nternational s urinary incontinence, - … international consultation on incontinence...
TRANSCRIPT
3rd International Consultation onIncontinence
Recommendations of theInternational Scientific Committee:
Evaluation and Treatment ofUrinary Incontinence,
Pelvic Organ Prolapse andFaecal Incontinence
◆◆◆
P. Abrams, K.E. Andersson, L. Brubaker, L.Cardozo, A. Cottenden, L. Denis, J. Donovan, D. Fonda, C. Fry,
D. Griffiths, P. Hanno, S. Herschorn, Y. Homma, T. Hu,S.Hunskaar, P. van Kerrebroeck, S. Khoury, R. Madoff,
J. Morrison, J. Mostwin, D. Newman, R. Nijman, C. Norton, C. Payne, F. Richard, A. Smith, D. Staskin, J. Thuroff, A. Tubaro, D.B. Vodusek, L. Wall, A. Wein, D. Wilson,
JJ. Wyndaele, and The Members of the Committees
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Organised by
INTERNATIONAL
CONSULTATION ON
UROLOGICAL DISEASES
(ICUD)
INTERNATIONAL
CONTINENCE SOCIETY
(ICS)
INTERNATIONAL SOCIETY
OF UROLOGY (SIU)
AND THE MAJOR
INTERNATIONAL
ASSOCIATIONS OF
UROLOGY AND
GYNECOLOGY
In collaboration with
AmericanUrologicalAssociation
(AUA)
ConfederacionAmericana de
Urologia (CAU)
EuropeanAssocation of
Urology (EAU)
FIGO
UrologicalAssociation of Asia
(UAA)
and other medical associations
INTRODUCTION
The 3rd International Consultation on Incontinence met from June 26 - 29, 2004 in Monaco.
Organised by the International Continence Society (ICS), the InternationalConsultation on Urological Diseases a non-governmental organisation thein official collaboration with the World Health Organisation, SocieteInternational d’Urologie (SIU) in order to develop recommendations forthe diagnosis evaluation and treatment of urinary incontinence, faecalincontinence and pelvic organ prolapse.
The recommendations are evidence based following a thorough review ofthe available literature and the global subjective opinion of recognisedexperts serving on focused committees. The individual committee reportswere developed and peer reviewed by open presentation and comment.The Scientific Committee, consisting of the Chairmen of all the commit-tees then refined the final recommendations.
These recommendations published in 2005 will be periodically re-evalua-ted in the light of clinical experience and technological progress andresearch.
2005
1. DEFINITIONS
2. EVALUATION OF INCONTINENCE
3. MANAGEMENT RECOMMENDATIONS
4. RECOMMENDATIONS FOR THE PROMOTION, EDUCATION, AND ORGANIZATION OF CONTINENCE CARE
5. RECOMMENDATIONS FOR BASIC SCIENCE RESEARCH
6. RECOMMENDATIONS FOR EPIDEMIOLOGY
7. RECOMMENDATIONS FOR CLINCAL RESEARCH
Annex 1 : Bladder Charts and Diaries
Annex 2 : International Consultation on Incontinence Modular Questionnaire (ICIQ) - ICIQ UI SF(short-form)
VIII. FAECAL INCONTINENCE
VII. PELVIC ORGAN PROLAPSE
VI. PAINFUL BLADDER SYNDROME
V. NEUROGENIC INCONTINENCE
IV. FRAIL OLDER MEN AND WOMEN
III. WOMEN
II. MEN
I. CHILDREN
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Content
The consultation agreed to use the newInternational Continence Society definitions (ICS)for lower urinary tract dysfunction (LUTD) inclu-ding incontinence. These definitions appeared inthe journal Neurourology and Urodynamics (issue2, 2002; 21:167-178) or can be viewed on the ICSwebsite:www.icsoffice.org
LUTS are divided into storage symptoms and voi-ding symptoms.
Urinary incontinence is a storage symptom anddefined as:
• The complaint of any involuntary loss of urine.A definition suitable for epidemiologicalstudies, and
• Involuntary loss of urine that is a social orhygienic problem.
Urinary incontinence may be further definedaccording to the patient’s symptoms:
• Urgency Urinary Incontinence is the complaintof involuntary leakage accompanied by orimmediately preceded by urgency.
• Stress Urinary Incontinence is the complaint ofinvoluntary leakage on effort or exertion, or onsneezing or coughing.
• Mixed Urinary Incontinence is the complaint ofinvoluntary leakage associated with urgencyand also with effort, exertion, sneezing and cou-ghing.
• Nocturnal Enuresis is any involuntary loss ofurine occuring during sleep.
• Post-micturition dribble and continuous urina-ry leakage denotes other symptomatic forms ofincontinence.
Overactive bladder is characterised by the storagesymptoms of: urgency with or without urge incon-tinence, usually with frequency and nocturia.
• Overactive Detrusor Function, is characterised
by involuntary detrusor contractions during thefilling phase, which may be spontaneous or pro-voked.
The overactive detrusor is divided into:
- Idiopathic Detrusor Overactivity, defined asoveractivity when there is no clear cause.
- Neurogenic Detrusor Overactivity is defined asoveractivity due to a relevant neurologicalcondition.
Urodynamic stress incontinence is noted duringfilling cystometry, and is defined as the involunta-ry leakage of urine during increased abdominalpressure, in the absence of a detrusor contraction.
• Painful bladder syndrome is the complaint ofsuprapubic pain related to bladder filling,accompanied by other symptoms such asincreased daytime and night-time frequency, inthe absence of proven urinary infection or otherobvious pathology.
• Pelvic organ prolapse is defined as the sympto-matic descent of one or more of: the anteriorvaginal wall, the posterior vaginal wall, and theapex of the vagina (cervix/uterus) or vault (cuff)after hysterectomy. Prolapse support can be sta-ged from stage 0 to stage IV.
Faecal incontinence may be divided into:-
• Faecal incontinence, any involuntary loss offaecal material
• Flatus incontinence, any involuntary loss ofgas (flatus)
• Anal incontinence, any involuntary loss offaecal material and/or flatus.
These definitions are not currently covered bythe ICS terminology but follow the above defi-nition for urinary incontinence.
5. Faecal Incontinence
4. Pelvic Organ Prolapse
3. Painful Bladder Syndrome
2. Urodynamic Diagnosis
1. Lower Urinary Tract Symptoms (LUTS)
The following ICS definitions arerelevant:
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1. Definitions
The following was utilised to classify diagnostictests and studies:
• A highly recommended test is a test that shouldbe done on every patient.
• A recommended test is a test of proven value inthe evaluation of most patients and its use isstrongly encouraged during initial evaluation.
• An optional test is a test of proven value in theevaluation of selected patients; its use is left tothe clinical judgement of the physician.
• A not recommended test is a test of no provenvalue.
The main recommendations for this consultationhave been abstracted from the extensive work ofthe 25 committees of the 3rd InternationalConsultation on Incontinence (ICI).
Each committee has written a report that reviewsand evaluates the published scientific work in eachfield of interest in order to give Evidence Basedrecommendations. Each report ends with detailedrecommendations and suggestions for a program-me of research.
The initial evaluation should be undertaken inevery patient presenting with symptoms/signs sug-gestive of these conditions, by a health care pro-fessional.
Management of a disease such as incontinencerequires caregivers to assess the sufferer in a holis-tic manner. Many factors may influence a particu-lar individual’s symptoms, some may cause incon-tinence, and may influence the choice and the suc-cess of treatment. In addition to the usual generalhistory the assessment has a number of importantcomponents:
• Presence, severity, duration and bother of anyurinary, bowel or prolapse symptoms. It is use-ful to use validated questionnaires to assesssymptoms systematically and their impact onquality of life.
• Effect of any symptoms on sexual function :validated questionnaires are useful in a fullassessment.
• Previous conservative, medical and surgicaltreatment, in particular as they affect the geni-tourinary tract and lower bowel.
• Environmental issues: these may include thesocial, cultural and physical environment.
• Mental status: each individual needs to beassessed for their ability to understand proposedmanagement plans and to enter into discussionswhen there are a range of treatment options. Insome groups of patients formal testing of cogni-tive function is essential, eg. those thought to besuffering from dementia.
• Physical abilities: individuals who have com-promised mobility, dexterity, or visual acuitymay need to be managed differently
• Coexisting diseases may have a profound effecton incontinence and prolapse sufferers, forexample asthma patients with stress incontinen-ce will suffer greatly during attacks. Diseasesmay also precipitate incontinence, particularlyin frail older persons.
• Patient medication: it is always important toreview every patient’s medication and to make
1. History and General Assessment
The main recommendations should be read inconjunction with the management algorithmsfor children, men, women, the frail older person,neurogenic patients, bladder pain, pelvic organprolapse, and faecal incontinence.
I. HIGHLY RECOMMENDED TESTSDURING INITIAL EVALUATION
This section primarily discusses the Evaluationof urinary incontinence with or without PelvicOrgan Prolapse (including rectal prolapse) andFaecal Incontinence.
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2. Evaluation of Incontinence and PelvicOrgan Prolapse
an assessment as to whether current treatmentmay be contributing to the patient’s condition.
• Obstetric and menstrual history.
• Lifestyle: including exercise and food/fluidintake.
• Assess patients goals and expectations of treat-ment
• Patient’s support systems (including carers).
The more complicated the history, and the moreextensive the proposed therapy, the more comple-te the examination needs to be. Depending on thepatients symptoms and their severity, there are anumber of components in the examination of suf-ferers with incontinence and/or pelvic organ pro-lapse (POP).
• Abdominal examination.
• Perineal examination including sensation.
• Rectal examination.
• Examination of the external genitalia.
• Vaginal examination.
• Stress test for urinary incontinence.
• Neurological testing (see chapter on assess-ment)
Physical examination should be performed regard-less of whether the patient is a child, a woman, aman, someone with neurological disease or a frailelderly person.
In patients with urinary symptoms a urinaryinfection is a readily detected, and easily treatablecause of LUTS, urine testing is highly recommen-ded. Testing may range from dipstick testing, tourine microscopy and culture.
In a patients with urinary symptoms the use of a
simple frequency volume chart (example in Annex1) is highly recommended to document the fre-quency of micturition, the volumes of urine voi-ded, incontinence episodes and the use of inconti-nence pads.
In patients with suspected voiding dysfunction,PVR should be part of the initial assessment if theresult is likely to influence management, forexample, in neurological patients.
Initial imaging may be by Ultrasound, or plain Xray.
Imaging of the lower urinary tract/pelvis is high-ly recommended in those with urinary symptomsor whose initial evaluation indicates a possibleco-existing lower tract or pelvic pathology.
Imaging of the upper urinary tractis highly recommended in specific situations.These include:
• neurogenic urinary incontinence e.g. myelodys-plasia, spinal cord trauma,
• incontinence associated with significant post-void residual,
• co-existing loin/kidney pain,
• severe pelvic organ prolapse, not being treated
• suspected extra-urethral urinary incontinence,
• children with incontinence where indicated
• urodynamic studies which show a raised intra-vesical pressure on bladder filling (poor com-pliance).
LUT endoscopy is highly recommended:
• when initial testing suggest other pathologies,e.g. haematuria raises the possibility of bladdertumour
• when pain or discomfort features in the
d) Endoscopy
In anorectal conditions Anal US or MRIprior to anal sphincter surgery is highlyrecommended, when obvious anatomicdefects are not evident (cloacal formations).
c) Imaging
b) Estimation of post void residual urine(PVR)
a) Quatification of symptoms
4. Tests before Further Investigation/ Treatment
3. Urinalysis
2. Physical Examination
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patient’s LUTS : these may suggest an intrave-sical lesion
• when appropriate in the evaluation of vesicova-ginal fistula and extra-urethral urinary inconti-nence (in childbirth fistulae, endoscopy is oftenunnecessary).
The tests below are recommended when theappropriate indication(s) is present. Some recom-mended tests become highly recommended in spe-cific situations.
This section should also be read in conjunctionwith the relevant committee reports.
The use of the highest quality questionnaires(Grade A, where available) is recommended forthe assessment of the patient’s perspective ofsymptoms of incontinence and their impact onquality of life. The ICIQ is highly recommended(Grade A) for the basic evaluation of the patient’sperspective of urinary incontinence; with otherGrade A questionnaires recommended for moredetailed assessment. Further development is requi-red in the areas of pelvic organ prolapse and fae-cal incontinence, and for specific patient groups,only Grade B questionnaires are currently avai-lable.
Standard biochemical tests for renal function arerecommended in patients with urinary incontinen-ce and a high probability of renal impairment orprior to surgical interventions.
Uroflowmetry with the measurement of postvoidresidual urine is recommended as a screening testfor symptoms suggestive of voiding dysfunction(urinary) or suspicious physical signs.
• prior to most invasive treatments
• after treatment failure if more information isneeded in order to plan further therapy.
• as part of a long-term surveillance programmein neurogenic lower urinary tract dysfunction
• in “complicated incontinence”. (For detailsplease see relevant subcommittee reports).
• the assessment of bladder sensation
• the detection of detrusor overactivity
• the assessment of urethral competence duringfilling
• the determination of detrusor function duringvoiding
• the assessment of outlet function during voi-ding
• the measurement of residual urine
• In faecal incontinence, except when there hasbeen an acute sphicter injury, e.g during child-birth.
• With rectal prolapse, flexible sigmoidosco-py/colonoscopy to exclude other pathology.
• Other “alarm” symptoms, including rectalbleeding (see assessment chapter)
6. Endoscopy and Lower Bowel imaging is Recommeded
Proctography or MRI is recommended in sus-pected rectal prolapse which cannot be adequa-tely confirmed by physical examination.
5. Imaging of Rectal Prolapse
b) The aims of Routine UrodynamicEvaluation are
a) Urodynamic evaluation is recommended :
4. Urodynamic Testing
3. Uroflowmetry
2. Renal Function Assessment
1. Further Symptom and QoLAssessment
II. RECOMMENDED FURTHERASSESSMENT TESTS
In anorectal conditions proctoscopy or flexiblesigmoidoscopy should routinely be performed inthe evaluation of patients with fecal incontinen-ce. Colonoscopy or air contrast barium enema ishighly recommended in the presence of unex-plained change in bowel habit, rectal bleeding orother alarm symptoms or signs (see basic assess-ment chapter).
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➦ If a more detailed estimate of urethral functionis required then the following urethral functiontests are optional :• urethral pressure profilometry• abdominal leak point pressures• video-urodynamics and or electromyography➦ If initial urodynamics have failed to demons-trate the cause for the patient’s incontinence thenthe following tests are optional:• repeated routine urodynamics • ambulatory urodynamics
Pad testing is an optional test for the routine eva-luation of urinary incontinence. Either a short test(20 min to 1 hr) or a 24 hr test is suggested.
The information gained by clinical examinationand urodynamic testing may be enhanced by neu-rophysiological testing of striated muscle andnervous pathways. Appropriately trained person-nel should perform these tests. The followingneurophysiological tests can be considered inpatients with peripheral lesions prior to treatmentfor lower urinary tract or anorectal dysfunction.
• concentric needle EMG
• sacral reflex responses to electrical stimulationof penile or clitoris nerves.
They may be indicated in :
• Suspected pelvic floor dysfunction
• Failed surgery
• Assessment of urethral mobility
• Recurrent posterior vaginal wall prolapse
• Follow-up of failed sling implant
are an optional test in complicated or recurrentincontinence in children and neurogenic patients.The imaging modality may be ultrasound or Xray.
Even if simple imaging, for example spinal X-rays inpatients with suspected neurological disease, is nor-mal then further imaging can be considered. The fur-ther methods include myelography, CT and MRI.
is an optional test in complicated or recurrent uri-nary incontinence (e.g. after failed stress inconti-nence surgery in women, or in post prostatectomyincontinence in men)
is not recommended as part of the urodynamicevaluation of incontinence measurement.
is not recommended
Anal manometry is useful to assess resting andsqueeze anal pressures.
Electromyography is a useful investigativetool but is not needed for routine clinical eva-luation.
9. Anorectal physiology testing
8. Pudendal nerve latency testing
7. Gas cystometry
6. Endoscopy
5. Imaging of the Central NervousSystem, including Spine
b) Simultaneous LUT imaging and urodyna-mics,
a) Techniques include cysto-urethrography,ultrasound, CT or MRI.
4. Further Imaging
3. Neurophysiological Testing
2. Pad Testing
1. Additional Urodynamic Testing
III. OPTIONAL DIAGNOSTIC TESTS
These tests are recommended the presence ofunexplained diarrhea or when Crohn’s disea-se is suspected.
7. Small bowel follow-through or capsu-le endoscopy.
1595
1596
The management recommendations are derivedfrom the detailed work in the committee reports onmanagement in children, men, women, the frailelderly, neurological patients pelvic organ prolap-se, painful bladder syndrome, and faecal inconti-nence. The management of incontinence is presen-ted in algorithm form with accompanying notes.There are algorithms for • I. Children• II. Men • III. Women• IV. Frail Older Men and Women• V. Neurogenic Incontinence • VI. Painful Bladder Syndrome• VII. Pelvic Organ Prolapse• VIII. Faecal IncontinenceThese algorithms are divided into two for groups I,II, III and V : the two parts, initial management andspecialised management require a little furtherexplanation.The management algorithms are designed to beused for patients whose predominant problem isincontinence. However there are many otherpatients in whom the algorithms may be useful suchas those patients with urgency and frequency sug-gestive of detrusor overactivity but without inconti-nence.It should be noted that these algorithms, datedJanuary 2005, represent the “best opinion” at thattime. Our knowledge, developing from both aresearch base and because of evolving expert opi-nion, will inevitably change with time. TheConsultation does not wish those using the algo-rithms to believe they are carved in tablets of stone:there will be changes both in the relatively shortterm and the long term.
are intended for use by all or any health care wor-kers including health care assistants, nurses, physio-therapists, and family doctors as well as by specia-lists such as urologists and gynaecologists. Theconsultation has attempted to phrase the recommen-dations in the basic algorithms in such a way thatthey may be readily used by health care workers inall countries of the world, both in the developingand the developed world.
are intended for use by specialists. The speciali-sed algorithms, as well as the initial management
algorithms are based on evidence where possibleand on the expert opinion of the 700 healthcareprofessionals who took part in the Consultation. Inthis consultation committees ascribed level of evi-dence to the published work on the subject anddevised grades of recommendation to informpatient management.
Each algorithm contains a core of recommenda-tions in addition to a number of essential compo-nents of basic assessment (see I to III DiagnosticTests, above).
The patient’s desire for treatment. Today patienttreatment is a matter for discussion and joint deci-sion making between the patient and his or herhealth care advisors. This process of consultationincludes the specific need to assess whether or notthe sufferer of incontinence wishes to receive treat-ment and if so, what treatments he or she wouldfavour. Implicit in this statement is the assumptionthat the health care worker will give an appropriateexplanation of the patient’s problem and the alter-native lines of management, indications and therisks of treatment. The assumption that patientsalmost always wish to have treatment is flawed, andthe need to consult the patient is paramount.In each algorithm, treatments are listed in order ofsimplicity, the least invasive being listed first. Thisorder does not imply a scale of efficacy or cost, twofactors which need to be considered in choosing thesequence of therapy. The order is likewise notmeant to imply a suggested sequence of therapy,which is determined jointly by the treating healthcare providers and the patient, considering all therelevant factors listed above.In the initial management algorithms, treatment isempirically based, whilst, the specialized manage-ment algorithms usually rely on precise diagnosisfrom urodynamics and other testing.The assumption is made that patients will be reas-sessed at an appropriate time to evaluate their pro-gress.
◆ Joint decision making
• General assessment• Symptom assessment• Assessment of quality of life impact• Assessment of the desire for treatment• Physical examination• Urinalysis
◆ Essential components of basic assessment
➦ The specialised algorithms
➦ The algorithms for initial management
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3. Management Recommendations
1598
A.I
NIT
IAL
MA
NA
GE
ME
NT
I. C
HIL
DR
EN
➦ A
grou
p of
chi
ldre
n w
ith c
ompl
icat
ed i
ncon
tinen
ceas
soci
ated
with
:
• re
curr
ent u
rina
ry in
fect
ion
• vo
idin
g sy
mpt
oms
or e
vide
nce
of p
oor
blad
der
empt
ying
• ur
inar
y tr
act a
nom
alie
s,
• pr
evio
us p
elvi
c su
rger
y
• ne
urop
athy
Shou
ld h
ave
spec
ialis
t man
agem
entf
rom
the
outs
et
Tw
o ot
her
mai
n gr
oups
of c
hild
ren
shou
ld b
e id
entif
ied
by in
itial
ass
ess-
men
t:
➦a)
Noc
turn
al e
nure
sis
with
out o
ther
sym
ptom
s (m
ono-
sym
ptom
atic
).
➦b)
Day
time
sym
ptom
sof
fre
quen
cy, u
rgen
cy, u
rge
inco
ntin
ence
with
or
with
out n
ight
-tim
e w
ettin
g.
Chi
ldre
n pr
oduc
e sp
ecif
ic m
anag
emen
t pro
blem
sfo
r a v
arie
ty o
f rea
sons
:as
sess
men
t req
uire
s he
lp f
rom
thei
r pa
rent
san
d ca
rers
; con
sent
to tr
eat-
men
t may
be
prob
lem
atic
; and
coo
pera
tion
in b
oth
asse
ssm
ent a
nd tr
eat-
men
t may
be
diff
icul
t.
In c
hild
ren,
his
tory
and
gene
ral
asse
ssm
ent
requ
ires
par
ticul
ar a
ttent
ion
not
only
tak
ing
a fu
ll in
cont
inen
ce h
isto
ry b
ut a
lso
in a
sses
sing
bow
elfu
nctio
n, th
e ch
ild’s
soc
ial e
nvir
onm
ent a
nd th
e ch
ild’s
gen
eral
and
beh
a-vi
oral
dev
elop
men
t: ea
ch s
houl
d be
for
mal
ly a
sses
sed
and
reco
rded
.
Phy
sica
l exa
min
atio
nsh
ould
aim
to d
etec
t a p
alpa
ble
blad
der,
any
abno
r-m
ality
of
the
exte
rnal
gen
italia
, si
gns
of i
ncon
tinen
ce a
nd e
vide
nce
ofbo
ny a
bnor
mal
ities
in th
e gl
uteo
-sac
ral a
rea
(eg.
sac
ral d
impl
e) o
r fe
et.
Ifpo
ssib
le th
e ch
ild s
houl
d be
obs
erve
d vo
idin
g.
Initi
al m
anag
emen
t sho
uld
be in
stig
ated
for
thos
e w
ith «
unco
mpl
icat
ed»
noct
urna
l enu
resi
s an
d/or
day
time
sym
ptom
s.
➦a)
Mon
o-sy
mpt
omat
ic n
octu
rnal
enu
resi
ssh
ould
be
trea
ted
initi
ally
with
the
enur
esis
ala
rm (
Gra
de A
). O
ther
rec
omm
ende
d tr
eatm
ents
are
beha
vior
al m
odif
icat
ion,
dia
ries
to r
ecor
d en
ures
is e
piso
des,
and
ant
i-di
uret
ic h
orm
one
anal
ogue
s (G
rade
A).
➦b)
Day
time
inco
ntin
ence
shou
ld b
e tr
eate
d w
ith b
ladd
er tr
aini
ng (
timed
void
ing)
with
or
with
out a
ntim
usca
rini
c th
erap
y (G
rade
B).
Oth
er c
ondi
tions
usu
ally
see
n in
adu
lts m
ay b
e se
en in
chi
ldre
n, f
orex
ampl
e st
ress
uri
nary
inco
ntin
ence
.
Shou
ld in
itial
trea
tmen
t be
unsu
cces
sful
for
eith
er e
nure
sis
or d
ayti-
me
sym
ptom
s, th
en a
fter
a r
easo
nabl
e pe
riod
of
time
(8-1
2 w
eeks
),re
ferr
al f
or a
spe
cial
ist’s
adv
ice
is h
ighl
y re
com
men
ded.
2.T
reat
men
t1.
Ini
tial
ass
esse
men
t sh
ould
iden
tify
1599
HIS
TOR
Y/S
YM
PTO
MA
SS
ES
SM
EN
T
CL
INIC
AL
AS
SE
SS
ME
NT
TR
EA
TM
EN
TInit
ial M
anag
emen
t o
f U
rin
ary
Inco
nti
nen
ce in
Ch
ildre
n
PR
ES
UM
ED
DIA
GN
OS
IS
No
ctu
rnal
en
ure
sis
(mo
no
sym
pto
mat
ic)
• E
xpla
nat
ion
/ed
uca
tio
n•
En
ure
sis
Dia
ry•
Ala
rm•
Des
mo
pre
ssin
• B
lad
der
tra
inin
g•
An
tim
usc
arin
ics
MO
NO
SY
MP
TOM
AT
ICN
OC
TU
RN
AL
EN
UR
ES
ISU
RG
E IN
CO
NT
INE
NC
E
RE
CU
RR
EN
T
INF
EC
TIO
N
DY
SF
UN
CT
ION
AL
VO
IDIN
G
Day
tim
e ±
Nig
htt
ime
wet
tin
g
±U
rgen
cy /
freq
uen
cy
±Vo
idin
g s
ymp
tom
s
“Co
mp
licat
ed”
Inco
nti
nen
ce
asso
ciat
ed w
ith
:-
Uri
nar
y tr
act
ano
mal
y-
Neu
rop
ath
y-
Pel
vic
surg
ery
- Vo
idin
g (
emp
tyin
g)
sym
pto
ms
- R
ecu
rren
t u
rin
ary
infe
ctio
n
SP
EC
IAL
IZE
D M
AN
AG
EM
EN
T
Fai
lure
Fai
lure
An
y o
ther
abn
orm
alit
yd
etec
ted
e.g
. Po
st v
oid
resi
du
al
• G
ener
al a
sses
smen
t (
see
rele
van
t ch
apte
r)•
Ph
ysic
al e
xam
inat
ion
: ab
do
min
al, p
erin
eal,
ext.
gen
ital
ia, b
ack/
spin
e, n
euro
log
ical
• A
sses
s b
ow
el f
un
ctio
n -
> if
co
nst
ipat
ed, t
reat
an
d r
eass
ess
• U
rin
alys
is ±
Uri
ne
cult
ure
->
if in
fect
ed, t
reat
an
d r
eass
ess
• A
sses
s p
ost
-vo
id r
esid
ual
uri
ne
by
abd
om
inal
exa
min
atio
n
(op
tio
nal
: b
y u
ltra
sou
nd
)
1600
B.S
PE
CIA
LIZ
ED
MA
NA
GE
ME
NT
I. C
HIL
DR
EN
The
gro
upof
chi
ldre
n w
ith “
com
plic
ated
”in
cont
inen
ce s
houl
d ha
vesp
ecia
list m
anag
emen
t fro
m th
e ou
tset
.
Thr
ee o
ther
gro
ups
of in
cont
inen
t chi
ldre
n ar
e co
nsid
ered
und
er s
peci
a-lis
t m
anag
emen
t:
• th
ose
that
hav
e fa
iled
basi
c m
anag
emen
t
• ch
ildre
n w
hose
inco
ntin
ence
is d
ue to
, or
asso
ciat
ed w
ith, u
rina
rytr
act a
nom
alie
s
• ch
ildre
n w
ithou
t uri
nary
trac
t ano
mal
ies,
but
with
rec
urre
nt in
fect
ion
and,
pro
ven
or s
uspe
cted
, voi
ding
dys
func
tion.
As
part
of
furt
her
asse
ssm
ent,
the
mea
sure
men
t of
urin
e fl
ow (
in c
hild
ren
old
enou
gh),
tog
ethe
r w
ith t
he u
ltras
ound
est
imat
e of
res
idua
l ur
ine
and
the
uppe
r ur
inar
y tr
acts
is h
ighl
y re
com
men
ded.
Con
side
ratio
n sh
ould
be
give
n to
the
need
for
fur
ther
ren
al im
agin
g(n
ucle
otid
e sc
anni
ng, I
VP)
and
/or
low
er u
rina
ry tr
act i
mag
ing
and
/or
cyst
o-ur
ethr
osco
py. H
owev
er, e
ndos
copy
is r
arel
y in
dica
ted.
Uro
dyna
mic
stu
dies
are
high
ly r
ecom
men
ded:
• if
inva
sive
trea
tmen
tis
unde
r co
nsid
erat
ion,
for
exa
mpl
e, s
tres
sin
cont
inen
ce s
urge
ry, i
f th
ere
is s
phin
cter
ic in
com
pete
nce,
or
blad
der
augm
enta
tion
if th
ere
is d
etru
sor
over
activ
ity.
• If
upp
er tr
act d
ilata
tion
thou
ght t
o be
due
to b
ladd
er d
ysfu
nctio
n.
Uro
dyna
mic
stu
dies
are
not
rec
omm
ende
d: i
f th
e ch
ild h
as n
orm
alup
per
trac
t im
agin
g an
d is
to b
e tr
eate
d by
non
inva
sive
mea
ns, f
orex
ampl
e, b
io-f
eedb
ack
(with
or
with
out e
lect
rom
yogr
aphy
) fo
r dy
sfun
c-tio
nal v
oidi
ng.
Spin
al I
mag
ing
(US/
Xra
y/M
RI)
may
be
need
ed if
a b
ony
abno
rmal
ityor
neu
rolo
gica
l con
ditio
nis
sus
pect
ed.
The
trea
tmen
tof
inco
ntin
ence
ass
ocia
ted
with
uri
nary
trac
t ano
mal
ies
is c
ompl
exan
d ca
nnot
be
deal
t with
in a
n al
gori
thm
(pl
ease
see
chi
l-dr
en’s
com
mitt
ee r
epor
t).
Chi
ldre
n w
ith b
owel
dys
func
tion
shou
ld b
e tr
eate
d ap
prop
riat
ely.
The
trea
tmen
t of
stre
ssan
d ur
ge in
cont
inen
cew
ithou
t voi
ding
dys
func
-tio
n is
non
-inv
asiv
ean
d it
is r
are
for
inva
sive
ther
apy
to b
e co
nsid
ered
:su
ch c
hild
ren
shou
ld o
nly
be d
ealt
with
by
clin
icia
ns w
ith e
xper
tise
inin
cont
inen
ce a
nd m
anag
ing
child
ren.
Whe
n in
cont
inen
ce is
ass
ocia
ted
with
voi
ding
dys
func
tion,
whi
chre
sults
in s
igni
fica
nt p
ost-
void
res
idua
ls (
>30
% o
f to
tal b
ladd
er c
apac
i-ty
), th
en in
itial
trea
tmen
t sho
uld
be d
irec
ted
at a
chie
ving
bet
ter
blad
der
empt
ying
by
biof
eedb
ack
and
inte
rmitt
ent c
athe
teri
satio
n(G
rade
B/C
):su
ch th
erap
y sh
ould
be
taug
ht b
y th
ose
with
spe
cial
exp
ertis
e in
the
care
of c
hild
ren.
2.T
reat
men
t
1.A
sses
smen
t
1601
EX
PE
RT
HIS
TOR
Y&
PH
YS
ICA
LE
XA
MIN
AT
ION
CL
INIC
AL
AS
SE
SS
ME
NT
Sp
ecia
lized
Man
agem
ent
of
Uri
nar
y In
con
tin
ence
in C
hild
ren
DIA
GN
OS
IS
Inco
nti
nen
ce w
ith
ou
tsu
spic
ion
of
uri
nar
ytr
act
ano
mal
y
Inco
nti
nen
ce w
ith
su
spic
ion
of
uri
nar
y tr
act
ano
mal
y
• C
on
sid
er n
eed
fo
r u
rod
ynam
ics
• R
enal
/ b
lad
der
ult
raso
un
d
• A
sses
s P
ost
vo
id r
esid
ual
• F
low
rat
es ±
elec
tro
myo
gra
ph
y•
Beh
avio
ral E
valu
atio
n
if in
clu
sive
/ab
no
rmal
---
>}
Co
nsi
der
:•
Mic
tura
tin
g c
ysto
gra
m
• R
enal
sci
nti
gra
m•
Uro
dyn
amic
s•
Cys
tou
reth
rosc
op
y•
Sp
inal
imag
ing
STO
RA
GE
/VO
IDIN
G D
YS
FU
NC
TIO
NW
ITH
OU
T N
EU
RO
AN
ATO
MIC
B
AS
IS
NE
UR
OG
EN
IC
BL
AD
DE
RA
NA
TOM
IC C
AU
SE
S O
F
UR
INA
RY
INC
ON
TIN
EN
CE
• B
lad
der
tra
inin
g (
incl
NE
ala
rm)
• B
ow
el m
anag
emen
t.•
Pel
vic
flo
or
rela
xati
on
+/-
bio
feed
bac
k.•
Ph
arm
aco
th
erap
y (s
ing
le/ c
om
bin
atio
n)
: -
anti
mu
scar
incs
-
ααb
lock
ers
- D
esm
op
ress
in•
Neu
rom
od
ula
tio
n (
surf
ace
or
per
cuta
neo
us)
• C
lean
inte
rmit
ten
t ca
th.
• P
har
mac
oth
erap
y.•
Bo
wel
Man
agem
ent.
• In
trav
esic
al e
lect
rica
l st
imu
lati
on
• A
nti
bio
tics
if in
fect
ion
• C
orr
ect
ano
mal
y (s
ee:
surg
ical
tre
atm
ent
in
child
ren
)T
RE
AT
ME
NT
1602
A. I
NIT
IAL
MA
NA
GE
ME
NT
II.
ME
N
Men
with
“co
mpl
icat
ed”
inco
ntin
ence
ass
ocia
ted
with
hae
mat
uria
, pai
n,re
curr
ent
infe
ctio
n, o
r w
ho a
re k
now
n to
hav
e, o
r w
ho a
re t
houg
ht t
oha
ve p
oor
blad
der
empt
ying
for
exa
mpl
e du
e to
bla
dder
out
let
obst
ruc-
tion,
are
rec
omm
ende
d fo
r sp
ecia
lized
man
agem
ent.
Poo
r bl
adde
r em
ptyi
ng m
aybe
sus
pect
ed f
rom
sym
ptom
s, p
hysi
cal
exa-
min
atio
n or
if
imag
ing
has
been
per
form
ed b
y X
-ray
or
ultr
asou
nd a
fter
void
ing.
Initi
al a
sses
smen
taim
s to
iden
tify
3 gr
oups
of
men
suita
ble
for
initi
alm
anag
emen
t.
a) T
hose
with
pos
t-m
ictu
ritio
n dr
ibbl
e al
one,
b) T
hose
with
sym
ptom
s of
urg
ency
with
or
with
out u
rge
inco
ntin
ence
,to
geth
er w
ith f
requ
ency
and
noc
turi
a (o
vera
ctiv
e bl
adde
r) a
nd
c) T
hose
with
pos
t-pr
osta
tect
omy
inco
ntin
ence
.
a)P
ost-
mic
turi
tion
drib
ble
requ
ires
no
asse
ssm
ent
and
can
usua
lly b
eef
fect
ivel
y tr
eate
d by
pel
vic
floo
r m
uscl
e tr
aini
ng a
nd m
anua
l co
mpr
es-
sion
of
the
bulb
ous
uret
hra
dire
ctly
aft
er m
ictu
ritio
n. (
Gra
de A
)
b)U
rge
inco
ntin
ence
and
othe
r ov
erac
tive
blad
der
sym
ptom
s sh
ould
be
trea
ted
by n
on-i
nvas
ive
mea
ns in
itial
ly: (
Gra
de C
)
• L
ifes
tyle
inte
rven
tions
(gr
ade
C)
• pe
lvic
flo
or m
uscl
e tr
aini
ng (
Gra
deC
)
• bl
adde
r tr
aini
ng (
Gra
deC
)
• an
timus
cari
nic
drug
s if
det
ruso
r ov
erac
tivity
is
susp
ecte
d as
the
cau
sefo
r ov
erac
tive
blad
der
sym
ptom
s. (
Gra
de C
)
• al
pha
adre
nerg
ic a
ntag
onis
ts (
a-bl
ocke
rs),
can
be
cons
ider
ed i
f it
isth
ough
t tha
t the
re m
ay a
lso
be b
ladd
er o
utle
t obs
truc
tion.
(G
rade
C)
c) P
ost p
rost
atec
tom
y st
ress
inco
ntin
ence
shou
ld a
lso
be tr
eate
d in
itial
lyby
pel
vic
floo
r m
uscl
e tr
aini
ng (
Gra
de A
)au
gmen
ted
by l
ifes
tyle
int
er-
vent
ions
(G
rade
B)
or b
ladd
er tr
aini
ng. (
Gra
deC
)
➦ S
houl
d in
itial
tre
atm
ent
beun
succ
essf
ul a
fter
a r
easo
nabl
e pe
riod
of
time
(8-1
2 w
eeks
), r
efer
ral
for
a sp
ecia
list's
adv
ice
is h
ighl
y re
com
-m
ende
d.
Not
e :
It m
ay b
e ne
cess
ary
for
patie
nts
to u
se (
in)c
ontin
ence
pro
duct
sw
hils
t wai
ting
for
defi
nitiv
e tr
eatm
ent.
For
frai
l ol
der
men
with
neu
roge
nic
dysf
unct
ion
plea
se s
ee r
elev
ant
algo
ryth
m a
nd c
hapt
er
3. O
utco
me
Ass
essm
ent
2. T
reat
men
t
1. I
niti
al A
sses
sem
ent
shou
ld id
enti
fy :
1603
HIS
TOR
Y/S
YM
PTO
MA
SS
ES
SM
EN
T
CL
INIC
AL
AS
SE
SS
ME
NT
TR
EA
TM
EN
T
Init
ial M
anag
emen
t o
f U
rin
ary
Inco
nti
nen
ce in
Men
PR
ES
UM
ED
DIA
GN
OS
IS
• G
ener
al a
sses
smen
t (
see
rele
van
t ch
apte
r)•
Uri
nar
y S
ymp
tom
Ass
essm
ent
and
sym
pto
m s
core
(i
ncl
ud
ing
fre
qu
ency
-vo
lum
e ch
art
and
qu
esti
on
nai
re)
• A
sses
s q
ual
ity
of
life
and
des
ire
for
trea
tmen
t •
Phy
sica
l exa
min
atio
n: a
bdom
inal
, rec
tal,
sacr
al n
euro
logi
cal
• U
rin
alys
is ±
uri
ne
cult
ure
->
if in
fect
ed, t
reat
an
dre
asse
ss•
Ass
essm
ent
of
pel
vic
flo
or
mu
scle
fu
nct
ion
• A
sses
s p
ost
-vo
id r
esid
ual
uri
ne
Po
st-m
ictu
riti
on
dri
bb
leP
ost-
pros
tate
ctom
yin
cont
inen
ce
Inco
nti
nen
cew
ith
urg
ency
/fr
equ
ency
“Co
mp
licat
ed”
inco
nti
nen
ce
• R
ecu
rren
t in
con
tin
ence
•
Inco
nti
nen
ce a
sso
ciat
edw
ith
:-
Pai
n-
Hem
atu
ria
- R
ecu
rren
t in
fect
ion
- Vo
idin
g s
ymp
tom
s-
Pro
stat
e ir
rad
iati
on
- R
adic
al p
elvi
c su
rger
y
MIX
ED
IN
CO
NT
INE
NC
E
• U
reth
ral
milk
ing
• P
elvi
c fl
oo
r m
usc
le
trai
nin
g•
(In
) co
nti
nen
ce p
rod
uct
s •
Ext
ern
al a
pp
lian
ces
SP
EC
IAL
IZE
D M
AN
AG
EM
EN
T
An
y o
ther
ab
no
rmal
ity
det
ecte
d e
.g. s
ign
ific
ant
po
st v
oid
res
idu
al
Fai
lure
Fai
lure
Fai
lure
ST
RE
SS
IN
CO
NT
INE
NC
Ep
resu
med
du
e to
sp
hin
cter
ic in
com
pet
ence
UR
GE
INC
ON
TIN
EN
CE
pre
sum
ed d
ue
to
det
ruso
r o
vera
ctiv
ity
• A
nti
mu
scar
inic
s
Lif
esty
le in
terv
enti
on
sP
elvi
c fl
oo
r m
usc
le t
rain
ing
Bla
dd
er
trai
nin
g
1604
B.S
PE
CIA
LIZ
ED
MA
NA
GE
ME
NT
II.
ME
N
The
spe
cial
ist m
ay fi
rst r
eins
titut
e in
itial
man
agem
enti
f it i
s fe
lt th
at p
re-
viou
s th
erap
y ha
d be
enin
adeq
uate
,
➦ P
atie
nts
refe
rred
dir
ectly
to
spec
ializ
ed m
anag
emen
tar
e lik
ely
tore
quir
e ad
ditio
nal t
estin
g, c
ytol
ogy,
cys
tour
etho
scop
y an
d ur
inar
y tr
act
imag
ing.
If t
hese
tes
ts p
rove
nor
mal
the
n th
ose
indi
vidu
als
can
be t
reat
ed f
orin
cont
inen
ce b
y th
e in
itial
or s
peci
aliz
ed m
anag
emen
t opt
ions
as
appr
o-pr
iate
.
If s
ympt
oms
sugg
estiv
eof
det
ruso
r ov
erac
tivity
, or
of s
phin
cter
inco
m-
pete
nce
pers
ist,
then
uro
dyna
mic
stu
dies
are
reco
mm
ende
d in
ord
er to
arri
ve a
t a p
reci
se d
iagn
osis
.
and
if th
e pa
tient
’s in
cont
inen
ce m
arke
dly
disr
upts
his
qual
ity o
f lif
e th
enin
vasi
ve th
erap
ies
shou
ld b
e co
nsid
ered
.
➦ F
or s
phin
cter
inc
ompe
tenc
eth
e re
com
men
ded
optio
n is
the
art
ific
ial
urin
ary
sphi
ncte
r (G
rade
B).
➦ F
or t
he i
diop
athi
c de
trus
or o
vera
ctiv
ity,
(with
int
ract
ible
ove
ract
ive
blad
der
sym
ptom
s) t
he r
ecom
men
ded
ther
apie
s ar
e bl
adde
r au
gmen
ta-
tion
(Gra
de C
), a
utoa
ugm
enta
tion
(Gra
de D
), n
euro
mod
ulat
ion
and
uri-
nary
div
ersi
on (
Gra
de B
).
➦ W
hen
inco
ntin
ence
has
been
sho
wn
to b
e as
soci
ated
with
poo
r bl
ad-
der
empt
ying
and
detr
usor
und
erac
tivity
, it i
s re
com
men
ded
that
eff
ec-
tive
mea
ns a
re u
sed
to e
nsur
e bl
adde
r em
ptyi
ng, f
or e
xam
ple,
inte
rmit-
tent
cat
hete
risa
tion
(Gra
de B
/C).
➦If
inc
ontin
ence
is
asso
ciat
ed w
ith b
ladd
er o
utle
t ob
stru
ctio
n, t
hen
cons
ider
atio
n sh
ould
be
give
n to
sur
gica
l tr
eatm
ent
to r
elie
ve o
bstr
uc-
tion
(Gra
de B
/C).
α-
bloc
kers
or
5αre
duct
ase
inhi
bito
rs w
ould
be
anop
tiona
l tre
atm
ent (
Gra
de C
/D).
Not
e:A
t the
tim
e of
wri
ting
➦ B
otul
inum
toxi
n w
as s
how
ing
prom
ise
in th
e tr
eatm
ent o
f sy
mpt
oma-
tic d
etru
sor
over
activ
ity u
nres
pons
ive
to o
ther
ther
apie
s.
➦ S
ome
evid
ence
was
em
ergi
ng a
s to
the
saf
ety
of a
ntim
usca
rini
cs f
orov
erac
tive
blad
der
sym
ptom
s in
men
,chi
efly
in
com
bina
tion
with
an
αα -bl
ocke
r.W
hen
basi
c m
anag
emen
t ha
s fa
iled
2.T
reat
men
t
1. A
sses
sem
ent
1605
HIS
TOR
Y/S
YM
PTO
MA
SS
ES
SM
EN
T
CL
INIC
AL
AS
SE
SS
ME
NTS
pec
ializ
ed M
anag
emen
t o
f U
rin
ary
Inco
nti
nen
ce in
Men
DIA
GN
OS
IS
• C
on
sid
er u
rod
ynam
ics
and
imag
ing
of
the
uri
nar
y tr
act
• U
reth
rocy
sto
sco
py
(if
ind
icat
ed)
Po
st-p
rost
atec
tom
yin
con
tin
ence
Inco
nti
nen
ce w
ith
urg
ency
/ fr
equ
ency
Co
nsi
der
: •
Ure
thro
cyst
osc
op
y•
Fu
rth
er im
agin
g•
Uro
dyn
amic
s
“Com
plic
ated
” In
cont
inen
ce :
• R
ecur
rent
inco
ntin
ence
•
Inco
ntin
ence
ass
ocia
-te
d w
ith:
- P
ain
- H
emat
uria
- R
ecur
rent
infe
ctio
n-
Voi
ding
sym
ptom
s-
Pro
stat
e irr
adia
tion
- R
adic
al p
elvi
c su
rger
y
wit
h c
oex
isti
ng
bla
dd
er o
utl
eto
bst
ruct
ion
wit
h c
oex
isti
ng
un
der
acti
ved
etru
sor
(du
rin
g v
oid
ing
)
Lo
wer
uri
nar
ytr
act
ano
mal
y/p
ath
olo
gy
ST
RE
SS
IN
CO
NT
INE
NC
Ed
ue
to s
ph
inct
eric
inco
mp
eten
ce
MIX
ED
INC
ON
TIN
EN
CE
UR
GE
INC
ON
TIN
EN
CE
du
e to
det
ruso
r o
vera
ctiv
ity
(du
rin
g f
illin
g)
• A
rtif
icia
l uri
nar
y sp
hin
cter
• M
ale
slin
g•
Bu
lkin
g a
gen
ts
• N
euro
mo
du
lati
on
• A
uto
aug
men
tati
on
• B
lad
der
au
gm
en-
tati
on
•
Uri
nar
y d
iver
sio
n(S
ee n
ote
s)
• αα -
blo
cker
s, 5
αα RI
• C
orr
ect
anat
om
ic
bla
dd
er o
utl
et
ob
stru
ctio
n•
An
tim
usc
arin
ics
(See
no
te)
• C
orre
ct a
nom
aly
• Tr
eat
path
olog
y
If in
itia
l th
erap
y fa
ils:
If in
itia
l th
erap
y fa
ils:
TR
EA
TM
EN
T•
Inte
rmit
ten
t
cath
eter
isat
ion
•A
ntim
usca
rini
cs
1606
• “C
ompl
icat
ed”
inco
ntin
ence
gro
up.
In c
erta
in p
arts
of
the
deve
lopi
ng w
orld
, exc
eptio
nally
sev
ere
inco
ntin
en-
ce r
esul
ts f
rom
chi
ldbi
rth
inju
ry a
nd u
rina
ry f
istu
la.
The
se d
evas
tatin
gin
juri
es a
ffec
t m
illio
ns o
f w
omen
in
sub-
Saha
ran
Afr
ica.
T
hese
wom
enfo
rm a
spe
cial
gro
up o
f w
omen
with
spe
cial
nee
dsw
ho m
ust b
e id
entif
ied
at in
itial
ass
essm
ent,
and
requ
ire
spec
ialis
t man
agem
ent.
Oth
ers
incl
ude
thos
e w
ho a
lso
have
pai
nor
hae
mat
uria
, rec
urre
nt in
fec-
tions
, su
spec
ted
or p
rove
n vo
idin
g pr
oble
ms,
sig
nifi
cant
pel
vic
orga
npr
olap
seor
who
hav
e pe
rsis
tent
inc
ontin
ence
or
recu
rren
t in
cont
inen
ceaf
ter
prev
ious
sur
gery
, suc
h as
pel
vic
irra
diat
ion,
radi
calp
elvi
c su
rger
yor
pre
viou
s su
rger
y fo
r in
cont
inen
ce.
• T
hree
oth
er m
ain
grou
psof
pat
ient
s sh
ould
be
iden
tifie
d by
ini
tial
asse
ssm
ent.
a)W
omen
with
str
ess
inco
ntin
ence
on p
hysi
cal a
ctiv
ity
b)W
omen
with
urg
ency
,fr
eque
ncy
and
urge
inc
ontin
ence
(ove
ract
ive
blad
der-
OA
B)
c)T
hose
wom
en w
ith m
ixed
urge
and
str
ess
inco
ntin
ence
In w
omen
, abd
omin
al, p
elvi
c an
d pe
rine
al e
xam
inat
ions
shou
ld b
e a
rou-
tine
part
of
phys
ical
exa
min
atio
n.
Wom
en s
houl
d be
ask
ed t
o pe
rfor
m a
“str
ess
test
”(c
ough
and
str
ain
to d
etec
t lea
kage
like
ly to
be
due
to s
phin
c-te
r in
com
pete
nce)
. A
ny p
elvi
c or
gan
prol
apse
or
uro-
geni
tal
atro
phy,
shou
ld b
e as
sess
ed. V
agin
al o
r re
ctal
exa
min
atio
nal
low
s th
e as
sess
men
tof
vol
unta
ry p
elvi
c fl
oor m
uscl
e co
ntra
ctio
n, a
n im
port
ant s
tep
prio
r to
the
teac
hing
of
pelv
ic f
loor
mus
cle
trai
ning
.
➦ I
nitia
l tre
atm
ent s
houl
d in
clud
e lif
esty
le in
terv
entio
ns, s
uper
vise
d pe
l-vi
c fl
oor
mus
cle
trai
ning
, sup
ervi
sed
blad
der
trai
ning
, for
wom
en w
ithst
ress
uri
nary
inco
ntin
ence
, urg
e ur
inar
y in
cont
inen
ce o
r mix
ed U
rina
ryin
cont
inen
ce. (
Gra
de A
).➦
Lif
esty
le i
nter
vent
ions
inc
lude
wei
ght
redu
ctio
n, s
mok
ing
cess
atio
n,an
d di
etar
y/fl
uid
mod
ific
atio
n (i
nclu
ding
caf
fein
e). (
Gra
de A
).➦
If
oest
roge
n de
fici
ency
and
/or
UT
I is
fou
nd, t
he p
atie
nt s
houl
d be
trea
-te
d at
ini
tial
asse
ssm
ent
and
then
rea
sses
sed
afte
r a
suita
ble
inte
r-va
l.(G
rade
B).
➦ C
onse
rvat
ive
trea
tmen
t m
ay b
e au
gmen
ted
with
app
ropi
ate
drug
the
-ra
py.A
ntim
usca
rini
cs f
or O
AB
, du
al s
erot
onin
and
nor
adre
nalin
reup
take
inhi
bito
rs *
for
str
ess
urin
ary
inco
ntin
ence
(G
rade
A).
➦
Clin
icia
ns a
re li
kely
to w
ish
totr
eat t
he p
redo
min
ant s
ympt
om f
irst
inw
omen
with
sym
ptom
s of
mix
ed in
cont
inen
ce.(
Gra
de C
).So
me
wom
en w
ith c
oexi
stin
g si
gnif
ican
t pe
lvic
org
an p
rola
pse
can
betr
eate
d by
rin
g pe
ssar
y.In
itial
tre
atm
ent
shou
ld b
e m
aint
aine
d fo
r 8-
12 w
eeks
befo
re r
eass
ess-
men
t and
pos
sibl
e sp
ecia
list r
efer
ral f
or f
urth
er m
anag
emen
t.N
ote:
It m
ay b
e ne
cess
ary
for
patie
nts
to u
se (
in)c
ontin
ence
pro
duct
sw
hils
t wai
ting
for
defi
nitiv
e tr
eatm
ent.
Som
e w
omen
with
sig
nifi
cant
pel
vic
orga
n pr
olap
se c
an b
e tr
eate
d by
vagi
nal
devi
ces
that
tre
at b
oth
inco
ntin
ence
and
pro
laps
e (i
ncon
tinen
ceri
ngs
and
dish
es).
* Su
bjec
t to
loc
al r
egul
ator
y ap
prov
al.
2.T
reat
men
t1.
Init
ial a
sses
smen
t sh
ould
iden
tify
:
A. I
NIT
IAL
MA
NA
GE
ME
NT
III.
WO
ME
N
Inco
nti
nen
ceo
n p
hys
ical
acti
vity
Inco
nti
nen
cew
ith
mix
edsy
mp
tom
s
Inco
nti
nen
cew
ith
urg
ency
/ fr
equ
ency
• O
ther
ph
ysic
al t
her
apie
s•
Dev
ices
1607
HIS
TOR
Y/S
YM
PTO
MA
SS
ES
SM
EN
T
CL
INIC
AL
AS
SE
SS
ME
NTIn
itia
l Man
agem
ent
of
Uri
nar
y In
con
tin
ence
in W
om
en
PR
ES
UM
ED
DIA
GN
OS
IS
• G
ener
al a
sses
smen
t (s
ee r
elev
ant
chap
ter)
• U
rin
ary
Sym
pto
m A
sses
smen
t (i
ncl
ud
ing
fre
qu
ency
-vo
lum
e ch
art
and
qu
esti
on
nai
re)
• A
sses
s q
ual
ity
of
life
and
des
ire
for
trea
tmen
t •
Ph
ysic
al e
xam
inat
ion
: ab
do
min
al,
and
pel
vic
• C
ou
gh
tes
t to
dem
on
stra
te s
tres
s in
con
tin
ence
if a
pp
rop
riat
e•
Uri
nal
ysis
±u
rin
e cu
ltu
re -
> if
infe
cted
, tre
at a
nd
rea
sses
s if
ap
pro
pri
ate
• A
sses
s vo
lun
tary
pel
vic
flo
or
mu
scle
co
ntr
acti
on
• A
sses
s p
ost
-vo
id r
esid
ual
uri
ne
MIX
ED
INC
ON
TIN
EN
CE
Co
mp
licat
ed”
inco
nti
nen
ce
• R
ecu
rren
t in
con
tin
ence
•
Inco
nti
nen
ce a
sso
ciat
ed w
ith
:-
Pai
n-
Hem
atu
ria
- R
ecu
rren
t in
fect
ion
- Vo
idin
g s
ymp
tom
s-
Pel
vic
irra
dia
tio
n-
Rad
ical
pel
vic
surg
ery
- S
usp
ecte
d f
istu
la
SP
EC
IAL
IZE
D M
AN
AG
EM
EN
T
• If
oth
er a
bn
orm
alit
y fo
un
d
e.g
. •
Sig
nif
ican
t p
ost
vo
id r
esid
ual
• S
ign
ific
ant
pel
vic
org
an p
rola
pse
(s
ee n
ote
s)
• P
elvi
c m
ass
Fai
lure
Fai
lure
TR
EA
TM
EN
T
ST
RE
SS
INC
ON
TIN
EN
CE
pre
sum
ed d
ue
to
sph
inct
eric
inco
mp
eten
ce
UR
GE
INC
ON
TIN
EN
CE
pre
sum
ed d
ue
to d
etru
sor
ove
ract
ivit
y
• A
sses
s o
estr
og
en s
tatu
s an
d t
reat
as
app
rop
riat
e.•
Lif
e st
yle
inte
rven
tio
ns.
• P
elvi
c fl
oo
r m
usc
le t
rain
ing
, bla
dd
er r
etra
inin
g
An
tim
usc
arin
ics
Trea
t P
red
om
inan
tP
rob
lem
Fir
st
Du
al s
ero
ton
in a
nd
no
rad
ra-
nal
in r
eup
take
inh
ibit
ors
**
Sub
ject
to
loca
l re
gula
tory
app
rova
l.
1608
B.S
PE
CIA
LIZ
ED
MA
NA
GE
ME
NT
III.
WO
ME
N
Wom
en w
ho h
ave
“com
plic
ated
” in
cont
inen
ce(s
ee i
nitia
l al
gori
thm
)m
ay n
eed
to h
ave
addi
tiona
l tes
tssu
ch a
s cy
tolo
gy, c
ysto
uret
hros
copy
or
urin
ary
trac
t im
agin
g. I
f th
ese
test
s ar
e no
rmal
then
the
y sh
ould
be
trea
-te
d fo
r in
cont
inen
ce b
y th
e in
itial
or
spec
ializ
ed m
anag
emen
t op
tions
as
appr
opri
ate.
➦
Tho
se w
omen
who
hav
e fa
iled
initi
al m
anag
emen
tand
who
se q
uali-
ty o
f lif
e is
im
pair
edar
e lik
ely
to r
eque
st f
urth
er t
reat
men
t. I
f in
itial
man
agem
ent
has
been
giv
en a
n ad
equa
te t
rial
the
n in
terv
entio
nal t
he-
rapy
may
be
desi
rabl
e.
Prio
r to
int
erve
ntio
n ur
odyn
amic
tes
ting
ishi
ghly
rec
omm
ende
d, b
ecau
se it
is u
sed
to d
iagn
ose
the
type
of
inco
n-tin
ence
and
the
refo
re i
nfor
m t
he m
anag
emen
t pl
an. W
ithin
the
uro
dy-
nam
ic i
nves
tigat
ion
uret
hral
fun
ctio
n te
stin
gby
ure
thra
l pr
essu
repr
ofile
or
leak
poi
nt p
ress
ure
is o
ptio
nal.
➦
Syst
emat
ic a
sses
smen
t fo
r pe
lvic
org
an p
rola
pse
is h
ighl
y re
com
-m
ende
d an
d it
is s
ugge
sted
tha
t th
e IC
S m
etho
d sh
ould
be
used
in
rese
arch
st
udie
s.
Wom
en
with
co
-exi
stin
g pe
lvic
or
gan
prol
apse
shou
ld h
ave
thei
r pr
olap
se tr
eate
d as
app
ropr
iate
➦
Wom
en in
dev
elop
ing
coun
trie
s w
ith f
istu
la d
ue to
chi
ldbi
rth
inju
ries
do n
ot r
equi
re u
rody
nam
ic a
sses
smen
t and
are
bes
t tre
ated
in s
peci
alis
tfi
stul
a un
its.
➦ I
f ur
odyn
amic
str
ess
inco
ntin
ence
is
conf
irm
edth
en t
he t
reat
men
top
tions
tha
t ar
e re
com
men
ded
for
patie
nts
with
som
e de
gree
of
blad
-de
r-ne
ck a
nd u
reth
ral
mob
ility
incl
ude
the
full
rang
e of
non
-sur
gica
ltr
eatm
ents
, as
wel
l as
ret
ropu
bic
susp
ensi
on p
roce
dure
s, a
nd b
ladd
erne
ck/s
ub-u
reth
ral s
ling
oper
atio
ns. T
he c
orre
ctio
n of
sym
ptom
atic
pel
-vi
c or
gan
prol
apse
may
be
desi
rabl
e at
the
sam
e tim
e.
For
patie
nts
with
intr
insi
c sp
hinc
ter
defi
cien
cy a
nd li
mite
d bl
adde
r ne
ckm
obili
ty, s
ling
proc
edur
es, i
njec
tabl
e bu
lkin
g ag
ents
and
the
artif
icia
lur
inar
y sp
hinc
ter
can
be c
onsi
dere
d.
➦ U
rge
inco
ntin
ence
sec
onda
ry to
idio
path
ic d
etru
sor
over
activ
ity(o
ve-
ract
ive
blad
der)
may
be
trea
ted
by n
euro
mod
ulat
ion
or b
ladd
er a
ug-
men
tatio
n.
Det
ruso
r m
yect
omy
is a
n op
tiona
l pr
oced
ure
(aut
o au
g-m
enta
tion)
.
➦ T
hose
pat
ient
s w
ith v
oidi
ng d
ysfu
nctio
nle
adin
g to
sig
nifi
cant
pos
t-vo
id r
esid
ual u
rine
(for
exa
mpl
e, >
30%
of
tota
l bla
dder
cap
acity
) m
ayha
ve b
ladd
er o
utle
t ob
stru
ctio
n or
det
ruso
r un
dera
ctiv
ity. P
rola
pse
isa
com
mon
cau
se o
f vo
idin
g dy
sfun
ctio
n.
Not
e:A
t the
tim
e of
wri
ting
:•
Bot
ulin
um to
xin
was
sho
win
g pr
omis
e in
the
trea
tmen
t of
sym
ptom
atic
detr
usor
ove
ract
ivity
unr
espo
nsiv
e to
oth
er th
erap
ies.
2.T
reat
men
t1.
Ass
esse
men
t
1609
HIS
TOR
Y/S
YM
PTO
MA
SS
ES
SM
EN
T
CL
INIC
AL
AS
SE
SS
ME
NT
Sp
ecia
lized
Man
agem
ent
of
Uri
nar
y In
con
tin
ence
in W
om
en
DIA
GN
OS
IS
• A
sses
s fo
r p
elvi
c o
rgan
mo
bili
ty /
pro
lap
se•
Co
nsi
der
imag
ing
of
the
UT
/ pel
vic
flo
or
• U
rod
ynam
ics
Bla
dd
er o
utl
eto
bst
ruct
ion
Un
der
acti
ved
etru
sor
Lo
wer
uri
nar
y tr
act
ano
mal
y/p
ath
olo
gy
UR
OD
YN
AM
ICS
TR
ES
S
INC
ON
TIN
EN
CE
(US
I)
MIX
ED
IN
CO
NT
INE
NC
E(U
SI/D
OI)
DE
TR
US
OR
OV
ER
AC
TIV
ITY
INC
ON
TIN
EN
CE
(DO
I)
INC
ON
TIN
EN
CE
asso
ciat
ed w
ith
po
or
bla
dd
erem
pty
ing
If in
itia
l th
erap
y fa
ils:
If in
itia
l th
erap
y fa
ils:
Inco
nti
nen
ceo
n p
hys
ical
acti
vity
Inco
nti
nen
cew
ith
mix
edsy
mp
tom
s
Inco
nti
nen
cew
ith
urg
ency
/ fr
equ
ency
“Co
mp
licat
ed”
inco
nti
nen
ce:
• R
ecu
rren
t in
con
tin
ence
•
Inco
nti
nen
ce a
sso
ciat
ed w
ith
:-
Pai
n-
Hem
atu
ria
- R
ecu
rren
t in
fect
ion
- Vo
idin
g s
ymp
tom
s-
Pel
vic
irra
dia
tio
n-
Rad
ical
pel
vic
surg
ery
- S
usp
ecte
d f
istu
la
• S
tres
s in
con
tin
ence
su
rger
y-
inje
ctio
ns
- lo
w t
ensi
on
slin
gs
- co
lpo
susp
ensi
on
- A
US
• N
euro
mo
du
lati
on
• B
lad
der
au
gm
enta
tio
n•
Uri
nar
y d
iver
sio
n
• C
orr
ect
anat
om
ic
bla
dd
er o
utl
et
ob
stru
ctio
n (
e.g
. ia
tro
gen
ic)
• In
term
itte
nt
cath
eter
izat
ion
• C
orr
ect
ano
mal
y•
Trea
t p
ath
olo
gy
Co
nsi
der
: •
Ure
thro
cyst
osc
op
y•
Fu
rth
er im
agin
g•
Uro
dyn
amic
s
TR
EA
TM
EN
T
• In
term
itte
nt
cath
eter
isa-
tio
n
1610
Old
er p
erso
ns in
gen
eral
sho
uld
rece
ive
a si
mila
r ra
nge
of tr
eatm
ent o
ptio
nsas
you
n-ge
r pe
rson
s. H
owev
er,
frai
l ol
der
pers
ons
pres
ent
diff
eren
t pr
oble
ms
and
chal
leng
esco
mpa
red
with
oth
er f
itter
old
er p
atie
nt p
opul
atio
ns. I
mpl
icit
in th
e te
rm “
frai
l” is
that
such
indi
vidu
als
may
nei
ther
wis
h no
rbe
fit e
noug
hto
be
cons
ider
ed fo
r the
full
rang
eof
ther
apie
s lik
ely
to b
e of
fere
d to
hea
lthie
r or
you
nger
per
sons
. T
heex
tent
of
inve
s-tig
atio
nan
dm
anag
emen
tin
frai
l old
er p
eopl
e sh
ould
take
into
acc
ount
the
degr
ee o
fbo
ther
to t
he p
atie
nt a
nd/o
r ca
rer,
thei
r m
otiv
atio
n an
d le
vel
of c
oope
ratio
n /
com
-pl
ianc
e as
wel
l as
the
over
all p
rogn
osis
and
life
expe
ctan
cy. A
t the
sam
e tim
e, m
ana-
gem
ent e
ffec
tive
to m
eet t
heir
goa
ls is
pos
sibl
e fo
r m
any
frai
l per
sons
[C
].
Thi
s al
gori
thm
app
lies
to th
e ev
alua
tion
of u
rina
ry in
cont
inen
ce in
frai
l per
sons
. M
any
of th
e sa
me
prin
cipl
es (
espe
cial
ly a
sses
smen
t and
trea
tmen
t of
pote
ntia
lly tr
eata
ble
orm
odif
iabl
e co
nditi
ons
and
med
icat
ions
tha
t m
ay c
ause
or
wor
sen
inco
ntin
ence
) al
soap
ply
to f
aeca
l inc
ontin
ence
(FI
) in
fra
il el
derl
y.
Tre
atab
leor
pote
ntia
lly r
ever
sibl
eco
nditi
ons
shou
ld b
e ad
dres
sed
firs
t, fo
llow
ed b
y a
phys
ical
ex
amin
atio
n ta
rget
ed
to
com
orbi
dity
and
func
tiona
l as
sess
men
t. T
he“D
IAP
PE
RS”
mne
mon
ic c
over
s so
me
of t
hese
con
ditio
ns.
Bow
el s
ympt
om h
isto
ry,
rect
al e
xam
inat
ion,
and
sto
ol d
iary
sho
uld
be c
onsi
dere
d. W
hile
mos
t ca
ses
of f
aeca
lin
cont
inen
ce a
re m
ultif
acto
ral,
the
prim
ary
goal
of
asse
ssm
ent
is t
o di
stin
guis
h ov
er-
flow
fae
cal i
ncon
tinen
ce, a
ssoc
iate
d w
ith c
onst
ipat
ion,
fro
m o
ther
cau
ses.
Whi
lepo
st-v
oid
resi
dual
uri
ne(P
VR
) m
easu
rem
ent i
s re
com
men
ded
beca
use
it co
uld
infl
uenc
e th
e ch
oice
of t
reat
men
t, it
is re
cogn
ized
that
it is
oft
en is
impr
actic
al to
obt
ain
a PV
R,
and
in m
any
case
s m
ay n
ot c
hang
e ov
eral
l m
anag
emen
t. I
mpa
ired
bla
dder
empt
ying
may
occ
ur i
n ol
der
men
and
wom
en f
or v
ario
us r
easo
ns i
nclu
ding
bla
dder
outle
t obs
truc
tion
and
detr
usor
und
erac
tivity
.Tre
atm
ent o
f co
exis
ting
cond
ition
s m
ayre
duce
PV
R,
e.g.
tre
atm
ent
of c
onst
ipat
ion
and
stop
ping
dru
gs w
ith a
ntim
usca
rini
cac
tion.
The
re i
s no
spe
cifi
c “c
ut o
ff”
in t
his
popu
latio
n, a
lthou
gh P
VR
ove
r 10
0 m
l(m
en)
and
200m
l (w
omen
) ar
e co
nsid
ered
ele
vate
d, a
nd a
low
PV
R d
oes
not
excl
ude
outle
t obs
truc
tion.
Mix
ed U
I(s
tres
s U
I an
d ur
ge U
I sy
mpt
oms)
is
com
mon
in
olde
r w
omen
. A
coug
hst
ress
tes
t is
app
ropr
iate
if
the
diag
nosi
s is
lik
ely
to i
nflu
ence
tre
atm
ent
choi
ce (
e.g.
,co
nsid
erat
ion
of s
urge
ry).
C
ombi
ned
urge
UI
and
high
PV
R (
with
out
obst
ruct
ion)
,kn
own
as d
etru
sor
hype
ract
ivity
with
im
pair
ed c
ontr
actil
ity (
DH
IC),
als
o is
com
mon
in th
e fr
ail e
lder
ly.
Initi
al tr
eatm
ents
houl
d be
indi
vidu
alis
ed a
nd in
flue
nced
by
the
mos
t lik
ely
clin
ical
dia
-gn
osis
. C
onse
rvat
ive
and
beha
viou
ral
ther
apy
for
UI
and
FI i
nclu
de l
ifes
tyle
cha
nges
[C],
bla
dder
trai
ning
in th
e m
ore
fit o
r al
ert p
atie
nt [
B],
ass
iste
d vo
idin
g fo
r m
ore
disa
-bl
ed p
atie
nts
[C] a
nd p
rom
pted
voi
ding
for f
raile
r and
mor
e co
gniti
vely
impa
ired
pat
ient
s[B
]. F
or s
elec
t, co
gniti
vely
inta
ct f
rail
pers
ons,
pel
vic
mus
cle
exer
cise
s m
ay b
e co
nsid
e-re
d, b
ut th
ey h
ave
not b
een
wel
l stu
died
in th
is p
opul
atio
n [C
]. A
caut
ious
tria
l of
anti-
mus
cari
nic
drug
sm
ay b
e co
nsid
ered
as
an a
djun
ct to
con
serv
ativ
e tr
eatm
ent o
fur
ge U
I[C
].
Sim
ilarl
y, αα
-blo
cker
sm
ay b
e ca
utio
usly
con
side
red
to a
ssis
t bl
adde
r em
ptyi
ng i
nfr
ail m
en w
ith a
n el
evat
ed P
VR
[C],
and
topi
cal o
estr
ogen
s co
nsid
ered
for
wom
en w
ithva
gina
l/ure
thra
l atr
ophy
[C
]. W
ith a
lldr
ug tr
eatm
ent,
it is
impo
rtan
t to
star
t with
a lo
wdo
se,
and
titra
te u
pwar
ds w
ith r
egul
ar r
evie
w o
f ef
fica
cy a
nd t
oler
abili
ty u
ntil
desi
red
effe
ct o
r un
wan
ted
side
eff
ects
occ
ur. F
orco
nstip
atio
n w
ith o
verf
low
FI,
bow
el c
lear
-ou
t with
com
bine
d su
ppos
itori
es/e
nem
as a
nd la
xativ
es is
reco
mm
ende
d [C
]. L
oper
amid
eca
n be
use
d fo
r FI
in th
e ab
senc
e of
con
stip
atio
n [B
].
If a
fter
ini
tial
asse
ssm
ent
a fr
ail
olde
r pe
rson
with
UI
is f
ound
to
have
oth
er s
igni
fi-
cant
fac
tors
(e.g
., pa
in,
haem
atur
ia,
rect
al b
leed
ing,
per
sist
ent
diar
rhoe
a),
then
ref
er-
ral f
orsp
ecia
list i
nves
tigat
ion
shou
ld b
e co
nsid
ered
.
Ref
erra
l to
spec
ialis
ts a
lso
may
be
appr
opri
ate
for
indi
vidu
als
who
hav
e no
t res
pond
edad
equa
tely
to
initi
al m
anag
emen
t an
d if
fur
ther
inv
estig
atio
n/tr
eatm
ent
is d
esir
able
whi
ch c
ould
impr
ove
cont
inen
ce a
nd q
ualit
y of
life
.
Age
per
se
is n
ot a
con
trai
ndic
atio
n to
inco
ntin
ence
sur
gery
[C
], b
ut b
efor
e su
rger
y:
•A
ll m
odif
iabl
e co
mor
bidi
ty s
houl
d be
add
ress
ed [
C];
•A
n ad
equa
te t
rial
of
cons
erva
tive
ther
apy
shou
ld b
e fo
llow
ed b
y re
asse
ssm
ent
ofth
e ne
ed f
or s
urge
ry [
C];
•U
rody
nam
ic t
estin
g sh
ould
be
done
bec
ause
clin
ical
dia
gnos
is m
ay b
e in
accu
rate
[A];
and
•Pr
eope
rativ
e as
sess
men
t pl
us c
aref
ul p
erio
pera
tive
care
is
esse
ntia
l to
min
imis
ege
riat
ric
com
plic
atio
ns s
uch
as d
elir
ium
, inf
ectio
n, d
ehyd
ratio
n an
d fa
lls [
A].
If th
e pa
tient
can
not a
chie
ve I
ndep
ende
nt C
ontin
ence
(dr
y, n
ot d
epen
dent
on
ongo
ing
trea
tmen
t) o
rD
epen
dent
Con
tinen
ce(d
ry w
ith a
ssis
tanc
e, b
ehav
iora
l tr
eatm
ent,
and/
or m
edic
atio
ns)
then
“C
onta
ined
Inc
ontin
ence
” (i
ncon
tinen
ce c
onta
ined
with
use
of a
ppro
pria
te a
ids
and/
or a
pplia
nces
) sh
ould
be
the
trea
tmen
t goa
l. Im
port
antly
, opt
i-m
al c
are
can
usua
lly b
e ac
hiev
ed b
y a
com
bina
tion
of th
e ab
ove
appr
oach
es [
C].
IV. O
NG
OIN
G M
AN
AG
EM
EN
TA
ND
RE
ASS
ESS
ME
NT
III.
SP
EC
IAL
IZE
D M
AN
AG
EM
EN
T
II. I
NIT
IAL
MA
NA
GE
ME
NT
Clin
ical
dia
gnos
is
Clin
ical
ass
essm
ent
I. H
IST
OR
YA
ND
SY
MP
TO
M A
SSE
SSM
EN
T
IV. U
RIN
AR
YIN
CO
NT
INE
NC
E I
N F
RA
ILO
LD
ER
ME
N A
ND
WO
ME
N
1611
D I A P P E R S
HIS
TOR
Y/S
YM
PTO
M/ A
SS
ES
SM
EN
T
CL
INIC
AL
AS
SE
SS
ME
NT
ON
GO
ING
MA
NA
GE
ME
NT
an
d
RE
AS
SE
SS
ME
NT
INIT
IAL
EM
AN
AG
EM
EN
T
MA
NA
GE
ME
NT
OF
UR
INA
RY
INC
ON
TIN
EN
CE
IN F
RA
ILO
LD
ER
PE
RS
ON
S
CL
INIC
AL
DIA
GN
OS
IS
• D
elir
ium
• In
fect
ion
• A
tro
ph
ic v
agin
itis
• P
har
mac
euti
cals
• P
sych
olo
gic
al•
Exc
ess
uri
ne
ou
tpu
t•
Red
uce
d M
ob
ility
• S
too
l im
pac
tio
nan
d o
ther
fac
tors
INC
ON
TIN
EN
CE
Urg
e U
I *
Sig
nif
ican
t P
VR
* S
tres
s U
I* U
I ass
oci
ated
wit
h:
• P
ain
• H
aem
atu
ria
• R
ecu
rren
t sy
mp
tom
atic
U
TI
• P
elvi
c m
ass
• P
elvi
c ir
rad
iati
on
• P
elvi
c/L
UT
su
rger
y•
Maj
or
pro
lap
se (
wo
men
)•
Po
st p
rost
atec
tom
y (m
en)
(If
Mix
ed U
I, in
itial
ly t
reat
pred
omin
ant
sym
ptom
s)
* T
hese
dia
gnos
es m
ay o
verla
p in
vario
us c
ombi
natio
ns,
eg,
MIX
ED
UI,
DH
IC (
see
text
)
• A
sses
s, t
reat
an
d r
eass
ess
po
ten
tial
ly t
reat
able
co
nd
itio
ns,
in
clu
din
g r
elev
ant
com
orb
idit
ies
and
act
ivit
ies
of
dai
ly li
vin
g (
AD
Ls)
• A
sses
s Q
oL
, des
ire
for
Rx,
go
als
of
Rx,
pt
& c
areg
iver
p
refe
ren
ces
• Ta
rget
ed p
hys
ical
exa
m in
cl c
og
nit
ion
, mo
bili
ty, n
euro
log
ical
•
Uri
nal
ysis
+ M
SU
•
Bla
dd
er d
iary
• C
ou
gh
tes
t an
d P
VR
(I
f fe
asib
le a
nd
if it
will
ch
ang
e m
anag
emen
t)
If f
ails
, co
nsi
der
nee
d f
or
spec
ialis
t as
sess
men
t
• L
ifes
tyle
inte
rven
tio
ns
• B
ehav
iora
l th
erap
ies
• C
on
sid
er c
auti
ou
s ad
dit
ion
and
tri
al o
f an
tim
usc
arin
icd
rug
s
• +
Top
ical
est
rog
ens
(wo
men
)
• Tr
eat
con
stip
atio
n
• R
evie
w m
edic
atio
ns
• D
ou
ble
vo
idin
g
• C
on
sid
er t
rial
of
alp
ha-
blo
cker
(m
en)
• If
PV
R>5
00:
cath
eter
dec
om
pre
ssio
n t
hen
re
asse
ss
• L
ifes
tyle
in
terv
enti
on
s
• B
ehav
iora
l th
erap
ies
• +
Top
ical
est
rog
ens
(wo
men
)
Co
nti
nu
e co
nse
rvat
ive
met
ho
ds
±D
epen
den
t co
nti
nen
ce ±
Co
nta
ined
co
nti
nen
ce
1612
A.I
NIT
IAL
MA
NA
GE
ME
NT
V.
NE
UR
OG
EN
IC I
NC
ON
TIN
EN
CE
In a
sses
sing
pat
ient
s w
ith in
cont
inen
ce d
ue to
neu
roge
nic
vesi
co-u
reth
ral
dysf
unct
ion
the
man
agem
ent
depe
nds
on a
n un
ders
tand
ing
of t
he l
ikel
ym
echa
nism
s pr
oduc
ing
inco
ntin
ence
,whi
ch i
n tu
rn d
epen
ds o
n th
esi
teof
the
ner
vous
sys
tem
abn
orm
ality
. T
here
fore
, ne
urog
enic
inc
ontin
ence
patie
nts
can
be d
ivid
ed a
s fo
llow
ing:
Two
grou
ps o
f pa
tient
s, (
a) w
ith p
erip
hera
l ner
ve le
sion
s (b
) an
d th
e ot
her
with
cen
tral
les
ions
bel
ow t
he p
ons,
sho
uld
be m
anag
ed b
y th
e sp
ecia
list
with
a p
artic
ular
inte
rest
/ tr
aini
ng in
neu
rolo
gica
l low
er u
rina
ry tr
act d
ys-
func
tion.
Incl
udin
g pe
riph
eral
ner
ve l
esio
ns,
for
exam
ple
dene
rvat
ion
that
occ
urs
afte
r m
ajor
pel
vic
surg
ery
such
as
for
canc
er o
f th
e re
ctum
or
cerv
ix. A
lso
incl
uded
are
tho
se l
esio
ns i
nvol
ving
the
low
est
part
of
the
spin
al c
ord
(con
us/c
auda
equ
ina
lesi
ons)
, eg.
lum
bar
disc
pro
laps
e.
Supr
asac
ral
infr
apon
tine
spin
al c
ord
lesi
ons,
eg.
tra
umat
ic s
pina
l co
rdle
sion
s, s
houl
d be
trea
ted
acco
rdin
g to
the
resu
lts o
f ur
odyn
amic
stu
dies
:th
e in
itial
tre
atm
ent
shou
ld b
e m
aint
aine
d fo
r 8-
12 w
eeks
, be
fore
rea
s-se
ssm
ent a
nd p
ossi
ble
refe
rral
to th
e sp
ecia
list.
Supr
apon
tine
cent
ral
lesi
ons
incl
ude,
for
exa
mpl
e, c
ereb
ro-v
ascu
lar
acci
-de
nt, s
trok
e, P
arki
nson
´s D
isea
se a
nd m
ultip
le s
cler
osis
➦ D
urin
g in
itial
ass
essm
ent
• ph
ysic
al e
xam
inat
ion
is i
mpo
rtan
t in
hel
ping
to
dist
ingu
ish
thes
e 3
grou
ps a
nd a
sim
ple
neur
olog
ical
exa
min
atio
nsh
ould
be
a ro
utin
e.
•A
n es
timat
e of
post
-voi
d re
sidu
al P
VR
is h
ighl
y re
com
men
ded
(pre
fe-
rabl
y by
ultr
asou
nd).
If
a si
gnif
ican
t PV
R i
s fo
und,
the
n up
per
trac
tim
agin
g is
req
uire
d.
Initi
al t
reat
men
t is
sui
tabl
e fo
r th
e la
rge
grou
p of
pat
ient
s w
ith i
ncon
ti-ne
nce
due
to s
upra
pont
ine
cond
ition
s lik
e st
roke
s. A
t in
itial
ass
essm
ent,
thes
e pa
tient
s ne
ed t
o be
ass
esse
d fo
r th
eir
degr
ee o
f m
obili
tyan
d th
eir
abili
ty t
o co
oper
ate,
as
thes
e tw
o fa
ctor
s w
ill d
eter
min
e w
hich
the
rapi
esar
e po
ssib
le.
The
trea
tmen
ts r
ecom
men
ded
are:
beh
avio
ral(
incl
udin
g tim
ed v
oidi
ng)
and
blad
der-
rela
xan
t dr
ugs
for
pres
umed
de
trus
or
over
acti
vity
.A
pplia
nces
or
cath
eter
s m
ay b
e ne
eded
in
patie
nts
who
are
im
mob
ile o
rca
nnot
coo
pera
te.
2.T
reat
men
t
c) C
entr
al le
sion
s ab
ove
the
pons
b) C
entr
al le
sion
s be
low
the
pons
a) P
erip
hera
l les
ions
,
1. I
niti
al a
sses
smen
t
1613
LE
VE
LO
F L
ES
ION
/H
ISTO
RY
AS
SE
SS
ME
NT
CL
INIC
AL
AS
SE
SS
ME
NTInit
ial M
anag
emen
t o
f N
euro
gen
ic U
rin
ary
Inco
nti
nen
ce
PR
ES
UM
ED
DIA
GN
OS
IS
• G
ener
al a
sses
smen
t in
clu
din
g h
om
e as
sess
men
t•
Uri
nar
y d
iary
an
d s
ymp
tom
sco
re•
Ass
ess
qu
alit
y o
f lif
e an
d d
esir
e fo
r tr
eatm
ent
• P
hys
ical
exa
min
atio
n:
asse
ssm
ent
in r
egar
ds
to u
rge
and
pai
n s
ensa
tio
n in
th
e sa
cral
d
erm
ato
mes
, an
al t
on
e, v
olu
nta
ry c
on
trac
tio
n, b
ulb
oca
vern
osu
s re
flex
, an
al r
efle
x an
d g
ait
• U
rin
alys
is ±
uri
ne
cult
ure
->
if in
fect
ed, t
reat
as
nec
essa
ry
• U
rin
ary
trac
t im
agin
g, s
eru
m c
reat
inin
e
• A
sses
s p
ost
-vo
id r
esid
ual
uri
ne
(PV
R)
by
abd
om
inal
exa
min
atio
n
(o
pti
on
al :
by
ult
raso
un
d)
Per
iph
eral
ner
ve le
sio
n(e
.g. r
adic
al p
elvi
c su
rger
y)co
nu
s/ca
ud
a eq
uid
a le
sio
n(e
.g. l
um
bar
dis
c p
rola
pse
)
Su
pra
sacr
al in
frap
on
tin
esp
inal
co
rd le
sio
n(e
.g. t
rau
ma,
mu
ltip
le
scle
rosi
s)
Su
pra
po
nti
ne
cere
bra
l les
ion
(e.g
. Par
kin
son
´s d
isea
se,
stro
ke, m
ult
iple
scl
ero
sis)
ST
RE
SS
INC
ON
TIN
EN
CE
DU
E T
O
SP
HIN
CT
ER
INC
OM
PE
TE
NC
E
“RE
FL
EX
” IN
CO
NT
INE
NC
EW
ITH
PO
OR
B
LA
DD
ER
EM
PT
YIN
G(s
ign
ific
ant
PV
R)
Co
op
erat
ive
mo
bile
pat
ien
tU
ncoo
pera
tive
imm
obile
pat
ient
“RE
FL
EX
” IN
CO
NT
INE
NC
E“U
RG
EN
CY
-SY
ND
RO
ME
”(n
eglig
ible
PV
R)
if ab
norm
al
Inte
rmit
ten
t ca
thet
eriz
atio
n
• B
ehav
iou
ral
mo
dif
icat
ion
•
An
tim
usc
arin
ics
• E
xter
nal
Ap
plia
nce
s•
Ind
wel
ling
cat
het
er•
An
tim
usc
arin
ics
SP
EC
IAL
IZE
D M
AN
AG
EM
EN
T
Fai
lure
Fai
lure
Fai
lure
TR
EA
TM
EN
T
1614
B.S
PE
CIA
LIZ
ED
MA
NA
GE
ME
NT
V.
NE
UR
OG
EN
IC I
NC
ON
TIN
EN
CE
Mos
t pat
ient
s w
ith p
erip
hera
l les
ion
or c
entr
al le
sion
s be
low
the
pons
requ
ire
spec
ializ
ed a
sses
smen
t and
man
agem
ent.
Uro
dyna
mic
stu
dies
are
high
ly r
ecom
men
ded
in th
ese
patie
nts
to e
sta-
blis
h bo
th b
ladd
er a
nd u
reth
ral f
unct
ion.
Upp
er u
rina
ry tr
act i
mag
ing
isne
eded
in m
ost p
atie
nts
and
mor
e de
taile
d re
nal i
mag
ing
or r
enal
fun
c-tio
n st
udie
sw
ill b
e de
sira
ble
in s
ome.
Uro
dyna
mic
s w
ill d
efin
e th
e fi
lling
fun
ctio
n, w
ith d
etru
sor
over
activ
ityan
d ne
urog
enic
str
ess
inco
ntin
ence
sec
onda
ry to
den
erva
tion
bein
g th
em
ost c
omm
on a
bnor
mal
ities
. Dur
ing
void
ing,
sph
inct
er o
vera
ctiv
ity a
ndde
trus
or u
nder
activ
ity a
re b
oth
likel
y to
lead
to p
ersi
sten
t fai
lure
toem
pty.
Man
agem
ent i
s st
raig
htfo
rwar
d in
con
cept
alth
ough
the
ther
apeu
ticop
tions
are
ext
ensi
ve. T
he a
lgor
ithm
det
ails
the
reco
mm
ende
d op
tions
.
For
sphi
ncte
r in
com
pete
nce
the
reco
mm
ende
d op
tions
are
the
artif
icia
lur
inar
y sp
hinc
ter,
slin
g pr
oced
ures
(in
wom
en)
and
inje
ctab
les
in s
elec
-te
d pa
tient
s.
Com
bina
tions
of
abno
rmal
ities
are
com
mon
e.g
. in
men
ingo
mye
loce
le.
Inco
ntin
ence
may
be
due
to a
com
bina
tion
of d
etru
sor
over
activ
ity a
ndne
urog
enic
str
ess
inco
ntin
ence
bec
ause
of
sphi
ncte
r un
dera
ctiv
ity.
Res
idua
l uri
ne m
ay b
e ca
used
by
detr
usor
und
erac
tivity
as
wel
l as
func
-tio
nal s
phin
cter
obs
truc
tion
in th
e sa
me
patie
nt. E
ach
elem
ent o
f ve
sico
-ur
ethr
al d
ysfu
nctio
n ne
eds
to b
e de
alt w
ith. H
owev
er, i
t mus
t be
rem
em-
bere
d th
at p
rese
rvat
ion
of u
pper
trac
t fun
ctio
n is
of
para
mou
nt im
por-
tanc
e.
For
deta
iled
disc
ussi
on o
n tr
eatm
ent,
plea
se r
ead
the
rele
vant
cha
pter
from
the
cons
ulta
tion.
2.T
reat
men
t1.
Ass
essm
ent
1615
LE
VE
LO
F L
ES
ION
/H
ISTO
RY
AS
SE
SS
ME
NT
CL
INIC
AL
AS
SE
SS
ME
NT
Sp
ecia
lized
Man
agem
ent
of
Neu
rog
enic
Uri
nar
y In
con
tin
ence
DIA
GN
OS
IS
• U
rod
ynam
ics
(co
nsi
der
th
e n
eed
fo
r si
mu
ltan
eou
s im
agin
g /
EM
G)
• U
rin
ary
trac
t im
agin
g -
> if
ab
no
rmal
: re
nal
sca
n
Per
iph
eral
ner
ve le
sio
n( e
.g. r
adic
al p
elvi
c su
rger
y)co
nu
s ca
ud
a eq
uid
ale
sio
n (
e.g
. lu
mb
ar d
isc
pro
lap
se)
Su
pra
po
nti
ne
cere
bra
l les
ion
(e.g
. Par
kin
son
´s d
isea
se,
Str
oke
, mu
ltip
le s
cler
osi
s)
Su
pra
sacr
al in
frap
on
tin
e sp
inal
co
rd le
sio
n(e
.g. t
rau
ma,
mu
ltip
le
scle
rosi
s)
ST
RE
SS
IN
CO
NT
INE
NC
ED
UE
TO
SP
HIN
CT
ER
ICIN
CO
MP
ET
EN
CE
SD
AF
= S
acra
l dea
ffer
enta
tio
nS
AR
S=
Sac
ral a
nte
rio
r ro
ot
stim
ula
tio
nIC
= In
term
itte
nt
cath
eter
izat
ion
DS
D=
Det
ruso
r sp
hin
cter
dys
syn
erg
ia
INC
ON
TIN
EN
CE
AS
SO
CIA
TE
D W
ITH
PO
OR
BL
AD
DE
R
EM
PT
YIN
G D
UE
TO
DE
TR
US
OR
U
ND
ER
AC
TIV
ITY
Wit
ho
ut
DS
DW
ith
DS
D
Co
op
erat
ive
mo
bile
pat
ien
t
Un
coo
per
ativ
eim
mo
bile
pat
ien
t
“RE
FL
EX
” IN
CO
NT
INE
NC
E(I
nfr
apo
nti
ne)
“RE
FL
EX
” IN
CO
NT
INE
NC
E(S
up
rap
on
tin
e)“U
RG
EN
CY
SY
ND
RO
ME
”
• Ti
med
vo
idin
g•
Ext
. ap
plia
nce
s•
Bu
lkin
g a
gen
ts•
Art
ific
ial s
ph
inct
er•
Slin
g p
roce
du
re
• IC
• A
lph
a 1
blo
cker
s•
Intr
aves
ical
el
ectr
ost
imu
lati
on
• B
lad
der
exp
ress
ion
• Tr
igg
ered
vo
idin
g•
An
tim
usc
arin
ics
• N
euro
stim
ula
tio
n(i
nco
mp
l.les
ion
s)/
Neu
rost
imu
lati
on
(co
mp
l. le
sio
ns)
±
IC
• B
ehav
iour
al
mod
ifica
tion
(tim
ed v
oidi
ng)
anti
mu
scar
inic
s •
Neu
rost
imu
lati
on
• B
lad
der
au
gm
en-
tati
on
/ su
b-
stit
uti
on
• E
xter
nal
App
lianc
es•
Ind
wel
ling
ca
thet
er ±
• A
nti
mu
scar
inic
s
• A
nti
mu
scar
inic
s •
SD
AF
+ IC
• S
DA
F +
SA
RS
•
Ext
erna
lsp
hinc
tero
tom
y•
Bla
dder
aug
men
-ta
tion
+ IC
• U
rina
ry d
iver
sion
TR
EA
TM
EN
T
1616
VI. Painful Bladder Syndrome,Including IC (PBS/IC)
Men or women with bladder pain, with orwithout a sensation of urgency, often with uri-nary frequency and nocturia (especially ifdrinking a normal amount of fluids) and noabnormal gynecologic findings to explain thesymptoms should be evaluated for PBS/IC.The initial assessment consists of a frequen-cy/volume chart, focused physical exam, uri-nalysis, and urine culture. Cytology and cys-toscopy are recommended if clinically indica-ted.
Patients with infection should be treated andreassessed. Those with recurrent urinaryinfection, abnormal urinary cytology, and hae-maturia are evaluated with appropriate ima-ging and endoscopic procedures, and only iffindings are unable to explain the symptomsare they diagnosed with PBS/IC.
Grade of recommendation: C
Patient education, dietary manipulation, non-prescription analgesics, and pelvic floorrelaxation techniques comprise the initialmanagement of PBS/IC. When these fail, orsymptoms are severe and conservative mana-gement unlikely to succeed, oral medicationor intravesical treatment can be prescribed.Grade of recommendation: C
If initial oral or intravesical therapy fails, orbefore beginning such therapy, it is reasonableto consider further evaluation which caninclude urodynamics, pelvic imaging, and cys-toscopy with bladder distention and possiblebladder biopsy under anesthesia. Findings ofbladder overactivity suggest a trial of antimus-carinic therapy. Findings of a Hunner’s ulcersuggest therapy with transurethral fulgurationor resection of the ulcer. Distention itself canhave therapeutic benefit in up to one-third ofpatients, though benefits rarely persist for lon-ger than a few months.
Grade of recommendation: C
Those patients with persistent, unacceptablesymptoms despite oral and/or intravesical the-rapy are candidates for more aggressive moda-lities. These might include neuromodulation,pain clinic consultation, narcotic analgesia,and/or experimental treatment protocols. Thelast step in treatment is usually some type ofsurgical intervention aimed at increasing thefunctional capacity of the bladder or divertingthe urine stream. Augmentation (substitutioncystoplasty) and urinary diversion with orwithout cystectomy have been used as a lastresort with good results in selected patients.
Grade of recommendation: C
4. REFRACTORY PBS/IC
3. SECONDARY ASSESSMENT
2. INITIAL TREATMENT
1. HISTORY / INITIALASSESSMENT
1617
PAINFUL BLADDER SYNDROME
Improved with acceptable quality
of life: Follow and Support
Consider Oral and / orIntravesical Treatments
Consider:• pain clinic referral• neuromodulation• experimental protocols
Consider:• diversion with or without
cystectomy• substitution cystoplasty
• Bladder Pain
• Urinary Freqency / Nocturia
• With or Without Urgency
HistoryFrequency / Volume ChartFocused PhysicalExaminationUrinalysis, Culture, Cytology
"SIMPLE PBS"Conservative TreatmentPatient educationDietary manipulationNonprescription AnalgesicsPelvic Floor Relaxation
• "Complicated PBS"
• incontinence
• UTI's
• haematuria
• gynecologic signs /symptoms
Consider:• urine cytology• further imaging• endoscopy• urodynamics
test and reassess
Treat as indicated
UrinaryInfection
NORMAL
ABNORMALInadequateimprovement
Inadequateimprovement
Inadequateimprovement
Inadequateimprovement
Consider :• cystoscopy under anesthesia
with hydrodistention; fulgeration or resection of
Hunner's ulcer if present
SYMPTOM
BASICASSESSMENT
FIRST LINETREATMENT
SECOND LINETREATMENT
1618
VII
. P
ELV
IC O
RG
AN
PR
OL
AP
SE
Pelv
ic o
rgan
pro
laps
e in
clud
es u
roge
nita
land
rec
tal p
rola
pse
and
may
or
may
not
be
asso
ciat
ed w
ith u
rina
ry o
r fa
ecal
inc
ontin
ence
.In
gen
eral
,tr
eatm
ent
for
urog
enita
l pr
olap
se s
houl
d be
res
erve
d fo
r sy
mpt
omat
icpa
tient
s.H
owev
er,
in s
elec
t ci
rcum
stan
ces,
asy
mpt
omat
ic P
OP
may
requ
ire
trea
tmen
t, es
peci
ally
rec
tal
prol
apse
tha
t ca
n pr
ogre
ss a
nd c
ause
faec
al in
cont
inen
ce.
Sym
ptom
enq
uiry
will
rev
eal
a ra
nge
of s
ympt
oms
with
var
ying
com
po-
nent
s of
pro
laps
e an
d in
cont
inen
ce s
ympt
oms.
• N
eed
for
prol
apse
rep
lace
men
t to
im
prov
e ur
inar
y sy
mpt
oms,
or
ifre
plac
emen
t le
ads
to s
ympt
oms,
suc
h as
inc
ontin
ence
, th
is i
s si
gnif
i-ca
nt.
• N
eed
for
prol
apse
rep
lace
men
t in
ord
er t
o m
ictu
rate
or
defa
ecat
e is
impo
rtan
t.
Phy
sica
l exa
min
atio
n sh
ould
def
ine
:
• T
hety
pean
dst
age
of p
rola
pse
: ex
amin
ing
the
wom
en s
tand
ing
and
stra
inin
g is
des
irab
le
• Ass
ocia
ted
abno
rmal
ities
such
as
pelv
ic m
ass,
or u
lcer
atio
ns o
r sor
es o
nex
pose
d va
gina
l/cer
vica
l tis
sues
, whi
ch m
ay c
ause
ble
edin
g or
cop
ious
disc
harg
e.
• M
easu
rem
ent o
f pos
t voi
d re
sidu
al (
PVR
) is
use
ful.
If th
ere
is a
n an
te-
rior
vag
inal
wal
l pro
laps
e be
yond
the
hym
en, t
hen
the
uret
hra
may
be
dist
orte
d (k
inke
d) l
eadi
ng t
o a
sign
ific
ant
PVR
in
whi
ch c
ase
imag
ing
of t
he u
pper
uri
nary
tra
ct i
s in
dica
ted
part
icul
arly
whe
n co
nser
vativ
e
man
agem
ent
is p
lann
ed.
Stre
ss i
ncon
tinen
ce t
est,
if p
ositi
ve,
is m
ea-
ning
ful u
nles
s th
e po
st v
oid
resi
dual
uri
ne is
larg
e (e
g >
500m
l)
• R
ecta
l pr
olap
se i
s be
st d
etec
ted
whe
n th
e pa
tient
is
stra
inin
g w
hils
t si
tting
on
a to
ilet.
• W
hen
obse
rvat
ion
of u
roge
nita
l pr
olap
se i
s m
edic
ally
saf
e an
d se
lec-
ted
by th
e pa
tient
,PF
MT
may
be
effe
ctiv
e in
pre
vent
ing
prol
apse
fro
mw
orse
ning
(G
rade
C).
In
addi
tion,
con
serv
ativ
e tr
eatm
ent
(inc
ludi
nglif
esty
le i
nter
vent
ions
, ph
ysic
al t
hera
pies
and
the
use
of
pess
arie
s)ap
pear
s sa
fe a
nd i
s sa
tisfa
ctor
y fo
r se
lect
ed p
atie
nts
(gra
de D
). W
hen
ring
s an
d pe
ssar
ies
are
used
for
tre
atm
ent,
regu
lar
follo
w-u
p an
d ca
reis
nec
essa
ry. L
ocal
oes
trog
en th
erap
y m
ay b
e he
lpfu
l in
prev
entin
g an
dtr
eatin
g va
gina
l ulc
erat
ion.
• R
econ
stru
ctiv
e su
rgic
al tr
eatm
ent o
f ur
ogen
ital p
elvi
c or
gan
prol
apse
shou
ld a
im to
res
tore
nor
mal
ana
tom
y as
far
as
it is
pos
sibl
e. T
he s
pe-
cifi
c pr
oced
ure
(or
grou
p of
pro
cedu
res)
sho
uld
be s
elec
ted
afte
r an
asse
ssm
ent
of c
oncu
rren
t pe
lvic
sym
ptom
s, t
he n
eces
sity
for
con
cur-
rent
pel
vic
surg
ery
and
the
risk
/ben
efit
for
the
indi
vidu
al w
oman
.
• O
blite
rativ
e va
gina
l su
rger
yis
res
erve
d fo
r hi
ghly
sel
ecte
d w
omen
who
agr
ee to
per
man
ent v
agin
al c
losu
re.
• T
reat
men
t of
rect
al p
rola
pse
is in
dica
ted
in m
ost c
ases
to tr
eat c
urre
ntan
d pr
even
t de
velo
pmen
t of
fae
cal
inco
ntin
ence
. A
bdom
inal
rep
airs
prov
ide
the
low
est
recu
rren
ce r
ate,
alth
ough
per
inea
l re
pair
s m
ay b
ew
arra
nted
in p
atie
nts
with
sig
nifi
cant
com
orbi
ditie
s.
• Fo
r th
e ch
oice
and
det
ails
of
surg
ical
tech
niqu
e pl
ease
see
cha
pter
text
.
2.T
reat
men
t
1. A
sses
smen
t
Intr
oduc
tion
1619
Man
agem
ent
of
Pel
vic
Org
an P
rola
pse
(P
OP,
incl
ud
ing
rec
tal P
rola
pse
)
Pel
vic
Org
an P
rola
pse
Wit
h O
ther
Pel
vic
Sym
pto
ms
Sym
pto
ms
of
pel
vic
org
an p
rola
pse
alo
ne
TR
EA
TM
EN
T
HIS
TOR
Y/
SY
MP
TOM
/ A
SS
ES
SM
EN
T
DIA
GN
OS
IS
CL
INIC
AL
AS
SE
SS
ME
NT
• o
bse
rvat
ion
•
lifes
tyle
inte
rven
tio
ns
• p
essa
ry•
surg
ery
(see
ch
apte
r fo
r d
etai
ls)
- tr
ansv
agin
al-
tran
sab
do
min
al-
ob
liter
ativ
e (r
arel
y)
• o
bse
rvat
ion
• lif
esty
le in
terv
enti
on
• tr
ansp
erin
eal s
urg
ery
• tr
ansa
bd
om
inal
su
rger
y
UR
OG
EN
ITA
LP
OP
WIT
H O
R W
ITH
OU
TO
TH
ER
PE
LVIC
SY
MP
TOM
SR
EC
TAL
PO
PW
ITH
OR
WIT
HO
UT
OT
HE
R P
ELV
IC S
YM
PTO
MS
Sym
pto
ms
Scr
een
ing
: o
f U
rinar
y, A
no-r
ecta
l, G
enita
l and
S
exua
l Sym
ptom
s, a
s in
dica
ted
•U
rin
ary:
PV
R,
coug
h st
ress
tes
t.
•P
hys
ical
Exa
min
atio
n:
Suf
ficie
nt t
o de
term
ine
the
site
and
sev
erity
of
prol
apse
and
det
ect
othe
r si
gnifi
cant
fin
ding
s
- S
elec
tive
use
of u
rody
nam
ics
- S
elec
tive
use
of im
agin
g w
hen
of u
pper
tra
ct im
agin
g w
hen
obse
rvat
ion
is p
lann
ed
•A
no
-Rec
tal:
End
osco
py
low
er G
I tr
act
Imag
ing
1620
VIII. Faecal Incontinence
Patients present with a variety of symptom complexes.
• Serious bowel pathology needs to be considered ifthe patient has symptoms such as an unexplainedchange in bowel habit, weight loss, anaemia, rectalbleeding, severe or nocturnal diarrhoea, or an abdo-minal or pelvic mass.
• History will include bowel symptoms, systemicdisorders, local anorectal procedures (e.g. haemor-rhoidectomy), childbirth for women, medication,diet and effects of symptoms on lifestyle.
• Examination will include anal inspection, abdomi-nal palpation, a brief neurological examination, digi-tal rectal examination and usually anoscopy andproctoscopy.
• Two main symptoms are distinguished: urge faecalincontinence (FI) which is often a symptom ofexternal anal sphincter dysfunction or intestinalhurry; and passive loss of stool may indicate internalanal sphincter dysfunction. Both urge and passive FImay be exacerbated in the presence of loose stool.
➦ Once local or systemic pathology has been exclu-ded, initial management includes
• Discussion of options with the patient
• Patient information and education,
• Diet and fluid advice, adjusting fibre intake (GradeA), and establishing a regular bowel habit with com-plete rectal evacuation and
• Simple exercises to strengthen and enhance aware-ness of the anal sphincter (Grade C).
➦ Anti-diarrhoeal medication can help if stools areloose (Grade B).
➦ Irrigation is helpful in a small number of patients(mainly neurological - Grade C).
➦ Initial management can often be performed in pri-mary care. If this is failing to improve symptomsafter 8-12 weeks, consideration should be given toreferral for further investigations.
A variety of anorectal investigations, including mano-metry, EMG, and anal ultrasound can help to definestructural or functional abnormalities of anorectalfunction.
➦Patients with a clearly disrupted external analsphincter as seen on anal ultrasound often benefitfrom surgical sphincter repair (Grade B).
➦ “Biofeedback” therapy is usually a package of mea-sures designed to enhance the patient’s awareness ofanorectal function, improve sphincter function andcoordination and retrain the bowel habit (Grade C).
➦ Products to manage severe faecal incontinence areineffective in most cases. Severe faecal incontinencewhich fails to respond to management may lead toconsideration of a novel surgical approach such asformation or implantation of a neosphincter, sacralnerve stimulation, or formation of a colostomy(Grade D).
The main chapter (refer to the book) also gives algo-rithms for the management of third degree obstetrictears, soiling in children and faecal incontinence inolder adults.
5. Special patient groups
4. Specialised management
3. Investigations
2. Initial management
1. Initial assessment
1621
Management of Faecal Incontinence in Adults
Immediate surgical referral:complete rectal prolapse; acutesphincter trauma; major recto-vaginal fistula; “major” EASdefect or perineal deformity
Consider:• Repeat biofeedback in specia-
list centre;• Sacral nerve stimulation;• Dynamic graciloplasty;• Artificial sphincter;• Antegrade irrigation;• Stoma
• Diagnostic testing:• Anorectal manometry • Endoanal ultrasound • MRI
No major sphincter defect,failed biofeedback
• Consider repeat sphincteroplasty +/- biofeedback
Patient presents with faecal incontinence: Basic assessment (history, examination, medication review)
If medical investigations or treatmentindicated (e.g. alarm signals, active IBD)address these before proceeding
Patient education.Address reversible risk factors (e.g. medication); PFME (C); Diet counselling; Soluble fibre (loose stool (A);Manage constipation; Toilet access (physical & social).
Add: Medication: Loperamide (Loose stools/increased frequency) (B); Laxatives (constipation) (C);Irrigation (selected & neurological (C)
No alarmsignals
Persistentsphincter defect
No sphincterdefect
Add Biofeedback (C)
Major sphincter defect
Sphincteroplasty
Fails
Fails: consider
Fails
Fails
Fails
Fails
Fails
Repeat endoanal ultrasound
1622
Continence promotion involves informing and educa-ting both the public and health care professionals thatincontinence (both urinary and bowel) is not inevitableor shameful, but is treatable or at least manageable.Progress has been made in the promotion of continenceawareness through primary prevention, education ofprofessionals and consumers, organization of the delive-ry of care, and public access to information on a world-wide basis. However, incontinence needs to be identi-fied as a separate issue on the world health care agenda.All governments are encouraged to take an interest inand to support the development of continence servicesby actively developing policies and providing adequatefunding. These should include a primary preventionstrategy.
1. PRIMARY PREVENTION
Primary prevention studies should not be limited to indi-vidual interventions, but also test the impact of popula-tion-based public health strategies (Grade C)
Pelvic floor muscle training (PFMT) should be a stan-dard component of prenatal and postpartum care(Grade B)
Randomised controlled trials (RCTs) should be conduc-ted to test the preventive effect of PFMT for men post-prostatectomy (Grade B)
Further investigation is warranted to assess the efficacy ofPFMT and bladder training (BT) for primary preventionof urinary incontinence (UI) in older adults (Grade B)
2. CONSUMER AND PROFESSIONAL EDUCATION
There is a need for rigorously evaluated continence edu-cation programmes which adhere to defined minimumstandards for continence specialists, generalists and thepublic/consumer, utilizing web-based and distance lear-ning techniques alongside traditional methods. (GradeD)
• Compulsory inclusion of incontinence in the basiccurriculum (physicians, nurses, physiotherapists andallied health professionals). Incontinence should beidentified, planned and preferably taught as a separa-te topic
• Specific education programmes adhering to approvedstandards should be reported to a recognized centralbody.
• Public education programmes should be indepen-dently evaluated
There is a need for research on the most effective meansto educate the public and professional groups on conti-nence issues. (Grade D)
• Translation of research into improved clinical practi-ce and identification of methods by which this hap-pens.
• Mechanisms for increasing professional motivationto acquire education and improve performance.
• Effectiveness and impact of consumer education ini-tiatives
There is a need for collaboration at the national, interna-tional and practice level to ensure that efforts are notduplicated or in conflict. Information banks of conti-nence education material should be shared. This couldbe facilitated by the ICS. (Grade D)
3. ORGANIZATION
a) Delivery of Continence Care and Services
Government support and co-operation are needed todevelop services, and responsibility for this should beidentified at a high level in each Health Ministry.Incontinence should be identified as a separate issue onthe health care agenda. There is a need for funding as adiscrete item for funding, not to be linked to any onepatient group (e.g. elderly or disabled), and not as anoptional service. (Grade D)
No single model for Continence services can be recom-mended. Because of the magnitude of UI prevalence,detection and basic assessment will need to be perfor-med by primary care clinicians. Specialist consultationshould generally be reserved for those patients whereappropriate conservative options have failed, or for spe-cified indications. (Grade D)
There is a need for research on outcomes, not just theprocess of service delivery. These outcomes must bepatient-focused outcomes, evaluate the outcomes of allsufferers who present for care using validated audittools/outcome measures and assess the values of ser-vices in the long-term by the undertaking of longitudinalstudies. (Grade D)
There is a need for cost-effectiveness studies of the ser-vices currently provided. (Grade D)
b) National Organisation
There is a need for the formation of a worldwide resour-ce centre, preferably through the ICS. The centre shouldupdate educational materials, verify best practice expe-riences or activities while ensuring efficient sharing andoptimum utilisation of resources for promoting conti-nence. This is especially important for countries wherethere is little development of services, education andawareness. A regular update via survey is useful for thispurpose. (Grade D)
Continence organisations should establish long-termgovernmental, as well as, commercial collaboration,particularly in terms of continuing support and fundingfor mutual benefits. Agenda and funding priorities mustbe for the benefit of consumers and the general public.(Grade D)
It is critical that Continence organisations undergo inde-pendent evaluations. This evaluation process shouldinclude a measure of cost-effectiveness for each conti-nence promotion activity or programme. (Grade D)
4. RECOMMENDATIONS FOR CONTINENCE PROMOTION: PREVENTION, EDUCATION AND ORGANISATION
1. To place a greater emphasis on the integratedsystems physiology and systems pharmacologyof the lower urinary tract (LUT), lower gastro-intestinal tract (LGIT) and genital tract (GT).
2. To generate and characterise good animalmodels to study the pathophysiology of theLUT, LGIT and GT
3. To identify targeted drug models, using humantissue from well-characterised patient groupsand tissue from animal models.
4. To generate a greater understanding of structu-re-function relationships of all the tissues of theLUT, LGIT and GT
These should include:
• Smooth muscle function from: bladder dome,trigone, bladder neck and vesico-urethral junc-tion; urethra; prostate; rectum and anus; andgenital tract such as vaginal wall.
• Striated muscle of intraurethral sphincter,external anal sphincter and pelvic floor
• Tissue interactions, such as between epitheliumand stroma.
• Their functional innervation.
5. There should be a greater promotion of basicresearch into LUT, LGIT and GT functionthrough:
• Increased collaboration between basic, medicaland surgical sciences
• Greater representation of medical and surgicalscientists on research advisory boards of majorfunding agencies.
• Identification of multidisciplinary researchstrategies to investigate LUT, LGIT and GTpathophysiology
• Organisation of structured, multidisciplinaryresearch meetings on topics relevant to unders-tanding the pathophysiology of the LUT, LGITand GT.
• The establishment of research centres of excel-lence.
1623
5. Recommendations forfurther basic science research
6. Recommendations forfurther Research in Epidemiology
It is recommended that more sustained research iscarried out on the measurement of urinary inconti-nence, its types and severity to further our unders-tanding of the subject. Longitudinal study designsare needed to estimate incidence and remission ofUI, describe the course of the condition, its diffe-rent forms, and to investigate its risk factors andpossible protective factors.
As there is little knowledge regarding the preva-lence, incidence, and other epidemiological datain developing countries, it is recommended thatresearch should be encouraged, and tailored to thecultural, economic and social environment of thepopulation under study.
Crude prevalence studies (descriptive epidemiolo-gy) from USA and Europe are abundant, and fur-ther studies should be done only with recommen-ded and validated questionnaires or in order to
combine prevalence data in studies of co-factorsand predictors for Urinary Incontinence (analyti-cal epidemiology). Control for confounders, strati-fication, and multivariate techniques should beincreasingly used because of the need for moreadvanced epidemiological analyses of risk factorsand comorbidity. Strength of associations shouldbe determined by relative risks and odds ratios,and confidence limits should be given.
There is a need for more epidemiological researchin all areas of faecal incontinence and pelvic organprolapse, covering prevalence, incidence, and riskfactors. Uniform definitions of FaecalIncontinence and Pelvic Organ Prolapse should beused in studies, and there should be a move towardthe standardisation of measurement instruments incommunity surveys that can be used worldwide.
1624
7. Recommendations forfor Clinical Research Methodology
• Randomized controlled trials (RCTs) eliminatemost of the biases that can corrupt research and pro-vide the strongest level of evidence to direct clinicalcare. The primacy of RCTs in incontinence resear-ch should be fully acknowledged by researchers,reviewers, and editors.
• Careful attention to the planning and design of allresearch is of the utmost importance. This shouldbegin with a structured literature review whichshould be described in the manuscript. High quali-ty, systematic reviews on many topics in inconti-nence have been published by the CochraneIncontinence Group (www.otago.ac.nz/cure) andprovide a valuable starting point.
• The design, conduct, analysis and presentation ofRCTs must be fully in accordance with theConsolidated Standards of Reporting Trials(CONSORT) guidelines. Statistical expertise isrequired at the start of the design of a RCT and the-reafter on an ongoing basis.
• Equivalence trials are underutilized. Failing to finda difference between two treatments is not the sameas proving equivalence if the correct design is notused.
• Inclusion and exclusion criteria inherently reflect aconflict between detecting a specific treatmenteffect and generalizability of the results. It isrecommended that the study population in RCTscomprise a sample that is representative of the ove-rall population. All patients who have the disorderin question, who could benefit from the treatmentunder investigation, and who are evaluable shouldbe eligible. Exclusion criteria should be limited andrelated to clearly defined, supportable hypotheses.
• One or more high quality, validated symptom ins-truments should be chosen at the outset of a clinical
trial representing the viewpoint of the patient, accu-rately defining baseline symptoms as well as anyother areas in which the treatment may produce aneffect. The objective severity and subjective impactor bother should be reflected.
• Whenever relevant, observations of anatomic sup-port and pelvic muscle/voluntary sphincter functionshould be recorded using standardized, reprodu-cible measurements.
• All observations should be repeated after interven-tion and throughout follow-up and their relation-ships with primary clinical outcome measuresinvestigated. Most research follow-up has beeninadequate in the past. Given the nature of thedisorder, short term follow-up in incontinence trialsshould begin with all participants having reachedone year.
• Clinical trials of incontinence and LUTS shouldinclude a validated frequency volume chart or blad-der diary as an essential baseline and outcome mea-sure. Pad tests are a desirable adjunctive measureand should be considered in clinical trials whenpractical.
• Urodynamic studies have not been proven to haveadequate sensitivity, specificity or predictive valueto justify routine use of testing as entry criteria oroutcome measures in clinical trials. Most large scaleclinical studies should enroll subjects by carefullydefined symptom driven criteria when the treatmentwill be given based on an empiric diagnosis.
• High quality, hypothesis driven research into theutility of using urodynamic studies to define patientpopulations or risk groups within clinical trials isgreatly needed.
• In all trials employing urodynamics, standardizedprotocols (based on ICS recommendations) aredefined at the outset. In multicenter trials, urody-namic tests should be interpreted by a central readerto minimize bias unless inter- and intrarater reliabi-lity has already been established by standardizedprocedures within the trial.
III. RECOMMENDATIONS ON TESTS USED IN
URINARY INCONTINENCE RESEARCH:
II. RECOMMENDATIONS ON OBSERVATIONS
DURING INCONTINENCE RESEARCH:
I. RECOMMENDATIONS ON STUDY CONDUCT
AND STATISTICAL METHODS
PART I: GENERALRECOMMENDATIONS
1625
• High quality, gender specific quality of life andbother scores should be employed when assessingoutcome in male incontinence research.
• Uroflow and measurement of post-void residualurine should be recorded pre-treatment and theeffect of therapy on these parameters should bedocumented simultaneously with assessment of theprimary outcome variables. The value of invasivepressure-flow urodynamics in stratifying patientsdeserves further investigation.
• Measurement of prostate size (or at least PSA, as asurrogate) should be performed before and aftertreatment (synchronous with other outcome mea-sures) whenever prostate size is expected to changedue to the treatment. Patients should be stratifiedby prostate size at randomization when size isconsidered to be a potentially important determi-nant of treatment outcome.
• Specific information about the menopausel, hyste-rectomy, and hormonal status, parity and obstetrichistory should be included in baseline clinical trialdata
• Strict criteria for cure / improve / fail should bedefined based on patient perception as well asobjective and semi-objective instruments such asvalidated questionnaires, diaries and pad tests.
• “Clinically significant” outcome measures and rela-tionships of outcome to socioeconomic costs arecritically important to establishing the utility oftreating urinary incontinence in the frail elderly.
• Entry into RCTs should be defined by performancestatus rather than an arbitrary age limit.
• Establishing the safety of incontinence treatment iseven more important in the frail elderly than inother populations.
• We support the NIH statement(http: / /grants .nih.gov/grants/guide/notice-files/not98-024.html) calling for increased clinicalresearch in children. All investigators that workwith children should be aware of the details of thedocument.
• Long-term follow-up is of critical importance in thepediatric population with a primary focus of establi-shing safety of chronic treatments.
• Detailed urodynamic studies are required for classi-fication of neurogenic lower urinary tract disordersin clinical trials because the nature of the lower tractdysfunction cannot be accurately predicted fromclinical data.
• Change in detrusor leak point pressure should bereported as an outcome as appropriate, and can beconsidered a primary outcome for spina bifidapatients.
• An area of high priority for research is the develop-ment of a classification system to define neurogenicdisturbances. Relevant features would include theunderlying diagnosis, the symptoms, and the natureof the urodynamic abnormality.
• Data should be collected on fecal incontinence whe-never practical as part of research in urinary incon-tinence.
• Well designed and adequately powered studies areneeded to define best practice in investigation andfor all treatment modalities currently available
• Further considertion should be given to newapproaches and adoption of technologies/interven-tions that are of established value in treating urina-ry incontinence
• The patient population for PBS trials must be care-fully defined. When appropriate, relaxed entry cri-teria should be used to reflect the full spectrum ofthe PBS patient population
VII. RECOMMENDATIONS FOR RESEARCH IN
PAINFUL BLADDER SYNDROMES (INCLUDING
INTERSITIAL CYSTITUS):
VI. RECOMMENDATIONS FOR RESEARCH IN
FAECAL INCONTINENCE:
V. RECOMMENDATIONS FOR RESEARCH IN
NEUROGENIC PATIENTS:
IV. RECOMMENDATIONS FOR RESEARCH IN
CHILDREN:
III. RECOMMENDATIONS FOR RESEARCH IN
FRAIL OLDER AND DISABLED PEOPLE:
II. RECOMMENDATIONS FOR RESEARCH IN
WOMEN:
I. RECOMMENDATIONS FOR RESEARCH
IN MEN:
PART II: CONSIDERATIONS FORSPECIFIC PATIENT GROUPS
• The primary endpoint of PBS trials should bepatient driven and the Global Response Assessmentis recommended. A rich spectrum of secondaryendpoints will be useful in defining the effect oftreatments
• Investigation of antiproliferative factor as an entrycriteria for clinical research is desirable.
• There should be a focus on patient reported out-comes with the goal of determining “clinicallysignificant” prolapse. The implications of stage 2prolapse in terms of natural history and treatmentoutcome are key issues.
• Research is needed to define the epidemiology ofnocturia and how the symptom relates to normalaging
• Clinical research in treatment of nocturia shouldbegin with classification of patients by voidingdiary categories, 24 hour polyuria, nocturnal poly-uria, and apparent bladder storage disorders. Ifdesired, patients with low bladder capacity can befurther divided into those with sleep disturbancesand those with primary lower urinary tract dysfunc-tion.
• Treatment protocols must be detailed to the degreethat the work can easily be reproduced
• The highest practical level of blinding should beused.
• More work is needed to separate the specific andnon-specific effects of treatment
• Safety and serious side effects of new devices mustbe adequately defined with adequate follow-up,especially for use of implantable devices and biolo-gic materials, so that risks can be weighed againstefficacy. All new devices and procedures requireindependent, large scale, prospective, multicentercase series when RCTs are not feasible.
• Valid informed research consent is required in alltrials of surgical interventions, which is separatefrom the consent to surgery.
• Reports of successful treatment should be limited tosubjects with a minimum (not mean) of one yearfollow-up and should include a patient perspectivemeasure. Specific assumptions about patients lostto follow-up should be stated; last observation car-ried forward is generally not the appropriate methodof handling this data.
• In urinary incontinence safe, effective non-invasivetherapy is available for the vast majority of patients.Most trials should offer “standard therapy” ratherthan a pure placebo where efficacy is established.
• Effective drug therapy is available for most forms ofincontinence. Comparator arms are recommendedfor most trials.
• Continuity in clinical direction from design throughauthorship is mandatory. Investigators should beinvolved in the planning stage and a publicationscommittee should be named at the beginning of theclinical trial. The Uniform Requirements forManuscripts Submitted to Biomedical Journals,from the International Committee of MedicalJournal Editors should be followed. Authorshiprequires:
- Substantial contributions to conception and designor acquisition of data or analysis and interpretationof data,
- Drafting the article or revising it critically for impor-tant intellectual content,
- Final approval of the version to be published
• Authors should provide a description of what eachcontributed and editors should publish that informa-tion.
• Authors should have access to all raw data from cli-nical trials, not simply selected tables
• Clinical trial results should be published regardlessof outcome. The sponsor should have the right toreview manuscripts for a limited period of timeprior to publication but the manuscript is the intel-lectual property of its authors, not the sponsor.
• All authors should be able to accept responsibilityfor the published work and all potential conflicts ofinterest should be fully disclosed.
IV. RECOMMENDATIONS FOR ETHICS IN
RESEARCH
III. RECOMMENDATIONS FOR
PHARMACOTHERAPY TRIALS:
II. RECOMMENDATIONS FOR SURGICAL AND
DEVICE RESEARCH
I. RECOMMENDATIONS FOR BEHAVIORAL AND
PHYSIOTHERAPY RESEARCH:
PART III: CONSIDERATIONS FORSPECIFIC TYPES OF RESEARCH
IX. RECOMMENDATIONS FOR RESEARCH IN
NOCTURIA:
VIII. RECOMMENDATIONS FOR RESEARCH IN
PELVIC ORGAN PROLAPSE:
1626
Three types of Bladder Charts and Diaries can be used to collect data :-
MICTURITION TIME CHART
• times of voiding and
• incontinence episodes
FREQUENCY VOLUME CHART
• times of voiding with voided volumes measured,
• incontinence episodes and number of changes of inconti-nence pads or clothing.
BLADDER DIARIES
• the information above, but also
• assessments of urgency,
• degree of leakage (slight, moderate or large) and descrip-tions of factors leading to symptoms such as stress leakage,eg. running to catch a bus
It is important to assess the individual’s fluid intake, remem-bering that fluid intake includes fluids drunk plus the watercontent of foods eaten. It is often necessary to explain to apatient with LUTS that it may be important to change thetiming of a meal and the type of food eaten, particularly in theevenings, in order to avoid troublesome nocturia.
The micturition time and frequency volumes charts can becollected on a single sheet of paper (Fig. 1). In eachchart/diary, the time the individual got out of bed in the mor-ning and the time they went to bed at night should be clearlyindicated.
Each chart/diary must be accompanied by clear instructionsfor the individual who will complete the chart/diary: the lan-guage used must be simple as in the suggestions given forpatient instructions. There are a variety of designs of chartsand diaries and examples of a detailed bladder diary aregiven. The number of days will vary from a single day up toone week.
This chart helps you and us to understand why you get troublewith your bladder. The diary is a very important part of thetests we do, so that we can try to improve your symptoms. Onthe chart you need to record:-
1. When you get out of bed in the morning, show this on thediary by writing ‘GOT OUT OF BED’.
2. The time, eg. 7.30am, when you pass your urine. Do thisevery time you pass urine throughout the day and also atnight if you have to get up to pass urine.
3. If you leak urine, show this by writing a ‘W’ (wet) on thediary at the time you leaked
4. When you go to bed at the end of the day show it on thediary - write ‘WENT TO BED’.
This chart helps you and us to understand why you get troublewith your bladder. The diary is a very important part of thetests we do, so that we can try to improve your symptoms. On
the chart you need to record:-
1. When you get out of bed in the morning, show this on thechart by writing ‘Got out of bed’.
2. The time, eg. 7.30am when you pass your urine. Do thisevery time you pass urine throughout the day and also atnight if you have to get up to pass urine.
3. Each time you pass urine, collect the urine in a measuringjug and record the amount (in mls or fluid ozs) next to thetime you passed the urine, eg. 1.30pm - 320 mls.
4. If you leak urine, show this by writing ‘W’ (wet) on thediary at the time.
5. If you have a leak, please add ‘P’ if you have to change apad and ‘C’ if you have to change your underclothes oreven outer clothes. So, if you leak and need to change apad, please write ‘WP’ at the time you leaked.
6. At the end of each day please write in the column on theright the number of pads you have used, or the number oftimes you have changed clothes.
When you go to bed at the end of the day show it on the diary- write ‘Went to Bed’
This diary helps you and us to understand why you get troublewith your bladder. The diary is a very important part of thetests we do, so that we can try to improve your symptoms. Onthe chart you need to record:-1. When you get out of bed in the morning, show this on the
diary by writing ‘GOT OUT OF BED’.2. During the day please enter at the correct time the drinks
you have during the day, eg. 8.00am - two cups of coffee(total 400 ml).
3. The time you pass your urine, eg. 7.30am. Do this everytime you pass urine throughout the day and night.
4. Each time you pass urine, collect the urine in a measuringjug and record the amount (in mls or fluid ozs) next to thetime you passed the urine, eg. 1.30pm/320ml.
5. Each time you pass your urine, please write down howurgent was the need to pass urine:
‘O’ means it was not urgent.+ means I had to go within 10 minutes.++ means I had to stop what I was doing and go to the toilet.6. If you leak urine, show this by writing an ‘W’ on the diary
at the time you leaked.7. If you have a leak, please add ‘P’ if you have to change a
pad and ‘C’ if you have to change your underclothes oreven outer clothes. So if you leak and need to change apad, please write ‘WP’ at the time you leaked.
8. If you have a leakage please write in the column called‘Comments’ whether you leaked a small amount or a largeamount and what you were doing when you leaked, eg.‘leaked small amount when I sneezed three times’.
9. Each time you change a pad or change clothes, please writein the ‘Comments’ column.
10. When you go to bed at the end of the day show it on thediary - write ‘Went to Bed’.
INSTRUCTIONS FOR USING THEBLADDER DIARY
INSTRUCTIONS FOR USING THEFREQUENCY VOLUME CHART
INSTRUCTIONS FOR COMPLETINGTHE MICTURITION TIME CHART
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Annex 1 : Bladder Charts and Diaries
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ICIQ IntroductionThe scientific committee which met at the end of the 1stICI in 1998 supported the idea that a universally appli-cable questionnaire should be developed, that could bewidely applied both in clinical practice and research.
The hope was expressed that such a questionnairewould be used in different settings and studies andwould allow cross-comparisons, for example, betweena drug and an operation used for the same condition, inthe same way that the IPSS (International prostatesymptoms score) has been used.
An ICIQ Advisory Board was formed to steer the deve-lopment of the ICIQ, and met for the first time in 1999.The project’s early progress was discussed with theBoard and a decision made to extend the concept fur-ther and to develop the ICIQ Modular Questionnaire.
The first module to be developed was the ICIQ ShortForm Questionnaire for urinary incontinence: the ICIQ-SF. The ICIQ-SF has now been fully validated andpublished1. Given the intention to produce an interna-tionally applicable questionnaire, requests were madefor translations of the ICIQ-SF at an early stage, forwhich the Advisory Board developed a protocol for theproduction of translations of its modules. The ICIQ-SFhas been translated into 30 languages to date.
In addition to the ICIQ-SF, ten modules have beenadopted which are direct (unchanged) derivations fromalready published questionnaires. (Table below)
WWW.ICIQ.net will be used to provide the validationstatus of the modules under development for urinarysymptoms, bowel symptoms and vaginal symptoms.
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Table 1. Fully validated ICIQ modules derived from previously developed questionnaires
ICIQ Modules Derived from For use in
ICIQ-MLUTS ICS maleSF [4] Men
ICIQ-MLUTS-LF ICS male[2] Men
ICIQ-FLUTS BFLUTS SF [5] Women
ICIQ-FLUTS-LF BFLUTS [3] Women
ICIQ-LUTSqol KHQ [6] Men and women
ICIQ-Nqol N-QOL [7] Men and women
ICIQ-OABqol OABq [8] Men and women
ICIQ-MLUTSsex ICS male [2] Men
ICIQ-FLUTSsex BFLUTS [3] Women
ICIQ-UIqol I-QOL [9] Men and women
*indicates a validated module
Annex 2 : International Consultation on Incontinence Questionnaire (ICIQ) -ICIQ UI SF (Short-form)
REFERENCES
1. Avery K, Donovan J, Peters T, Shaw C, Gotoh M, &Abrams P. The ICIQ: a brief and robust measure for eva-luating the symptoms and impact of urinary incontinence.Neurourol.Urodyn. 2004; 23(4): 322-330.
2. Donovan J, Abrams P, Peters T, et al. The ICS-'BPH'study: the psychometric validity and reliability of theICSmale questionnaire. Br.J.Urol. 1996; 77: 554-562.
3. Jackson S, Donovan J, Brookes S, et al. The BristolFemale Lower Urinary Tract Symptoms questionnaire:development and psychometric testing. Br.J.Urol. 1996;77: 805-812.
4. Donovan J, Peters T, Abrams P, et al. Scoring the ShortForm ICSmaleSF questionnaire. J.Urol. 2000; 164: 1948-1955.
5. Brookes ST, Donovan JL, Wright M, Jackson S, AbramsP. A scored form of the Bristol Female Lower Urinary
Tract Symptoms questionnaire: data from a randomizedcontrolled trial of surgery for women with stress inconti-nence. Am.J.Obstet.Gynecol. 2004;191(1):73-82.
6. Kelleher C, Cardozo L, Khullar V, et al. A new question-naire to assess the quality of life of urinary incontinentwomen. Br.J.Obstet.Gynaecol. 1997; 104: 1374-1379.
7. Abraham L, Hareendran A, Mills I, et al. Developmentand validation of a quality-of-life measure for men withnocturia. Urology 2004; 63(3): 481-486.
8. Coyne K, Revicki D, Hunt R, et al. Psychometric valida-tion of an overactive bladder symptom and health-relatedquality of life questionnaire: The OAB-q. Qual.Life.Res.2003;11:563-574.
9. Wagner TH, Patrick DL, Bavendam TG, Martin ML,Buesching DP. Quality of life of persons with urinaryincontinence: development of a new measure. Urology1996;47(1):67-72.
3 How often do you leak urine? (Tick one box)never 0
about once a week or less often 1
two or three times a week 2
about once a day 3
several times a day 4
all the time 5
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Annex 2 : International Consultation on Incontinence Questionnaire (ICIQ) -ICIQ UI SF (Short-form)
Initial number DAY MONTH YEAR Today’s date
DAY MONTH YEAR 1 Please write in your date of birth:
2 Are you (tick one): Female Male
ICIQ score: sum scores 3+4+5
Many people leak urine some of the time. We are trying to find out how many people leak urine,and how much this bothers them. We would be grateful if you could answer the following ques-tions, thinking about how you have been, on average, over the PAST FOUR WEEKS.
4 We would like to know how much urine you think leaks.How much urine do you usually leak (whether you wear protection or not)? (Tick one box)
none 0
a small amount 2
a moderate amount 4
a large amount 6
5 Overall, how much does leaking urine interfere with your everyday life?Please ring a number between 0 (not at all) and 10 (a great deal)
0 1 2 3 4 5 6 7 8 9 10
not at all a great deal
6 When does urine leak? (Please tick all that apply to you)
never – urine does not leak
leaks before you can get to the toilet
leaks when you cough or sneeze
leaks when you are asleep
leaks when you are physically active/exercising
leaks when you have finished urinating and are dressed
leaks for no obvious reason
leaks all the time
Thank you very much for answering these questions.