8 . management recommendations: clean …...56 . management recommendations: clean intermittent self...

�. Management recommendations: clean intermittent self catheterisation (CISC)54

8 . Management recommendations: clean intermittent self catheterisation (CISC)Section 8 has been developed using non-systematic, narrative methodology.

8 .1 OverviewThe main aims of clean intermittent self catheterisation (CISC) are to empty the bladder and prevent bladder over distension in order to avoid complications and to improve urological conditions (Cottenden, Bliss, Fader et al., 2005). Infrequent emptying leads to excessive bladder volumes, with long periods of urine stagnation. As residual urine plays a role in infection, attention must be made to complete emptying of the bladder (Cottenden, Bliss, Fader et al., 2005). It is generally recommended that total emptying be performed at least four times per day. Catheterising more than six times in 24 hours is inconvenient and should be discouraged. If catheterising six times in 24 hours still produces any single volume over 500mL, fluid intake should be investigated. Reducing fluid in the evening will minimise excessive urine volumes during the night (Heard, 2005).

When low urine volumes are produced (<1200mL per day), clients have been found to be less inclined to empty as frequently as recommended, causing stagnation and bladder distension (Heard, 2005). Clients should be advised to drink 1.5 to 2 litres of water daily (Sullivan, 2006) unless otherwise indicated.

If persistent difficulty with catheter insertion occurs, the client should be referred on for urological evaluation. In the short term, observe technique and help correct faulty insertion techniques. Catheters with alternative tip designs, (eg. Coudé, Tiemann), may be useful for difficult insertions (Heard, 2005).

8 .2 Definition of clean intermittent self catheterisationCISC is a clean, non-sterile, technique that can be used independently by the individual, a carer or clinician to facilitate emptying the bladder (Williams, 2005).

8 .3 Indications for clean intermittent self catheterisationCISC should be used where there is a clinical indication to empty the bladder and the client is unable to do so (Hirst, 2006). The June 2004 National Health Service Quality Improvement Scotland Best Practice Statement on Urinary Catheterisation and Catheter Care states that “intermittent catheterisation is the preferred alternative to indwelling catheterisation for individuals in whom bladder emptying is incomplete, providing this is safe and acceptable to them” (NHSQIS, 2004). It has fewer complications and gives a better outcome (Cottenden, Bliss, Fader et al., 2005).

CISC may be used short term or long term in a variety of circumstances, including:• Neuropathic disorders where the bladder loses the ability to empty completely, providing

that bladder capacity is sufficient, bladder pressure can be kept low and urethral resistance is high enough to maintain continence (Cottenden, Bliss, Fader et al., 2005).

• Where there is an obstruction to the outflow of urine and the bladder can’t empty itself (Hirst, 2006).

• Post operative urinary retention (Williams, 2005).• Following surgery for incontinence (colposuspension) if obstruction occurs in short or

long term (Getliffe & Dolman, 2003).• When a continent urinary diversion such as Mitrofanoff diversion is performed to create

a continent catheterisable channel into the bladder from the abdominal surface (Getliffe & Dolman, 2007).

• Following bladder substitution or augmentation (Sullivan, 2006).

Link to Section 2

Link to Appendix 3

�. Management recommendations: clean intermittent self catheterisation (CISC) 55

8 .4 Client selection criteria Physiological requirements to be met include:• Adequate bladder capacity to enable sufficient urine storage so that catheterisation can

be restricted to only every four hours (Hirst, 2006)• Adequate sphincter mechanism (Sullivan, 2006).

The person undertaking CISC must have good manual dexterity, mobility, motivation, and the ability to learn and carry out the procedure correctly (NHSQIS, 2004). As a general rule, a person who is able to write and feed him/herself has the manual dexterity to self catheterise. The presence of a disability does not necessarily preclude CISC. Indeed, success in the technique has been achieved by people with blindness, lack of perineal sensation, tremor, mental disability, and paraplegia (Getliffe & Dolman, 2007). If a person has problems with balance or hip abduction, help from a physiotherapist or other health professional is recommended (Sullivan, 2006).

8 .5 Advantages and disadvantages of clean intermittent self catheterisation Advantages of CISC include the following:• Urinary tract complications are reduced by improving bladder drainage• Continence should be achieved unless co-existing detrusor overactivity is present• Improved quality of life and empowerment through greater independence and personal

control over bladder function• Greater freedom for expression of sexuality as compared with use of an indwelling

catheter• Reduced burden on hospital and community resources, especially cost factors• Reduced common indwelling catheter associated problems, including urethral trauma,

UTI and encrustation• Improved sleep for those with nocturia and nocturnal enuresis(Getliffe & Dolman, 2007; Shaw, Logan, Webber et al., 2008; Sullivan, 2006).

Disadvantages of clean intermittent self catheterisation have been reported to include:• Difficulty finding hygienic facilities and privacy away from the home environment• The time involved in the process• Increased risk of urinary tract infections • Shorter sleep due to client staying up late for final catheterisation, and rising early for

first catheterisation in the morning• Perceived stigma and embarrassment• Fear of pain/discomfort in the early phase • Physical and technical difficulties• Disposal issues (Shaw, Logan, Webber et al., 2008).

8 .6 Complications of clean intermittent self catheterisation As with indwelling catheterisation, some complications may occur when using intermittent catheters (Cottenden, Bliss, Fader et al., 2005). These include the following: • Urinary tract infections (UTI)

If catheterisation is begun by clients with recurrent or chronic UTI and urinary retention, the incidence of infection decreases and some patients may become totally free of infection. If symptomatic infections occur, improper CISC technique often can be identified as the cause. Recurrent infection persists if the primary cause is not addressed.

�. Management recommendations: clean intermittent self catheterisation (CISC)56

• Other complications

Urethral bleeding may be seen in clients new to CISC. Trauma of the urethra may very rarely cause false passage and meatal stenosis in men. The incidence of urethral strictures increases with the number of years of CISC. Forceful manipulation during catheter insertion and significant bleeding are important contributing factors for the development of urethral strictures in clients on CISC (Cottenden, Bliss, Fader et al., 2005)

Rare complications from CISC include bladder calculi caused by introduction of pubic hair, loss of the catheter in the bladder, bladder perforation and bladder necrosis (Cottenden, Bliss, Fader et al., 2005). Clinical practice feedback indicates excessive bladder volumes (>500mL at each CISC) may also be a complication (Sullivan, 2006).

8 .7 Managing and treating complicationsFor clients using CISC, there are inconsistent findings regarding the effect of antibiotic prophylaxis on symptomatic UTI, and there is only limited evidence that receiving antibiotics reduces the rate of bacteriuria (asymptomatic and symptomatic) (Niel-Weise & van den Broek, 2005). While there is weak evidence that prophylactic antibiotics are better in terms of fewer symptomatic bacteriurias (Niel-Weise & van den Broek, 2005), there is usually no place for prophylactic antibiotics or treatment of the asymptomatic UTI (Hirst, 2006). There is, however, often a client expectation that an antimicrobial response is required, despite scant evidence in some cases to support such treatment (Brown & Nay, 2006).

The use of prophylactic antibiotics either orally or by installation poses a significant risk for the development of resistance to antibiotics. The risk of side effects from antibiotics, the expense, and the risk to other clients from cross-infection with resistant organisms are strong arguments against prophylactic antibacterials. The need for alternatives to broad spectrum antibiotic treatment should encourage further investigation of options such as ingesting large amounts of fluid to flush out harmful bacteria (Brown & Nay, 2006).

Ascorbic acid has been found to be useful only when used together with other antibacterial drugs (Cottenden, Bliss, Fader et al., 2005). Cranberry juice may inhibit Escherichia Coli from attaching to the bladder wall; however the juice may have little value in the presence of other bacteria (Brown & Nay, 2006). There is inconclusive evidence about the role cranberry juice or tablets play in preventing urinary tract infections (Cottenden, Bliss, Fader et al., 2005) and until the evidence for using cranberry juice is stronger, it should, at the very least, be used with caution. An awareness of its potential for neutral or even adverse effects needs to be brought to the attention of all health care workers (Brown & Nay, 2006).

Urethral strictures occur infrequently and can be avoided by gentle introduction of a well lubricated or hydrophilic catheter (Cottenden, Bliss, Fader et al., 2005).

Urethral trauma with false passages has been treated with six weeks of indwelling catheterisation and five days of antibiotics . The false passages disappeared and CISC was restarted . In a small study of only six people, urethral strictures were effectively treated with urethral dilatation in four cases, while two were treated with optical internal urethrotomy, followed by urethral stenting for two weeks (cited in Cottenden et al, 2005) .

Point of Interest

Link to Section 14.6


�. Management recommendations: clean intermittent self catheterisation (CISC) 5�

8 .8 Catheters - propertiesA catheter without a retention balloon is used for intermittent catheterisation (AUNS, 2006; Getliffe & Dolman, 2007; Sullivan, 2006). The catheters come in different lengths for men (approximately 40cm long) and women (approximately 22cm long).

To aid insertion, intermittent catheters are more rigid than indwelling ones. The longer length male catheters are made from PVC with variable rigidity (Sullivan, 2006), while the majority of female catheters have the same degree of rigidity. Some women, particularly those in wheelchairs, may prefer to use the longer male catheter (Sullivan, 2006).

The catheter has an eyelet on either side of the tip, and a funnel at the other end, which may help people with poor eyesight to distinguish between the two ends. The funnels are colour coded to indicate the size of the catheter. �.�.1 Catheters - size

The correct catheter diameter is the smallest size capable of providing adequate drainage. Too large a diameter can cause urethral irritation and subsequent damage. The size of the catheter can be determined by looking at the size of external meatus (Sullivan, 2006). The most common sizes are 10–12 Fg/Ch for women and 12-14 Fg/Ch for most males, with 1Fg/Ch equalling 1/3 mm (AUNS, 2006). The size of the catheter also influences how fast the bladder is drained. A smaller size catheter may be contraindicated for clients who are unwilling to spend sufficient time catheterizing, resulting in a larger post void residual volume (Hirst, 2006).

�.�.2 Catheters - lubricant

The catheters used for intermittent catheterisation are either single-use pre-lubricated catheters or polyvinyl chloride (PVC) catheters, which can be used with a water-based lubricant for men where needed (NHSQIS, 2004). Petroleum jelly is not suitable for catheter insertion (Sullivan, 2006). Hydrophilic catheters have been found to be easier to use and better tolerated by people using CISC who have had difficulties with conventional catheters (Cottenden, Bliss, Fader et al., 2005). When immersed in water, the water molecules bind to the surface so no additional lubricant is necessary. Hydrophilic catheters are more expensive than some PVC catheters and are single use only products (Sullivan, 2006). The surface of the catheter is claimed to be an important factor with less stricture development when hydrophilic catheters are used, however results are not conclusive (Cottenden, Bliss, Fader et al., 2005).

While overseas research indicates that local anaesthetic gel can be inserted 5-10 minutes before inserting the catheter (Cottenden, Bliss, Fader et al., 2005), other evidence suggests that anaesthetic gel is ineffective and is rarely used in Queensland (Hirst, 2006).

8 .9 Valsalva and Credé manoeuvresAdequate voiding can be attained by employing Valsalva and gentle Credé manoeuvre at the conclusion of catheterisation before the catheter is removed (Heard, 2005). These techniques can cause irreversible damage to the upper urinary tract if used as a primary approach to bladder emptying, or if undertaken without the catheter in place (Hirst, 2006). Therefore, discussion with the treating general medical practitioner and/or medical specialist is necessary before recommending either practice to an individual client.

The Valsalva manoeuvre (inhaling deeply and then exhaling forcefully against a closed glottis) greatly increases intra-abdominal pressure, and may enable bladder emptying by straining. In some people it also may trigger a bladder contraction. As this manoeuvre increases intracranial pressure, it only has a place at the end of catheterisation while the catheter is still in place (Hirst, 2006).

�. Management recommendations: clean intermittent self catheterisation (CISC)5�

The Credé manoeuvre, or manual expression, involves applying considerable pressure, usually with the ball of the hand, over the bladder. It assists in emptying the bladder in much the same way as use of the Valsalva technique, by raising bladder pressure or triggering a bladder contraction. These manoeuvres may be used in conjunction with the ‘double voiding’ technique, or voiding again to ensure emptying of the bladder.

8 .10 Education for use of clean intermittent self catheterisationCISC will not be successful without the client’s full cooperation, and cannot be started unless the client is willing (Sullivan, 2006). Education is very important. Clients and caregivers must understand what is wrong with the bladder/sphincter, what the cause is and why CISC is proposed for treatment. They need to learn how to catheterise correctly (Cottenden, Bliss, Fader et al., 2005).

Clean intermittent self catheterisation

Key points to cover in client education (Getliffe & Dolman, 2003; Sullivan, 2006)

• Acknowledge any anxiety before starting to teach the technique.

• Discuss the client’s bladder dysfunction and reasons for CISC.

• Discuss the technique, and issues such as how long the client will need to catheterise, any long-term effects, and the possibility of causing injury to oneself.

• Acknowledge any embarrassment at touching the genitals. Discuss personal anatomy and identification of urethral orifice.

• Be positive, optimistic, and patient, and provide encouragement at every step.

• Discuss alternatives to CISC, such as voiding techniques, IDC, surgery or drugs, continuing voiding difficulties or overflow incontinence. Indicate the advantages and disadvantages of each option.

• Discuss the possibility of initial discomfort. Taking urinary alkalinisation tablets (eg. sodium citrotartrate) and increasing water intake may help. Identify what to do if there is an infection, and who to contact if there are any problems.

• Discuss hygiene.

• Provide dietary advice for avoidance of constipation.

• Check manufacturer’s instructions for use.

• Discuss storage of new catheters including :

- Lie catheters flat, preferably in manufacturer’s box, away from heat or sunlight

- Do not bend

- Do not group with rubber bands

- Check the expiry date before use.

8 .11 Frequency of clean intermittent self catheterisationRegular, timely catheterisation prevents over-distension of the bladder, avoids incontinence whenever possible and helps to reduce infection (NHSQIS, 2004). One study found a five-fold increase in infection when CISC was done three times a day compared to six times a day (Cottenden, Bliss, Fader et al., 2005).

Frequency varies with individual needs and depends on the reasons for CISC. It is generally not necessary more than four hourly during the day – greater frequency will significantly impact on the individual’s social freedom (Hirst, 2006). Those who are in complete retention may need to catheterise five to six times a day. One author (Alderman, 1988) suggests the guideline of voided urinary volume plus residual urine should be no more than 400 -500mL (Getliffe & Dolman, 2007).

Good Practice Point

�. Management recommendations: clean intermittent self catheterisation (CISC) 5�

Where inefficient voiding leads to a gradual increase in post-void volume during the day, CISC may be needed only once a day or every couple of days. The client may choose to perform CISC before some activity that may limit access to toilet, or before sexual activity. Sleep should be as undisturbed as possible (Getliffe & Dolman, 2007), and modifying timing of fluid intake and/or use of night-time Desmopressin (DDAVP) may assist in achieving this (Fonda, DuBeau, Harari et al., 2005; Heard, 2005). However, the risks of this medication, including the reduced frequency of catheterisation, needs to be considered.

8 .12 Catheter cleaning In Australia, there are strict rules from the Therapeutics Goods Act 1989 regarding use of products in accordance with the product information. Any health professional who provides advice contrary to the manufacturer’s single use labelling may be professionally liable for any harm to the client as a result of the advice given with respect to cleaning and reuse. In a case of negligence, the health professional may be required to provide the evidence on which his/her recommendations for cleaning were based (TGA, 2006). In Australia, only one manufacturer claims to have a catheter for repeat use. All catheters should be used as per the manufacturer’s information.

A Cochrane review found no convincing evidence that any specific technique (sterile or clean), catheter type (coated or uncoated), method (single use or multiple use), person (self or other) or strategy is better than any other for all clinical settings . This reflects a lack of reliable evidence rather than evidence of no difference . Thus, clinicians must base decisions about which technique and type of catheter to use on clinical judgement, in conjunction with clients and medical practitioners . Differential costs of catheters/techniques may also inform decision making (Moore, Fader & Getliffe, 2007).

8 .13 Contraindications for clean intermittent self catheterisationUse of CISC may be contraindicated in the following circumstances (Cottenden, Bliss, Fader et al., 2005):• Spasticity interfering with catheterisation • Incontinence despite anticholinergic agents• Unhygienic environment prohibiting clean procedure• Limited dexterity• Poor technique.

• CISC is the first choice of treatment for those with an inability to empty the bladder adequately and safely.

• Proper education and teaching are necessary to permit a good outcome (Cottenden, Bliss, Fader et al., 2005).

• To prevent and reduce complications, a non-traumatising technique with adequate frequency of catheterisation and complete emptying should be strictly performed (Cottenden, Bliss, Fader et al., 2005).

• Minimal requirements for regular follow-up are history taking, physical examination, imaging, laboratory results and urodynamics tests, for early detection of risk factors and complications.

• Long-term results, cost and quality of life need to be further documented (Cottenden, Bliss, Fader et al., 2005).


Good Practice Point

Point of Interest

Link to Appendix 3

�. Management recommendations: in-dwelling catheterisation - urethral and suprapubic60

9 . Management recommendations: indwelling catheterisation - urethral and suprapubic Section 9 has been developed using non-systematic, narrative methodology.

9 .1 Indwelling catheters Indwelling urinary catheters are generally fed into the bladder via the urethra or, in the case of suprapubic, via the anterior abdominal wall. The term ‘indwelling’ implies that the catheter will remain in position for a defined period and that a balloon catheter will be used to anchor the catheter in the bladder (Oliver, 2006). Indwelling urinary catheters (urethral and suprapubic) can provide effective bladder management for either short (generally considered up to 14 days) or long periods. Indications for long term use of indwelling catheters include bladder outlet obstruction, chronic urinary retention, or restricted movements, eg. paralysis or coma (Cottenden, Bliss, Fader et al., 2005).

There are potential complications associated with long-term indwelling catheters, including urinary tract infection, bacteraemia, tissue trauma, bladder spasms, calculi and encrustation thereby necessitating effective care and monitoring within the community setting. The decision to manage bladder dysfunction by long term catheterisation should consider the quality of life and benefits against the potential risks and complications. Long term catheterisation may be the preferred management strategy for people with intractable urinary incontinence as a means of promoting quality of life (Cottenden, Bliss, Fader et al., 2005), but the probability of a catheter acquired urinary tract infection must be considered. Good hand washing is essential when providing catheter care, and the correct technique (use running water, wet hands, soap up, rinse off soap, and dry hands thoroughly with clean towel or air drier) must be followed.

Catheter materials

Silicone elastomer coated latex, hydrophilic polymer coated latex, and all silicone catheters cause minimal friction and tissue reaction, and are therefore the catheters of choice for long-term use . Hydrogels absorb aqueous fluids to produce a soft slippery surface that reduces trauma on insertion or during withdrawal of the catheter . Silicone can allow slow diffusion of water, which could lead to deflation of the balloon and the catheter falling out .

Frequency of changing the catheter depends on local catheter policy and manufacturer’s guidelines, and may be up to 12 weeks if problem-free .

Silver coating of the exterior and interior of catheters has been developed to reduce the risk of bacterial infections . Silver ions are bactericidal and non-toxic to humans . The silver may be present as a silver alloy or as silver oxide, with the silver alloy being superior in protecting against bacteriuria (Cottenden, Bliss, Fader et al., 2005).

The internal diameter of a catheter varies from brand to brand, depending on the manufacturing method. The urinary flow rate therefore depends on the internal diameter, but 12-16 Fg/Ch catheters are adequate to drain normal quantities of urine, including larger volumes produced by diuresis. Larger sizes are associated with increased bladder irritability and spasms. Small balloon sizes are recommended for all patients (10mL for adults) for reasons of comfort, reduced irritation and spasm causing possible expulsion of the inflated balloon.

�.1.1 Indwelling suprapubic catheters (SPC)

The suprapubic catheter is inserted into the bladder via a surgical incision into the anterior

Point of Interest

Link to Section 2

6161

abdominal wall (Cottenden, Bliss, Fader et al., 2005). The catheter is generally held in place by an inflated balloon. The placement of the SPC is a relatively minor procedure however there remains the remote possibility of damage to other abdominal structures during the course of placement (Oliver, 2006).

Indwelling suprapubic catheterisation may offer advantages over indwelling urethral catheterisation for the following reasons (Cottenden, Bliss, Fader et al., 2005):• Minimised risk of urethral trauma during insertion and withdrawal• Minimised risk of urethral damage and necrosis caused by the weight of poorly supported

urine collection bags, expulsion of the catheter, or sitting on the catheter (which is a particular problem for women using wheelchairs)

• Ease of catheter access for those with reduced mobility or who use a wheelchair, have restricted hip mobility or experience urethral pain

• Less impact of indwelling catheter on sexuality and sexual function, although the impact of altered body image must be considered

• Avoidance of urethritis, epididymitis or epididymo-orchitis and prostatitis in elderly men

• Management of urinary retention or voiding problems caused by prostatic obstruction or urethral stricture

• Following urethral or pelvic trauma.

The client or carer may regard the suprapubic catheter as more invasive than regular indwelling catheter. The continence clinician may need to reinforce the advantages listed above, particularly those of reduced infection, greater comfort and less restriction on sexual activities (Oliver, 2006).

Suprapubic catheter (SPC) insertion is generally contraindicated in people with hematuria of unknown origin, bladder tumour, or small contracted bladders resulting from free drainage or long term urethral catheterisation. For obese or immobile people, where the traditional stoma site may become concealed by an apron of excess anterior abdominal wall fatty tissue, the catheter should be inserted through the apron itself, not in it’s crease (Hirst, 2006).

Although the neurogenic bladder is not covered within the scope of this guideline, it is important to note that the use of SPC is controversial in this area, with some reports showing accelerated renal deterioration in people with a spinal injury, and the risk of autonomic dysreflexia at catheter change. However, there is a high level of client satisfaction with this procedure.

Not all urethral catheters are licensed for suprapubic use. Short-term catheters may be plastic, but all-silicone or coated latex catheters are the best materials for long-term suprapubic catheterisation (Cottenden, Bliss, Fader et al., 2005).

There is limited published evidence regarding frequency of catheter change, with reports varying widely from monthly to quarterly if the catheter is causing no problems (Cottenden, Bliss, Fader et al., 2005). When changing suprapubic catheters, the new one should be inserted as soon as possible after the removal of the old one, as a delay of only a few minutes can result in partial obliteration of the tract. It is important that the continence clinician discusses with the client, family and carer what happens if the SPC falls out at home. In practice, the carer may be given a catheter with the advice to replace such a catheter loss immediately and thereby preserve the tract (Hirst, 2006). Care must be taken to avoid inserting the catheter too far through the bladder and into the urethra; observing the length and angle of protrusion of the catheter prior to catheter change can help with correct positioning of the new catheter.

Some people, particularly women, may have continued urethral leakage with SPC, and therefore may require closure of the urethra (Cottenden, Bliss, Fader et al., 2005).

�. Management recommendations: in-dwelling catheterisation - urethral and suprapubic

�. Management recommendations: in-dwelling catheterisation - urethral and suprapubic62

9 .2 Complications of long term indwelling cathetersEffective care and monitoring within the community setting are key factors in preventing the risks and complications associated with long term catheterisation. Primary preventative measures may include ongoing assessment and evaluation of catheter management and drainage system, maintenance of adequate hydration, prevention of constipation, and appropriate cleansing.

Complications which may occur include catheter associated infection, tissue trauma, catheter encrustation leading to blockage, formation of calculi, histological changes, and an increased risk of bladder cancer after 5-10 years.

Catheter encrustation is a common feature affecting up to 50% of all long-term indwelling catheter users. Encrustation can occur without any infection present, and may be influenced by catheter surface properties. Heavy encrustation on the catheter tip and balloon can cause painful tissue trauma on catheter removal. The encrustation is a combination of calcium phosphates and magnesium ammonium phosphate, and is dependent on the acidity of the urine. Women with reduced mobility together with high urinary pH and ammonia concentrates are also prone to encrustation (Getliffe & Fader, 2007).

Catheter complications such as blockage and encrustation are best managed by early intervention and preventative care including monitoring of urine pH, examination of the catheter for signs of encrustation, replacement of the catheter if necessary, and ensuring adequate fixation of the catheter and drainage system to prevent trauma and facilitate drainage. Problems need to be identified early, acted upon and appropriately documented.

If a client is susceptible to recurrent catheter encrustation, aim for planned care not crisis care. Monitor the life of the catheter so a pattern of blockage can be established, and recatheterisaton can be implemented before the problem develops (Getliffe & Dolman, 2007).

Due to lack of evidence from randomised controlled trials, clear recommendations for management and treatment of encrustation in clinical practice are limited, but some strategies include oral cranberry juice/capsules, increasing fluid intake and taking urease inhibitors (Cottenden, Bliss, Fader et al., 2005). Bladder irrigation is not the preferred intervention within the community setting and should not be used as a substitute for changing the catheter if this is required. However, if other measures fail to rectify blockage then bladder irrigation may be one option. Oral acidification of urine through diet and oral medication (ascorbic acid and methenamine) is a more popular method of encrustation prevention (Getliffe & Fader, 2007).

There are potential risks associated with the incorrect instillation of irrigation fluid into the bladder for catheter blockage or encrustation, including the physical force of flushing the bladder and the type of solution used. Breakage of the closed drainage system inevitably increases the risk of introducing infection and this should be considered when determining a need for the procedure (Colpman & Welford, 2005).

Bladder irrigation with pre-boiled tap or sterile room temperature water may prevent stone and debris accumulation and may be an important element in the prevention of symptomatic infections and catheter blockages (Hirst, 2006) . Further research is required in this area . Normal saline may be used for flushing of debris and small blood clots, but it is not recommended as a suitable effective irrigation solution for catheter encrustation, due to its neutral pH (Getliffe & Fader, 2007).

On appraisal of current literature there is a lack of evidence to provide clear guidelines on bladder irrigation in the clinical setting . A systematic review protocol titled “Washout policies for the management of long-term indwelling catheterisation in adults” 2008, has been registered with The Cochrane Collaboration . Results of this research may guide the best practice for bladder irrigation .

Point of Interest

6363�. Management recommendations: in-dwelling catheterisation - urethral and suprapubic

‘Deflation cuff’ formation can be a particular problem for all-silicone suprapubic catheters, and although cuffs can form with other catheters such as hydrogel coated latex, the retention force is less than with all-silicone material. Slow deflation of the silicone balloon may be helpful, as is reinsertion of 0.5-1mL water to fill the catheter inflation lumen and eliminate the balloon cuff. Subsequent use of a lubricant with gentle removal of the catheter can reduce tissue trauma and pain.

Recommendations vary for assessment of people with catheters including a schedule of medical imaging of urinary tract, eg. cystoscopy, urinalysis, biopsy, urodynamics studies, and assessment of renal function (refer also to Table 6). However, the consensus appears to be that annual cystoscopy and/or biopsy should be instigated between 5-10 years after initial catheterisation, and suggested for people displaying hematuria or for those with chronic urinary tract infection resistant to standard therapy (Oliver, 2006).

Indwelling catheterisation

• Indwelling catheters should only be used after alternative management strategies have been considered.

• Ongoing assessment and evaluation of catheter care is the key factor in prevention of problems and risks associated with catheterisation.

• All-silicone or hydrogel-coated catheters are preferable to other materials for long-term use.

• A closed drainage system should be maintained to reduce risk of catheter-associated infection.

• Meatal cleansing by simple washing with soap and water during routine bathing or showering is recommended. Antiseptic agents are no advantage.

• Bladder irrigation and antibiotic prophylaxis are not recommended as routine infection control measures.

• The addition of disinfectants to drainage bags is not recommended as an infection control strategy.

• Asymptomatic bacteriuria should not be treated with antibiotics unless urological instrumentation is planned. All people with an IDC, especially a long term one, will have bacteruria and therefore culturing of the urine is not recommended.

• Identification of a characteristic pattern of catheter life can facilitate pre-emptive catheter changes in patients with recurrent catheter encrustation and blockage.

• Bladder cancer is a significant risk in long-term catheterised patients. Investigations should be case-specific rather than routine screening.

• If indwelling catheterisation is being considered, the suprapubic method should be considered alongside urethral catheterisation, following appropriate risk assessment.

• Suprapubic insertion should be carried out only by appropriately trained and skilled practitioners (Cottenden, Bliss, Fader et al., 2005).

9 .3 Closed drainage systemsMaintaining a sterile, continuously closed drainage system is important in the prevention of catheter-associated infection (CHRISP, 2004). A link drainage system such as attaching an overnight drainage bag to the leg bag can be used to maintain the integrity of the closed system (Schofield, 2001). Due to lack of evidence-based studies and involvement of other issues (such as cost-effectiveness), further studies on closed systems have been recommended (Dunn, Pretty, Reid et al., 2000). Clinicians are referred to the recommendations of the manufacturers and policy guidelines for each workplace.

Good Practice Point


10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches64

10 . Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approachesSection 10 has been developed using systematic review methodology.

10 .1 Outline of interventionsRecommendations in this section are divided into those for clients with cognitive impairment and those without. In general clinical practice, cognitive impairment is frequently defined by a Mini Mental State Examination (MMSE) score of 23 or below. For this guideline, relevant research studies have been systematically identified, critically appraised, the findings synthesised, and recommendations formed according to the GRADE system.

10.1.1 Interventions: people with cognitive impairment

Interventions for clients with cognitive impairment include toileting programs such as prompted voiding and habit retraining (refer to Table 12, Section 10.2). These are described in detail in Appendix 4. Timed voiding is not discussed in this guideline because research in this area involves older people in residential care rather than those living in the community. The findings therefore cannot be generalised to the target group of community-dwelling older people.

10.1.2 Interventions: people without cognitive impairment

Interventions for clients without cognitive impairment include pelvic floor muscle training (for women and for men post-prostatectomy), bladder training and a combination of approaches (refer to Table 12, Section 10.3, and Appendix 5). Additional interventions commonly used include biofeedback (pressure or electromyograph) as an adjunct to pelvic floor muscle training, and electrical stimulation. These two approaches are not explicitly considered in this guideline due to time limitations. Less common approaches include complementary therapies such as acupuncture, herbal medicine, nutritional therapy, and magnet therapy. These interventions are not considered in this guideline and the reader is encouraged to undertake evidence-based critical appraisal of the research in these areas.

A study of 771 community-dwelling men and women (mean age 82 .1 years for women and 80 .6 years for men), classified participants into two groups according to level of independence . The independent group needed help in personal, instrumental or technical daily activities less than once a week or not at all, while those who were dependent needed ADL assistance at least once per week .

The study found that, when controlled for age, the presence of both daytime frequency and nocturia was a predictor of the need for help in daily activities in both men and women . Although voiding symptoms were reported as being less bothersome than storage symptoms, both had a similar influence on daily life, causing people to avoid places and situations, to modify fluid intake and to limit social life (Stenzelius, 2006).

Link to Section 2.1 and Appendix 2

Link to Section 2

Link to Appendix 4

Link to Appendix 5

Point of Interest

656510. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches

Tabl

e 12

: Rec

omm

enda

tions

for t

oile

ting

prog

ram

s, p

elvi

c fl

oor m

uscl

e tr

aini

ng, b

ladd

er tr

aini

ng a

nd c

ombi

ned

appr

oach

es

Topi

cEv

iden

ce s

tate

men

tQ

ualit

y of

ev

iden

ce

(GR

ADE)

Rec

omm

enda

tion

and

rati

onal

e

10.2

.1 P

rom

pted

vo

idin

g an

d ha

bit r

etra

inin

g

Colli

ng, O

wen

, M

cCre

edy

et a

l.,

2003

.En

gber

g, S

erei

ka,

McD

owel

l et

al.,

2002

.Ji

rove

c &

Tem

plin

, 20

01.

Thes

e ar

ticle

s w

ere

revi

ewed

by

auth

ors

of t

his

guid

elin

e

Evid

ence

sho

ws

a lo

w

leve

l of

supp

ort

for

the

bene

fit

of t

oile

ting

prog

ram

s fo

r ol

der,

frai

l, co

mm

unity

-dw

ellin

g ad

ults

with

in

cont

inen

ce a

nd

cogn

itive

impa

irm

ent

LOW

PRO

BABL

Y D

O:

Cont

inen

ce c

linic

ians

pro

babl

y sh

ould

impl

emen

t to

iletin

g pr

ogra

ms

for

sele

cted

old

er, f

rail,

com

mun

ity-d

wel

ling

adul

ts w

ith in

cont

inen

ce a

nd

cogn

itive

impa

irm

ent,

unde

r th

e fo

llow

ing

circ

umst

ance

s:•

The

clie

nt’s

car

er h

as h

ad t

he t

oile

ting

prog

ram

exp

lain

ed f

ully

to

him

/her

, inc

ludi

ng r

ealis

tic e

stim

atio

n of

the

impa

ct o

n tim

e,

laun

deri

ng a

nd s

o on

• Th

e cl

ient

’s c

arer

is m

otiv

ated

and

has

ade

quat

e so

cial

sup

port

m

echa

nism

s in

pla

ce•

The

clie

nt’s

car

er is

will

ing

and

able

to

follo

w t

he p

roto

col

Spec

ifica

lly, t

he c

linic

ian

shou

ld:

• En

sure

tha

t th

e fi

rst

step

s in

inco

ntin

ence

man

agem

ent

have

bee

n as

sess

ed, i

.e. s

cree

ning

for

‘red

flag

s’ a

nd t

reat

ing

pote

ntia

lly

reve

rsib

le c

ondi

tions

ass

ocia

ted

with

inco

ntin

ence

(DIA

PPER

S)

(MA

SS 2

007)

• En

sure

tha

t th

e cl

ient

has

bee

n sc

reen

ed f

or s

igni

fica

nt p

ost-

void

re

sidu

al u

sing

a b

ladd

er s

can,

and

if p

rese

nt, t

hat

this

is b

eing

m

anag

ed•

Enco

urag

e th

e pr

ogra

m t

o be

com

men

ced

as e

arly

as

poss

ible

af

ter

the

diag

nosi

s of

cog

nitiv

e im

pair

men

t, in

ord

er t

o es

tabl

ish

a ro

utin

e•

Prov

ide

ongo

ing

supp

ort

and

revi

ew f

or t

he c

lient

and

the

ir c

arer

• M

onito

r th

e le

vel o

f st

rain

/bur

den

on t

he c

arer

10 .2

Inte

rven

tion

s fo

r tho

se w

ith

cogn

itiv

e im

pair

men

t

Link

to G

ood

Prac

tice

Poin

t wi

thin

Sec

tion

4.4.

8

Link

to S

ectio

n 4.

2

Link

to A

ppen

dix 2

10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches66

10.2

.1 P

rom

pted

vo

idin

g an

d ha

bit

retr

aini

ng (c

ont)

.

See

App

endi

x 4

for

spec

ific

guid

elin

es o

n im

plem

enta

tion

of t

oile

ting

prog

ram

s –

Hab

it Re

trai

ning

and

Pro

mpt

ed V

oidi

ng

Ratio

nale

:A

lthou

gh t

he li

mite

d av

aila

ble

evid

ence

doe

s no

t de

mon

stra

te b

enefi

t of

th

is in

terv

entio

n, it

is r

ecom

men

ded

for

sele

cted

clie

nts

(see

abo

ve) f

or

the

follo

win

g re

ason

s:•

The

high

eco

nom

ic a

nd p

erso

nal c

osts

of

inco

ntin

ence

to

the

com

mun

ity a

nd t

he in

divi

dual

• Th

e hi

gh b

urde

n of

inco

ntin

ence

to

the

com

mun

ity a

nd t

he

indi

vidu

al•

The

need

for

pro

activ

e ap

proa

ches

to

avoi

d or

del

ay a

dmis

sion

to

resi

dent

ial c

are

due

to in

cont

inen

ce•

The

rela

tivel

y lo

w b

urde

n an

d co

st o

f th

e in

terv

entio

n to

the

in

divi

dual

, pro

vidi

ng t

heir

car

er is

mot

ivat

ed a

nd s

uppo

rted

Topi

cEv

iden

ce s

tate

men

tQ

ualit

y of

ev

iden

ce

(GR

ADE)

Rec

omm

enda

tion

and

rati

onal

e

Link

to A

ppen

dix 4

10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches 6�

Topi

cEv

iden

ce s

tate

men

tQ

ualit

y of

ev

iden

ce

(GR

ADE)

Rec

omm

enda

tion

and

rati

onal

e

10.3

.1 P

elvi

c fl

oor

mus

cle

trai

ning

Mill

er, A

shto

n-M

iller

, &

DeL

ance

y, 1

998.

Bu

rgio

, Loc

her,

Goo

de e

t al

., 19

98.

Thes

e ar

ticle

s w

ere

revi

ewed

by

the

auth

ors

of t

his

guid

elin

e

Evid

ence

sho

ws

a ve

ry

low

leve

l of

supp

ort

for

the

bene

fit

of t

each

ing

a sp

ecifi

cally

tim

ed p

elvi

c fl

oor

mus

cle

cont

ract

ion

to a

sel

ect

grou

p of

ol

der,

frai

l, co

gniti

vely

in

tact

com

mun

ity-

dwel

ling

wom

en w

ith

inco

ntin

ence

VER

Y L

OWPR

OBA

BLY

DO

:Co

ntin

ence

clin

icia

ns p

roba

bly

shou

ld t

each

a p

elvi

c fl

oor

mus

cle

cont

ract

ion

that

is p

reci

sely

tim

ed w

ith t

he a

ctiv

ity t

hat

prov

okes

in

cont

inen

ce (e

g a

coug

h) in

a s

elec

t gr

oup

of o

lder

, cog

nitiv

ely

inta

ct

wom

en w

ith s

tres

s in

cont

inen

ce in

the

fol

low

ing

circ

umst

ance

s:•

Opp

ortu

nist

ical

ly, w

hen

perf

orm

ing

a va

gina

l exa

min

atio

n, a

nd a

n ef

fect

ive

volu

ntar

y pe

lvic

floo

r m

uscl

e co

ntra

ctio

n is

con

firm

ed;

• Th

e cl

ient

has

str

ess

inco

ntin

ence

tha

t is

ass

ocia

ted

with

par

ticul

ar

activ

ities

(eg

coug

hing

), bu

t no

t ur

ge in

cont

inen

ce a

lone

• Th

e cl

ient

doe

s no

t ha

ve a

neu

rolo

gica

l dis

orde

r

Ratio

nale

:A

lthou

gh t

he e

vide

nce

for

this

inte

rven

tion

is lo

w, i

t is

rec

omm

ende

d fo

r th

e fo

llow

ing

reas

on:

• Re

sour

ce im

plic

atio

ns (c

ost,

time

and

equi

pmen

t) ar

e in

sign

ifica

nt,

espe

cial

ly if

don

e op

port

unis

tical

ly d

urin

g a

vagi

nal e

xam

inat

ion

10 .3

Inte

rven

tion

s fo

r tho

se w

ho a

re c

ogni

tive

ly in

tact

Link

to S

ectio

n 11

an

d Ap

pend

ix 2

10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches6�

Topi

cEv

iden

ce s

tate

men

tQ

ualit

y of

ev

iden

ce

(GR

ADE)

Rec

omm

enda

tion

and

rati

onal

e

10.3

.2 B

ladd

er

trai

ning

Fant

l, W

yman

, M

cClis

h et

al.,

199

1.M

attia

sson

, Bla

akae

r, H

oye

et a

l., 2

003.

Excl

uded

stu

dies

:Ja

rvis

& M

illar

, 198

0.

Jarv

is &

Mill

ar, 1

981.

Co

lom

bo, Z

anet

ta,

Scal

ambr

ino

et a

l.,

1995

.

Thes

e ar

ticle

s w

ere

revi

ewed

by

the

auth

ors

of t

his

guid

elin

e

Ther

e is

a lo

w le

vel o

f ev

iden

ce f

or t

he b

enefi

t of

bla

dder

tra

inin

g in

old

er c

omm

unity

-dw

ellin

g, c

ogni

tivel

y in

tact

clie

nts

LOW

DO

Cont

inen

ce c

linic

ians

sho

uld

impl

emen

t a

blad

der

trai

ning

pro

gram

w

ith o

lder

com

mun

ity-d

wel

ling,

cog

nitiv

ely

inta

ct c

lient

s w

ith u

rina

ry

freq

uenc

y an

d in

cont

inen

ce

Ratio

nale

:A

lthou

gh t

he li

mite

d av

aila

ble

evid

ence

doe

s no

t de

mon

stra

te b

enefi

t of

th

is in

terv

entio

n, it

is r

ecom

men

ded

for

the

follo

win

g re

ason

s:•

The

high

eco

nom

ic c

osts

of

inco

ntin

ence

to

the

com

mun

ity a

nd t

he

indi

vidu

al•

The

high

bur

den

of in

cont

inen

ce t

o th

e co

mm

unity

and

the

in

divi

dual

• Th

e ne

ed f

or p

roac

tive

appr

oach

es t

o av

oid

or d

elay

adm

issi

on t

o re

side

ntia

l car

e du

e to

inco

ntin

ence

See

App

endi

x 5

for

spec

ific

guid

elin

es o

n ca

rryi

ng o

ut a

bla

dder

tr

aini

ng p

rogr

am

Link

to A

ppen

dix

2 an

d Ta

ble

2,

Sect

ion

2

Link

to A

ppen

dix 5

10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches 6�

Topi

cEv

iden

ce s

tate

men

tQ

ualit

y of

ev

iden

ce

(GR

ADE)

Rec

omm

enda

tion

and

rati

onal

e

10.3

.3 P

elvi

c fl

oor

mus

cle

trai

ning

co

mbi

ned

with

bl

adde

r tra

inin

g

Burg

io, G

oode

, Lo

cher

et

al.,

2002

. D

ough

erty

, Dw

yer,

Pend

erga

st e

t al

., 20

02.

Hol

teda

hl, V

erel

st, &

Sc

hiefl

oe, 1

998.

M

cDow

ell,

Engb

erg,

Se

reik

a et

al.,

199

9.Su

bak,

Que

senb

erry

, Po

sner

et

al.,

2002

. W

yman

, Fan

tl,

McC

lish

et a

l., 1

998.

Thes

e ar

ticle

s w

ere

revi

ewed

by

the

auth

ors

of t

his

guid

elin

e

Evid

ence

sho

ws

a lo

w

leve

l of

supp

ort

for

the

bene

fit

of a

com

bine

d

appr

oach

of

pelv

ic fl

oor

mus

cle

trai

ning

and

bl

adde

r tr

aini

ng in

old

er

com

mun

ity-d

wel

ling,

co

gniti

vely

inta

ct

clie

nts

LOW

DO

Cont

inen

ce c

linic

ians

sho

uld

use

a co

mbi

ned

appr

oach

of

pelv

ic fl

oor

mus

cle

trai

ning

and

bla

dder

tra

inin

g w

ith o

lder

com

mun

ity-d

wel

ling,

co

gniti

vely

inta

ct c

lient

s w

here

bot

h in

terv

entio

ns a

re a

ppro

pria

teSp

ecifi

cally

:•

Ensu

re t

hat

the

firs

t st

eps

in in

cont

inen

ce m

anag

emen

t ha

ve

occu

rred

, i.e

. scr

eeni

ng f

or ‘r

ed fl

ags’

and

tre

atin

g po

tent

ially

re

vers

ible

con

ditio

ns a

ssoc

iate

d w

ith in

cont

inen

ce (D

IAPP

ERS)

(M

ASS

200

7)•

Ensu

re t

hat

the

clie

nt h

as b

een

scre

ened

for

sig

nifi

cant

pos

t-vo

id

resi

dual

usi

ng a

bla

dder

sca

n, a

nd if

pre

sent

, tha

t th

is is

bei

ng

man

aged

Ratio

nale

:•

Ther

e is

a la

ck o

f ev

iden

ce f

or b

iofe

edba

ck p

lus

PFM

T ov

er P

FMT

alon

e in

thi

s gr

oup

• Th

ere

is e

vide

nce

at t

he le

vel o

f a

syst

emat

ic r

evie

w (a

lbei

t fr

om a

yo

unge

r ag

e gr

oup)

tha

t ad

ding

bio

feed

back

pro

vide

s no

fur

ther

be

nefi

t ov

er P

FMT

alon

e•

Vagi

nal b

iofe

edba

ck e

quip

men

t, if

ava

ilabl

e, m

ay b

e us

ed,

prov

idin

g th

at c

orre

ct p

elvi

c fl

oor

mus

cle

cont

ract

ion

has

been

co

nfirm

ed o

n va

gina

l exa

min

atio

n, a

nd t

he c

linic

ian

cont

inue

s to

mon

itor

that

cor

rect

pat

tern

of

pelv

ic fl

oor

mus

cle

cont

ract

ion

occu

rs (M

ASS

200

7). V

agin

al b

iofe

edba

ck p

robe

s ar

e fo

r si

ngle

pa

tient

use

onl

y. S

teri

lisat

ion

and

re-u

se is

not

rec

omm

ende

d

Link

to A

ppen

dix

2 an

d Ta

ble

2,

Sect

ion

2

Link

to G

ood

prac

tice

Poin

t wi

thin

Sec

tion

4.4.

8

10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches�0

Topi

cEv

iden

ce s

tate

men

tQ

ualit

y of

ev

iden

ce

(GR

ADE)

Rec

omm

enda

tion

and

rati

onal

e

10.3

.4 M

anag

emen

t of

pos

t-pr

osta

te

surg

ery

inco

ntin

ence

w

ith p

elvi

c fl

oor

mus

cle

trai

ning

Bale

s, G

erbe

r, M

inor

et

al.

2000

.Bu

rgio

, Goo

de, U

rban

et

al.

2006

.Fi

loca

mo,

Li M

arzi

, Del

Po

polo

et a

l. 20

05.

Flor

atos

, Son

ke, R

apid

ou

et a

l. 20

02.

Fran

ke, G

ilber

t, G

rier

et a

l. 20

00.

Jose

ph &

Cha

ng 2

000.

Mat

thew

son-

Chap

man

199

7.Ov

erga

rd, A

ngel

sen,

Ly

ders

en e

t al.

2008

.Po

rru,

Cam

pus,

Caria

et

al.

2001

.Va

n Ka

mpe

n 20

00.

Will

e, S

obot

tka,

H

eide

nrei

ch e

t al.

2003

.

Excl

ude

stud

ies:

Pare

kh, F

eng,

Kira

ges

et a

l. 20

03.

Thes

e ar

ticle

s w

ere

revi

ewed

by

the

auth

ors

of th

is g

uide

line

Evid

ence

sho

ws

a m

oder

ate

leve

l of

supp

ort

for

the

bene

fit

of p

elvi

c fl

oor

mus

cle

trai

ning

fol

low

ing

pros

tate

sur

gery

for

ea

rlie

r at

tain

men

t of

ur

inar

y co

ntin

ence

MO

DER

ATE

DO

Cont

inen

ce c

linic

ians

sho

uld

impl

emen

t a

pelv

ic fl

oor

mus

cle

exer

cise

pr

ogra

m a

s ea

rly

as p

ossi

ble

afte

r re

mov

al o

f th

e ca

thet

er p

ost-

pros

tate

su

rger

y. C

lose

liai

son

with

the

clie

nt’s

uro

logi

st a

nd/o

r ge

nera

l med

ical

pr

actit

ione

r sh

ould

occ

ur

Ratio

nale

:•

A p

roac

tive

appr

oach

to

cont

inen

ce is

req

uire

d w

hen

the

aim

is t

o pr

even

t or

del

ay r

esid

entia

l car

e.•

The

asso

ciat

ed c

osts

and

res

ourc

e im

plic

atio

ns a

re n

ot s

igni

fica

nt

whe

n co

mpa

red

with

the

pot

entia

l cos

t sa

ving

s •

Alth

ough

mos

t of

the

stu

dies

use

d bi

ofee

dbac

k to

tea

ch P

FMT,

it

is n

ot p

ossi

ble

to id

entif

y th

e re

lativ

e co

ntri

butio

ns o

f th

e ex

erci

ses

and

the

biof

eedb

ack

assi

stan

ce t

o th

e be

nefi

t of

the

tr

eatm

ent.

Non

e of

the

stu

dies

tha

t co

mpa

red

biof

eedb

ack-

taug

ht

PFM

T an

d ve

rbal

ly-t

augh

t PF

MT

show

ed a

dif

fere

nce

betw

een

the

two

met

hods

. Thu

s th

ere

is in

suffi

cien

t ev

iden

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his

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n •

Ther

e is

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ence

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m t

he a

vaila

ble

stud

ies

that

ele

ctri

cal

stim

ulat

ion

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fur

ther

ben

efit

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his

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an

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ix 2

10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches �1

A Cochrane review sought to assess the effectiveness of vaginal cones (Herbison, Plevnick & Mantle, 2002), and found some evidence that weighted cones are better than no active treatment in women with stress urinary incontinence . Cones may be of similar effectiveness to pelvic floor muscle therapy and electrostimulation, but this conclusion must remain tentative owing to the inadequate size of the studies reviewed, and different outcome measures used . Some women do not like using vaginal cones .

Point of Interest

11. Pelvic floor muscle rehabilitation�2

11 . Pelvic floor muscle function assessment and rehabilitationAs indicated in its title, this guideline is written for continence clinicians. Continence physiotherapists are recognised as being the ideal health professionals to undertake pelvic floor muscle function assessment and rehabilitation. If other health professionals are interested in developing their skills and knowledge in this area, they are encouraged to undertake further training.

Section 11 has been developed using non-systematic, narrative review.

11 .1 Assessment of pelvic floor muscle function11.1.1 Correct activation

A correct contraction of the pelvic floor muscles (PFM) involves an inward and upward movement of the genital openings. This can be discerned via direct observation of the perineum. The “lift” of the bladder base can also be imaged using transabdominal ultrasound. A correct contraction of the PFM avoids co-contraction of the gluteals and adductors but includes contraction of the deep abdominal muscles (transversus abdominis and internal oblique) (Sapsford, Hodges, Richardson et al., 2001). More than 30% of women do not perform a correct “lifting” contraction of the PFM when given verbal instruction (Bump, Hurt, Fantl et al., 1991). This has also been confirmed via imaging of the bladder base using transabdominal ultrasound. A study of women with incontinence and/or prolapse found only 38% were able to produce a lift of the bladder base – that is, an effective pelvic floor muscle contraction. In 43% of the women, pelvic floor muscle contraction resulted in a depression of the bladder base (Thompson & O’Sullivan 2003).

An incorrect pattern of contraction that involves a “bearing down” manoeuvre has the potential to compromise pelvic floor function (Bump, Hurt, Fantl et al., 1991). It is therefore essential to determine correct lifting pattern of contraction when providing pelvic floor muscle exercises.

11.1.2 Strength

A variety of methods for assessing the pelvic floor muscles via a digital vaginal muscle test have been documented (Bo & Sherburn, 2005). Two key differences are the use of one versus two fingers, and the scale used to record findings. It has been hypothesized that the use of two fingers in digital palpation could stretch the PFM and either inhibit their activity or conversely, increase their activity by providing increased proprioceptive feedback (Bo & Sherburn 2005). Therefore, number of fingers used in assessment should be documented and should be consistent within the one client. Health professionals are referred to their postgraduate training course content for advice on these and other issues; however, a short summary of the modified Oxford Scale, a commonly used scale, follows (table 13).

The Oxford Scale can be used for either per vaginam or per rectum assessment, and therefore in both males and females. Use of the Scale assumes a correct contraction has been verified via visual observation of perineum. Usually, the best of three maximum voluntary contractions (MVCs), held for 3-5 seconds, is recorded. This helps to negate the problem that, in some women, the first contraction is better than subsequent contractions due to fatigue, whereas in other women, subsequent contractions are better as a learning effect takes place (Bo & Sherburn 2005).

Good Practice Point

Link to Section 2

11. Pelvic floor muscle rehabilitation �3

It is important to note that grading PFM via the Oxford Scale is not appropriate for clients with pelvic or perineal pain, vaginismus or other related disorders (Frawley, 2006).

Results of studies on reliability of digital muscle testing are conflicting (Bo & Sherburn 2005). A recent study suggests that intra-therapist reliability is good for grading strength, but not endurance (Frawley, Galea, Phillips et al., 2006).

Table 13: Laycock’s modified Oxford Scale

Level Descriptor

0 No discernible muscle contraction

1 Flicker or pulsation is felt under the examiner’s finger

2 An increase in tension is detected, without any discernible lift

3 Muscle tension is further enhanced and characterized by lifting of the muscle belly and also elevation of the posterior vaginal wall. A grade 3 and stronger can be observed as an in-drawing of the perineum and anus

4 Increased tension and a good contraction are present which are capable of elevating the posterior vaginal wall against resistance (digital pressure applied to the posterior vaginal wall)

5 Strong resistance can be applied to the elevation of the posterior vaginal wall; the examining finger is squeezed and drawn into the vagina

(Laycock & Jerwood 2001)

Other documented forms of assessing pelvic floor muscle strength include MRI, EMG, vaginal dynamometers and vaginal weighted cones. The reader is referred to a summary article for more information and discussion of validity and reliability of these methods (Bo and Sherburn 2005).

11.1.2.1 Importance of position and documentation of position in assessment

Variations in body position can affect the function of the pelvic floor muscles and, therefore, assessment findings. A study comparing continent and incontinent women investigated the timing of superficial versus deep pelvic floor muscles with PFM contraction (Devreese, Staes, De Weerdt et al., 2004). Continent women, when performing a PFM contraction, were more likely to contract the superficial before the deep PFM, in contrast to incontinent women. Some timing variation was also seen in different positions. In crook lying and upright sitting, the “suboptimal” pattern of deep before superficial contraction was seen in incontinent women more often than in supine, forward-lean standing and forward-lean sitting.

Good Practice Point


A study of continent women by found that: • Vaginal squeeze pressure was highest in lying and crook lying (versus sitting and

standing) • The measured grade tended to be lower in standing versus crook lying and supine • Displacement of the pelvic floor on trans-abdominal ultrasound, however, was higher in

standing than supine and sitting • Women preferred the lying position over any upright position for digital muscle

testing.(Frawley, Galea, Phillips et al., 2006)

The traditional lying position should be used for performing a digital muscle assessment, as it is practical, as well as preferred by the client. Crook lying and supine lying may produce differing assessment findings. Therefore, the specific position in lying, including the positioning of the legs, should be recorded and kept consistent on reassessment.

Similarly, the client’s position should be recorded when assessing bladder base movement via trans-abdominal ultrasound.

11.1.2.2 Manometry

Manometry involves the use of a device commonly called a perineometer. Using a pressure sensor, the intra-vagina or intra-anal pressure is measured while performing a pelvic floor contraction. However, evidence indicates that it is the urethral pressure that is of critical relevance in measuring closure pressure (Bo & Sherburn 2005). Use of a perineometer requires precise placement of the pressure probe for test-retest reliability. Inaccurate readings may result from the use of different diameters of vaginal probe. Also, measured increases in pressure may equally reflect intra-abdominal pressure rise. Contraction of other muscles such as the hip external rotators, gluteals and adductors may affect measurement (Bo & Sherburn 2005).

While manometry may be useful in the research environment, it is unlikely to provide reliable information in the clinical setting .

11.1.3 Endurance

Muscle endurance is defined as the length of time a maximum voluntary contraction (MVC) can be sustained before strength is reduced by >35%. In the pelvic floor, this is commonly tested as the length of contraction or the number of repetitions at set intervals before fatigue. Clinically, fatigue can be accompanied by initiation of extraneous muscle contractions including adductors and gluteals (Laycock & Jerwood, 2001).

11.1.4 Displacement

Transabdominal ultrasound assessment of pelvic floor muscle function involves the use of a curved-array ultrasound probe, 3.5 or 5 MHz, placed suprapubically (either sagitally or transversely), and is undertaken to assess displacement of the bladder base during PFM contraction. It does not correlate with PFM strength (Sherburn, Murphy, Carroll et al., 2005). It is therefore not used to measure strength, but rather to confirm or teach correct contraction of the pelvic floor muscles.

Point of Interest

Good Practice Point

11. Pelvic floor muscle rehabilitation �5

Bladder base motion on transabdominal ultrasound cannot be measured from a fixed bony landmark, unlike perineal ultrasound which uses the pubic symphysis. However, bladder base motion during PFM contraction has been shown to correlate closely with bladder neck movement as measured with perineal ultrasound (Thompson, O’Sullivan, Briffa, et al, 2004a) and a lift of the bladder base on contraction of the PFM is the normal pattern of movement shown on MRI (Mikuma, Tamagawa, Morita et al., 1998).

With a correct PFM contraction, a sagittal plane view displays displacement of the posterior bladder wall in an anterocephalic direction. For reliability of the sagittal plane view, it is important that the transducer is directly in the midline, aligned with the pubic symphysis (Sherburn, Murphy, Carroll et al., 2005).

A concern with the use of transabdominal ultrasound is that a greater lift may not necessarily correlate with better PFM function, but rather, may reflect the degree of connective tissue laxity in the pelvic floor (Bo & Sherburn 2005). This technique is therefore best used to teach or confirm correct contraction; quantifying the displacement may not be clinically useful .

11.1.5 Integration with abdominal, respiratory and deep spinal muscle function

A recent study in five healthy females and one healthy male provided some indications of the role of the pelvic floor muscles in breathing and postural control (Hodges, Sapsford & Pengel, 2007). By measuring EMG response of the PFM with breathing and rapid and repetitive arm movements, the study demonstrated a number of findings. The PFM were continually (tonically) active during the breathing cycle, the PFM activity increased in preparation for the postural challenge imposed by upper limb movement, and in association with abdominal muscle activity (rather than simply with increased intra-abdominal pressure). It seems likely that the PFM have an important tonic role and an anticipatory role in postural adjustment, probably contributing to control of the spinal and pelvic joints.

Research has shown that a proportion of both continent and incontinent women demonstrate an abnormal increase in activation of chest and superficial abdominal wall muscles when attempting a pelvic floor muscle contraction (Thompson, O’Sullivan, Briffa, et al., 2004c). Women with urge incontinence and prolapse were significantly more likely to demonstrate abnormal patterns of muscle activation (Thompson & O’Sullivan, 2003; Thompson, O’Sullivan, Briffa, et al., 2004c). Increased PFM activity in women with incontinence was associated with greater activity of the external oblique abdominal muscles, resulting in increased intra-abdominal pressure (Smith, Coppieters & Hodges 2007). This effect was even greater with severe incontinence.

Assessment of pelvic floor muscle function should include assessment of breathing pattern and abdominal and respiratory muscle use.

11 .2 Treatment of pelvic floor muscle dysfunction in urinary incontinence Readers are referred to table 12, Sections 10.3.1, 10.3.3 and 10.3.4 of this guideline for a systematic review of management recommendations for pelvic floor muscle training.

Point of Interest

Good Practice Point


11.2.1 Importance of position

Variations in body position have been demonstrated to affect the function of muscles important to continence (see Section 11.1 in this guideline). The PFM are able to produce a stronger contraction in upright, unsupported sitting compared to slumped sitting (Sapsford, Richardson & Stanton 2006).

Variation in sequencing of the superficial and the deep pelvic floor muscles occurs in different positions. Continent women, unlike incontinent women, contract the superficial PFM before the deep PFM (Devreese, Staes, Janssens, et al., 2007). This pattern is more likely to occur in sitting leaning forward, standing leaning forward or lying with legs outstretched, whereas the opposite pattern is more likely to occur when lying with knees bent or sitting upright (Devreese, Staes, Janssens, et al., 2007).

Choice of body position for teaching pelvic floor muscle activation should consider research findings, as well as the client’s functional ability and the daily activities that provoke symptoms .

• Side lying should be chosen over crook lying and supine (due to tendency to recruit gluteal muscles in this position).

• While it may be easiest to gain PFM contraction in the recumbent position (supine, crook lying or side lying), the more functional upright position should be tried early, but adapted to recruit the muscles most effectively (forward-lean sitting, standing or forward-lean standing). Standing is a position used regularly by most people, so it is important to practise PMF contraction in standing, even though it has been associated with a suboptimal recruitment pattern.

• Clients demonstrating suboptimal muscle recruitment patterns or breathing patterns should practise PFME in side lying or supine with support under the knees until they master the correct pattern before progressing to upright positions.

• Slumped sitting should be avoided, and lumbar spine posture in sitting should be monitored closely when exercises are performed in sitting (see Section 11.2.2).

11.2.2 Importance of lumbar spine posture

EMG activity of transversus abdominis on contraction has been found to be greater in extension compared to a flexed lumbar spine posture (Sapsford & Hodges, 2001). Transversus abdominis activation has also been shown to produce PFM contraction (Sapsford, 2001).

Considering the evidence for interaction between muscles of the lumbar spine and the PFM, clients should avoid a flexed lumbar spine during PFME, aiming for a neutral to extended posture.

11.2.3 Functional integration with abdominal capsule

11.2.3.1 Abdominal muscle recruitment

EMG studies have shown that during a correct pelvic floor muscle contraction in lying, there is increased activation of the pelvic floor muscles and the lower fibres of internal oblique, with minimal activation of external oblique and chest wall muscles (Thompson, O’Sullivan, Briffa et al., 2004c).

Good Practice Point

Point of Interest

Good Practice Point

11. Pelvic floor muscle rehabilitation ��

Lower abdominal wall movement should not be discouraged when performing PFME. Physiotherapists may use deep abdominal muscle activation to facilitate contraction of the pelvic floor muscles where assessment has indicated suboptimal pelvic floor muscle activation.

11.2.3.2 Breathing pattern

Research has shown that a proportion of both continent and incontinent women demonstrate an abnormal increase in activation of chest and superficial abdominal wall muscles when attempting a pelvic floor muscle contraction (Thompson, O’Sullivan, Briffa, et al., 2004c).

Clients should be encouraged to maintain a normal breathing pattern when performing PFME. Features of an incorrect breathing pattern include:• Breath holding• Shallow breathing• Increased rate of breathing• Excessively deep breathing• Recruitment of accessory muscles of respiration (upper chest and neck)• Decreased abdominal wall and lower rib movement.

If the client is using an incorrect breathing pattern when performing pelvic floor muscle exercises, the correct breathing pattern should be taught.

11.2.4 Retraining motor patterns

11.2.4.1 Timing

Timing is a critical issue in pelvic floor muscle contraction. Postural activation of the PFM is delayed in women with stress urinary incontinence; in fact, in some women the activity of the muscles actually decreases just before the movement (Smith, Coppieters & Hodges 2006). Retraining of prolonged gentle (tonic) holds of the tranversus abdominis and/or the pelvic floor muscles may restore the normal pattern (Sapsford, 2001). This may need to occur prior to strength training of the pelvic floor (Sapsford, 2004).

Training of a PFM contraction prior to and during a cough has been shown to reduce incontinence in women (Miller, Ashton-Miller & DeLancey 1998). Training of PFM contraction with appropriate abdominal muscle recruitment can also occur with nose blowing, laughing and sneezing, and if relevant, with high impact activities (Sapsford, 2004).

Contemporary muscle rehabilitation focuses on retraining normal patterns of movement rather than specific muscles. For example, restoring optimal function of the lumbo-pelvic joints involves training correct stabilization strategies and movement patterns (Lee, 2004). In the same way, correct muscle activation patterns that avoid bladder descent, as identified in research, should be taught to achieve and maintain continence (Lee & Lee, 2004). These include:

• Co-activation of the deep abdominals without excessive activity of the superficial abdominals and without gluteals and adductors

• Maintenance of a diaphragmatic breathing pattern without excessive use of the accessory muscles of respiration,

• Coughing without bulging of the abdominal wall.

Good Practice Point

Good Practice Point

11. Pelvic floor muscle rehabilitation��

In addition to motor control deficits, other musculoskeletal factors contributing to incontinence should also be treated (Grewar & McLean, 2008). For example, manual compression through the pelvis has been shown to eliminate the increased descent of the bladder and pelvic floor muscles in women with sacroiliac joint pain. Specific rehabilitation of muscles of the pelvis and other strategies to restore adequate sacro-iliac joint compression may be helpful in clients with these deficits along with continence problems. Similarly, articular, muscular or fascial restrictions that contribute to postures and movement patterns that promote incontinence should be treated (Grewar & McLean, 2008).

Both motor control deficits and musculoskeletal factors that compromise the client’s continence should be treated.

11.2.5 Strength training/endurance training

Strength of the PFM is not well correlated with a decrease in incontinence episodes or decreased pad weight (Devreese, Staes, De Weerdt et al., 2004). Additionally, women with stress incontinence produce greater PFM activity with challenges to their postural control (postural perturbations) than continent women (Smith, Coppieters & Hodge, 2007).

It is clear that PFM strength is not the only factor in stress incontinence and may not even be the most important factor . However, it is often appropriate to provide clients with a PFM strength training program based on assessment findings .

When providing a strength training program for the PFM, teaching PFM contraction as opposed to transversus abdominis muscle contraction will result in a greater upward displacement of the pelvic floor, which probably represents a stronger PFM contraction (Bo, Sherburn & Allen, 2003).

Structuring a PFME program

• Teach correct activation pattern including best cue for individual client based on assessment, substitution manoeuvres to avoid, etc.

• Utilise whole abdomino-pelvic capsule concept to facilitate optimal activation patterns with other muscles for spinal and pelvic joint stabilization

• Provide appropriate positions for exercise based on client function and assessment findings. Consider using forward-lean sitting or standing, especially for clients having difficulty

• Provide recommendations for number of sessions per day, number of contractions, rest periods, number of sets – minimum 25 contractions total per day (Choi, Palmer & Park, 2007)

• Treat, or refer for treatment, conditions that may be compromising the function of PFM and/or abdominal wall or spinal muscles, including constipation and obstructed defecation, spinal or pelvic pain, etc.

• It has been suggested there be a rest interval of four seconds between contractions. Once ten contractions with ten second holds have been achieved, the rest interval should be shortened (Laycock & Jerwood, 2001).

Good Practice Point

Point of Interest

Good Practice Point

11. Pelvic floor muscle rehabilitation ��

The following summary articles provide further reading on different approaches to pelvic floor muscle assessment and treatment . • Sapsford, R . (2004) . Rehabilitation of pelvic floor muscles utilizing trunk stabilization .

Manual Therapy 9: 3-12• Grewar, H . and McLean, L . (2008) . The integrated continence system: A manual therapy

approach to the treatment of stress urinary incontinence . Manual Therapy article in press . Available online 12 March 2008

• Bo, K . and Sherburn, M . (2005) . Evaluation of female pelvic floor muscle function and strength . Physical Therapy 85: 269-282) .

11 .3 Pelvic floor muscle rehabilitation for menThere is some evidence that pelvic floor muscle rehabilitation in men is an effective form of conservative management for:

• Post prostatectomy urinary incontinence• Post micturition dribble

• Erectile dysfunction.

A smaller study of 55 men found post-micturition dribble in 36 subjects (Dorey, 2004). After three months of pelvic floor muscle exercises and three months of home exercises, 27 of the 36 subjects (75%) were cured, three (8%) improved, five (14%) dropped out and one still experienced leakage. Use of this ‘squeeze out’ technique (performing a strong contraction of the pelvic floor muscles after voiding) may facilitate a contraction of the bulbocavernosus muscle, thereby eliminating urine from the bulbar portion of the urethra.

Erectile dysfunction increases with age, with two thirds of men at the age of 70 years having this problem. A randomised control trial (n=55) has shown that after three months, subjects in the treatment group had a significant improvement in their dysfunction. It should be noted that lifestyle changes can also improve erectile dysfunction, including reducing alcohol intake, quitting smoking, reducing weight, getting fit, and avoiding saddle pressure for push-bike riders (Dorey, Speakman, Feneley et al., 2004).

A Cochrane systematic review of 17 trials of conservative management for post prostatectomy urinary incontinence found conflicting information about the benefit of pelvic floor muscle training, for either prevention or treatment of urine leakage after prostate surgery, whether for cancer or benign enlargement of the prostate (endoscopic resection). The review noted three trials that recruited pre-operatively and included all men undergoing radical prostatectomy, and suggests that men presenting with persistent urinary incontinence are a different population, who may not achieve the same level of benefit from pelvic floor muscle rehabilitation as those undergoing radical prostatectomy (Hunter, Moore & Glazener, 2007).

Another systematic review of 11 papers evaluating the effectiveness of PFMT for treating urinary incontinence after radical prostatectomy found that PFMT with or without biofeedback enhancement hastens the return to continence more than no PFMT in men with urinary incontinence after radical prostatectomy (MacDonald, Fink, Huckabay et al., 2007).

Point of Interest

Link to Sections 6.5.4 and 13

12 . Adherence issues relating to pelvic floor muscle rehabilitation managementSection 12 has been developed using non-systematic, narrative methodology.

There are a number of theories and models that underpin thinking and research in this area. This guideline does not address all of these in detail, but provides a summary of three models. Table 14 provides information on studies which address adherence in this context.

12 .1 Outline of the importance of adherence to treatmentAdherence (compliance) to programs to treat incontinence, such as a pelvic floor muscle exercise program, is important to optimise outcome. Several studies have demonstrated a relationship between adherence to continence programs and improved outcome (Bo & Talseth, 1996; Chen, Chang, Lin et al., 1999; Lagro-Jansenn, Debruyne, Smits et al., 1991; Siu, Chang, Yip et al., 2003).

12 .2 Psychosocial models to promote adherence There are numerous psychosocial models of behaviour and behaviour change. The following is a selection of models that have been cited in the pelvic floor muscle exercise literature.

12.2.1 Transtheoretical (Stages of Change) Model

The Transtheoretical Model outlines five stages through which an individual progresses to successfully change behaviour (Prochaska & DiClemente, 1983). Progression through these stages occurs at varying rates. This is not necessarily a linear process, as the individual may regress and move back into an earlier stage (Marcus, Rossi, Selby et al., 1992). The model describes ten different strategies, or ‘processes of change’ that are applied to varying degrees in each of these five stages. Using a technique that is targeted at the particular stage of behaviour change of an individual can help to promote successful behaviour change (Marcus, Rossi, Selby et al., 1992). Table 14 outlines specific strategies that can be used to promote adherence to pelvic floor muscle exercises according to the client’s stage of change.

The ten processes of change are broadly divided into experiential processes and behavioural processes. Experiential processes refer to the cognitive strategies people use, such as consciousness raising (seeking out information), while behavioural processes (taking actions) includes strategies such as counter conditioning (replacing an undesirable behaviour with a more favourable one).

The model was originally applied to addictive behaviours such as smoking (Prochaska & DiClemente, 1983) but has also been applied to exercise behaviour (Marcus, Rossi, Selby et al., 1992).

12. Adherence issues relating to pelvic floor muscle rehabilitation management�0

Link to Table 14 in this Section

Link to Section 2

Link to Table 14 inthis Section

12. Adherence issues relating to pelvic floor muscle rehabilitation management �1

Tabl

e 14

: App

licat

ion

of th

e tr

anst

heor

etic

al m

odel

to a

pel

vic

floo

r mus

cle

exer

cise

pro

gram

Sta

ge o

f cha

nge

(Pro

chas

ka &

D

iCle

men

te, 1

983)

Def

init

ion

Chan

ge p

roce

sses

to

be

used

(Mar

cus,

Ros

si,

Selb

y et

al.,

199

2)

Exam

ple

stra

tegi

es fo

r PFM

EA

dapt

ed f

rom

(Ale

wijn

se, M

este

rs, M

etse

mak

ers

et a

l., 2

002;

Mar

cus,

Sel

by, N

iaur

a et

al

., 19

92; P

roch

aska

& D

iCle

men

te, 1

983)

Pre-

cont

empl

atio

n N

ot c

urre

ntly

pr

actis

ing

the

beha

viou

r an

d no

t in

tend

ing

to

with

in s

ix m

onth

s

Less

like

ly t

han

thos

e in

oth

er

stag

es t

o us

e an

y ch

ange

pro

cess

es

Esta

blis

h ra

ppor

t w

ith c

lient

Ex

plor

e cl

ient

’s b

elie

fs a

roun

d co

ntin

ence

and

the

ir a

bilit

y to

per

form

PFM

E. A

sk

them

to

rate

how

muc

h th

eir

inco

ntin

ence

bot

hers

the

m /

10, r

ate

thei

r co

nfide

nce

in P

FME

bein

g ab

le t

o he

lp t

hem

/10

, and

the

ir c

onfi

denc

e in

bei

ng a

ble

to s

tick

to t

he p

rogr

am /

10Te

ach

fact

s, m

yths

abo

ut in

cont

inen

ce, P

FM a

nd P

FME.

Pro

vide

han

dout

s w

ith

info

rmat

ion,

dia

gram

s, d

ebun

king

myt

hsW

eigh

up

pros

and

con

s of

doi

ng P

FME

• • • •

Cont

empl

atio

nN

ot c

urre

ntly

pr

actis

ing

the

beha

viou

r bu

t in

tend

ing

to

with

in s

ix m

onth

s

Like

ly t

o us

e ex

peri

entia

l pr

oces

ses

Less

like

ly t

o us

e be

havi

oura

l pr

oces

ses

Teac

h fa

cts,

myt

hs a

bout

inco

ntin

ence

, PFM

and

PFM

E. P

rovi

de h

ando

uts

with

in

form

atio

n, d

iagr

ams,

deb

unki

ng m

yths

Wei

gh u

p pr

os a

nd c

ons

of P

FME

Expl

ore

clie

nt’s

bel

iefs

aro

und

cont

inen

ce a

nd t

heir

abi

lity

to p

erfo

rm P

FME.

Ask

th

em t

o ra

te h

ow m

uch

thei

r in

cont

inen

ce b

othe

rs t

hem

/10

, rat

e th

eir

confi

denc

e in

PFM

E be

ing

able

to

help

the

m /

10, a

nd t

heir

con

fide

nce

in b

eing

abl

e to

stic

k to

the

pro

gram

/10

Enco

urag

e cl

ient

to

iden

tify

peop

le w

ho h

ave

succ

essf

ully

inco

rpor

ated

PFM

E, o

r gi

ve c

ase

stud

ies

of p

eopl

e in

sim

ilar

circ

umst

ance

sEn

cour

age

disc

ussi

on a

bout

how

the

y w

ould

fee

l abo

ut t

hem

selv

es if

the

y w

ere

able

to

inco

rpor

ate

PFM

E in

to t

heir

live

sEn

cour

age

iden

tifica

tion

of b

arri

ers

and

solu

tions

Enco

urag

e co

nfidi

ng in

par

tner

/fri

end

and

aski

ng f

or s

uppo

rt/r

emin

ders

to d

o PF

ME

• • • • • • •


Sta

ge o

f cha

nge

(Pro

chas

ka &

D

iCle

men

te, 1

983)

Def

init

ion

Chan

ge p

roce

sses

to

be

used

(Mar

cus,

Ros

si,

Selb

y et

al.,

199

2)

Exam

ple

stra

tegi

es fo

r PFM

EA

dapt

ed f

rom

(Ale

wijn

se, M

este

rs, M

etse

mak

ers

et a

l., 2

002;

Mar

cus,

Sel

by, N

iaur

a et

al

., 19

92; P

roch

aska

& D

iCle

men

te, 1

983)

Cont

empl

atio

n (c

ont.)

Enco

urag

e ac

tive

cont

ribu

tion

to g

oal-

sett

ing

Enco

urag

e br

ains

torm

ing

appr

opri

ate

rew

ards

Giv

e ex

ampl

es o

f po

sitiv

e se

lf-t

alk

Ask

clie

nt t

o id

entif

y an

out

com

e th

at o

ccur

red

in t

heir

life

bec

ause

of

thei

r ta

king

res

pons

ibili

ty a

nd t

akin

g po

sitiv

e ac

tion

Form

a ‘c

ontr

act’

with

the

clie

ntPr

ovid

e an

d en

cour

age

use

of s

ticke

r re

min

ders

Enco

urag

e as

soci

atin

g PF

ME

with

a r

egul

ar a

ctiv

ity, s

uch

as w

ashi

ng h

ands

, ha

ving

a d

rink

, or

afte

r vo

idin

g

• • • • • • •

Prep

arat

ion

Curr

ently

pr

actis

ing

the

beha

viou

r bu

t no

t re

gula

rly

Mor

e lik

ely

to

use

beha

viou

ral

proc

esse

s th

an in

th

e pr

evio

us s

tage

Equa

lly li

kely

to

use

expe

rien

tial

proc

esse

s as

in t

he

prev

ious

sta

ge

Dis

cuss

impa

ct o

f in

cont

inen

ce o

n di

ffer

ent

aspe

cts

of li

fe. U

se o

f Q

oL

ques

tionn

aire

may

be

a us

eful

sta

rtin

g po

int

Wei

gh u

p pr

os a

nd c

ons

of r

egul

ar P

FME

Set

shor

t an

d lo

ng-t

erm

goa

lsCo

nsid

er r

ewar

ds f

or b

ehav

iour

Mak

e a

cont

ract

Ass

ess

abili

ty t

o pe

rfor

m P

FME

corr

ectly

and

cor

rect

sub

stitu

tion

patt

erns

(eg

inco

rrec

t br

eath

ing,

con

trac

tion

of in

appr

opri

ate

mus

cles

)Pr

ovid

e si

mpl

e te

chni

que

for

self

-ass

essi

ng c

orre

ct P

FME

cont

ract

ion

(eg

chec

king

nor

mal

bre

athi

ng, f

eelin

g fo

r lif

t, vi

sual

fee

dbac

k of

per

ineu

m w

ith

mir

ror)

Enco

urag

e cl

ient

to

iden

tify

peop

le w

ho h

ave

succ

essf

ully

inco

rpor

ated

PFM

E, o

r gi

ve c

ase

stud

ies

of p

eopl

e in

sim

ilar

circ

umst

ance

sD

iscu

ss h

ow o

ther

peo

ple

may

suc

cess

fully

inco

rpor

ate

PFM

E in

to d

iffe

rent

se

ttin

gs a

nd c

ircu

mst

ance

s

• • • • • • • • •

Link

to S

ectio

n 7.3


Sta

ge o

f cha

nge

(Pro

chas

ka &

D

iCle

men

te, 1

983)

Def

init

ion

Chan

ge p

roce

sses

to

be

used

(Mar

cus,

Ros

si,

Selb

y et

al.,

199

2)

Exam

ple

stra

tegi

es fo

r PFM

EA

dapt

ed f

rom

(Ale

wijn

se, M

este

rs, M

etse

mak

ers

et a

l., 2

002;

Mar

cus,

Sel

by, N

iaur

a et

al

., 19

92; P

roch

aska

& D

iCle

men

te, 1

983)

Prep

arat

ion

(con

t)En

cour

age

iden

tifica

tion

of b

arri

ers

and

solu

tions

Prov

ide

and

enco

urag

e us

e of

stic

ker

rem

inde

rsEn

cour

age

asso

ciat

ing

PFM

E w

ith a

reg

ular

act

ivity

, suc

h as

was

hing

han

ds,

havi

ng a

dri

nk, o

r af

ter

void

ing

• • •

Act

ion

Curr

ently

pr

actis

ing

the

beha

viou

r re

gula

rly,

but

has

on

ly b

egun

doi

ng

so in

the

last

six

m

onth

s

Mor

e lik

ely

to

use

expe

rien

tial

and

beha

viou

ral

proc

esse

s th

an in

th

e pr

evio

us s

tage

Enco

urag

e id

entifi

catio

n of

bar

rier

s an

d so

lutio

nsEn

cour

age

confi

ding

in p

artn

er/f

rien

d an

d as

king

for

sup

port

/rem

inde

rs t

o do

PF

ME

Enco

urag

e ac

tive

cont

ribu

tion

to g

oal-

sett

ing

Enco

urag

e br

ains

torm

ing

appr

opri

ate

rew

ards

Giv

e ex

ampl

es o

f po

sitiv

e se

lf-t

alk

Ask

clie

nt t

o id

entif

y a

posi

tive

life

outc

ome

due

to h

avin

g ta

ken

resp

onsi

bilit

y an

d po

sitiv

e ac

tion

Form

a ‘c

ontr

act’

with

the

clie

ntPr

ovid

e an

d en

cour

age

use

of s

ticke

r re

min

ders

Dis

cuss

fac

tors

tha

t ha

ve le

d to

or

coul

d le

ad t

o re

laps

eRe

-fra

me

rela

pse

in p

ositi

ve t

erm

sRe

info

rce

skill

s th

roug

h co

ntin

ued

feed

back

Rein

forc

e se

lf-e

ffica

cy t

hrou

gh e

ncou

rage

men

tTe

ach

furt

her

cues

to

mon

itor

that

the

PFM

E ar

e be

ing

perf

orm

ed c

orre

ctly

Enco

urag

e ke

epin

g an

exe

rcis

e di

ary

Prov

ide

regu

lar

cont

act

(eve

n te

leph

one)

to

prov

ide

enco

urag

emen

t an

d ch

eck

prog

ress

Dis

cuss

how

oth

er p

eopl

e m

ay s

ucce

ssfu

lly in

corp

orat

e PF

ME

into

dif

fere

nt

sett

ings

and

cir

cum

stan

ces

• • • • • • • • • • • • • • • •


Sta

ge o

f cha

nge

(Pro

chas

ka &

D

iCle

men

te, 1

983)

Def

init

ion

Chan

ge p

roce

sses

to

be

used

(Mar

cus,

Ros

si,

Selb

y et

al.,

199

2)

Exam

ple

stra

tegi

es fo

r PFM

EA

dapt

ed f

rom

(Ale

wijn

se, M

este

rs, M

etse

mak

ers

et a

l., 2

002;

Mar

cus,

Sel

by, N

iaur

a et

al

., 19

92; P

roch

aska

& D

iCle

men

te, 1

983)

Mai

nten

ance

Curr

ently

pr

actis

ing

the

beha

viou

r an

d ha

s be

en r

egul

arly

fo

r lo

nger

tha

n si

x m

onth

s

Less

like

ly t

o us

e ex

peri

entia

l pr

oces

ses,

but

st

ill li

kely

to

use

beha

viou

ral

proc

esse

s

Enco

urag

e id

entifi

catio

n of

bar

rier

s an

d so

lutio

nsRe

info

rce

skill

s, s

elf-

effi

cacy

and

sel

f-es

teem

Dis

cuss

fac

tors

tha

t ha

ve le

d to

or

coul

d le

ad t

o re

laps

e an

d st

rate

gies

to

coun

ter

them

• • •


12.2.2 Bandura’s Self-Efficacy and Social Influence Theory

The foundation of the Social Cognitive Theory, developed by Bandura, is that human beings are proactive, rather than reactive organisms shaped by environmental forces or driven by inner impulses. Human behaviour is therefore the product of a complex interplay of personal, behavioural and environmental influences. Bandura’s theory highlights the importance of the role of cognition in human behaviour. A key component influencing cognition is seen to be self-efficacy, the self-beliefs that enable the individual to exert control over their thoughts, feelings and actions. These beliefs influence the choices that people make, the amount of effort that will be expended on an activity, how long they will persevere when confronted with obstacles, and how resilient they will be in the face of adverse circumstances (Pajares, 2002).

The reader is encouraged to explore this theory further in relation to how to an increase in self efficacy can improve adherence.

12.2.3 Attitudes - Social Influence – Self-Efficacy (ASE) Model

The ASE model is based on a theory of behavioural intention rather than behavioural change, which suggests that behavioural change is best predicted by an individual’s intention to perform that behaviour. The ASE model postulates that behavioural intention is determined by three key factors: attitudes, social influences and self-efficacy expectations (Alewijnse, Mesters, Metsemakers et al., 2003). These are seen as the proximal factors that directly affect the behavioural intention, while distal factors are those which influence the proximal factors indirectly. Distal factors include socio-demographic, psychological, socio-cultural and medical variables.

In relation to intention to perform pelvic floor muscle exercises, specific proximal and distal determinants have been delineated as shown in figure 4.

Specific Proximal Factors (direct effect on behavioural intention)• Positive and negative outcome expectations regarding adherence to PFME• Perceived social norms• Modelling• Social support• Self-efficacy beliefs.

Specific Distal Factors (indirect effect on behavioural intention)• Lay beliefs about incontinence• Self-care strategies• Illness representation• Cultural norms and values• Risk perception• Prognosis• Severity of symptoms• Symptom impact.

Figure 4: Specific proximal and distal factors affecting adherence to pelvic floor muscle training

(Alewijnse, Mesters, Metsemakers et al., 2003)


According to this model, barriers can be encountered once the behaviour has commenced, and can in turn influence the three key factors of attitudes, social influences and self-efficacy expectations. Barriers to PFM training are outlined in Figure 5.

Barriers to pelvic floor muscle training:• Lack of discipline• Lack of time• Lack of energy• Forgetting to do exercises• Stressful situations• Associations with sex• Perceiving the pelvic floor as an unfamiliar body area• Difficulties integrating exercises in daily life• Fluctuations in effectiveness• Muscle pain in the bladder• Self-esteem• Body esteem• Verbal feedback or reinforcement from others.

Figure 5: Barriers to pelvic floor muscle training

(Alewijnse, Mesters, Metsemakers et al., 2002; Alewijnse, Mesters, Metsemakers et al., 2003)

12 .3 Evidence12.3.1 Factors associated with adherence

Several studies have specifically examined psychological/behavioural variables and their association with adherence to treatment programs, and table 15 summarises these studies. The reader is encouraged to assess the reliability and validity of these studies, bearing in mind that retrospective studies are less ideal than cross-sectional cohort and case series studies.

• A case-series (Kartha, 1989) that applied a prediction model of adherence to a published study of 55-90 year-old stress-incontinent women undergoing a PFME program over six months found that the ‘perception of seriousness’ of their condition was associated with increased adherence to PFME.

• A cross-sectional cohort study of 55 Taiwanese women with urinary incontinence tested the hypothesis that adherence to PFME could be predicted by five key concepts: ‘knowledge of PFME’, ‘attitudes towards PFME’, ‘partner cohesion’, ‘perceived benefits of PFME’ and ‘PFME self-efficacy’ (i.e. confidence in successfully performing PFME). Self-efficacy directly predicted both perceived adherence and adherence behaviour to PFME (Chen, 2001).

• Using the ASE model, a cross-sectional cohort study (Alewijnse, Mesters, Metsemakers et al., 2001) also found that self-efficacy (perception of ability to perform the exercises as recommended under various circumstances) predicted intention to adhere to a physiotherapy program in a sample of 129 women with urinary incontinence.

Link to Table 15, Section 12.3.3

Link to Section 12.2.3

12. Adherence issues relating to pelvic floor muscle rehabilitation management ��

12.3.2 Scales predicting adherence

Broome developed a self efficacy scale based on Bandura’s Self-Efficacy and Social Influence Theory which was tested on a sample of 125 women aged 50 and older with urinary incontinence, including a subset of women who had completed a course of behavioural treatment for their incontinence. The scale revealed that the higher the initial self-efficacy, the greater the likelihood of a positive outcome (Broome, 1999).

Similarly, Chen developed a self-efficacy scale for the performance of PFME (Chen, 2004). This scale incorporated aspects of Bandura’s Model and the Health Promotion Model (Pender & Pender, 1986). The scale was tested on 106 Taiwanese women with urinary incontinence, aged 24 to 89, who had been instructed to perform PFME for at least six weeks, and revealed a moderate correlation between the scale and the subjects’ perception of outcome; that is, the higher their self-efficacy as measured by the scale, the better they tended to perceive the outcome of their program.

People with higher self-efficacy tend to have an actual or perceived positive outcome to treatment of their incontinence .

12.3.3 Health education programs and devices to assist adherence

A number of studies have examined the effects of specific health education programs or tools as supplements to treatment for urinary incontinence, and a table summarising techniques to promote adherence is included in this section (refer table 15). The reader is encouraged to assess the reliability and validity of these studies, bearing in mind that retrospective studies are less ideal than cross-sectional cohort and case series studies.

A randomised controlled trial of 133 women with incontinence (Alewijnse, Mesters, Metsemakers et al., 2003) compared a “usual patient education and PFME program” provided by a physiotherapist to the same program supplemented with a health education program. The health education program was based on the ASE model and hence aimed to influence adherence through the mediation of attitudes, social expectations and self-efficacy. A self-help guide was used, which included reminders to exercise (eg. stickers), guidance for adherence (eg. tips to address barriers to adherence and relapse prevention strategies) and structured feedback. Data from the 23% who dropped out was not collected. The drop-out group had more severe and more frequent urinary incontinence episodes. There was no statistically significant difference found between the two groups. Intention to adhere did not significantly predict long-term adherence behaviour, a finding not in support of the ASE theory. However, short-term adherence to the program was a predictor of long-term adherence.

A quasi-randomised controlled trial (i.e. allocation by alternation rather than at random) of 48 Japanese women with stress urinary incontinence (Kim, 2001) compared the efficacy of a PFME program (control group) with the addition of a Continence Efficacy Intervention Program (treatment group). The program consisted of a pamphlet on PFM instruction, a video, a training diary, a schedule guideline, and a follow-up phone call including further education and encouragement. Adherence and improvement in condition were measured subjectively, and showed significantly better results in the treatment group.

Point of Interest


12. Adherence issues relating to pelvic floor muscle rehabilitation management��

A non-randomised controlled trial involving 46 Japanese women with stress urinary incontinence (Sugaya, Owan, Hatano et al., 2003) compared two approaches to a PFME program. The control group received a pamphlet about PFME whereas the treatment group received the pamphlet plus timer that sounded three times a day to cue the subject to perform her exercises. Its visual display indicated a rhythm to which the subject was encouraged to perform her PFME. There was no statistically significant difference between groups in number of incontinence episodes or pad use, but there was a statistically significant improvement in quality of life in the treatment group compared to the control group.

A quasi-randomised controlled trial of women with stress urinary incontinence (Gallo & Staskin, 1997) was guided by the Health Promotion Model (Pender & Pender, 1986), which highlights the importance of cues to action. The trial compared a biofeedback-assisted PFME program (control group) with the addition of an audiotape (treatment group). The audiotape contained cues for PFM contraction and ran through a PFME session. A significantly greater percentage of those in the treatment group demonstrated greater adherence to the program. Effect of adherence on continence outcomes was not reported.

Limited research of variable quality and reliability investigating factors predicting adherence to continence programs suggests the following:

• Encouraging clients to complete a bladder diary, in addition to assisting assessment and monitoring of progress, can give the clinician an indication of the client’s likelihood of adhering to treatment.

• Depression itself is a risk factor for some chronic diseases, and can affect adherence to medical regimes, the effectiveness of care, the potential speed of recovery and it may increase the risk of poor outcomes (Queensland Health strategy for chronic disease 2005-2115, 2005). Screening for depression, followed by appropriate referral is essential, as depression may predict poor adherence to continence programs.

• Clients should be fully informed of the likely outcomes of untreated urinary incontinence in order to increase understanding of the seriousness of their condition, as this may improve adherence with the program.

• Treatment programs should focus on strategies to improve the client’s self-efficacy, as this might be associated with improved adherence.

Limited research of variable quality and reliability investigating health education programs to supplement continence programs and devices to promote adherence suggests the following:

• Clients who are poorly compliant with their program in the short-term are less likely to be compliant in the long term. Clinicians should aim to identify poor adherence as early as possible and focus on strategies to improve it.

• Use of additional resources, such as pamphlets, videos, DVDs, audiotapes and training diaries, as well as follow-up support, may help improve adherence.

• Use of culturally appropriate and gender specific staff and resources.

Good Practice Point

12. Adherence issues relating to pelvic floor muscle rehabilitation management ��

Tabl

e 15

: Sum

mar

y of

stu

dies

com

pari

ng a

dher

ence

and

pel

vic

floo

r mus

cle

trai

ning

Auth

or

Kinc

ade,

Pec

kous

, &

Bus

by-

Whi

tehe

ad, 2

001

Stu

dy ty

pe

Retr

ospe

ctiv

e ca

se

serie

s

Sam

ple

98 m

en a

nd

wom

en, 5

0 ye

ars

and

over

Inte

rven

tion

Co

ntro

l

Tre

atm

ent

Non

e st

ated

Bi

ofee

dbac

k-as

sist

ed P

FME

Sig

nific

ant

adhe

renc

e fa

ctor

s

Com

plet

ion

of 7

day

bl

adde

r dia

ry

Non

-sig

nific

ant

adhe

renc

e fa

ctor

s Age

, gen

der,

educ

atio

n,

race

, inc

ontin

ence

re

late

d va

riabl

es,

dist

ance

clie

nt tr

avel

led

to c

linic

, ref

erra

l sou

rce,

pr

evio

us tr

eatm

ent,

num

ber o

f co-

mor

bidi

ties,

pres

crip

tion

med

icin

es

Kart

ha, 1

989

Case

stu

dy

serie

s ap

plyi

ng a

pr

edic

tion

mod

el

of a

dher

ence

55-9

0 ye

ar o

ld

stre

ss in

cont

inen

t w

omen

Non

e st

ated

Un

derg

oing

PFM

E pr

ogra

m o

ver 6

m

onth

s

Perc

eptio

n of

se

rious

ness

Shis

hani

, 200

3 Re

tros

pect

ive

stat

istic

al a

naly

sis

of ra

ndom

ised

co

ntro

lled

tria

ls

Non

e st

ated

Incr

ease

d fr

eque

ncy

of u

rinar

y le

akag

e ep

isod

es a

t bas

elin

e

Few

er d

epre

ssed

sy

mpt

oms

at b

asel

ine

Age

, mob

ility

leve

l, us

e of

hor

mon

e th

erap

y or

di

uret

ics,

hom

ebou

nd

stat

us, c

areg

iver

sta

tus,

livin

g ar

rang

emen

ts,

dura

tion

of u

rinar

y in

cont

inen

ce


Auth

or

Chen

, 200

1

Stu

dy ty

pe

Cros

s-se

ctio

nal

coho

rt s

tudy

Sam

ple

55 T

aiw

anes

e w

omen

with

ur

inar

y in

cont

inen

ce

Inte

rven

tion

Co

ntro

l

Tre

atm

ent

Sig

nific

ant

adhe

renc

e fa

ctor

s

PFM

E se

lf ef

ficac

y,

nam

ely

confi

denc

e in

suc

cess

fully

pe

rfor

min

g PF

ME

Non

-sig

nific

ant

adhe

renc

e fa

ctor

s Kn

owle

dge

of P

FME

Atti

tude

s to

war

ds P

FME

Part

ner c

ohes

ion

Perc

eive

d be

nefit

s of

PF

ME

Broo

me,

199

9 Se

lf ef

ficac

y sc

ale

base

d on

Ba

ndur

a’s

self

effic

acy

and

soci

al

influ

ence

theo

ry

125

aged

50

and

olde

r with

urin

ary

inco

ntin

ence

, in

clud

ing

a su

bset

of

wom

en w

ho

had

com

plet

ed

a be

havi

oura

l tr

eatm

ent f

or

inco

ntin

ence

The

high

er th

e in

itial

se

lf ef

ficac

y, th

e gr

eate

r the

like

lihoo

d of

a p

ositi

ve o

utco

me

Ale

wijn

se, M

este

rs,

Met

sem

aker

s et

al.,

20

01

Cros

s-se

ctio

nal

coho

rt s

tudy

12

9 w

omen

w

ith u

rinar

y in

cont

inen

ce

Non

e st

ated

Ph

ysio

ther

apy

prog

ram

Se

lf ef

ficac

y (p

erce

ptio

n of

ab

ility

to p

erfo

rm

the

exer

cise

s as

re

com

men

ded

unde

r var

ious

ci

rcum

stan

ces)

Chen

, 200

4Se

lf ef

ficac

y sc

ale

106

Taiw

anes

e w

omen

with

ur

inar

y in

cont

inen

ce a

ged

24 –

89

year

s

Non

e st

ated

PF

ME

for a

t lea

st

6 w

eeks

Th

e hi

gher

the

perc

eptio

n of

sel

f ef

ficac

y, th

e be

tter t

he

perc

eive

d ou

tcom

e.


Auth

or

Ale

wijn

se, M

este

rs,

Met

sem

aker

s et

al.,

20

03

Stu

dy ty

pe

Rand

omis

ed

cont

rol t

rial

Sam

ple

133

wom

en w

ith

inco

ntin

ence

Inte

rven

tion

Co

ntro

l

Tre

atm

ent

Usua

l pat

ient

ed

ucat

ion

and

PFM

E pr

ogra

m

prov

ided

by

a ph

ysio

ther

apis

t

As

for c

ontr

ol b

ut

supp

lem

ente

d w

ith

a he

alth

edu

catio

n pr

ogra

m b

ased

on

ASE

mod

el

Sig

nific

ant

adhe

renc

e fa

ctor

s

Shor

t ter

m a

dher

ence

w

as a

pre

dict

or to

lo

ng te

rm a

dher

ence

Non

-sig

nific

ant

adhe

renc

e fa

ctor

s In

tent

ion

to a

dher

e

Suga

ya, O

wan

, H

atan

o et

al.,

200

3 N

on-r

ando

mis

ed

cont

rolle

d tr

ial

46 J

apan

ese

wom

en w

ith

stre

ss u

rinar

y in

cont

inen

ce

Pam

phle

t abo

ut

PFM

EPa

mph

let p

lus

devi

ce to

impr

ove

adhe

renc

e to

th

e pr

ogra

m

Stat

istic

ally

si

gnifi

cant

im

prov

emen

t in

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13. Containment management of urinary incontinence�2

13 . Containment management of urinary incontinenceDespite the best treatment of bladder and bowel problems, incontinence commonly persists. While improving and/or regaining continence should be the ultimate goal, the appropriate selection and use of continence aids can make incontinence more manageable and comfortable, and boost confidence and self-esteem. Prescription of continence aids should follow a thorough continence assessment, appropriate interventions and management (Miller & Burgin, 2008).

The selection of continence aids should be carried out using a problem solving approach. Health professionals assessing continence problems should be aware of the many choices available and ensure clients receive comprehensive advice when selecting and fitting continence aids to ensure optimal outcomes. Manufacturers are continually updating and developing new products and it is essential that health professionals regularly update their knowledge (Miller & Burgin, 2008).

To ensure prescription of the most appropriate continence aid after the comprehensive assessment, management, and review of management outcomes, product selection should consider the following points: • Volume lost in incontinence episodes • Diurnal pattern of urinary incontinence• Ease of use and disposal• Client preference• Cost.

When choosing a product the EASE mnemonic may assist:• E - effect of the product to contain odour and urine/faeces• A - appropriateness for client/carer• S - safety of product for client• E - effective cost considerations.

A booklet titled “Continence products: personal characteristics and specific considerations when selecting continence products” may assist clinicians when considering the functional implications of most of the commonly prescribed continence products (MASS 2007b).

Referral to an occupational therapist for a detailed functional assessment should be considered, as other health professionals will not have the necessary knowledge and skills to assess a client’s full functional ability .

Increased awareness of functional aspects of continence promotion can often solve the environmental and functional issues that are causing or contributing to the incontinence . This includes assisting with the best method of applying and removing the continence aid .

13 .1 Skin health and continence productsThe healthy skin has a protective acid mantle, with a pH of between 5.4 – 5.9 (Ersser, Getliffe, Voegeli et al., 2005). With incontinence, decomposition of urinary urea by micro-organisms release ammonia to form the alkali, ammonium hydroxide. Chemical irritation of the skin may arise from both the rise in alkalinity and bacterial proliferation (Ersser, Getliffe,

Point of Interest

13. Containment management of urinary incontinence �3

Voegeli et al., 2005). The combination of urine and faeces causes significantly higher levels of irritation than urine or faeces alone, since the presence of faecal urease results in the breakdown of urinary urea causing an increase in pH to 8.0 or higher, which increases the activities of faecal proteases and lipases (Ersser, Getliffe, Voegeli et al., 2005; Gray, Bliss, Erner-Seltun et al., 2007; Gray, Ratliff & Donovan, 2002). Liquid stool tends to be richer in digestive enzymes, which, when combined with its elevated water content, is particularly damaging to the skin (Gray, Bliss, Erner-Seltun et al., 2007).

Prolonged exposure to water alone has been shown to cause hydration dermatitis, and prolonged occlusion of the skin (as with a continence product) reduces skin barrier function and significantly raises microbial counts and pH (Ersser, Getliffe, Voegeli et al., 2005; Gray, Bliss, Erner-Seltun et al., 2007). Even in the absence of incontinence, prolonged exposure of the perineal skin to perspiration under an incontinence containment brief raises the local pH to approximately 7.1, increasing the risk for irritant dermatitis (Gray, Ratliff & Donovan, 2002). Prolonged occlusion of the skin under an absorptive incontinence product for five days has been shown to increase sweat production and compromise barrier function, resulting in elevated trans-epidermal water loss, CO2 emission, and pH (Gray, Bliss, Erner-Seltun et al., 2007).

Use of containment aids increases susceptibility to over-hydration and elevated skin temperatures, both of which compromise the skin barrier (Lekan-Rutledge, Doughty, Moore, et al., 2003), and contribute to incontinence associated dermatitis (Gray, Bliss, Erner-Seltun et al., 2007). Excess moisture on the skin will eventually produce mechanical change. Twice as much energy is required to produce frictional erosions on dry skin as on skin subjected to 24 hour water exposure (Farage, Miller, Berardesca et al., 2007). Skin hydration following occlusion is significantly higher and slower to dissipate in aged skin (Farage, Miller, Berardesca et al., 2007). Thus, continence aids should be firmly fitting but not too tight, to avoid an occlusive environment (Lekan-Rutledge, Doughty, Moore, et al., 2003), be sufficiently absorbent to draw urine away from the skin and lock it into the core of the pad, and should be changed before they become sodden (Ersser, Getliffe, Voegeli et al., 2005; Nazarko, 2007).

With urinary incontinence, dermatitis begins between the labial folds in women, or the scrotum in men (Farage, Miller, Berardesca et al., 2007; Gray, Bliss, Erner-Seltun et al., 2007), while dermatitis associated with faecal incontinence originates in the perianal area (Farage, Miller, Berardesca et al., 2007; Gray, Bliss, Erner-Seltun et al., 2007) and progresses to the posterior aspect of the upper thighs. Unusual patterns may reflect occlusion of the skin by a containment device (Farage, Miller, Berardesca et al., 2007). The prevention of perineal dermatitis or the restoration of perineal skin integrity and prevention of recurrent damage are of critical consideration in management of urinary and/or faecal incontinence (Lekan-Rutledge, Doughty, Moore, et al., 2003).

Three key factors contribute to incontinence associated dermatitis:

• Tissue tolerance: affected by age, health status, nutritional status, oxygenation, perfusion and core body temperature

• Perineal environment: affected by the character of the incontinence (urinary, faecal or double incontinence), the volume and frequency of incontinence, mechanical chafing, introduced agents such as allergens or irritants, and factors that compromise the skin’s barrier function such as hydration, pH, faecal enzymes, and fungal or bacterial pathogens

• Toileting ability: mobility, sensory perception, cognitive awareness (Brown, 1995, cited in Gray, Bliss, Erner-Seltun et al., 2007).

Points of Interest


Active preventative care to maintain skin health is essential, including cleansing, moisturising and protecting skin . The best measures to prevent skin breakdown are by initial thorough assessment and a consistent approach to client and carer education with ongoing review (Lekan-Rutledge, Doughty, Moore, et al., 2003).

13.1.1 The perineal assessment tool

The perineal assessment tool has undergone content validation and may be used to assess incontinence associated dermatitis risk. However, as it has not been extensively used in research or clinical setting, it should be used in conjunction with regular, descriptive assessments of skin folds within the perineum, the lower abdomen, between the buttocks and adjacent skin folds of the inner thighs, scrotum and labia majora.

Table 16: The perineal assessment tool (Nix, 2002)

Factors Descriptor Score

Type and intensity of irritant Formed stool and/or urineSoft stool with or without urineLiquid stool with or without urine

012

Duration of irritant Linen/pad change at least every 2 hours or lessLinen/pad change at least every 4 hours or lessLinen/pad change at least every 8 hours or less

0

1

2

Perineal skin condition Clear and intactErythema/dermatitis with or without candidiasisDenuded/eroded skin with or without dermatitis

01

2

Contributing factors (low albumin, antibiotics, tube feeding, bacterial infections causing diarrhoea)

0 – 1 contributing factor2 contributing factors3 or more contributing factors

012

Calculate the cumulative score: higher scores indicate a greater risk for incontinence associated dermatitis. Cited in Gray, Bliss, Erner-Seltun et al., 2007

13.1.2 Types of skin products

Moisturisers are substances designed to soften and increase the pliability of the stratum corneum by increasing its hydration. Moisturisers containing occlusives and humectants can effectively repair the damaged stratum corneum. Barrier enhancing skin cleansers and moisturisers can both maintain and aid in the restoration of skin health. Petrolatum-depositing liquid cleansers offer therapeutic solutions for both diseased and healthy skin (Schwartz, Centurion & Draelos, 2008), while those containing humectants such as glycerin, lanolin or mineral oil, replace oils in the skin and promote its effectiveness as a moisture barrier. Moisturisers can be applied as a separate step in perineal skin care, but many are combined with perineal skin cleansers (Gray, Ratliff & Donovan, 2002).

Humectants attract water when applied to the skin, and include glycerin, sorbitol, urea, alpha hydroxy acids (AHAs) and sugars (Schwartz, Centurion & Draelos, 2008).

Points of Interest cont .

13. Containment management of urinary incontinence �5

Emollients are soothing to the skin or the mucous membrane. They smooth roughened skin, lubricate, replace natural skin lipids, and provide occlusion. Emollients are comprised of water in oil emulsions, so oil is the largest component. The oil concentration affects the ease of spreading and degree of occlusion required (Schwartz, Centurion & Draelos, 2008).

Lubricants reduce friction, heat or wear when introduced as a film between solid surfaces (Schwartz, Centurion & Draelos, 2008).

Occlusives (also referred to as moisture barriers or skin protectants), physically block the surface of the stratum corneum from exposure to irritants or moisture, and reduce trans-epidermal water loss. They have an emollient effect. Petrolatum is the principal ingredient used in occlusive formulations (Schwartz, Centurion & Draelos, 2008), with other active ingredients including dimethicone, lanolin and zinc oxide (Gray, Ratliff & Donovan, 2002). Hoggarth (2005) found that the most effective barriers are those that contained zinc oxide, followed by water-in-oil and non-aqueous based formulations. The least effective barrier product is an oil-in-water based formulation (Hoggarth, Waring, Alexander et al, 2005). A moisture barrier may be incorporated into skin cleansers or applied separately as a cream or ointment (Gray, Ratliff & Donovan, 2002). Alternatives to occlusives include:• Powders, which absorb excessive moisture and reduce friction and erosion when applied

to opposing skin surfaces. Cornstarch is preferred to talcum powder, because using talc powders in perineal area may increase risk of invasive ovarian cancer (Gray, Ratliff & Donovan, 2002). Powders should only be applied as a light dusting. Caking exacerbates, rather than relieves, friction and erosion produced when skin folds in the perineum move against one another (Gray, Ratliff & Donovan, 2002).

• Pastes, which are ointments with powder added for durability. A barrier paste may be used if extensive perineal skin erosion is producing exudate. Pastes absorb excess drainage and block exposure to irritants. Zinc oxide is common ingredient in barrier pastes. It is important to use an appropriate product such as mineral oil to remove pastes, as otherwise vigorous scrubbing may be required (Gray, Ratliff & Donovan, 2002).

• Liquid barrier films (skin sealants) comprise a polymer combined with a solvent (usually alcohol). The solvent evaporates on skin, and polymer dries to form a barrier. Use judiciously, as alcohol may be irritating or locally cytotoxic to compromised perineal skin. A liquid film barrier should not be used with a barrier cream or paste because the products are often incompatible (Gray, Ratliff & Donovan, 2002).

13.1.3 Prevention of incontinence associated dermatitis (IAD)

• Cleanse skin gently with a pH neutral product to remove irritants and pathogens. Cleansing agents should be pH balanced and contain surfactants to emulsify stool and lift irritants from the skin surface with minimal force. Added fragrances may contribute to allergic contact dermatitis (Gray, Bliss, Erner-Seltun et al., 2007; Lekan-Rutledge, Doughty, Moore, et al., 2003)

• Moisturisers contain emollients that penetrate the skin to restore lipids, and humectants to bind moisture at the epidermal level. Some cleanser products contain moisturisers (Gray, Bliss, Erner-Seltun et al., 2007; Lekan-Rutledge, Doughty, Moore, et al., 2003).

• Routine use of a skin protectant is recommended for those at risk of incontinence associated dermatitis, including those experiencing high volume or frequent incontinence, or those with double urinary and faecal incontinence. Moisture barriers to protect the skin against irritants and moisture, by providing a water-repellent coating to the skin. Many clinicians advocate application of products that incorporate a skin protectant into a one-step cleansing solution or system, thus reducing the time required to adequately cleanse and protect the perineal and perigenital skin, particularly in residential care settings (Gray, Bliss, Erner-Seltun et al., 2007; Lekan-Rutledge, Doughty, Moore, et al., 2003).


13.1.3.1 Cleansing

Repetitive cleansing increases the rate at which the epidermal cells and surface lipids are removed. This compromises skin barrier properties and increases the risk of dermatitis, particularly in older people, whose risk is higher due to thinning of the epidermis and reduced production of skin lipids. Repetitive cleansing and exposure to alkaline urine or stool can also disrupt the skin’s acid mantle (Lekan-Rutledge, Doughty, Moore, et al., 2003).

Soap is made from a mixture of alkalis and fatty acids, and tends to have a higher pH than that of normal skin. Its ability to cleanse the skin requires decomposition in water releasing free alkali and insoluble acid salts that remove dirt and irritating substances from the skin (Gray, Bliss, Erner-Seltun et al., 2007). Soap may adversely affect the skin by removing natural sebum oil from the skin and raising its alkalinity (Ersser, Getliffe, Voegeli et al, 2005).

Perineal skin cleaners combine detergents and surfactant ingredients to loosen and remove dirt or irritants. Many also contain emollients, moisturisers, or humectants to restore or preserve optimal barrier function, and many are pH neutral, ensuring their pH is close to that of normal healthy skin (5.0-5.9) (Ersser, Getliffe, Voegeli et al, 2005; Farage, Miller, Berardesca et al., 2007; Gray, Bliss, Erner-Seltun et al., 2007).There is some evidence suggesting that a cleanser that matches the pH of the skin and contains moisturisers or humectants may be preferable to soap and water, especially in aged skin (Ersser, Getliffe, Voegeli et al, 2005; Gray, 2007). The pH of cleansing products should be verified before use as many common products have pH outside the recommended range (Farage, Miller, Berardesca et al., 2007).

13.1.3.2 Drying

The mechanical and chemical drying of the skin can adversely affect barrier function. A minimal rubbing drying technique, such as patting, may reduce the friction damage caused (Ersser, Getliffe, Voegeli et al, 2005).

13.1.4 Management of incontinence associated dermatitis (IAD)

The principles of a structured skin care regimen comprise gentle cleansing, moisturisation, and application of a skin protectant or moisture barrier (Gray, 2007).

13.1.4.1 Mild to moderate incontinence associated dermatitis

For mild to moderate IAD, characterised by erythema and tenderness of intact skin, a structured skin care regimen similar to those recommended for prevention should be used, with the addition of a skin protectant. Skin care should be provided following each major incontinence episode, particularly if faecal matter is present. Skin protectant should be used daily or more frequently if the client has high-volume or frequent episodes of incontinence. Combination products are usually recommended, particularly in the residential care setting, as they reduce several steps into a single intervention, maximising time efficiency and encouraging adherence to a structured skin care regimen. These include moisturising cleansers, moisturising skin protectant creams, and disposable washcloths that incorporate cleansers, moisturisers and skin protectants into a single product (Gray, Bliss, Erner-Seltun et al., 2007).

13.1.4.2 Severe incontinence associated dermatitis

For severe IAD, associated with denudation of the skin, a structured skin care program combined with regular application of a skin protectant product may provide adequate protection to promote healing in some clients (Gray, Bliss, Erner-Seltun et al., 2007).

Topical antibiotics and antimicrobials should be used only when an infection has been confirmed (Farage, Miller, Berardesca et al., 2007).

13.1.5 Specific skin care with use of absorbent pads

Skin should be kept dry using absorbent incontinence pads (Farage, Miller, Berardesca et al., 2007). Absorbent products may actually increase the tissue interface pressures when soaked, even when used in conjunction with pressure reducing or relieving support surfaces (Gray, Bliss, Erner-Seltun et al., 2007). Wet or soiled garments should be changed promptly, and skin cleansing should follow every incontinent episode. Efforts should be made to prevent further moisture from reaching the skin (Farage, Miller, Berardesca et al., 2007).

Barrier ointments should be used to protect the skin from contact with moisture, while at the same time preventing friction from continence pads and bed linens (Farage, Miller, Berardesca et al., 2007). It is important that the barrier cream, ointment or film is suitable for use with incontinence pads. It is recommended that only water based barrier creams are used if pads are to be worn. Oil based creams and talcum powder should be avoided as these clog the pad and affect the absorbency of the pad, allowing urine to sit next to the skin for longer (Whitely, 2008).

13. Containment management of urinary incontinence ��

14. Pharmacological management��

14 . Pharmacological managementSection 14 has been developed using non-systematic, narrative methodology.

14 .1 OutlinePharmacological management of incontinence is used for incontinence resistant to conservative treatment, or as an adjunct to other management strategies. Use of pharmacological agents aims to relieve symptoms, reduce complications of incontinence and improve the quality of life.

Successful treatment depends upon the specific cause of the incontinence and correct diagnosis. If incorrectly diagnosed, some treatments may actually worsen the incontinence or cause other problems. It is recommended to treat the most prominent incontinence type and check for effectiveness before using a second agent.

As the elderly are more sensitive to both the beneficial and adverse effects of medication, appropriate consideration should be given when instituting any medication therapy. Slow titration and monitoring of effect should be followed. Early cessation is standard practice if no benefit is provided or adverse effects are suffered.

It is necessary to assess and check for medications that may be contributing to the incontinence. For further information refer to Appendix 14 in this guideline. It should be remembered that ‘medications’ refers to prescription, over-the-counter, (OTC) and complementary medications. Continence clinicians must know their professional roles and responsibilities in relation to pharmacological management.

14 .2 Medication reviewsMedication reviews should be an integral part of a continence assessment. The Home Medicines Review Program (an Australian government funded service) provides the opportunity for any client, carer or professional to request a medication review. This enables a specially trained pharmacist to visit the client following consent from the client and the general medical practitioner. The review facilitates use of the pharmacist’s special skills and knowledge in supporting and assisting other health professionals, and in contributing to the care of clients by ensuring optimal use of medicines.

14 .3 Medications for stress incontinence14.3.1 Adrenergic agonists

There is only weak evidence to suggest that the use of an adrenergic agonist (such as Pseudoephedrine) is better than placebo treatment, and insufficient evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Clients using adrenergic agonists may suffer from minor side effects, occasionally leading them to stop treatment. Rare but serious side effects such as cardiac arrhythmias and hypertension have been reported, and these medications are not widely used for managing stress incontinence in Australia (Alhasso, Glazener, Pickard et al., 2005).

14.3.2 Topical oestrogen

Topical oestrogens may prevent urinary tract infections and help female clients with chronic voiding dysfunction. Topical oestrogens increase urethral vascularity and thickness, and sensitise alpha adrenergic receptors in bladder neck, both of which theoretically should improve urethral closure. However, recently Weiss found no objective improvement in measured urine loss with oestrogen therapy (Weiss, 2005) while Casper reported that some forms of incontinence showed benefit through oestrogen therapy (Casper, 2006).

Link to Section 2


Link to Appendix 14

Link to Appendix 14

14. Pharmacological management ��

Although the amount of oestrogen absorbed may not be significant, clinicians are advised to consider the possible risks associated with the use of topical oestrogen products with each client through reference to manufacturer guidelines, pharmacist advice, and other resources.

Adapted from MIMS on-line as cited by Golding (2006).

14.3.3 Duloxetine

Duloxetine hydrochloride is a combined norepinephrine and serotonin reuptake inhibitor which increases contraction of urethral sphincters during urine storage. It is the only medication licensed specifically for stress incontinence and is approved for this use in the United Kingdom. In the United States of America, incontinence is a non-FDA labelled indication for duloxetine. Whilst now available in Australia, it is currently only registered by the Therapeutic Goods Administration (TGA) for use in treating depression. The most common side effect is nausea (Weiss, 2005).

14 .4 Medications for detrusor overactivity and urge incontinence14.4.1 Oral Oestrogen

The most recent evidence suggests that oestrogen treatment increases the risk of new onset incontinence in previously continent women, and worsens existing incontinence (Hendrix, Cochrane, Nygaard et al, 2005; Waetjen, 2006). Therefore, oral oestrogen should not be prescribed for the treatment of stress or urge incontinence in post-menopausal women (Martin & Barbieri, 2008). Hormone therapy for bothersome menopausal symptoms may increase the risk of developing or worsening incontinence, although the absolute risk is small, and appears to be reversible with cessation of the hormone therapy (Waetjen, 2006).

The 2005 Women’s Health Initiative study (Hendrix, Cochrane, Nygaard et al., 2005) assessed the effects of menopausal hormone therapy on the incidence and severity of symptoms of urinary incontinence in healthy postmenopausal women . This study included two trials – one examining the effects of oral oestrogen plus progestin (for women who had not had a hysterectomy) and the other trial examining the effects of oral oestrogen alone (for women who previously had a hysterectomy) . Over 27,000 women in total were enrolled in the studies . In both trials, oral hormone therapy was associated with an increased incidence of urinary incontinence and worsening symptoms of pre-existing urinary incontinence, and this effect persisted at three years .

14.4.2 Oral anticholinergics (antimuscarinics)

Anticholinergics with antimuscarinic effects are among the medications most frequently prescribed for urge incontinence. A systematic Cochrane review (2005) found that treatment with these agents compared with placebo resulted in a 40 percent higher rate of cure or improvement, and an absolute decrease of 0.6 in both incontinent episodes and voids per 24 hours; the rate of dry mouth was more than 2.5 times higher with treatment. The absolute benefit over placebo was small, in part because patients tended to do well whether they received active treatment or placebo. This may have been due to patients’ use of concomitant bladder retraining in some of the underlying studies, whether directed to or not. Thus, although


Points of Interest

Good Practice Point

Link to Table 23 Appendix 14

14. Pharmacological management100

statistically significant, the differences between anticholinergic drugs and placebo were small, apart from the increased rate of dry mouth in patients receiving active treatment. For many of the outcomes studied, the observed difference between anticholinergics and placebo may be of questionable clinical significance (Hay-Smith, Herbison, Ellis et al., 2005).

Currently in Australia, medications registered for detrusor overactivity and urinary incontinence include the anticholinergics imipramine, propantheline, oxybutynin and tolterodine, darifenacin and solifenacin.

Oxybutynin — Oxybutynin has direct antispasmodic effects and inhibits the action of acetylcholine on smooth muscle. The efficacy of oxybutynin may continue to increase beyond two weeks, suggesting that physicians should avoid escalating the dose too quickly or abandoning therapy too soon.

Anticholinergic side effects, especially dry mouth, can limit therapy with oxybutynin. However, side effects can be minimized by slow titration of the drug. The newer slow release patch formulation may assist in reducing side effects to some degree (manufacturers claim).

Tolterodine — A meta-analysis found that tolterodine has similar clinical efficacy to oxybutynin, is better tolerated than oxybutynin , but is considerably more expensive than generic oxybutynin (Harvey, Baker, & Wells, 2001). There have been case reports of cognitive side effects mimicking dementia with tolterodine.

Darifenacin and Solifenacin — These are newer anticholinergic agents (recently registered in Australia) that are more selective for muscarinic receptors in the bladder. However, they do not have significantly improved efficacy, and patients may still experience adverse effects (eg dry mouth) (Bochner, 2008).

Constipation and compensatory fluid intake for a dry mouth may exacerbate urinary incontinence. As a dry mouth predisposes clients to dental caries, regular dental care must be implemented if they are maintained on the drug.

The post void residual should be monitored in older patients. Worsening of urinary incontinence can result from subclinical retention that requires lower (not higher) drug dosages (Up-to-date, 2006).

14.4.3 Botulinum toxin injections for adults

Intravesical botulinum toxin shows promise as a therapy for overactive bladder symptoms, but as yet too little controlled trial data exist on benefits and safety compared with other interventions, or with placebo. At present there is little more than anecdotal evidence in the form of case reports, to support the efficacy of intravesical botulinum toxin; there is not much in the way of substantial, robust safety data. Furthermore, the optimal dose of botulinum toxin for efficacy and safety has not yet been demonstrated. Botulinum toxin injections into the bladder appeared to give few side effects or complications, but there were no long-term follow-up studies (Duthie, Wilson, Herbison et al, 2007).

14.4.4 Common side effects of anticholinergics in the older person

Antimuscarinic agents may impair aspects of CNS functioning including memory and sleep, and may lead to hallucinations, confusion or delirium, although serious CNS disturbances are uncommon. Cardiac effects (i.e. tachycardia) are also possible (Hijaz & Rackley, 2005).

14. Pharmacological management 101

The most common side effects with these medications are constipation and dry mouth. They may worsen cognitive function and may present an increasing risk of falls. These effects are said to be less problematic with Tolterodine compared to Oxybutynin, although they are still present (Hay-Smith, Herbison, Ellis et al., 2005). Urinary retention can be a common side effect of anticholinergic medications.

Imipramine and propantheline may be poor choices in the elderly due to their increased side effect profile. Imipramine is a tricyclic antidepressant that works via anticholinergic effects and by relaxing the dome of the detrusor (Kuteesa & Moore, 2006). It commonly causes drowsiness, especially in the first three weeks, and is therefore often taken at night for nocturnal symptoms. Propantheline is a synthetic analogue of atropine that blocks muscarinic receptors at all sites and therefore may cause significant side effects. However, it is only approximately 60% of the cost of oxybutynin (Kuteesa & Moore, 2006).

14 .5 Medications for voiding difficultiesVoiding difficulties may be due to Bladder Outlet Obstruction (BOO), poor detrusor contractility, or detrusor sphincter dyssynergia. These are covered in detail in section five of this guideline.

Medications indicated for those with voiding difficulties include:• Alpha-adrenergic antagonists • Androgen blockage provided by Finasteride • Saw Palmetto (Serenoa Repens), which provides mild to moderate improvement in

urinary symptoms and flow measures in benign prostatic hyperplasia. It shows a similar improvement in urinary symptoms and flow when compared to Finasteride, and is associated with fewer adverse treatment events. While Serenoa Repens may be a useful treatment option, patients and providers need to be aware that there are no guarantees regarding product purity and potency (Wilt, Ishani, & Mac Donald, 2002).

14 .6 Medications for urinary tract infectionsUrinary tract infections (UTI) cause urge incontinence due to irritation associated with cystitis. They should be treated effectively using appropriate antibiotics and, if recurrent, with appropriate prophylactic use of antibiotic therapy.

There is conflicting data on the risk of UTI with oestrogen use. Oral oestrogen does not appear to reduce the frequency of UTI, but intravaginal oestrogen may reduce the risk of recurrence in women with frequent UTIs. The relative efficacy, safety and client tolerability of intravaginal oestrogen have not been directly compared with antimicrobial prophylaxis (Martin & Barbieri, 2008).

Post menopausal women who have three or more recurrent UTIs per year, and who do not take oral oestrogen, may benefit from intravaginal oestrogen, particularly when resistance to multiple drugs limits the efficacy of antimicrobial prophylaxis (Martin & Barbieri 2008).

A recent Cochrane review of ten studies found some evidence that cranberry juice may decrease the number of symptomatic urinary tract infections over a 12 month period for women although the evidence for elderly men and women is inconclusive. There was poor adherence to the treatment over time. There is evidence that cranberry juice is not effective in people with a neurogenic bladder. The optimum dose, method of administration (eg. juice, tablets or capsules) and length of treatment all require further investigation (Jepson, Mihaljevic & Craig, 2008).

Link to Appendix 14

Link to Table 10 Section 6.5.2

Link to Section 8.7

14 .7 Medications for vaginal atrophy Topical oestrogen applications (creams, pessaries or vaginal ring) have been reviewed separately all were found to be effective for symptoms of vaginal atrophy. Extremely low doses of unopposed (i.e. without progestin) transdermal oestrogen do not appear to increase the risk of urinary incontinence (Martin & Barbieri, 2008). As a treatment choice, women appeared to favour the oestradiol releasing vaginal ring for ease of use, comfort of product and overall satisfaction. However the oestradiol ring is not currently available in Australia and requires approval prior to treatment (Suckling, Lethaby, & Kennedy, 2003). Some women prefer an oestrogen tablet which adheres to the vaginal wall, while others prefer pessaries (Hirst, 2006).

14 .8 Medications for nocturnal diuresis People with excessive nocturnal diuresis may benefit from use of nasal Desmopressin Acetate (DDAVP) at bedtime (Fonda, DuBeau, Harari et al., 2005). However, the role of DDAVP is very limited, and its significant risks and side effects (for example, heart failure in older people) indicate the need for careful consideration before prescribing (Golding, 2006).

14 .9 Medications for overactive bladderA recent Cochrane review has compared the use of anticholinergic drugs with non-drug therapies for overactive bladder syndrome in adults. Although there is limited evidence available, it was found that, during initial treatment, the greatest symptomatic improvement was seen amongst those on a combined therapy of an anticholinergic drug plus bladder training. Anticholinergic drugs showed more symptomatic improvement compared to bladder training alone. There was insufficient evidence to determine if there is any sustained symptomatic improvement after stopping either treatment (Alhasso, McKinlay, Patrick et al., 2006).

14. Pharmacological management102


15 . Indications for referral for further assessmentThe ‘First Steps’ CPG (MASS 2007), contains a clinical algorithm referral pathway for primary level clinicians which highlights significant factors requiring further investigation. These include: • Red Flags – as outlined in Section 9.1 of the ‘First Steps’ CPG (MASS 2007). Immediate

medical assessment is needed if the client has pain, recent unexplained weight loss, recent sudden change in bowel habit, pelvic mass, rectal bleeding, persistent diarrhoea, hematuria, recurrent symptomatic urinary tract infection, history of pelvic surgery or irradiation, major pelvic organ prolapse, or recent prostatectomy surgery.

• DIAPPERS – as outlined in Section 9.2 of the ‘First Steps’ CPG (MASS 2007), the ‘DIAPPERS’ mnemonic alerts health professionals to the following conditions:

* Delirium – any sign

* Infection – positive reagent strip test

* Atrophic Vaginitis – reports vaginal dryness, itching, irritation, pain with intercourse or signs present on examination

* Pharmaceuticals

* Psychological

* Excess urine output

* Restricted mobility

* Stool impaction.

If further assessment or treatment is indicated, or if the continence clinician is unsure about appropriate management strategies, the continence clinician can refer to the algorithm shown as figure 6, and to the flowchart shown in figure 7 on the following pages. Additional indicators for further assessment by a general medical practitioner include: • Males: refer for general medical practitioner review if no medical review current

• Neurological examination (dermatome testing/reflex testing) equivocal or not normal, or secondary level clinician lacks competency to complete specific assessment

• Perineal examination reveals presence of prolapse extending beyond the vaginal introitus, skin lesions, vaginal epithelium that is pale, smooth, shiny or dry, vaginal discharge, vaginal malodour

• Rectal examination/observation reveals rectal prolapse, haemorrhoids, presence of stool in addition to a recent history of bowel function suggesting faecal impaction

• Polyuria or nocturnal polyuria identified on bladder diary

• Poor responses to treatment in women with incontinence in whom voiding difficulties are also present (recommend referral to a medical specialist for urodynamics/uroflowmetry)

• No response to treatment in 12 weeks or inadequate response (client not satisfied) by six months – refer on with view to medical specialist investigations/consideration for surgical interventions

• Persistent difficulty reported with catheter insertion – refer to general medical practitioner with view to specialist urology referral.

15. Indications for referral for further assessment 103

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15. Indications for referral for further assessment104

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15. Indications for referral for further assessment 105

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8 . management recommendations: clean …...56 . management recommendations: clean intermittent self...

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