VOL: 101, ISSUE: 18, PAGE NO: 53
Linda Morrow, MSc, PGCert, RGN, RM, DipDN, is professional adviser, continence management, the Care Commission, Musselburgh, ScotlandThe aim of a recent guideline (Number 79) from the Scottish Intercollegiate Guidelines Network (SIGN), Management of Urinary Incontinence in Primary Care (SIGN, 2004), is to identify opportunities in primary care for assessing and treating urinary incontinence, to offer the primary care practitioner information on the current recommended treatment options and indicate the factors that should lead to an onward referral.
The aim of a recent guideline (Number 79) from the Scottish Intercollegiate Guidelines Network (SIGN), Management of Urinary Incontinence in Primary Care (SIGN, 2004), is to identify opportunities in primary care for assessing and treating urinary incontinence, to offer the primary care practitioner information on the current recommended treatment options and indicate the factors that should lead to an onward referral.
The guideline is divided into eight treatment sections, as follows:
- Quality of life and health promotion;
- Physical therapies;
- Containment products;
- Information appropriate to patients and carers;
- Implementation, research, and audit.
The guideline was developed using an explicit methodology; see www.sign.ac.uk
Quality of life and health promotion
Incontinence has a significant impact on quality of life, so it is appropriate that the guideline begins with recommendations that address the patient's view of the problem: 'Healthcare practitioners should consider using a validated quality of life and incontinence severity questionnaire to evaluate the impact of urinary symptoms and to audit the effectiveness of any management strategy' (SIGN, 2004). The guideline summarises the questionnaires that are available and recommends that where practitioners have developed their own questionnaire they should confirm that it is consistent with the validated tools and ensure that it addresses both quality of life and severity of urinary incontinence.
The guideline acknowledges that it is important to involve patients in their ongoing care. Thus it recommends that patients are given comprehensive information about the options available to them, including the opportunity to access specialist staff in primary care without a GP referral. This is particularly important when patients are too embarrassed to discuss their problem with their GP and would prefer to see a stranger. The literature reviewed by the SIGN guideline development group and the national survey of patients conducted by the Association for Continence Advice in 2000 identified the difficulty some patients have in raising their continence problems with a professional and the importance of the professional taking the problem seriously and making it clear to patients that something can be done.
Incontinence is a symptom of an underlying condition and the key to successful treatment is a comprehensive assessment leading to a diagnosis of the underlying condition and not simply management of the symptoms. Although this may seem an obvious approach, the Audit Commission (1999) found that many community nurses attending patients with continence problems focused their visit and subsequent paperwork on the appropriate product for containment. However, all individuals with continence difficulties are entitled to assessment and treatment that aims to achieve a cure.
The assessment of urinary incontinence requires several investigations in addition to routine clinical examination and history-taking.
The guideline states that each individual case is unique and that its recommendations should be used to support clinical judgment, not replace it. This is particularly important in the case of patients who are unable or unwilling to consent to a full examination but who may benefit from some of the treatment recommendations.
Physical therapies and pharmacotherapy
Pelvic floor muscle assessment was included in the treatment section of the guideline rather than in the assessment section as it was viewed as being integral to implementing and assessing the progress of a pelvic floor exercise regime. There was good evidence for the use of pelvic floor muscle exercises in the treatment of stress and mixed urinary incontinence and, as with other recommendations, the actual regime of exercises must be tailored to the individual patient. In addition to pelvic floor exercises, some individuals with moderate to severe stress incontinence may benefit from a course of duloxetine, the only drug currently licensed in the UK for the treatment of stress incontinence.
Evidence for bladder retraining was less convincing; the studies reviewed were of good quality, but there was only weak evidence to support bladder retraining for individuals with urge incontinence, and such therapy was most effective where the symptoms were mild. For individuals with moderate to severe urge incontinence there is good evidence that antimuscarinic medication is beneficial, but the dose should be titrated to achieve the best result with minimal side-effects.
The literature search identified several studies relating to the use of oestrogens, antidepressants, and adrenoreceptor agonists for treating urinary incontinence. None of these is included in the recommendations as they are not licensed in the UK for such use.
The guideline recommends that containment products should only be issued following a continence assessment (SIGN, 2004). Research on containment is limited by the fact that the use of products is heavily influenced by personal preference. The clinician must consider patients' preferences, and their ability to manage connectors, taps or fitting requirements. This is affected by patients' self caring ability.
Good evidence was found that suggests that men who use sheaths prefer a one-piece sheath with internal adhesive and no applicator (Fader et al, 2001).
While the majority of patients with continence problems can be cured or managed in primary care, some patients require further assessment and treatment in a specialist centre. Although the only published evidence for referral criteria was based on expert opinion, the guideline development group felt that it was important to include guidance about when to refer. It was recommended that the patients who should be referred to secondary care are:
- Those whose previous surgery or non-surgical treatment for urinary incontinence has failed;
- Those who are being considered for surgery to treat urinary incontinence;
- Female patients with suspected voiding dysfunction;
- Female patients with symptomatic pelvic organ prolapse;
- Male patients with reduced urinary flow rates;
- Male patients with an elevated post-void residual volume of urine.
Information for patients and carers
The patients' representatives on the guideline development group wrote a section on information for discussion with patients and carers. This section is not evidence-based but reflects the wealth of experience of the patients' representatives and their contacts. The guideline explains the type of information that patients want, and serves as a prompt to patients to prepare their questions in advance of a consultation, and to clinicians to ensure that the information they are giving is tailored to the needs of the patient. There is also a comprehensive list of patient-focused organisations and their contact details.
Implementation, research and audit
Despite the number of people who have continence problems and the huge impact it has on their quality of life, many areas of continence care have little research evidence to support practice.
The final section of the guideline highlights areas where the guideline development group felt there is a need for more research. Many of these are related to common practice. This presents an ideal opportunity for nurses who have an interest in continence care to evaluate their own practice and add to the evidence base for the benefit of patients.
SIGN guideline 79 was launched in December 2004 to an audience that represented the majority of health boards in Scotland. It was a joint launch with the Scottish Programme for Improving Clinical Effectiveness in Primary Care (SPICE). This programme integrated the recommendations of the guideline into the computer system used by the majority of GPs in Scotland. In this way, the recommendations can be easily accessed by a GP during a consultation, making it more likely that the guideline will inform practice.
The challenge now is for individual practitioners to embrace the recommendations in the guideline to develop their own practice supported by the evidence base.