114 Canadian Family Physician • Le Médecin de famille canadien VOL 48: JANUARY • JANVIER 2002
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romoting a Collaborative Consumer-Focused Approach to Continence Care in Canada” was sponsored by the Canadian Continence Foundation. This initiative responded to consumers’ need for information on treatment options for incontinence and health care professionals’ need for infor- mation on managing urinary incontinence. It was funded by Health Canada’s Population Health Fund. Producing the guide- lines involved review of international models of continence care, review of existing international clinical practice guide- lines and management flow charts, an updated literature review, and a consensus conference followed by regional dis- cussions during which consumers and health care profession- als (“reactor panels”) could react to the material produced.The Canadian Continence Foundation then convened a multidisciplinary committee of consumers and health care professionals knowledgeable about managing incontinence.
The committee had representatives from family medicine, nursing, physiotherapy, gynecology, urology, urogynecol- ogy, geriatric medicine, and Health Canada’s Division of Seniors and Aging, along with an independent evaluator.
The committee accepted the second edition (1996) of the United States Agency for Health Care Policy and Research’s (AHCPR) “Clinical Practice Guideline for Urinary Incontinence in Adults” as a starting point. Committee teams did systematic literature searches from January 1995 to January 2000 using key search terms and reviewed relevant papers using estab- lished levels of evidence.
The committee then looked at the AHCPR guideline and recommendations again and endorsed or modified them according to the new evidence from their literature review.
A series of flowcharts, produced for the First International Consultation on Incontinence in 1998, were adapted in light of the findings of the literature review to reflect management of incontinence in men, women, and frail elderly people.
Participants were selected, based primarily on nomina- tions, from national associations of health professionals and consumer groups and from various geographic regions across Canada for a consensus conference, which was held in May 2000. Draft guidelines were circulated to partici- pants before the conference; during the conference, the draft guidelines were presented and discussed in small groups and further revised. Consensus was defined as more than 80% of participants voting in favour of a revision.
The resulting consensus guidelines and flowcharts were presented to reactor panels at seven community meetings.
A consistent recommendation from the reactor panels was to consolidate the flowcharts for men, women, and frail
elderly people into one chart. Figure 1 presents the result- ing integrated “Initial Management of Urinary Incontinence”
chart. Specialist health professionals attending the Canadian Continence Foundation’s Biennial Conference in October 2001 also indicated their preference for an integrated flow- chart for specialized management of urinary incontinence.
The guidelines and initial management flowchart emphasize assessment of consumers’ goals, consideration of quality-of-life issues, and use of appropriate outcome measures, such as void- ing diaries. A continence history, focused physical examination, and consideration of non-urologic contributing factors, partic- ularly in elderly people, can establish type of incontinence and guide interventions. Lifestyle strategies, such as fluid intake volume and timing; caffeine reduction; and conservative behavioural interventions, such as bladder retraining, pelvic muscle exercise and urgency suppression techniques, are first- line interventions for most people with incontinence.
Patient education is critical; taking time to instruct patients makes positive outcomes more likely. Family physi- cians might elect to do the initial assessments and instruc- tion themselves. Alternatively, they might identify the problem of incontinence and refer their patients to health professionals (such as nurses or physiotherapists) or to interdisciplinary continence clinics, who can provide the expertise and time to ensure effective instruction, reinforce- ment, and follow up. Referral to specialists for second-line management is required for those with complex histories, those who do not respond to initial lifestyle and behavioural interventions, and those in whom urodynamic assessment or cystoscopic assessment is necessary to evaluate other options, such as periurethral bulking agents or surgery.
The positive message from the consensus conference to people with incontinence and to health professionals involved in their care is that urinary incontinence can be resolved, better managed, or better contained in 100% of people affected. The full text of the process, guidelines, and flowchart can be seen on the Canadian Continence Foundation website at www.continence -fdn.ca. A complimentary laminated copy of the initial manage-
ment flow chart may be obtained by contacting the Canadian Continence Foundation at help@continence-fdn.ca.
Dr Borrie is Chair of the Division of Geriatric Medicine at the University of Western Ontario in London and is Medical Director of the Continence Clinic at Parkwood Hospital. Dr Valiquette is Director of the Urology Training Program at the Université de Montréal. Drs Borrie and Valiquette are Co-Chairs of the Canadian Continence Foundation’s Guidelines Committee.
Managing adults with urinary incontinence
Clinical practice guidelines
Michael J. Borrie, MBCHB, FRCP Luc Valiquette, MD, FRSC
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116 Canadian Family Physician • Le Médecin de famille canadien VOL 48: JANUARY • JANVIER 2002
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Presenting symptoms Initial history/ clinical assessment Presumed etiology Treatment/ management, includes containment & skin care
Urinary incontinence with: Physical activityMixed symptomsUrgency/ frequencyOther or unclear symptomsIsolated post-void dribble General history +Focused incontinence history + Physical Examination + Investigations, urinalysis &/or culture/sensitivity (often with caregiver) Goals & expectations of treatment Medications Previous medical history Chronic conditions Focus on: environmental/ functional factors polypharmacy drug interactions comorbidity constipation/fecal impaction
Environmental/functional assessment Quantification of urine loss Qualification of urine loss Fluid intake (amount/type) Associated urinary symptoms Feeling of prolapse Bowel function/fecal incontinence Sexual function Impact on quality of life
General assessment Abdominal examination Specific assessment: vaginal inspection pelvic examination assessment of pelvic floor strength genital exam rectal exam Focus on: functional/neurological/ musculoskeletal exam/gait pelvic inspection/exam (atrophic vaginitis, discharge) Signs of leakage
Voiding diary Post-void residual Focus on: voiding diary & fluid intake post-void residual assess for depression & cognitive function Stress incontinenceMixed incontinenceUrge incontinenceIncomplete emptying Non-urological factors (impaired mobility/dexterity, impaired cognition, depression, polypharmacy, nocturnal polyuria, pain, environment)
Trapping urine in posterior urethra Environment & lifestyle interventions; pelvic floor muscle training; bladder retraining
Complex history significant pelvic organ prolapse possible obstruction hematuria pelvic pain significant post-void residual recurrent urinary tract infections pelvic irradiation neurologic condition radical pelvic surgery suspected fistula fecal incontinence complex psychiatric causes complex comorbidities devices estrogen tricyclics refer for surgical evaluation
treat both etiologies or the dominant oneanticholinergics tricyclics refer alpha blockers finasteride intermittent catheter indwelling catheter refer for surgical evaluation Credé manoeuvre
environmental modifications specific treatment of non-urological factors prompted voiding improve mobility treat depression manage dementia address polypharmacy address nocturia refer for geriatric assessment urethral massage pelvic muscle exercises + Lifestyle Interventions (fluid intake, caffeine, alcohol, cigarettes, weight loss, diet, scheduled toileting, bowel management); focus on: reduced Drug Dosage Subjective/objective report of improvement Number of pads/type used; voiding diary Quality of life measures Goals/expectations met? Second-line management or care or continuing management (in community or long-term care); multidisciplinary approach
Women Men Frail elderly
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Figure 1. Initial management of urinary incontinence in men, women, and frail elderly people
