2a:  Managing Acute and Chronic Urinary Incontinence: Quick Reference Guide for Clinicians Number 2 (1996 Update)

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.

Table 1. Symptoms and subtypes of urinary incontinence (more...)

Table 1. Symptoms and subtypes of urinary incontinence

Type of UI	Definition	Pathophysiology	Symptoms and signs
Urge	Involuntary loss of urine associated with a strong sensation of urinary urgency.	Involuntary detrusor (bladder) contractions (detrusor instability (DI)). Detrusor hyperactivity with impaired bladder contractility (DHIC). Involuntary sphincter relaxation.	Loss of urine with an abrupt and strong desire to void; usually loss of urine on way to bathroom DHIC--elevated post-void residual (PVR) volume. Involuntary loss of urine (without symptoms).
Stress	Urethral sphincter failure usually associated with increased intra-abdominal pressure.	Urethral hypermobility due to anatomic changes or defects such as fascial detachments (hypermobility). Intrinsic urethral sphincter deficiency (ISD) failure of the sphincter at rest.	Small amount of urine loss during coughing, sneezing, laughing, or other physical activities. Continuous leak at rest or with minimal exertion (postural changes).
Mixed	Combination of urge and stress UI.	.Combination of urge and stress features as above. Common in women, especially older women.	Combinations of urge and stress UI symptoms as above. One symptom (urge or stress) often more bothersome to the patient than the other.
Overflow	Bladder overdistention.	Acontractile detrusor. Hypotonic or underactive detrusor secondary to drugs, fecal impaction, diabetes, lower spinal cord injury, or disruption of the motor innervation of the detrusor muscle. In men--secondary obstruction due to prostatic hyperplasia, prostatic carcinoma, or urethral stricture. In women--obstruction due to severe genital prolapse or surgical overcorrection of urethral detachment.	Variety of symptoms, including frequent or constant dribbling or urge or stress incontinence symptoms, as well as urgency and frequent urination.
Other
Functional	Chronic impairments of physical and/or cognitive functioning.	Chronic functional and mental disabilities.	Urge incontinence or functional limitations
Unconscious or reflex	Neurologic dysfunction.	Decreased bladder compliance with risk of vesicoureteral reflux and hydronephrosis. Secondary to radiation cystitis, inflammatory bladder conditions, radical pelvic surgery, or myelomeningocele. In many nonneurogenic cases, no demonstrable DI.	Postmicturitional or continual incontinence. Severe urgency with bladder hypersensitivity (sensory urgency).

• 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.

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: Evaluation and management of urinary incontinence (more...)

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

Figure 1

Basic Evaluation Checklist

Bladder Records

Figure 2. Sample bladder record

Figure 2. Sample bladder record

NAME: ____________________________________________
DATE: ____________________________________________
INSTRUCTIONS: Place a check in the appropriate column next to the time you urinated in the toilet or when an incontinence episode occurred. Note the reason for the incontinence and describe your liquid intake (for example, coffee, water) and estimate the amount (for example, one cup).
6-8 a.m.	__________________	__________________	__________________	__________________	__________________
8-10 a.m.	__________________	__________________	__________________	__________________	__________________
10-noon	__________________	__________________	__________________	__________________	__________________
Noon-2 p.m.	__________________	__________________	__________________	__________________	__________________
2-4 p.m.	__________________	__________________	__________________	__________________	__________________
4-6 p.m.	__________________	__________________	__________________	__________________	__________________
6-8 p.m.	__________________	__________________	__________________	__________________	__________________
8-10 p.m.	__________________	__________________	__________________	__________________	__________________
10-midnight	__________________	__________________	__________________	__________________	__________________
Overnight	__________________	__________________	__________________	__________________	__________________
No. of pads used today:			No. of episodes:
Comments:

See Figure 2.

• Frequency, timing, and amount of voids.

• Amount of incontinent episodes.

• Activities associated with UI.

• Fluid intake.

Initial Care

Table 2. Identification and management of reversible (more...)

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

Condition		Comment		Management
Conditions affecting the lower urinary tract
Urinary tract infection		Dysuria and urgency from symptomatic infection may defeat the older person's ability to reach the toilet in time, causing urge incontinence. Asymptomatic infection, although more common than symptomatic infection, is rarely a cause of incontinence.		Treat symptomatic urinary tract infection (UTI) with antibiotics
Atrophic urethritis or vaginitis		Hypoestrogenism causes atrophic changes of the lower genitourinary tract. Although its association to incontinence and sensory symptoms has long been suspected direct cause-effect has not yet been proven.		Estrogen replacement therapy
Pregnancy/vaginal delivery/episiotomy		Pelvic floor anatomic and physiologic changes (e.g., fetal pressure, hormonal changes) may temporarily alter continence physiology		Behavioral intervention. Condition may be self-limiting. Conservative management recommended.
Postprostatectomy		Disruption of sphincter mechanisms may or may not be permanent		Behavioral intervention. Avoid surgical therapy until clear condition will not resolve.
Stool impaction		Patients with stool impaction present with either urge or overflow incontinence. Stool impaction may induce fecal incontinence as well.		Disimpaction restores continence in most instances if this was the cause. Implement a bowel regimen: appropriate use of stool softeners, bulk-forming agents, and laxatives if necessary; implement high fiber intake, adequate mobility, and fluid intake.
Drug side effects [a]
Diuretics		The brisk diuresis induced by diuretics may precipitate incontinence. This is particularly relevant in older persons and in those in whom continence is already impaired. Diuretics were observed to increase the severity of UI in already incontinent persons.		Discontinue or change therapy if clinically possible. Changing time of administration of diuretic may alter incontinence.
Caffeine		Diuretic effect may aggravate or precipitate UI.		Eliminate caffeine intake or substitute with decaffeinated products.
Anticholinergic agents Psychotropics Antidepressants (TCAs) Phenothiazines Disopyramide Antispasmodics Anti-parkinsonian agents		Prescription as well as over-the-counter drugs with anticholinergic properties are taken commonly by patients with insomnia, coryza, pruritus, vertigo, and other symptoms or conditions. Anticholinergic side effects include urinary retention with associated urinary frequency and overflow incontinence. In addition to anticholinergic actions, antipsychotics such as thorazine and haloperidol may cause sedation, rigidity, and immobility.		Discontinue use if clinically appropriate.
Narcotic analgesics
Sedatives/ hypnotics/ CNS depressants/ alcohol		Benzodiazepines, especially long-acting agents such as flurazepam and diazepam, may accumulate in elderly patients and cause confusion and secondary incontinence. Diazepam can have a strong anticholinergic effect. Alcohol, frequently used as a sedative, can cloud the sensorium, impair mobility, and induce a diuresis, resulting in incontinence.		Discontinue use if clinically possible.
Alpha-adrenergic agents: antihistamines, sympathomimetics (decongestants), sympatholytics (e.g., prazosin, terazosin, and doxazosin) Beta-adrenergic agonists		Alpha-adrenergic stimulation increases urethral tone and alpha-adrenergic block reduces it. Alpha-agonists may induce retention symptoms in older men. Stress incontinence may become symptomatic in a woman treated with alpha- antagonist as antihypertensive therapy. An older man with prostate enlargement or a woman with severe genital prolapse, may develop acute urinary retention and overflow incontinence when taking multicomponent "cold" capsules that contain alpha-agonists and anticholinergic agents, especially if a nasal decongestant and a nonprescription hypnotic antihistamine are added.		Discontinue use if clinically appropriate.
Calcium channel blockers		Calcium channel blockers can reduce smooth muscle contractility in the bladder and occasionally can cause urinary retention and overflow incontinence.		Discontinue use if clinically appropriate.
Increased urine production
Metabolic (hyperglycemia, hypercalcemia) Excess fluid intake Volume overload: venous insufficiency with edema, congestive heart failure		Excess intake, endocrine conditions that cloud the sensorium and induce a diuresis (e.g., hypercalcemia, hyperglycemia, and diabetes insipidus), and expanded volume states such as congestive heart failure, lower extremity venous insufficiency, drug-induced ankle edema (e.g., nifedipine, indomethacin), and low albumin states can cause polyuria and can lead to incontinence by unduly rapid and excessive filling of the bladder.		Treatment of the underlying condition. Implement bladder retraining to assist with frequency.
Impaired ability or willingness to reach a toilet
Delirium		In the delirious patient, incontinence is usually an associated symptom that will abate with proper diagnosis and treatment of the underlying cause of confusion.		Reassess patient for possible bladder retraining once delirium abates.
Psychological		The relationships between psychological conditions and UI are still poorly understood as cause-effect are still controversial.		Treatment of the psychological disorder.
Restricted mobility		Limited mobility is an aggravating or precipitating cause of incontinence that can frequently be corrected or improved by treating the underlying condition chronic illness or injury (e.g., arthritis, poor eyesight, Parkinson's disease, or orthostatic hypotension). A urinal or bedside commode and scheduled toileting often help resolve the incontinence that results from hospitalization and its environmental barriers (e.g., bed rails, restraints, and poor lighting).		Treatment of underlying condition, facilitation of toileting facilities, and use of toileting aids and devices.

[a] Many side effects are seen with over-the-counter drugs, the use of which may not be reported by some patients.

Further Evaluation

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

Table 4a. Management options: behavioral interventions (more...)

Table 4a. Management options: behavioral interventions

Type of Intervention	Definition	Target population
Toileting programs
Scheduled toileting/habit training	Timed scheduled voiding Habit training scheduled to match patient's voiding habits Caregiver dependent	Cognitively impaired Functionally disabled Incomplete bladder emptying Caregiver dependent
Prompted voiding	Scheduled voiding that requires prompting from caregiver Caregiver dependent	Functionally able to use toilet or toileting device Able to feel urge sensation Able to request toileting assistance Availability of caregiver
Bladder training	Systematic ability to delay voiding through the use of urge inhibition Active rehabilitation and education techniques	Cognitively intact Ability to discern urge sensation Cognitively able to understand or learn how to inhibit urge Able to toilet themselves or with assistance
Pelvic muscle rehabilitation
Pelvic muscle exercises	Planned, active exercises of pelvic muscles to increase periurethral muscle strength Active rehabilitation and education techniques	Able to identify and contract pelvic muscles Compliance with instructions
Vaginal weight training	Active retention of increasing vaginal weights to induce increased pelvic muscle strength Active rehabilitation and education techniques Contraindication: Pelvic organ prolapse	Cognitively intact Compliant with instructions Must be able to stand Must have sufficient pelvic floor strength to be able to contract muscle and retain lightest weight
Biofeedback	Method that uses electronic or mechanical instruments to display information about neuromuscular and/or bladder activity, particularly with pelvic muscle exercises. Can be used in association with other programs. Active rehabilitation and education techniques	Ability to understand analog or digital signals using auditory or visual display Motivated persons who are able to learn voluntary control through observation of the biofeedback. Health care provider who can appropriately assess the UI problem and provide behavioral interventions
Electrical stimulation	Application of electrical current to sacral and pudendal afferent fibers via intra-anal and/or intravaginal electrodes to inhibit bladder instability and improve striated sphincter and levator ani contractility and efficiency Active rehabilitation and education techniques Contraindication: Vaginal soreness, constipation, hematoma with needle stimulation	Useful as adjunct therapy in identification of pelvic muscles Ability to discern stimulation

Table 4b. Management options: pharmacologic interventions (more...)

Table 4b. Management options: pharmacologic interventions

Classification	Examples (usual oral dosages)	Action	Indications	Side effects and complications
Anti-cholinergic agents; TCAs	Oxybutinin (2.5-5 mg tid or qid), propantheline (7.5-30 mg at least tid), dicyclomine (10-20 mg tid). Imipramine, doxepin, desipramine, nortriptyline (25-100 mg/day).	Reduction or inhibition of involuntary detrusor contraction and increase in bladder capacity.	Urge incontinence	Dry mouth, visual disturbances, constipation, dry skin. Should not be used in cases of obstruction.
Alpha-adrenergic agents	Phenylpropanolamine (25-100 mg bid), pseudoephedrine (15-30 mg tid), ephedrine, epinephrine, norepinephrine	Alpha-adrenergic stimulation increases striated and/or smooth muscle tone increasing urethral resistance.	Stress incontinence	Anxiety, insomnia, agitation, respiratory difficulty, sweating, cardioarrhythmia, hypertension. Should not be used in cases of obstructive syndromes and/or hypertensive disease.
Estrogen replacement agents	Conjugated estrogens (0.3-1.25 mg/day orally or 2 g or fraction/day vaginally)	Stimulation of squamous epithelium; other mechanisms not known.	Stress or mixed incontinence	Should not be used in cases of suspected or confirmed cancer of the breast, undiagnosed vaginal bleeding, suspected or confirmed cancer of the uterus. Progesterone should be given if the patient has not had hysterectomy. Other contraindications may apply; individual assessment is important.

Table 4c. Management options: surgical management

Table 4c. Management options: surgical management

Type of UI	Cause	Treatment
Stress	Hypermobility Intrinsic sphincter deficiency	Retropubic suspension. Needle endoscopic suspension. Sling (mostly women). Artificial sphincter. Urethral bulking
Urge	Refractory detrusor instability	Augmentation cystoplasty
Overflow	Obstruction Nonobstructive	Relieve obstruction Intermittent catheterization Other

The ratings in parentheses indicate the scientific evidence supporting each recommendation according to the following scale:

• A - The recommendation statement is supported by scientific evidence from properly designed and implemented controlled trials providing statistical results that consistently support the guideline statement.

• B - The recommendation statement is supported by scientific evidence from properly designed and implemented clinical series that support the guideline statement.

• C - The recommendation statement is supported by expert opinion.

Other Measures and Supportive Devices

Table 5. Summary of guideline recommendations

Table 5. Summary of guideline recommendations

	Recommendation	Recommendation against
Basic evaluation	History (B). Physical examination (B). Measurement of PVR volume (B). Urinalysis (B). Direct visualization (C).
Supplementary laboratory tests	Blood testing (BUN, creatinine, glucose, and calcium) if compromised renal function is suspected or if polyuria (in the absence of diuretics) is present (C).	Urine cytology (B).
Risk factors/prevention	Identify risk factors associated with UI and attempt to modify them (B). Teach women PMEs (C). Teach exercises to strengthen pelvic floor muscles (C).	Specialized tests as part of the basic evaluation (B).
Further evaluation	For patients who fail trial management after the basic evaluation or who are not appropriate for treatment based on presumptive diagnosis (C).
Urodynamic tests	Simple cystometry for detecting detrusor compliance and contractibility, measuring PVR, and determining capacity (A). More complex cystometric tests appropriate in other situations (B). Urethral sphincteric evaluation (e.g., pressure transmission ratio, leak point pressure) when appropriate (C). Attempt to reproduce the patients' symptoms when performing urodynamic studies (C).
Endoscopic	Cystoscopy when the following are present: sterile hematuria or pyuria (B); when urodynamics fail to duplicate symptoms (C); new onset of irritative voiding symptoms, bladder pain, recurrent cystitis, or suspected foreign body (B).	Cystoscopy in the basic evaluation of UI (B).
Imaging tests	Radiographic, ultrasonographic, and other imaging tests should be used for the evaluation of anatomic conditions associated with UI when clinically needed (C).
Behavioral interventions
Routine/scheduled toileting	Routine/scheduled toileting on a consistent schedule for patients who cannot participate in independent toileting (C).
Habit training	Habit training for patients for whom a natural voiding pattern can be determined (B).
Prompted voiding	Prompted voiding in 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 toilet. Patients who are appropriate for prompted voiding may not have sufficient cognitive ability to participate in other, more complex behavioral therapies (A).
Bladder training	Bladder training strongly recommended for management of urge (DI) and mixed incontinence. Also recommended for management of stress urinary incontinence (SUI) (A).
Pelvic muscle rehabilitation	PMEs strongly recommended for women with SUI (A). PMEs recommended in men and women in conjunction with bladder training for urge incontinence (B). PMEs may also benefit men who develop UI following prostatectomy (C). Pelvic muscle rehabilitation and bladder inhibition using biofeedback therapy for patients with stress UI, urge UI, and mixed UI (A). Vaginal weight training for SUI in premenopausal women (B). Pelvic floor electrical stimulation has been shown to decrease incontinence in women with SUI (B) and may be useful for urge and mixed incontinence (B).
Pharmacologic treatment
Urge incontinence	The following pharmacologic agents are reported to be useful in urge incontinence as observed in clinical practice (B): Anticholinergic agents - oxybutynin, dicyclomine hydrochloride, and propantheline. TCAs - imipramine, doxepin, desipramine, and nortriptyline.	Flavoxate for the treatment of patients with DI (A). NSAIDs for the primary treatment of DI (C).
	Anticholinergic agents as first-line pharmacologic therapy for patients with DI (A). Oxybutynin is the anticholinergic agent of choice. The recommended dosage is 2.5-5 mg taken orally three or four times per day (A). Propantheline is a second-line anticholinergic agent in the treatment of patients with DI who can tolerate the full dose. The recommended doses are 7.5-30 mg administered in the fasting state three to five times per day; higher doses (15-60 mg qid) may be required (B). The use of TCAs should be reserved for carefully evaluated patients. The usual oral dosages are 10-25 mg initially administered one to three times per day, but less frequent administration is usually possible because of the long half-life of these drugs. The daily total dose is usually 25-100 mg (B).
Stress incontinence	PPA or pseudoephedrine as first-line pharmacologic therapy for women with SUI who have no contraindications for its use, particularly hypertension. The recommended dosage for PPA is 25-100 mg in sustained-release form, administered orally, twice daily (A). The usual dose of pseudoephedrine is 15-30 mg tid. Estrogen (oral or vaginal) as an adjunctive pharmacologic agent for postmenopausal women with SUI or mixed incontinence. Conjugated estrogen is usually administered either orally (0.3-1.25 mg/day) or vaginally (2 g or fraction/day). Progestin (e.g., medroxyprogesterone 2.5-10 mg/day) may be given continuously or intermittently (B). Combination therapy of oral or vaginal estrogens and PPA in the treatment of SUI in postmenopausal women when initial single-drug therapy has proven inadequate (A). Imipramine as an alternative pharmacologic therapy for SUI when first-line agents have proven unsatisfactory (C).	Propranolol or other beta-blockers for treatment of SUI because of lack of clinical experience and clinical studies (C).
Surgical treatment
Stress incontinence	Surgery is recommended for treatment of stress incontinence in men and women and may be recommended as first-line treatment for appropriately selected patients and those who are unable to comply with other nonsurgical therapies (B).
Hypermobility in women	Retropubic or needle suspension for women with hypermobility when SUI is the primary indication for surgery. On the basis of greater efficacy, these procedures are recommended over anterior vaginal repair for hypermobility (B).
Intrinsic sphincter deficiency in women (ISD)	Sling procedures for women who have ISD with coexisting hypermobility or as first-line treatment for ISD (B). Periurethral bulking injections as first-line treatment for women with ISD who do not have coexisting hypermobility (B). Artificial sphincter for ISD patients who are unable to perform intermittent catheterization and have severe SUI that is unresponsive to other surgical treatments. Because of the high complication rate, this treatment is rarely used as primary therapy (B).
ISD in men	Periurethral bulking injections as a first-line surgical treatment for men with ISD (B). Artificial sphincter for ISD during the 6 months after prostatectomy. Behavioral intervention should also be tried during this period (B).
Urge incontinence: detrusor instability	Augmentation intestinocystoplasty for those with intractable, severe bladder instability or for those with bladders that have poor compliance when the patient is unresponsive to other nonsurgical therapies (B). Urinary diversion is recommended in severe intractable cases of detrusor instability that is unresponsive to other therapies (C).
Overflow incontinence: bladder neck or urethral obstruction	Symptoms of overflow or incontinence secondary to obstruction should be addressed with a surgical procedure to relieve the obstruction (B). Intermittent catheterization or an indwelling catheter in patients who are not candidates for surgery (C).	The panel found no evidence to support the use of urethral dilation for treating incontinence in women, although it may be useful in the extremely rare cases of primary obstruction (C). Internal urethrotomy for treating urethral obstruction in women (C).
Other measures and supportive devices
Intermittent catheterization	Intermittent catheterization (IC) as a supportive measure for patients with spinal cord injury, persistent UI, or with chronic urinary retention secondary to underactive or partially obstructed bladder (B). Clean technique for IC in young, male, neurologically impaired individuals (B). Sterile technique for IC for elderly patients and patients with compromised immune system (C).	Routine use of long-term suppressive therapy with antibiotics in patients with chronic, clean IC (B). In high-risk populations, for example, those with internal prosthesis or those who are immunosuppressed due to age or disease, the use of antibiotic therapy for asymptomatic bacteriuria must be individually reviewed (C).
Indwelling catheters	As a supportive measure for patients whose incontinence is caused by obstruction and for whom other interventions are not feasible (B). Incontinent patients who are terminally ill or for patients with pressure ulcers as short-term treatment (B). In severely impaired individuals in whom alternative interventions are not an option and when a patient lives alone and a caregiver is unavailable to provide other supportive measures (C).
Suprapubic catheters	For short-term use following gynecologic, urologic, and other surgery, or as an alternative to long-term catheter use (B).	In persons with chronic unstable bladder (DI, DH) and ISD (B).
External collection systems	For incontinent men and women who have adequate bladder emptying, who have intact genital skin, and in whom other therapies have failed or are not appropriate (C).
Penile compression devices	Penile compression devices are known to be used in clinical practice in the treatment of UI. No scientific literature was found to support the use of these devices. The panel recognizes the temporary use of penile compression devices in males in selected circumstances under the supervision of a health care provider (C).
Pelvic organ support devices	Pessaries for women who have symptomatic pelvic organ prolapse (C).	Data are not available to recommend or discourage the use of pessaries for the treatment of UI in women (C).
Absorbent products	During evaluation (C). As an adjunct to other therapy (C). For long-term care of patients with chronic, intractable UI (C).
Long-term management of chronic intractable UI
Physical and environmental alterations	Caregiver assessment of the environment in which the elderly or disabled patient resides. Simple alterations or the addition of toileting or ambulation devices to eliminate or reduce episodes of involuntary urine loss (C). Strategies that maintain or improve mobility to prevent or reduce incontinent episodes in the frail elderly (B).
Fluid and dietary management	A bowel regimen based on adequate fiber and fluid intake. Elimination of bowel impaction and consequent pressure on the bladder and urethra as necessary first steps in the treatment of chronic UI (C).
Management of nocturia	Preventive measures to decrease night-time voids. Simple electronic urine detection devices for more efficient and effective patient monitoring of night-time urine loss (B).
Interventions for protection and comfort	Most absorbent and skin- friendly products. However, no scientific literature was found to guide in selection of the most effective product (C). Intermittent catheterization preferable to indwelling catheters for the management of urinary retention and overflow incontinence (B). Suprapubic catheters as alternative for indwelling urethral catheters when patient choice or circumstances require the use of a bladder drainage device (B).
Skin care	Standard measures of cleansing the skin immediately before and after urine loss (B). Most absorbent and skin-friendly pads and garments for protection from skin damage (C).
Public and professional education
	Comprehensive and multidisciplinary patient education about incontinence and all management alternatives (C). More research to test the effectiveness of patient education activities (C). Inclusion of education about UI evaluation and treatment in the basic curricula of undergraduate and graduate training programs of all health care providers (C). Continuing education programs on UI for health care providers (C).

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.

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.