determine the cause, chronicity, and type of UI experienced by the patient. A stress test and evaluation of PVR volume are recommended, and general guidelines are provided for referral for additional evaluation. A bladder record should be added to determine the frequency and severity of the UI to provide appropriate treatment. Formal assessment of cognitive function may be helpful in selecting appropriate behavioral intervention, but a short trial is pivotal to assess responsiveness to a particular intervention. The combination of the Resident Assessment Profile and application of the above definitions can help in evaluating residents and for selecting appropriate intervention. Although such evaluation tools are not mandated for home care agencies, the assessment and management of UI among homebound individuals require a systematic, consistent approach as outlined in the basic evaluation checklist.

Interventions for Chronic UI

Before a patient is classified as suffering from chronic intractable UI, the most appropriate intervention should be attempted. This guideline and most experts suggest that if the patient has stress, urge, or mixed UI, low-risk behavioral treatments should be attempted first if there are no contraindications. Persons with overflow UI who do not have correctable obstruction may be candidates for intermittent catheterization. Some patients may be candidates for surgical or pharmacologic interventions. However, side effects and complications of these treatments are major factors to consider in the treatment of dependent homebound or long-term care patients.

Specific recommendations for the management of chronic UI are provided in Table 5.

Public and Professional Education

Because of the social stigma of UI, many sufferers do not even report the problem to a health care provider. In addition, when it is reported, many physicians and nurses, who need to be educated in this area, fail to pursue investigation of UI. As a result, this medical problem is vastly underdiagnosed and underreported.

One of the major areas for which the guideline provides practice recommendations is education both of the public and of health care providers. The guideline calls for continued efforts to educate health care providers about this condition so that they are sufficiently knowledgeable to diagnose and treat it. It recommends that the public be advised to report incontinence problems once they occur and be informed that incontinence is not inevitable or shameful but is a treatable or at least manageable condition.

UI outcome measures need to be developed so that nursing home surveyors are better able to assess the effectiveness of interventions for UI in this setting.

Availability of Guidelines

For each clinical practice guideline developed under the sponsorship of the Agency for Health Care Policy and Research (AHCPR), several versions are produced to meet different needs.

The Clinical Practice Guideline presents recommendations with brief supporting information, tables and figures, and pertinent references.

The Quick Reference Guide for Clinicians is a distilled,version of the Clinical Practice Guideline Update, with summary points for ready reference on a day-to-day basis.

The Consumer Version, available in English and Spanish, is an information booklet for the general public to increase patient knowledge and involvement in health care decisionmaking.

For this guideline update, a separate Caregiver Guide provides instructions to persons caring for incontinent patients either at home or in long-term care facilities.

To order single copies of guideline products or to obtain further information on their availability, call the AHCPR Publications Clearinghouse toll-free at 800-358-9295 or write to: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

Single copies of the Clinical Practice Guideline Update are available for sale from the Government Printing Office, Superintendent of Documents, Washington, DC 20402, with a 25-percent discount given for bulk orders of 100 copies or more. The Quick Reference Guide for Clinicians, the Consumer Version in English, and the Caregiver Guide are also available for sale in bulk quantities only. Call (202) 512-1800 for price and ordering information.

The Guideline Technical Report contains complete supporting materials for the Clinical Practice Guideline, including background information, methodology, literature review, scientific evidence tables, recommendations for research, and a comprehensive bibliography. It is available from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161. Call (703) 487-4650 for price and ordering information.

The full text of guideline documents for online retrieval may be accessed through a free electronic service from the National Library of Medicine called HSTAT (Health Services/Technology Assessment Text). Guideline information is also available through some of the computer-based information systems of the National Technical Information Service, professional associations, nonprofit organizations, and commercial enterprises.

A fact sheet describing Online Access for Clinical Practice Guidelines (AHCPR Publication No. 94-0075) and copies of the Quick Reference Guide for Clinicians and the Consumer Version of each guideline are available through AHCPR's InstantFAX, a fax-on-demand service that operates 24 hours a day, 7 days a week. AHCPR's InstantFAX is accessible to anyone using a facsimile machine equipped with a touchtone telephone handset: Dial (301) 594-2800, push "1," and then press the facsimile machine's start button for instructions and a list of currently available publications.

Selected Bibliography

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