1.INTRODUCTION Urinary incontinence (UI) is an extremely common complaint in every part of the world. It causes a great deal of distress and embarrassment, as well as significant costs, to both individuals and societies. Estimates of prevalence vary according to the definition of incontinence and the population studied. However, there is universal agreement about the importance of the problem in terms of human suffering and economic cost.

1.1.Aim and objectives These Guidelines from the European Association of Urology (EAU) Working Panel on Urinary Incontinence are written by a multidisciplinary group, primarily for urologists, and are likely to be referred to by other professional groups. They aim to provide sensible and practical evidence-based guidance on the clinical problem of UI rather than an exhaustive narrative review. Such a review is already available from the International Consultation on Incontinence [], and so the EAU Guidelines do not describe the causation, basic science, epidemiology and psychology of UI. The focus of these Guidelines is entirely on assessment and treatment reflecting clinical practice. The Guidelines also do not consider patients with UI caused by neurological disease, or in children, as this is covered by complementary EAU Guidelines [,]. The elderly The Panel decided to include a separate but complimentary set of recommendations referring to the elderly population within each section.

Older people with UI deserve special consideration for a number of reasons. Physiological changes with natural ageing mean that all types of UI become more common with increasing age.

Urinary incontinence commonly co-exists with other comorbid conditions, reduced mobility, and impaired cognition and may require specific interventions, such as assisted toileting. For the elderly person expectations of assessment and treatment may need to be modified to fit in with specific circumstances, needs, and preferences, while also taking into account any loss of capacity for consent. When the urologist is dealing with a frail elderly patient with urinary incontinence, collaboration with other healthcare professionals such as elderly care physicians is recommended. It must be emphasised that clinical guidelines present the best evidence available to the experts. However, following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.

Deitel® Series Page. How To Program Series. Android How to Program, 2/E. C++ How to Program, 9/E. C How to Program, 7/E. Java™ How to Program, 10/E. Java™ How to. Visual C++® 2008 How to Program, 2/E. Visual Basic®. Chapters 26–34 and Appendices F–N are PDF documents posted online at the book's.

1.2.Panel composition The EAU Urinary Incontinence Panel consists of a multidisciplinary group of experts, including urologists, a gynaecologist and a physiotherapist. All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website:. 1.3.Available publications A quick reference document (Pocket Guidelines) is available, both in print and in a number of versions for mobile devices. These are abridged versions which may require consultation together with the full text versions.

Two scientific publications in the journal European Urology are also available [,]. All documents are accessible through the EAU website:.

1.4.Publication history The EAU published the first Urinary Incontinence Guidelines in 2001. This 2017 publication presents a limited update of the 2016 Urinary Incontinence Guidelines. 1.4.1.Summary of changes. Section 4.2 Pharmacological management has been revised for this 2017 print, including the addition of a new section 4.3.5.1 on Drug therapy. Changed evidence summaries and recommendations can be found in sections: 4.2.1 Antimuscarinic drugs Summary of evidence LE There is limited evidence that one antimuscarinic drug is superior to an alternative antimuscarinic drug for cure or improvement of urgency urinary incontinence. 1b Higher doses of antimuscarinic drugs are more effective to cure or improve urgency urinary incontinence, but with a higher risk of side effects.

1b Once daily (extended release) formulations are associated with lower rates of adverse events compared to immediate release ones, although similar discontinuation rates are reported in clinical trials. 1b Dose escalation of antimuscarinic drugs may be appropriate in selected patients to improve treatment effect although higher rates of adverse events can be expected. 1b Transdermal oxybutynin (patch) is associated with lower rates of dry mouth than oral antimuscarinic drugs, but has a high rate of withdrawal due to skin reaction. 1b 4.2.3.3 Recommendations for antimuscarinic drugs Recommendations GR Offer antimuscarinic drugs for adults with urgency urinary incontinence who failed conservative treatment. A Consider extended release formulations in patients who do not tolerate immediate release antimuscarinics. A If antimuscarinic treatment proves ineffective, consider dose escalation or offering an alternative treatment. B Consider using transdermal oxybutynin if oral antimuscarinic agents cannot be tolerated due to dry mouth.

B Offer and encourage early review (of efficacy and side effects) of patients on antimuscarinic medication for urgency urinary incontinence. C 4.2.4 Antimuscarinic agents: adherence and persistence Summary of evidence LE Adherence to antimuscarinic treatment is low and decreases over time because of lack of efficacy, adverse events and/or cost.

2 Most patients will stop antimuscarinic agents within the first three months. 2 4.2.5 Antimuscarinic and beta3 agonist agents, the elderly and cognition Summary of evidence LE Antimuscarinic drugs are effective in elderly patients. 1b Mirabegron has been shown to efficacious and safe in elderly patients.

1b In older people, the cognitive impact of drugs which have anticholinergic effects is cumulative and increases with length of exposure. 2 Oxybutynin may worsen cognitive function in elderly patients. 2 Solifenacin, darifenacin, fesoterodine and trospium have been shown not to cause cognitive dysfunction in elderly people in short-term studies.

1b 4.2.5.2.13 Additional recommendations for antimuscarinic drugs in the elderly Recommendations GR In older people being treated for urinary incontinence, every effort should be made to employ nonpharmacological treatments first. C Long-term antimuscarinic treatment should be used with caution in elderly patients especially those who are at risk of, or have, cognitive dysfunction. B * When prescribing antimuscarinic for urgency urinary incontinence, consider the total antimuscarinic load in older people on multiple drugs. C Consider the use of Mirabegron in elderly patients if additional antimuscarinic load is to be avoided. C *Recommendation based on expert opinion. 4.2.6 Mirabegron Summary of evidence LE Mirabegron is better than placebo and as efficacious as antimuscarinics for improvement of urgency urinary incontinence symptoms.

1a Adverse event rates with mirabegron are similar to placebo. 1a Patients inadequately treated with solifenacin 5 mg may benefit more from the addition of mirabegron than dose escalation of solifenacin.

1b Recommendation GR In patients with urgency urinary incontinence and an inadequate response to conservative treatments, offer mirabegron unless they have uncontrolled hypertension. A 4.2.7 Drugs for stress urinary incontinence Summary of evidence LE Duloxetine, 40 mg twice daily improves stress urinary incontinence in women. 1a Duloxetine causes significant gastrointestinal and central nervous system (CNS) side effects leading to a high rate of treatment discontinuation, although these symptoms are limited to the first weeks of treatment.

1a Recommendations GR Duloxetine can be used with caution to treat women with symptoms of stress urinary incontinence. A Duloxetine should be initiated using dose titration because of high adverse event rates. A 4.2.8 Oestrogen Recommendation GR Vaginal oestrogen therapy for vulvovaginal atrophy should be prescribed long-term.

In women with a history of breast cancer, the treating oncologist needs to be consulted. C 4.2.9.2.2 Monitoring for hyponatraemia Recommendations GR Consider offering desmopressin to patients requiring occasional short-term relief from daytime urinary incontinence and inform them that this drug is not licensed for this indication. A Monitor plasma sodium levels in patients on desmopressin. A * *Recommendation based on expert opinion. 4.2.10 Drug treatment in mixed urinary incontinence Recommendation GR Offer antimuscarinic drugs or beta3 agonists to patients with urgency-predominant mixed urinary incontinence. A * *Recommendation based on expert opinion.

4.3.5.1 Drug therapy Summary of evidence LE Duloxetine, either alone or combined with conservative treatment, can hasten recovery of continence but does not improve continence rate following prostate surgery. 1b 4.3.5.5 Compression devices in males Recommendation GR Consider offering duloxetine to hasten recovery of continence after prostate surgery but inform the patient about the possible adverse events.

2.METHODS 2.1.Introduction For the 2017 Urinary Incontinence Guidelines, the literature has been assessed for Section 4.2 – Pharmacological management. Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between January 2012 and April 20 th, 2016.

A total of 1164 unique records were identified, retrieved and screened for relevance. A detailed search strategy is available online:. A systematic review was performed assessing nocturia and nocturnal incontinence in both men and women, in collaboration with the EAU Non-Neurogenic Male LUTS Guidelines Panel []. Due to the paucity of literature addressing nocturnal incontinence, the Panel did not include new information on this topic.

The findings relating to nocturia in males are presented in the Non-Neurogenic Male LUTS Guidelines. References used in this text are assessed according to their level of evidence (LE) and Guidelines are given a grade of recommendation (GR), according to a classification system modified from the Oxford Centre for Evidence-Based Medicine Levels of Evidence [].

Additional methodology information can be found in the general Methodology section of this print, and online at the EAU website:. A list of Associations endorsing the EAU Guidelines can also be viewed online at the above address. The current Guidelines provide: • A clear pathway (algorithm) for common clinical problems.

This can provide the basis for thinking through a patient’s management and also for planning and designing clinical services. • A brief but authoritative summary of the current state of evidence on clinical topics, complete with references to the original sources. • Clear guidance on what to do or not to do, in most clinical circumstances. This should be particularly helpful in those areas of practice for which there is little or no high-quality evidence. In this edition the Panel has continued to focus, largely, on the management of a ‘standard’ patient.

The Panel has referred in places to patients with ‘complicated incontinence’, by which we mean patients with associated morbidity, a history of previous pelvic surgery, surgery for UI, radiotherapy and women with associated genitourinary prolapse. An appendix is included on non-obstetric genitourinary fistulae. The subject of prevention of urinary incontinence has not been addressed. A systematic review on nocturnal incontinence found no studies on the topic. The Panel are of the opinion that nocturnal incontinence should be considered in future research studies. 2.2.Review This document was subjected to peer review prior to publication in 2015. The decision for re-review is made based on the extent of the revision.

A major revision resulting in significant changes to the clinical recommendations presented in the text will warrant re-review. 2.3.Terminology Evidence summaries provide a succinct summary of what the currently available evidence tells us about an individual clinical question. They are presented according to the levels of evidence used by the EAU. Recommendations have been deliberately written as ‘action-based’ sentences. The following words or phrases are used consistently throughout the Guidelines; • Consider an action.

This word is used when there is not enough evidence to say whether the action causes benefit or risk to the patient. However, in the opinion of the Panel, the action may be justified in some circumstances.

Action is optional. • Offer an action. This word is used when there is good evidence to suggest that the action is effective, or that, in the opinion of the Panel, it is the best action. Action is advisable.

• Carry out (perform) an action. Do something. This phrase is used when there is strong evidence that this is the only best action in a certain clinical situation. Action is mandatory. • Do not perform (i.e. Avoid) an action.

This phrase is used when there is high-level evidence that the action is either ineffective or is harmful to the patient. Action is contraindicated. Future goals: • An extended literature search revisiting the topic of female nocturia will be undertaken in collaboration with the Non-neurogenic male LUTS Guidelines Panel.

• An Algorithm for the management of nocturia in both males and females will be presented in the 2018 Urinary Incontinence Guidelines publication. 3.DIAGNOSTIC EVALUATION 3.1.History and physical examination Taking a careful clinical history is fundamental to the clinical process. Despite the lack of formal evidence, there is universal agreement that taking a history should be the first step in the assessment of anyone with UI. The history should include details of the type, timing and severity of UI, associated voiding and other urinary symptoms. The history should allow UI to be categorised into stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI). It should also identify patients who need rapid referral to an appropriate specialist.

These include patients with associated pain, haematuria, a history of recurrent urinary tract infection (UTI), pelvic surgery (particularly prostate surgery) or radiotherapy, constant leakage suggesting a fistula, voiding difficulty or suspected neurological disease. In women, an obstetric and gynaecological history may help to understand the underlying cause and identify factors that may impact on treatment decisions. The patient should also be asked about other ill health and for the details of current medications, as these may impact on symptoms of UI. Similarly, there is little evidence from clinical trials that carrying out a clinical examination improves care, but wide consensus suggests that it remains an essential part of assessment of people with UI.

It should include abdominal examination, to detect an enlarged bladder or other abdominal mass, and perineal and digital examination of the rectum (prostate) and/or vagina. Examination of the perineum in women includes an assessment of oestrogen status and a careful assessment of any associated pelvic organ prolapse (POP). A cough test may reveal SUI if the bladder is sufficiently full while pelvic floor contraction together with urethral mobility can be assessed digitally. 3.2.Patient questionnaires This section includes symptom scores, symptom questionnaires, scales, indexes, patient reported outcome measures (PROMs) and health-related quality of life (HRQoL) measures.

The latter include generic or condition specific measures. Questionnaires should have been validated for the language in which they are being used, and, if used for outcome evaluation, must have been shown to be sensitive to change. The US Food and Drug Administration (FDA) published guidance for industry on patient-reported outcome instruments (questionnaires) in 2009 []. 3.2.1.Questions • In patients with UI, can the use of Questionnaires/PROMS differentiate between stress, urgency and mixed incontinence, and does this differentiation impact on quality of life (QoL) after treatment? • In adults with UI, does assessment using either urinary symptom or QoL questionnaires improve treatment outcome for UI? • In adults with UI, does assessment of the patient perspective (concerns or expectations) improve patient outcomes, regarding either urinary symptoms or QoL, compared to no patient-reported assessment?

3.2.2. Windows 7 Ultimate Warez Forum. Evidence Although many studies have investigated the validity and reliability of urinary symptom questionnaires and PROMs most of these studies did not include adult patients diagnosed with UI. This limits the extent to which results and conclusions from these studies can be applied in adults with UI. Some questionnaires (QUID, 3IQ) have potential to discriminate UI types in women [,]. In men ICIQ-UI-SF score does not differentiate UI types []. Some questionnaires are responsive to change and may be used to measure outcomes, though evidence on their sensitivity is inconsistent []. No evidence was found to indicate whether use of QoL or condition specific questionnaires have an impact on outcome of treatment.

Table 1 shows a summary of the ICUD review (2012) with recent additions. Criteria on which questionnaires are assessed include validity, reliability and responsiveness to change. Table 1: Summary of the ICUD review 2012 *. 4.DISEASE MANAGEMENT 4.1.Conservative management In clinical practice, it is the convention that non-surgical therapies are tried first because they usually carry the least risk of harm. They are often used in combination which makes it difficult to determine which components are effective. Containment devices play an important role, especially for individuals who prefer to avoid the risks of interventional treatments, or in whom active treatment is impossible for any reason. 4.1.1.Simple clinical interventions 4.1.1.1.Underlying disease/cognitive impairment Urinary incontinence, especially in the elderly, has been associated with multiple comorbid conditions including: • cardiac failure; • chronic renal failure; • diabetes; • chronic obstructive pulmonary disease; • neurological disease including stroke and multiple sclerosis; • general cognitive impairment; • sleep disturbances, e.g.

Sleep apnoea; • depression; • metabolic syndrome. It is possible that improvement of associated disease may reduce the severity of urinary symptoms.

However, this is often difficult to assess as patients frequently suffer from more than one condition. In addition, interventions may be combined and individualised, making it impossible to decide which alteration in an underlying disease has affected a patient’s UI. 4.1.1.1.1.Question In adults with UI, does improving an associated condition improve UI compared to no correction of that condition? 4.1.1.1.2.Evidence There is compelling evidence that there is a higher prevalence of UI in women with type 2 diabetes. One study showed no correlation between earlier intensive treatment of type 1 diabetes mellitus and the prevalence of UI in later life vs.

Conventional treatment []. Summary of evidence LE There is a lack of evidence that improving any associated condition improves urinary incontinence, with the exception of weight loss (see section 4.1.2.4 Obesity and weight loss).

3 Recommendation GR Patients with urinary incontinence who have associated conditions, should have appropriate treatment for those conditions in line with good medical practice. A * * Recommendation based on expert opinion. 4.1.1.2.Adjustment of other (non-incontinence) medication Although UI is listed as an adverse effect of many drugs in drug compendia, this mainly results from uncontrolled individual patient reports and post-marketing surveillance. Few controlled studies have used the occurrence of UI as a primary outcome, or were powered to assess the occurrence of statistically significant UI, or worsening rates against placebo. In most cases, it is therefore not possible to be sure that a drug causes UI. In patients with existing UI, particularly the elderly, it may be difficult or impossible to distinguish between the effects of medication, comorbidity or ageing on UI. Although changing drug regimens for underlying disease may be considered as a possible early intervention for UI, there is very little evidence of benefit [].

There is also a risk that stopping or altering medication may result in more harm than benefit. 4.1.1.2.1.Question In adults with UI, does adjustment of other (non-incontinence) medication improve UI compared to no change in treatment?

4.1.1.2.2.Evidence Structured literature review failed to identify any studies addressing whether adjustment of specific medications could alter existing symptoms of UI. Also, there is little evidence relating to the occurrence or worsening of UI in relation to prescription of any specific drugs. Summary of evidence LE There is very little evidence that alteration of non-incontinence medication can cure or improve symptoms of urinary incontinence.

3 Recommendations GR Take a drug history from all patients with urinary incontinence. A Review any new medication associated with the development or worsening of urinary incontinence. C 4.1.1.3.Constipation Several studies have shown strong associations between constipation and UI. Constipation can be improved by behavioural, physical and medical treatments. 4.1.1.3.1.Question Does treatment for constipation improve UI? 4.1.1.3.2.Evidence Two, large, cross-sectional population-based studies [,] and two longitudinal studies [,] showed that constipation was a risk factor for LUTS. An observational study comparing women with UI and women with pelvic organ prolapse (POP) to controls found that a history of constipation was associated with both prolapse and UI [].

One RCT found that a multimodal intervention in elderly patients, involving assisted toileting, fluid intake, etc., reduced the occurrence of UI and constipation, while behavioural therapy appeared to improve both []. In conclusion, constipation appears to be associated with UI. However, there is no evidence to show whether or not treating constipation improves UI, although both constipation and UI appear to be improved by certain behavioural interventions. Summary of evidence LE There is a consistent association between a history of constipation and the development of urinary incontinence and pelvic organ prolapse.

3 There is no consistent evidence in adults that treatment of constipation alone improves urinary incontinence. 4 Recommendation GR Adults with urinary incontinence who also suffer from constipation should be given advice about bowel management in line with good medical practice. C 4.1.1.3.3.Research priority Does the normalisation of bowel habit improve UI in patients who are constipated? 4.1.1.4.Containment Containment is important for people with UI when active treatment does not cure the problem, or when it is not available or not possible. Some individuals may prefer containment rather than undergo active treatment with its associated risks. This includes the use of absorbent pads, urinary catheters, external collection devices, penile clamps for men and intravaginal devices for women.

Studies of catheter use are not specific to patients with non-neurogenic UI. Detailed literature summaries can be found in the current ICUD monograph [] and in European Association of Urological Nurses guidance documents []. A useful resource for health care professionals and patients can be found at:.

4.1.1.4.1.Question For adults with UI, is one type of containment device better than another? 4.1.1.4.2.Evidence One RCT involving elderly women in care comparing management with pads to indwelling urethral catheter found no difference in dependency level or skin integrity score at six months []. Use of an external sheath was compared with indwelling catheterisation over 30 days in an RCT involving elderly men resident in hospital []; there were no differences in bacteriuria or symptomatic UTI but the sheath was more comfortable. A short-term (two weeks) crossover RCT in men with UI found that disease specific QoL was better when using an external sheath and more men preferred it, compared to pads []. 4.1.1.4.3.Question For men or women with UI, is one type of pad better than another? 4.1.1.4.4.Evidence A systematic review of six RCTs comparing different types of pads found that pads filled with superabsorbent material were better than standard pads, whilst evidence that disposable pads were better than washable pads was inconsistent [].

For men with light UI, a randomised crossover trial found that a leaf-shaped type of pad was preferred to rectangular pads []. A series of three crossover RCTs examined performance of different pad designs for differing populations []. For women with light UI, disposable insert pads (within washable pouch pants) were most effective. In adults with moderate/severe incontinence, disposable pull-up pants were more effective for women, whilst for men disposable diapers were more effective during the day and washable diapers at night. 4.1.1.4.5.Question For men or women with UI, is one type of catheter or external collection device better than another? 4.1.1.4.6.Evidence A Cochrane review summarised three RCTs comparing different types of long-term indwelling catheters and found no evidence that one catheter material or type of catheter was superior to another [].

A systematic review of non-randomised studies found no differences in UTI outcome or UUT changes between use of suprapubic or urethral catheter drainage; however, patients with suprapubic catheters were less likely to have urethral complications []. For people using intermittent catheterisation, a Cochrane review found no evidence that one type of catheter or regimen of catheterisation was better than another []. However, there is recent evidence from a narrative review suggesting that in certain populations using single-use catheters may reduce urethral trauma and UTI []. A Cochrane review summarising five trials comparing washout policies in adults with indwelling urinary catheters found inconsistent evidence of benefit []. A further Cochrane review summarising eight trials testing whether antibiotic prophylaxis was beneficial for adults using intermittent or indwelling catheterisation found it reduced incidence of symptomatic UTI but possible harms were not assessed []. 4.1.1.4.7.Question For men and women with UI, are external pressure devices more effective than standard treatment and is one device better than another? 4.1.1.4.8.Evidence A crossover RCT in twelve men with post-prostatectomy incontinence found a hinge-type penile clamp to be more effective than circular clamps for control of UI and that the hinge-type penile clamp was preferred by participants, although it reduced penile blood flow [].

A Cochrane review summarised seven trials comparing mechanical devices in women with UI finding limited evidence that SUI was reduced by intravaginal devices, no evidence on the effectiveness of intra-urethral devices, and that there was no difference in control of UIns between intravaginal and intra-urethral devices []. There was no difference in outcome at twelve months in women with SUI between vaginal pessary alone; pelvic floor muscle training (PFMT) alone; and vaginal pessary + PFMT, although vaginal pessary was inferior to PFMT at three months for bother from UI. Summary of evidence LE Pads are effective in containing urine. 1b Hinge-type penile clamps are more effective than circular clamps to control stress urinary incontinence in men. 2a Vaginal devices may improve stress urinary incontinence in women in selective groups. 2a Recommendations GR Ensure that adults with urinary incontinence and/or their carers are informed regarding available treatment options before deciding on containment alone.

A * Suggest use of disposable insert pads for women and men with light urinary incontinence. A * In collaboration with other healthcare professionals with expertise in urinary incontinence, help adults with moderate/severe urinary incontinence to select the individually best containment regimen considering pads, external devices and catheters, balancing benefits and harms. A * Choice of pad, from the wide variety of different absorbent materials and designs available, should be made with consideration of the individual patient’s circumstance, degree of incontinence and preference. B * Recommendation based on expert opinion. 4.1.1.4.9.Research priority To develop methods for assessing the best method of containment for individual adults with UI.

4.1.2.Lifestyle interventions Examples of lifestyle factors that may be associated with incontinence include obesity, smoking, level of physical activity and diet. Modification of these factors may improve UI. 4.1.2.1.Caffeine reduction Many drinks contain caffeine, particularly tea, coffee and cola.

Anecdotal evidence of urinary symptoms being aggravated by excessive caffeine intake has focused attention on whether caffeine reduction may improve UI. However, a cross-sectional population survey found no statistical association between caffeine intake and UI []. Lack of knowledge about the caffeine content of different drinks has made the role of caffeine reduction in alleviating UI difficult to assess. 4.1.2.1.1.Question In adults with UI, does caffeine reduction improve UI or QoL compared to no caffeine reduction? 4.1.2.1.2.Evidence Four studies were found on the effect of caffeine reduction on UI [].

They were of moderate quality and the results were inconsistent. The studies were mainly in women, so results can only be cautiously generalised to men [,]. One RCT showed that reducing caffeine intake as an adjunct to behavioural therapy resulted in reduced urgency but not reduced UI compared to behavioural therapy alone []. Another RCT found that reducing caffeine had no benefit for UI [].

A further interventional study in the elderly showed borderline significance for the benefit of reducing caffeine intake on UI []. In a large prospective cohort study there was no evidence that caffeine reduction reduced the risk of progression of UI over two years []. Summary of evidence LE Reduction of caffeine intake does not improve urinary incontinence.

2 Reduction in caffeine intake may improve symptoms of urgency and frequency. 2 4.1.2.2.Physical exercise Regular physical activity may strengthen the pelvic floor musculature and possibly decrease the risk of developing UI, especially SUI. However, it is also possible that heavy physical exercise may aggravate UI. 4.1.2.2.1.Question Does physical exercise cause, improve or exacerbate UI in adults? 4.1.2.2.2.Evidence The association between exercise and UI is unclear. Four studies [,] in differing populations concluded that strenuous physical exercise increases the risk of SUI during periods of physical activity.

There is also consistent evidence that physically active females and elite athletes experience higher levels of SUI than control populations []. On the other hand, the presence of UI may prevent women from taking exercise []. There is no evidence that strenuous exercise predisposes athletes to the development of SUI later in life []. Lower levels of UI have been observed in cohorts of women who undertake moderate exercise, but it remains unclear whether taking exercise can prevent development of UI [,]. The elderly Three RCTs in the elderly confirmed that exercise, as a component of a multidimensional regime including PFMT and weight loss, was effective in improving UI in women. It is not clear which component of such a scheme is most important [,,]. Summary of evidence LE Female athletes may experience urinary incontinence during intense physical activity but not during common activities.

3 Strenuous physical activity does not predispose for women to urinary incontinence later in life. 3 Moderate exercise is associated with lower rates of urinary incontinence in middle-aged or older women. 2b 4.1.2.3.Fluid intake Modification of fluid intake, particularly restriction, is a strategy commonly used by people with UI to relieve symptoms. Advice on fluid intake given by healthcare professionals should be based on 24-hour fluid intake and urine output measurements. From a general health point of view, it should be advised that fluid intake should be sufficient to avoid thirst and that low or high 24-hour urine output should be investigated.

4.1.2.3.1.Question In adults with UI, what is the effect of modifying fluid intake compared to not modifying fluid intake on symptoms and QoL? 4.1.2.3.2.Evidence The few RCTs [,,] provide inconsistent evidence. In most studies, the instructions for fluid intake were individualised and it is difficult to assess participant adherence to protocol.

All available studies were in women. An RCT [] showed that a reduction in fluid intake by 25% improved symptoms in patients with OAB but not UI. Personalised fluid advice compared to generic advice made no difference to continence outcomes in people receiving antimuscarinics for OAB, according to an RCT comparing drug therapy alone to drug therapy with behavioural advice []. Summary of evidence LE There is conflicting evidence on whether fluid modification improves urinary incontinence. 2 4.1.2.4.Obesity and weight loss Being overweight or obese has been identified as a risk factor for UI in many epidemiological studies [,]. There is evidence that the prevalence of both UUI and SUI increases proportionately with rising body mass index []. The proportion of patients who undergo surgery for incontinence who are overweight or obese is higher than that of the general population [].

4.1.2.4.1.Question In adults with UI, does weight loss lead to an improvement in symptoms of UI or QoL? 4.1.2.4.2.Evidence All the available evidence relates to women. Three systematic reviews plus two large RCTs concluded that weight loss was beneficial in improving UI [,,]. Five further RCTs reported a similar beneficial effect on incontinence following surgical weight reduction programmes []. Two large studies in women with diabetes, for whom weight loss was the main lifestyle intervention, showed UI did not improve but there was a lower subsequent incidence of UI among those who lost weight [,].

There have been other cohort studies and case-control studies suggesting similar effects, including surgery for the morbidly obese []. Summary of evidence LE Obesity is a risk factor for urinary incontinence in women. 1b Non-surgical weight loss in overweight and obese women improves urinary incontinence. 1a Surgical weight loss improves urinary incontinence in obese women. 1b Weight loss in obese women improves urinary incontinence.

1b Weight loss in obese adults with diabetes mellitus reduces the risk of developing urinary incontinence. 1b 4.1.2.5.Smoking Smoking cessation is now a generalised public health measure and has been shown to be weakly associated with improving urgency frequency and UI [,]. 4.1.2.5.1.Question In adults with UI, does smoking cessation improve patient outcomes regarding either urinary symptoms or QoL compared to continued smoking? 4.1.2.5.2.Evidence The effect of smoking cessation on UI was described as uncertain in a NIHR review []. Summary of evidence LE There is no evidence that smoking cessation will improve the symptoms of urinary incontinence. 4 4.1.2.6.Recommendations for lifestyle interventions Recommendations GR Encourage obese women with urinary incontinence to lose weight and maintain weight loss.

A Advise adults with urinary incontinence that reducing caffeine intake may improve symptoms of urgency and frequency but not incontinence. B Patients with abnormally high or abnormally low fluid intake should be advised to modify their fluid intake appropriately in line with good medical practice. C Counsel female athletes experiencing urinary incontinence with intense physical activity that it will not predispose them to urinary incontinence in later life. C Patients with urinary incontinence who smoke should be given smoking cessation advice in line with good medical practice. A 4.1.2.7.Research priority Which lifestyle modifications are effective for the cure or sustained improvement of UI? 4.1.3.Behavioural and Physical therapies Terminology relating to behavioural and physical therapies remains confusing because of the wide variety of ways in which treatment regimens and combinations of treatments have been delivered in different studies []. The terms are used to encompass all treatments which require a form of self-motivated personal retraining by the patient and also include techniques which are used to augment this effect.

Approaches include bladder training (BT) and pelvic floor muscle training (PFMT), but terms such as bladder drill, bladder discipline and bladder re-education and behaviour modification are also used. Almost always in clinical practice, these will be introduced as part of a package of care including lifestyle changes, patient education and possibly some cognitive therapy as well. The extent to which individual therapists motivate, supervise and monitor these interventions is likely to vary but it is recognised that these influences are important components of the whole treatment package. 4.1.3.1.Prompted voiding The term ‘prompted voiding’ implies that carers, rather than the patient, initiate the decision to void and this applies largely to an assisted care setting. Two systematic reviews (nine RCTs) [,] confirmed a positive effect on continence outcomes for prompted voiding in comparison to standard care [].

Timed voiding is defined as fixed, pre-determined, time intervals between toileting, applicable for those with or without cognitive impairment. A Cochrane review of timed voiding reviewed two RCTs, finding inconsistent improvement in continence compared with standard care in cognitively impaired adults []. 4.1.3.2.Bladder Training Bladder training (also referred to in the past as bladder drill, bladder discipline, bladder re-education, bladder retraining): A programme of patient education along with a scheduled voiding regimen with gradually adjusted voiding intervals. Specific goals are to correct faulty habit patterns of frequent urination, improve control over bladder urgency, prolong voiding intervals, increase bladder capacity, reduce incontinent episodes and restore patient confidence in controlling bladder function. The ideal form or intensity of a BT programme for UI is unclear.

It is also unclear whether or not BT can prevent the development of UI. 4.1.3.2.1.Questions In adults with UI: • Is BT better than no treatment for cure or improvement of UI? • Is BT better than other conservative treatments for cure or improvement of UI? • Does BT, as an adjunct to other conservative treatments, cure or improve UI? • Are the benefits of BT durable in the longer term?

• Are there any patient groups for whom BT is more effective? 4.1.3.2.2.Evidence There have been three systematic reviews on the effect of BT compared to standard care [,,] confirming that BT is more effective than no treatment in improving UUI. The addition of BT to anticholinergic therapy did not improve UI compared to antimuscarinics alone but it did improve frequency and nocturia []. This review identified seven RCTs in which BT was compared to drug therapy alone and showed only a benefit for oxybutynin in cure and improvement of UI []. Bladder training alone is inferior to a high-intensity programme of PFMT to improve SUI in elderly women [].

Bladder training is better than intravaginal pessaries to control SUI, although the improvement may only be short term. Whatever the method of training used, any benefit of BT on UI is likely to be of short duration unless the BT programme is practised repeatedly. No adverse events have been reported with BT. Biofeedback combined with BT increased continence rates and improved MUI in two RCTs []. Summary of evidence LE Bladder training is effective for improvement of urinary incontinence in women. 1b The effectiveness of bladder training diminishes after the treatment has ceased. 2 The comparative benefit of bladder training and drugs for the improvement of urgency urinary incontinence remains uncertain.

2 The combination of bladder training with antimuscarinic drugs does not result in greater improvement of urinary incontinence but may improve frequency and nocturia. 1b Bladder training is better than pessary alone.

1b Prompted voiding, either alone or as part of a behavioural modification programme, improves continence in elderly, care-dependent people. 1b For recommendations see section 4.1.3.5. 4.1.3.3.Pelvic floor muscle training (PFMT) Pelvic floor muscle training is used to improve function of the pelvic floor, improving urethral stability. There is some evidence that improving pelvic floor function may inhibit bladder contraction in patients with OAB []. Pelvic floor muscle training may be used to prevent UI, e.g. In childbearing women before birth, in men about to undergo radical prostatectomy, or as part of a planned recovery programme after childbirth or surgery.

Most often, PFMT is used to treat existing UI, and may be augmented with biofeedback (using visual, tactile or auditory stimuli), surface electrical stimulation or vaginal cones. 4.1.3.3.1.Question In adult men and women suffering from UI, does treatment with PFMT, given either alone or augmented with biofeedback, electrical stimulation or vaginal cones, improve or cure UI or improve QoL, compared to no treatment, sham treatment or other conservative treatments, e.g. Bladder training, electrical stimulation or vaginal cones?

4.1.3.3.2.Evidence In a recent UK Health Technology Appraisal (HTA), the role of PFMT in the care of women with SUI was analysed in a direct comparison of treatments using a mixed treatment comparison model, which compared different ‘packages’ of care []. This extensive meta-analysis reviewed data from 37 interventions and 68 direct comparisons, while the mixed treatment comparisons examined combinations of fourteen different types of intervention from 55 separate trials. The mixed treatment comparison used both indirect and direct comparisons and may provide more accurate estimates of effect. Where relevant, the Health Technology Appraisal has influenced the evidence and recommendations in these Guidelines. The Agency for Healthcare Research and Quality (AHRQ) review of nonsurgical treatment of UI in adult women also included indirect comparison methods as well as conventional meta-analysis []. 4.1.3.3.3.Efficacy of PFMT in SUI, UUI and MUI in women This question has been addressed by several systematic reviews [,,], all report inconsistency between studies because of poor reporting of technique and different outcome measures.

Meta-analysis showed that PFMT was effective for cure or improvement of incontinence, and improvement in QoL. The effect applies in women with SUI, UUI and MUI though the effect in MUI is lower than in women with pure SUI. A Cochrane review comparing different approaches to delivery of PFMT (21 RCTs) concluded that increased intensity of delivery of the therapy improves response and that there is no consistent difference between group therapy and individualised treatment sessions []. No other consistent differences between techniques were found. With regard to the durability of PFMT, another RCT reported fifteen-year follow-up outcomes of an earlier RCT, showing that long-term adherence to treatment was poor and half of patients had progressed to surgery []. Numerous systematic reviews have addressed the question of whether the effects of PFMT and BT are additive [,,]. These reviews are confounded by differences in patient selection and have arrived at conflicting conclusions leaving uncertainty about the extent to which one treatment may augment the other.

Similarly, there remains uncertainty about the additional value of biofeedback with systematic reviews reaching differing conclusions [,]. Comparison of PFMT to other treatments was extensively reviewed by both AHRQ and the 2010 UK HTA [,], which considered additional non-randomised data as part of a mixed treatment comparison. The UK HTA resulted in a number of different findings from those based solely on direct comparisons. In conclusion, the HTA, using a revised methodology, supporting the general principle that greater efficacy was achieved by adding together different types of treatment and by increasing intensity. Efficacy of PFMT in childbearing women Two systematic reviews [,] reviewed RCTs in pregnant or postpartum women, which included PFMT in one arm of the trial. Treatment of UI with PFMT in the postpartum period increased the chances of continence at 12 months’ postpartum. 4.1.3.3.4.PFMT in the elderly The effect of PFMT in women with SUI does not seem to decrease with increased age: in trials with older women with SUI it appeared both primary and secondary outcome measures were comparable to those in trials focused on younger women [,,].

4.1.3.3.5.PFMT and Radical prostatectomy A 2015 Cochrane review concluded that there was no overall benefit at twelve months post-surgery for men who received post-operative PFMT for the treatment of post-prostatectomy urinary incontinence (PPI) and that the benefits of conservative treatment of PPI remain uncertain []. A meta-analysis within this review showed that a greater proportion of men were dry from between three and twelve months suggesting that PFMT may speed recovery of continence. A subsequent study adds to this evidence []. Two additional RCTs have shown that written instructions alone offer similar levels of improvement to supervised PFMT [,].

One RCT found that PFMT was helpful in men who had been incontinent for at least one year after prostatectomy, and who had had no previous therapy []. One RCT compared PFMT to no treatment in men undergoing TURP. There was no demonstrable difference in the incidence of post-operative incontinence up to twelve months []. Summary of evidence LE Pelvic floor muscle training (PFMT) for women with urinary incontinence Pelvic floor muscle training is better than no treatment for improving urinary incontinence and QoL in women with stress urinary incontinence and mixed urinary incontinence. 1 Higher-intensity, supervised treatment regimes, and the addition of biofeedback, confer greater benefit in women receiving PFMT. 1 Short-term benefits of intensive PFMT are not maintained at fifteen-year follow-up.

2 Pelvic floor muscle training commencing in the early postpartum period improves urinary incontinence in women for up to twelve months. 1 Pelvic floor muscle training for post-prostatectomy urinary incontinence Pelvic floor muscle training appears to speed the recovery of continence following radical prostatectomy. 1b Pelvic floor muscle training does not cure urinary incontinence in men post radical prostatectomy or transurethral prostatectomy. 1b There is conflicting evidence on whether the addition of bladder training, electrical stimulation or biofeedback increases the effectiveness of PFMT alone. 2 Pre-operative PFMT does not confer additional benefit to men undergoing radical prostatectomy.

1b For recommendations see section 4.1.3.5. 4.1.3.3.6.Electrical stimulation The details and methods of delivery of electrical stimulation vary considerably. Electrical stimulation (ES) of the pelvic floor can also be combined with other forms of conservative therapy, e.g. PFMT and biofeedback.

Electrical stimulation is often used to assist women who cannot initiate contractions to identify their pelvic floor muscles. Electrical stimulation is also used in patients with OAB and UUI, for detrusor inhibition.

It has been suggested that ES probably targets the pelvic floor directly in SUI and the detrusor muscle or pelvic floor muscle or afferent innervation in UUI. Tu Mujhe Soch Kabhi Video Free Download. 4.1.3.3.7.Question In adults with UI, does treatment with ES improve or cure symptoms of UI or QoL compared to no/sham treatment or antimuscarinics? 4.1.3.3.8.Evidence Most evidence on ES refers to women with SUI. The topic has been included in two HTAs [,] and three systematic reviews [,,]. The reviews include analysis of fifteen trials and use different comparison methods, but differ in their assessment of whether ES is more effective than sham stimulation and whether ES adds to the benefit of PFMT alone. Studies were considered to be of generally low quality, with a variety of stimulation parameters, treatment regimens and outcome parameters [].

A subanalysis in a systematic review on one small low quality RCT in which ES had been compared to oxybutynin and PFMT in patients with UI, showed no difference in incontinence outcomes []. A Cochrane review of ES in men with UI (six RCTs) concluded that there was some evidence that electrical stimulation enhanced the effect of PFMT in the short-term but not after six months.

Electrical Stimulation was also more effective than sham stimulation at six, but not twelve months. There were, however, more adverse effects (pain or discomfort) with ES []. Electromagnetic stimulation has been promoted as treatment for UI but weak evidence of the short-term and long-term effects has been found in systematic reviews [,]. Summary of evidence LE In adults with urinary incontinence, electrical stimulation may improve urinary incontinence compared to sham treatment and antimuscarinics. 2 Electrical stimulation may add benefit to pelvic floor muscle training in the short-term. 2 For recommendations see section 4.1.3.5.

4.1.3.4.Posterior tibial nerve stimulation Electrical stimulation of the posterior tibial nerve (PTNS) delivers electrical stimuli to the sacral micturition centre via the S2-S4 sacral nerve plexus. Stimulation is done percutaneously with a fine, 34-G, needle, inserted just above the medial aspect of the ankle (P-PTNS). Transcutaneous stimulation is also available (T-PTNS).

Treatment cycles typically consist of twelve weekly treatments of 30 minutes. 4.1.3.4.1.Question In adults suffering from UUI, what is the clinical effectiveness of PTNS compared to sham treatment or alternative treatment such as antimuscarinic drugs?

4.1.3.4.2.Evidence P-PTNS The reviewed studies included two twelve-week RCTs of PTNS against sham treatment [,], one comparing PTNS to tolterodine, and a three-year extension trial utilising a maintenance protocol in patients with UUI [,]. The results of studies of PTNS in women with refractory UUI are consistent. Considered together, these results suggest that PTNS improves UUI in women who have had no benefit from anti-muscarinic therapy or who are not able to tolerate these drugs.

However, there is no evidence that PTNS cures UUI in women. In addition, PTNS is no more effective than tolterodine for improvement of UUI in women.

In men there is insufficient evidence to reach a conclusion about efficacy. T-PTNS A small RCT compared transcutaneous PTNS plus standard treatment (PFMT and BT) with PFMT and BT alone in older women []. Women in the T-TPNS group were more likely to achieve improvement at the end of therapy.

Summary of evidence LE Percutaneous posterior tibial nerve stimulation (P-PTNS) appears effective for improvement of urgency urinary incontinence in women who have had no benefit from antimuscarinic medication. 2b A maintenance programme of P-PTNS has been shown to be effective up to three years. 1b Percutaneous Posterior tibial nerve stimulation has comparable effectiveness to tolterodine for improvement of urgency urinary incontinence in women. 1b No serious adverse events have been reported for P-PTNS in urgency urinary incontinence. 3 There is limited evidence for effectiveness of transcutaneous posterior tibial nerve stimulation (PTNS). 2a There is no evidence that P-PTNS cures urinary incontinence. 2b 4.1.3.5.Recommendations for behavioural and physical therapies Recommendations GR Offer bladder training as a first-line therapy to adults with urgency urinary incontinence or mixed urinary incontinence.

A Offer prompted voiding for adults with incontinence who are cognitively impaired. A Offer supervised intensive pelvic floor muscle training (PFMT), lasting at least three months, as a first-line therapy to women with stress urinary incontinence or mixed urinary incontinence. A Pelvic floor muscle training programmes should be as intensive as possible. B Offer PFMT to elderly women with urinary incontinence. A Offer PFMT to post-natal women with urinary incontinence. A Consider using biofeedback as an adjunct in women with stress urinary incontinence.

B Offer PFMT to men undergoing radical prostatectomy to speed recovery of incontinence. A Do not offer electrical stimulation with surface electrodes (skin, vaginal, anal) alone for the treatment of stress urinary incontinence. A Consider offering electrical stimulation as an adjunct to behavioural therapy in patients with urgency urinary incontinence.

B Do not offer magnetic stimulation for the treatment of incontinence or overactive bladder in adult women. B Offer, if available, PTNS as an option for improvement of urgency urinary incontinence in women who have not benefitted from antimuscarinic medication. B Support other healthcare professionals in use of rehabilitation programmes including prompted voiding for elderly care-dependent people with urinary incontinence. A 4.1.4.Conservative therapy in mixed urinary incontinence About one-third of women with UI have MUI with symptoms of both SUI and UUI, and this becomes more common with increasing age. In terms of evidence base, many studies include patients with MUI, but it is rare for these studies to provide a separate analysis of patients with MUI. 4.1.4.1.Question In adults with MUI, is the outcome of conservative therapy different to that obtained with the same treatment in patients with either pure SUI or pure UUI?

4.1.4.2.Evidence No specific systematic reviews were found that addressed the above question. However, a Cochrane report on pelvic floor muscle training (PFMT) [] concluded that training was less likely to result in a cure in patients with MUI than in patients with pure SUI, though it is not clear from the report how this conclusion was reached. A small RCT (n=71) compared delivery of PFMT, with or without an instructive audiotape. It showed equal efficacy for different types of UI []. Following a RCT of PFMT, a review of 88 women available for follow-up at five years found that outcomes were less satisfactory in women with MUI than in women with pure SUI [].

Summary of evidence LE Pelvic floor muscle training appears less effective for mixed urinary incontinence than for stress urinary incontinence alone. 2 Electrical stimulation is equally effective for mixed urinary incontinence and stress urinary incontinence. 1b 4.1.4.3.Recommendations conservative therapy in mixed urinary incontinence Recommendations GR Treat the most bothersome symptom first in patients with mixed urinary incontinence. C Warn patients with mixed urinary incontinence that the chance of success of pelvic floor muscle training is lower than for stress urinary incontinence alone. B 4.2.Pharmacological management 4.2.1.Antimuscarinic drugs Antimuscarinic (anticholinergic) drugs are currently the mainstay of treatment for UUI.

They differ in their pharmacological profiles, e.g. Muscarinic receptor affinity and other modes of action, in their pharmacokinetic properties, e.g. Lipid solubility and half-life, and in their formulation. The evaluation of cure or improvement of UI is made harder by the lack of a standard definition of improvement and the failure to use cure as a primary outcome.

In general, systematic reviews note that the overall treatment effect of drugs is usually small but larger than placebo. Dry mouth is the commonest side effect, though constipation, blurred vision, fatigue and cognitive dysfunction may occur []. The immediate release (IR) formulation of oxybutynin is the archetype drug in the treatment of UUI.

Oxybutynin IR provides maximum dosage flexibility, including an off-label ‘on-demand’ use. Immediate-release drugs have a greater risk of side effects than extended release (ER) formulations because of differing pharmacokinetics. A transdermal delivery system (TDS) and gel developed for oxybutynin gives a further alternative formulation.

4.2.1.1.Question In adults with UUI, are antimuscarinic drugs better than placebo for improvement or cure of UUI and for the risk of adverse effects? 4.2.1.2.Evidence Seven systematic reviews of individual antimuscarinic drugs vs. Placebo were reviewed for this section [,] as well as studies published since these reviews up until April 2016. Most studies included patients with a mean age of 55-60 years.

Both female and male subjects were included in different studies but results cannot be generalised across sexes. Only short-term rates for improvement or cure of UUI are reported. The evidence reviewed was consistent, indicating that ER and IR formulations of antimuscarinics offer clinically significant short-term cure and improvement rates for UUI compared to placebo. On balance, IR formulations tend to be associated with more side effects compared to ER formulations []. Cure of UI was deemed to be the most important outcome measure. Risk of adverse events was best represented by withdrawal from a trial because of adverse events, although this does not reflect practice.

Table 2 shows a summary of the findings from a systematic review []. In summary, every drug where cure of UI was available shows superiority compared to placebo in achieving UI, but the absolute size of effect is small. Table 2: Summary of cure rates and discontinuation rates of antimuscarinic drugs from RCTs which reported these outcomes [] Drug No.

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