2009 4th International Consultation on Incontinence Co-Sponsored by Recommendations of the INTERNATIONAL CONSULTATION ON International Scientific Committee: UROLOGICAL DISEASES (ICUD)

INTERNATIONAL Evaluation and Treatment SOCIETY OF (SIU) of ,

In collaboration and with the Major Faecal Incontinence International ◆◆◆ Associations of P. Abrams, K.E. Andersson, L. Birder, L. Brubaker, Urology, Gynecology and L.Cardozo, C.Chapple, A. Cottenden, W. Davila, Urodynamics D. de Ridder, R. Dmochowski, M.Drake, C. DuBeau, C. Fry, P. Hanno, J. Hay Smith, S. Herschorn, G.Hosker, and other medical associations C.Kelleher, H.Koelbl, S. Khoury, R. Madoff, I.Milsom, K.Moore, D. Newman, V.Nitti, C. Norton, I.Nygaard, C. Payne, A. Smith, D. Staskin, S.Tekgul, J. Thuroff, A. Tubaro, D.B. Vodusek, A. Wein, JJ. Wyndaele, and the Members of the Committees

INTRODUCTION The 4th International Consultation on Incontinence met from July 5th – 9th 2008 in Paris and was organised by the International Consultation on Urological Diseases, in order to develop recommendations for the diagnosis evaluation and treatment of urinary incontinence, faecal incontinence, pelvic organ prolapse and bladder pain syndrome. The recommendations are evidence based following a thorough review of the available literature and the global subjective opinion of recognised experts serving on focused committees. The individual committee reports were developed and peer reviewed by open presentation and comment. The Scientific Committee, consisting of the Chairmen of all the committees then refined the final recommendations. These recommendations published in 2009 will be periodically re-evaluated in the light of clinical experience, technological progress and research.

1767 CONTENTS

1. DEFINITIONS 2. EVALUATION 3. MANAGEMENT RECOMMENDATIONS I. URINARY INCONTINENCE IN CHILDREN

II. URINARY INCONTINENCE IN MEN

III. URINARY INCONTINENCE IN WOMEN

IV. VESICOVAGINAL FISTULA IN THE DEVELOPING WORLD

V. PELVIC ORGAN PROLAPSE

VI. NEUROGENIC URINARY INCONTINENCE

VII. URINARY INCONTINENCE IN FRAIL OLDER MEN AND WOMEN

VIII. PAINFUL BLADDER SYNDROME, INCLUDING IC (PBS/IC)

IX. FAECAL INCONTINENCE

X. FAECAL INCONTINENCE IN NEUROLOGICAL PATIENTS

4. RECOMMENDATIONS FOR PROMOTION, EDUCATION, AND PRIMARY PREVENTION 5. RECOMMENDATIONS FOR BASIC SCIENCE RESEARCH 6. RECOMMENDATIONS FOR EPIDEMIOLOGY 7. RECOMMENDATIONS FOR CLINICAL RESEARCH International Consultation on Incontinence Modular Questionnaire (ICIQ) - ICIQ UI SF(short-form) Annex 1 : Bladder Charts and Diaries

1768 1. Definitions

The consultation agreed to use the current International The overactive detrusor is divided into: Continence Society definitions (ICS) for lower urinary - Idiopathic Detrusor Overactivity, defined as tract dysfunction (LUTD) including incontinence, except overactivity when there is no clear cause. where stated. These definitions appeared in the journal Neurourology and Urodynamics (2002; 21:167- - Neurogenic Detrusor Overactivity is defined 178 and 2006; 25: 293) or can be viewed on the ICS as overactivity due to a relevant neurological website:www.icsoffice.org condition. The following ICS definitions • Urodynamic stress incontinence is noted during are relevant: filling , and is defined as the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction. 1. Lower Urinary Tract Symptoms (LUTS) 3. Bladder Pain Syndrome * LUTS are divided into storage symptoms and voiding symptoms. • Bladder pain syndrome is defined as an Urinary incontinence is a storage symptom and unpleasant sensation (pain, pressure, discomfort) defined as the complaint of any involuntary loss of perceived to be related to the , urine. This definition is suitable for epidemiological associated with lower urinary tract symptom(s) of studies, but when the prevalence of bothersome more than 6 weeks duration, in the absence of incontinence is sought, the previous ICS definition of infection or other identifiable causes. an “Involuntary loss of urine that is a social or hygienic problem " can be useful. Urinary incontinence may be further defined according 4. Pelvic Organ Prolapse to the patient’s symptoms: • Urgency Urinary Incontinence is the complaint • Uro-genital prolapse is defined as the of involuntary leakage accompanied by or symptomatic descent of one or more of : the anterior immediately preceded by urgency. vaginal wall, the posterior vaginal wall, and the • Stress Urinary Incontinence is the complaint of apex of the (cervix/uterus) or vault (cuff) involuntary leakage on effort or exertion, or on after hysterectomy. Uro-genital prolapse is sneezing or coughing. measured using the POPQ system. • Mixed Urinary Incontinence is the complaint of • Rectal prolapse is defined as circumferential full involuntary leakage associated with urgency and thickness rectal protrusion beyond the anal margin. also with effort, exertion, sneezing and coughing. • Nocturnal is any involuntary loss of urine occurring during sleep. 5. Anal Incontinence * • Post-micturition dribble and continuous urinary leakage denotes other symptomatic forms of • Anal incontinence, defined as “any involuntary incontinence. loss of faecal material and/or flatus” and may be is characterised by the storage divided into: symptoms of urgency with or without urgency incontinence, usually with frequency and . - Faecal incontinence, any involuntary loss of faecal material 2. Urodynamic Diagnosis - Flatus incontinence, any involuntary loss of gas (flatus)

• Overactive Detrusor Function, is characterised by involuntary detrusor contractions during the filling phase, which may be spontaneous or * To date, these definitions are not included in the provoked. current ICS terminology

1769 2. Evaluation

The following phrases are used to classify diagnos- tic tests and studies: 1. History and General Assessment • A highly recommended test is a test that should Management of a disease such as incontinence be done on every patient. requires caregivers to assess the sufferer in a holis- • A recommended test is a test of proven value in tic manner. Many factors may influence a particular the evaluation of most patients and its use is individual’s symptoms, some may cause inconti- strongly encouraged during initial evaluation. nence, and may influence the choice and the suc- cess of treatment. The following components of • An optional test is a test of proven value in the the medical history are particularly emphasized: evaluation of selected patients; its use is left to the clinical judgement of the physician. a) : • A not recommended test is a test of no proven value. • Presence, severity, duration and bother of any urinary, bowel or prolapse symptoms. Identifying This section primarily discusses the Evaluation symptoms in the related organ systems is critical of Urinary Incontinence with or without Pelvic to effective treatment planning. It is useful to use Organ Prolapse (POP) and Anal Incon- validated questionnaires to assess symptoms. tinence. • Effect of any symptoms on sexual function: validated questionnaires including impact on quality The recommendations are intended to apply to chil- of life are a useful part of a full assessment. dren and adults, including healthy persons over the age of 65. • Presence and severity of symptoms suggesting neurological disease These conditions are highly prevalent but often not reported by patients. Therefore, the Consultation b) Past Medical History: strongly recommends case finding, particularly in high risk groups. • Previous conservative, medical and surgical treatment, in particular, as they affect the I. HIGHLY RECOMMENDED TESTS genitourinary tract and lower bowel. The DURING INITIAL EVALUATION effectiveness and side effects of treatments should be noted.

The main recommendations for this consultation • Coexisting diseases may have a profound effect have been abstracted from the extensive work of on incontinence and prolapse sufferers, for example the 23 committees of the 4th International asthma patients with stress incontinence will suffer Consultation on Incontinence (ICI, 2008). greatly during attacks. Diseases may also precipitate incontinence, particularly in frail older Each committee has written a report that reviews persons. and evaluates the published scientific work in each field of interest in order to give Evidence Based • Patient medication: it is always important to review recommendations. Each report ends with detailed every patient’s medication and to make an recommendations and suggestions for a pro- assessment as to whether current treatment may gramme of research. be contributing to the patient’s condition. • Obstetric and menstrual history. The main recommendations should be read in conjunction with the management algorithms for • Physical impairment: individuals who have children, men, women, the frail older person, neu- compromised mobility, dexterity, or visual acuity rogenic patients, bladder pain, pelvic organ pro- may need to be managed differently lapse, and anal incontinence. c) Social History: The initial evaluation should be undertaken, by a clinician, in every patient presenting with symptoms/ • Environmental issues: these may include the signs suggestive of these conditions. social, cultural and physical environment.

1770 • Lifestyle: including exercise, smoking and the • Bimanual pelvic and anorectal examination for amount and type of food/fluid intake. pelvic mass, pelvic muscle function, etc. d) Other Treatment Planning Issues: • Stress test for urinary incontinence. d) Neurological testing (see chapter on • Desire for treatment and the extent of treatment assessment) that is acceptable.

• Patient goals and expectations of treatment Neurological examination should be performed regardless of whether the patient is a child, a • Patient support systems (including carers). woman, a man, someone with neurological disease • Cognitive function: all individuals need to be or a frail elderly person. assessed for their ability to fully describe their symptoms, symptom bother and quality of life impact, and their preferences and goals for care, 3. Urinalysis and to understand proposed management plans and to discuss, where appropriate, alternative In patients with urinary symptoms a urinary tract treatment options. In some groups of patients infection is a readily detected, and easily treatable formal testing is essential e.g. cognitive function cause of LUTS, and urine testing is highly recom- testing for individuals for whom the clinician has mended. Testing may range from dipstick testing, to concerns regarding memory deficits and/or urine microscopy and culture when indicated. inattention/confusion, and depression screening for individuals for whom the clinician has concerns about abnormal affect. Proxy respondents, such as Conclusion family and carers, may be used to discuss history, goals of care, and treatment for individuals with For simple treatments, particularly non- dementia only if the individual is incapable of invasive and inexpensive therapies, man- accurate reporting or weighing treatment decisions. agement may start without the need for the further investigations listed below. 2. Physical Examination

The more complicated the history and the more extensive and/or invasive the proposed therapy, the more complete the examination needs to be. II. RECOMMENDED FURTHER Depending on the patients symptoms and their ASSESSMENT PRIOR TO, OR severity, there are a number of components in the DURING, SPECIALIST examination of patients with incontinence and/or ASSESSMENT pelvic organ prolapse. a) General status: The tests below are recommended when the appropriate indication(s) is present. Some recom- mended tests become highly recommended in specific • Mental status situations. • Obesity (BMI) This section should also be read in conjunction with the relevant committee reports. • Physical dexterity and mobility b) Abdominal/flank examination: for masses, bladder distention, relevant sur- 1. Further Symptom and Health-Related gical scars QoL Assessment c) Pelvic examination: In patients with urinary symptoms the use of a simple frequency volume chart or bladder diary • Examination of the perineum and external genitalia (examples in Annex 1) is highly recommended to including tissue quality and sensation. document the frequency of micturition, the volumes of urine voided, incontinence episodes and the use • Vaginal (half-speculum) examination for prolapse of incontinence pads.

1771 The use of the highest quality questionnaires • Co-existing loin/kidney pain, (Grade A, where available) is recommended for the • Severe pelvic organ prolapse, not being treated assessment of the patient’s perspective of symptoms of incontinence and their impact on quality of life. • Suspected extra-urethral urinary incontinence, The ICIQ is highly recommended (Grade A) for the • Children with incontinence and UTIs, where basic evaluation of the patient’s perspective of urinary indicated incontinence; with other Grade A questionnaires recommended for more detailed assessment. Further • Urodynamic studies which show evidence of poor development is required in the areas of pelvic organ bladder compliance. prolapse, bladder pain syndrome and faecal incon- In anorectal conditions anal US or MRI prior to anal tinence, and for specific patient groups, as only Grade sphincter surgery is highly recommended, when B questionnaires are currently available (see obvious anatomic defects are not evident (cloacal Appendix). formations). Defaecating proctography or dynamic MRI is recommended in suspected rectal prolapse which cannot be adequately confirmed by physical 2. Renal Function Assessment examination.

Standard biochemical tests for renal function are 6. Endoscopy recommended in patients with urinary incontinence and a probability of renal impairment. Although routine cystourethroscopy is not recom- mended, LUT endoscopy is highly recommended: 3. Uroflowmetry • When initial testing suggest other pathologies, e.g. haematuria Uroflowmetry with the measurement of postvoid residual urine is recommended as a screening test for • When pain or discomfort features in the patient’s symptoms suggestive of urinary voiding dysfunction LUTS : these may suggest an intravesical lesion or physical signs of POP or bladder distension. • When appropriate in the evaluation of vesicovaginal fistula and extra-urethral urinary incontinence (in childbirth fistulae, endoscopy is often unnecessary). 4. Estimation of Post Void Residual In anorectal conditions, proctoscopy or flexible Urine (PVR) sigmoidoscopy should routinely be performed in the evaluation of patients with faecal incontinence. In patients with suspected voiding dysfunction, Colonoscopy, air contrast barium enema or CT PVR should be part of the initial assessment if the colography is highly recommended in the presence result is likely to influence management, for example, of unexplained change in bowel habit, rectal bleeding in neurological patients. or other alarm symptoms or signs (see Basic Assessment chapter).

5. Imaging 7. Urodynamic Testing

Although routine imaging is not recommended, imaging of the lower urinary tract and pelvis is highly a) Urodynamic evaluation is recommended recommended in those with urinary symptoms whose initial evaluation indicates a possible co-existing • When the results may change management, such lower tract or pelvic pathology. Initial imaging may be as prior to most invasive treatments for UI and by ultrasound, or plain X ray. POP Imaging of the upper urinary tract is highly recom- • After treatment failure, if more information is mended in specific situations. These include: needed in order to plan further therapy. • Haematuria • As part of both initial and long-term surveillance • Neurogenic urinary incontinence e.g. myelodys- programmes in some types of neurogenic lower plasia, spinal cord trauma, urinary tract dysfunction • Incontinence associated with significant post-void • In “complicated incontinence” (for details please residual, see relevant subcommittee reports).

1772 b) The aims of Urodynamic Evaluation are 2. Pad Testing

• To reproduce the patient’s symptoms and correlate Pad testing is an optional test for the routine evaluation these with urodynamic findings of urinary incontinence and, if carried out, a 24 hr test is suggested. • The assessment of bladder sensation • The detection of detrusor overactivity 3. Neurophysiological Testing and • The assessment of urethral competence during Imaging filling • The determination of detrusor function during The information gained by clinical examination and voiding urodynamic testing may be enhanced by neuro- physiological testing of striated muscle and nervous • The assessment of outlet function during voiding pathways. • The measurement of residual urine Appropriately trained personnel should perform these tests. The following neurophysiological tests can be 8. Small bowel follow-through, CT considered in patients with peripheral lesions prior to entography or capsule endoscopy. treatment for lower urinary tract or anorectal dysfunction. These tests are recommended in the presence of • Concentric needle EMG unexplained diarrhoea or when Crohn’s disease is suspected. • Sacral reflex responses to electrical stimulation of penile or clitoral nerves. Pudendal nerve latency testing is not recom- mended. Further imaging of the central nervous system, including spine, by myelography, CT and MRI may III. OPTIONAL DIAGNOSTIC TESTS prove useful if simple imaging, for example by spinal X-rays in patients with suspected neurological disease, proves normal.

1. Additional Urodynamic Testing 4. Further Imaging Video-urodynamics may be useful in the management of UI in children, in patients who fail Cysto-urethrography, US, CT and MRI may have an surgery and in some neurogenic patients, to obtain indication in case of : additional anatomical information. Both US and X-ray • Suspected dysfunction imaging can be used. • Failed surgery, such as recurrent posterior vaginal If a more detailed estimate of urethral function is wall prolapse or failed sling surgery required, then the following optional tests may give useful information: • Suspected fixed • Urethral pressure profilometry • Abdominal leak point pressures 5. Cysto-urethroscopy • Video-urodynamics This is an optional test in patients with complicated • Electromyography or recurrent UI (e.g. after failed SUI surgery) If initial urodynamics have failed to demonstrate the cause for the patient’s incontinence then the following tests are optional: 6. Anorectal physiology testing • repeated routine urodynamics Anal manometry is useful to assess resting and • ambulatory urodynamics squeeze anal pressures.

1773 3. Management Recommendations

The management recommendations are derived recommendations in the basic algorithms in such from the detailed work in the committee reports a way that they may be readily used by clinicians on the management of incontinence in children, in all countries of the world, both in the developing men, women, the frail elderly and neurological and the developed world. patients, obstetric fistula, pelvic organ prolapse, bladder pain syndrome, and faecal incontinence. ➦ The specialised algorithms The management of incontinence is presented in algorithm form with accompanying notes. are intended for use by specialists. The specialised algorithms, as well as the initial management The Consultation recognised that no algorithm algorithms are based on evidence where possible can be applied to every patient and each and on the expert opinion of the 700 healthcare patient’s management must be individualised. professionals who took part in the Consultation. There are algorithms for In this consultation, committees ascribed levels of • I. Urinary Incontinence in Children evidence to the published work on the subject and devised grades of recommendation to inform patient • II. Urinary Incontinence in Men management. • III. Urinary Incontinence in Women It should be noted that these algorithms, dated • IV. Obstetric Fistulae March 2009, represent the Consultation con- • V Urinary Incontinence in Frail Older Men sensus at that time. Our knowledge, developing and Women from both a research base and because of evolving • VI. Urinary Incontinence in Neurological expert opinion, will inevitably change with time. Patients The Consultation does not wish those using the algorithms to believe they are “carved in tablets of • VII Bladder Pain Syndrome stone”: there will be changes both in the relatively • VIII. Pelvic Organ Prolapse short term and the long term. • IX. Faecal Incontinence in Non-Neurological Patients ◆ Essential components of basic • X. Faecal Incontinence in Neurological assessment Patients Each algorithm contains a core of recommendations These algorithms are divided into two for groups I in addition to a number of essential components to III, IX, XI and X : the two parts, initial of basic assessment listed in sections I to III. management and specialised management require a little further explanation. • General assessment Although the management algorithms are designed • Symptom assessment to be used for patients whose predominant problem • Assessment of quality of life impact is incontinence, there are many other patients in • Assessment of the desire for treatment whom the algorithms may be useful such as those patients with urgency and frequency, so-called • Physical examination “OAB dry”. • Urinalysis

➦ The algorithms for initial management ◆ Joint decision making are intended for use by all clinicians including health care assistants, nurses, physiotherapists, The patient’s desires and goals for treatment : generalist doctors and family doctors as well as by Treatment is a matter for discussion and joint specialists such as urologists and gynaecologists. decision making between the patient and his or The consultation has attempted to phrase the her health care advisors. This process of

1774 consultation includes the specific need to assess whether or not the sufferer of incontinence wishes ◆ Use of Continence Products to receive treatment and, if so, what treatments he or she would favour. Implicit in this statement is the assumption that the health care provider will The possible role of continence products should give an appropriate explanation of the patient’s be considered at each stage of patient assessment, problem and the alternative lines of treatment and, if treatment is not (fully) successful, management, and the indications and the risks subsequent management. of treatment. The assumption that patients almost • Firstly, intermittent catheterisation or indwelling always wish to have treatment is flawed, and the catheter drainage often have a role to play in need to consult the patient is paramount. addressing . In each algorithm, treatments are listed in order • Secondly, assisted toileting using such devices of simplicity, the least invasive being listed first. as commodes, bedpans, and handheld urinals This order does not imply a scale of efficacy or may help to achieve dependent continence* cost, two factors which need to be considered in where access, mobility and / or urgency choosing the sequence of therapy. The order is problems under-mine a patient’s ability to likewise not meant to imply a suggested sequence maintain independent continence*, be it urinary of therapy, which is determined jointly by the treating and / or faecal. health care providers and the patient, considering all the relevant factors listed above. • Finally, containment products (to achieve contained incontinence*) for urine and / or In the initial management algorithms, treatment faeces find an essential role in enhancing the is empirically based, whilst, the specialized quality of life of those who: management algorithms usually rely on precise diagnosis from urodynamics and other testing. • Elect not to pursue treatment options The assumption is made that patients will be • Are awaiting treatment reassessed at an appropriate time to evaluate their • Are waiting for treatment to take effect progress. • Are unable to be (fully) cured Further guidance and care algorithms on which products might be suitable for a given patient are given in Committee 20.

* Useful terms suggested by Fonda & Abrams.(Cure sometimes, help always – a “continence paradigm” for all ages and conditions. Fonda D and Abrams P, Neurology & Urodynamics 25: 290-292, 2006).

1775 enuresis should should be managed holistically including: mono-symptomatic nocturnal Daytime incontinence include: A)*. It may be a parental choice if analogues desmopressin (Grade advantages and disadvantages are well explained. and bowel management when necessary (Grade B). detrusor overactivity (Grade C). Initial treatment for 2. Treatment Should initial treatment be unsuccessful for either enuresis or daytime symptoms, then after a reasonable period of time advice is highly (8-12 weeks), referral for a specialist’s recommended. - parental counselling and motivation A) and anti-diuretic hormone - a choice between either alarm (Grade ➦ - counselling, bladder training (timed voiding), behaviour modification - antimuscarinics may be used if there are symptoms that suggest A* regulatory warning exists for the danger of overhydration in children on desmopressin. ➦ NITIAL MANAGEMENT A. I I. CHILDREN investigation of voiding and bowel habits using a micturition diary and structured questionnaires. have: without other symptoms (mono-symptomatic enuresis). urgency incontinence with urgency, Daytime symptoms of frequency, or without night-time wetting of children who have complicated incontinence associated with: recurrent urinary infection voiding symptoms or evidence of poor bladder emptying urinary tract anomalies, previous pelvic surgery neuropathy Referrals for specialist treatment are recommended a group Initial treatment is recommended for the remaining patients who 1. Initial assessement should involve a detailed • • Children produce specific management problems for a variety of reasons: assessment requires help from their parents and carers; consent to treatment may be problematic; and cooperation in both assessment and treatment may be difficult. ➦ • • • • • ➦

1776 void residual detected e.g. Post Any other abnormality VOIDING associated with: “Complicated” Incontinence - Urinary tract anomaly - Neuropathy - Pelvic surgery (emptying) symptoms - Voiding - Recurrent urinary injection DYSFUNCTIONAL INFECTION RECURRENT Failure URGENCY • Bladder training • Antimuscarinics • Alarm • Desmopressin Daytime ± Nighttime wetting ± Urgency / frequency INCONTINENCE SPECIALIZED MANAGEMENT Failure Nocturnal enuresis (monosymptomatic) MONOSYMPTOMATIC (optional : by ultrasound) NOCTURNAL ENURESIS General assessment (see relevant chapter) • Physical examination: abdominal, perineal, ext. genitalia, back/spine, neurological Assess bowel function -> if constipated, treat and reassess • • Urinalysis ± Urine culture -> if infected, treat and reassess Assess post-void residual urine by abdominal examination • • Explanation/education • Enuresis Diary • Alarm • Desmopressin Initial Management of Urinary Incontinence in Children HISTORY/ CLINICAL SYMPTOM DIAGNOSIS PRESUMED TREATMENT ASSESSMENT ASSESSMENT

1777 is is likely complex surgical treatment urinary tract anomalies (DO): bladder training and and bladder augmentation may * then urodynamics is recommended to the treatment is mostly surgical and it (SUI): pelvic floor muscle training (Grade demands treatment. If there are botulinum toxin then a Mitrofanoff channel may be needed. then a Mitrofanoff : timed voiding, to teach pelvic floor as appropriate should be assessed and, if quality of life is still significantly sling surgery, bulking agent injection and AUS may be considered bulking agent injection and sling surgery, child’s progress child’s For stress urinary incontinence C) For suspected detrusor overactivity antimuscarinics (Grade C) For voiding dysfunction relaxation, intermittent catheterisation (when PVR > 30% of bladder capacity). (Grade B/C) For bowel dysfunction: confirm the diagnosis. For SUI, For DO / poor compliance, be performed. If the child cannot do IC DO and must be used with caution. If surgical treatment is required, Initial treatment should be non-surgical. At the time of writing, botulinum toxin is being used “off label” for refractory * 2. Treatment The treatment of incontinence associated with complex and cannot easily be dealt with in an algorithm. In many children, more than one pathophysiology congenital abnormalities present, should be individualised according to the type and severity of problem Committee Report). (please see Children’s nurses and therapists. Care should be given by specialist children’s ➦ • • • • The impaired, or if the upper urinary tracts are at risk, to be necessary. ➦ • • • and and, (in children should have PECIALIZED MANAGEMENT urinary tract B. S I. CHILDREN urine flow recurrent infection cannot be explained by if the child has normal upper tract , but who have neither neurogenic complicated” incontinence ultrasound estimate of residual urine and is thought to be due bladder dysfunction. , upper tract imaging and possibly a VCUG should highly recommended. with “ is and have neither neurogenic nor anatomical problems using micturition charts, symptom scores, urinalysis, voiding dysfunction. is under consideration, for example, stress incontinence (US/Xray/MRI) may be needed if a bony abnormality or neuropathy . failed the basic treatment and without urinary tract anomalies, but with fail treatment upper urinary tracts invasive treatment upper tract dilatation exists wo groups of children clinical findings If If the type and severity of lower tract dysfunction neurological condition is suspected. old enough), together with the the surgery or bladder augmentation, when there is sphincteric incompetence, or if there is detrusor overactivity. If nor anatomical problems, should also receive specialist management: Children specialist management from the outset. Children whose incontinence is due to, or associated with, anomalies proven or suspected, Spinal Imaging T As part of further assessment, the measurement Urodynamics should be considered: Children who 1. Assessment • Those who Uroflowmetry and residual urine determination. If there are recurrent infections endoscopy is rarely indicated. be considered. However, ➦ • should be reassessed imaging and is to be treated by non invasive means. ➦ • Urodynamic studies are not recommended ➦ ➦ • • ➦

1778 OF URINARY INCONTINENCE (see : surgical treatment in children) ANATOMIC CAUSES ANATOMIC • Correct anomaly of urinary tract anomaly Incontinence with suspicion Consider: • Micturating cystogram • Renal scintigram • Urodynamics • Cystourethroscopy • Spinal imaging VOIDING DYSFUNCTION Failure - blockers α biofeedback. - Antimuscarinics - Mitrofanoff if IC fails • Timed voiding • Timed • Pelvic floor relaxation ± • Pharmacotherapy • Intermittent cath. • Bowel Management Antibiotic if infection • if abnormal --> } Failure POOR COMPLIANCE DETRUSOR OVERACTIVITY / Incontinence without • Bladder training • Antimuscarincs • Bowel management. • Botulinum toxin • Bladder augmentation suspicion of urinary tract anomaly as appropriate INCONTINENCE Failure injection muscle training STRESS URINARY • Urinalysis: if UTI, treat and reassess bowel dysfunction and reassess • Treat • Renal / bladder ultrasound Assess Post void residual • • Flow rates ± electromyography • Behavioral Evaluation • AUS • Sling • Bulking agent • Pelvic floor and Specialized Management of Urinary Incontinence in Children EXPERT DIAGNOSIS CLINICAL TREATMENT ASSESSMENT HISTORY & PHYSI- CAL EXAMINATION

1779 is highly after a reasonable period this requires no assessment urgency / stress incontinence, specialist advice most bothersome symptom incontinence. mixed or mixed post-micturition dribble, stress, urgency -adrenergic antagonists (a-blockers), can be added if it is thought initial treatment should include appropriate lilfestyle advice, physical therapies, scheduled voiding regimes, behavioural therapies and medication. In particular: Lifestyle interventions (Grade D) Supervised pelvic floor muscle training for men with post radical SUI (Grade B) Scheduled voiding regimes for OAB (Grade C) Antimuscarinic drugs for OAB symptoms with or without urgency incontinence (Grade B) and the patient has no evidence of significant post-void residual urine α that there may also be bladder outlet obstruction. (Grade C) Should initial treatment be unsuccessful of time (for example, 8-12 weeks), For men with recommended. and can usually be treated by teaching the man how to do a strong pelvic floor muscle contraction after voiding, or manual compression of the bulbous urethra directly after micturition. (Grade B) For men with 2. Management • • • • • ➦ ➦ Clinicians are likely to wish treat the first in men with symptoms of ➦ NITIAL MANAGEMENT II. MEN A. I alone, (most often post-prostatectomy), (OAB) symptoms: urgency with or r initial management. of men should be identified by initial may be suspected from symptoms, physical urgency and stress incontinence (most often post- specialized management. stress incontinence overactive bladder post-micturition dribble mixed Four other main groups assessment as being suitable fo Those with prostatectomy) Those with without urgency incontinence, together with frequency and nocturia Those with and Those with Complicated” incontinence group 1. Initial Assessement should identify : 1. Initial ➦ Those with pain or haematuria, recurrent infections, suspected proven poor bladder emptying (for example due to outlet obstruction), or incontinence following pelvic irradiation, are recommended for Poor bladder emptying examination or if imaging has been performed by X-ray ultrasound after voiding. ➦ • • • •

1780 post void residual with: - Pain - Hematuria - Recurrent infection - irradiation - Radical pelvic surgery incontinence “Complicated” incontinence • Recurrent or “total” • Incontinence associated Any other abnormality detected e.g. significant presumed due to detrusor overactivity URGENCY INCONTINENCE Urgency / frequency, with or with- out urgency incontinence Incontinence with mixed symptoms symptom first) Failure MIXED INCONTINENCE (treat most bothersome SPECIALIZED MANAGEMENT -adrenergic antagonists (if also bladder outlet obstruction) α DISCUSS TREATMENT OPTIONS WITH THE PATIENT DISCUSS TREATMENT • Lifestyle interventions • Pelvic floor muscle training ± biofeedback • Scheduled voiding (bladder training) • Incontinence products Antimuscarinics (OAB ± urgency incontinence) and • (usually post- prostatectomy) Incontinence on physical activity sphincteric incompetence (including frequency-volume chart and questionnaire) presumed due to • General assessment (see relevant chapter) Assessment and symptom score • Urinary Symptom Assess quality of life and desire for treatment • • Physical examination: abdominal, rectal, sacral, neurological • Urinalysis ± urine culture -> if infected, treat and reassess Assessment of pelvic floor muscle function • Assess post-void residual urine • STRESS INCONTINENCE Post- muscle dribble contraction milking • Urethral • Pelvic floor micturition Initial Management of Urinary Incontinence in Men HISTORY CLINICAL DIAGNOSIS PRESUMED ASSESSMENT MANAGEMENT

1781 , * poor -blocker (Grade α it is recommended - reductase inhibitors α , (with intractible overactive the recommended option is -blockers and/or 5 α detrusor underactivity, and If incontinence is associated with bladder outlet obstruction For sphincter incompetence When incontinence has been shown to be associated with For idiopathic detrusor overactivity that effective means are used to ensure bladder emptying, for that effective example, intermittent catheterisation (Grade B/C). then consideration should be given to surgical treatment relieve obstruction (Grade B). would be an optional treatment (Grade C). There is increased would be an optional treatment (Grade C). evidence for the safety of antimuscarinics overactive bladder symptoms in men, chiefly combination with an bladder emptying B). artificial urinary sphincter (Grade B). other options, such as a male sling, may be considered (Grade C). bladder symptoms) the recommended therapies are augmentation (Grade C) and neuromodulation B). Botulinum toxin continues to show promise in the treatment of symptomatic detrusor overactivity unresponsive to other therapies Note: At the time of writing, botulinum toxin is being used “off-label”. Note: ➦ ➦ * ➦ ➦ if it is felt II. MEN PECIALIZED MANAGEMENT B. S referred directly to additional testing, studies are recommended then those individuals can be treated urodynamic should be considered. reinstitute initial management then complicated” incontinence suggestive of detrusor overactivity, or of sphincter suggestive of detrusor overactivity, persist, invasive therapies Patients with “ specialized management, are likely to require cystourethoscopy and urinary tract imaging. cytology, 1. Assessment 2. Treatment When basic management has failed that previous therapy had been inadequate. ➦ The specialist may first in order to arrive at a precise diagnosis, prior invasive treatment. incontinence markedly disrupts his quality of life and if the patient’s then If these tests prove normal for incontinence by the initial or specialized management options as appropriate. If symptoms incompetence

1782 pathology Lower urinary tract anomaly/ • Correct anomaly pathology • Treat Consider: • Urethrocystoscopy • Further imaging • Urodynamics - Prostate or pelvic irradiation - Radical pelvic surgery “Complicated” Incontinence : • Recurrent incontinence • Incontinence associated with: catheteri- sation carinics detrusor • Intermittent • Antimus- underactive with coexisting (during voiding) URGENCY due to detrusor INCONTINENCE Incontinence with If initial therapy fails: • Neuromodulation urgency / frequency overactivity (during filling) obstruction bladder outlet with coexisting MIXED reat major T -blockers, 5ARI component first INCONTINENCE (See note) α bladder outlet obstruction • • Correct anatomic • Antimuscarinics incontinence Post-prostatectomy STRESS • Consider urodynamics and imaging of the urinary tract • Urethrocystoscopy (if indicated) incompetence INCONTINENCE due to sphincteric urinary sphincter (see chapter) If initial therapy fails: • Artificial • Male sling Specialized Management of Urinary Incontinence in Men HISTORY/ HISTORY/ SYMPTOM DIAGNOSIS CLINICAL TREATMENT ASSESSMENT ASSESSMENT

1783 before can be vaginal 8-12 weeks (Grade A), is found, the patient may be considered for * most bothersome symptom UTI pelvic organ prolapse (Grade A) for OAB. (Grade and/or for OAB symptoms with or without urgency and possible specialist referral for further management on caffeine reduction (Grade B) and weight on caffeine for women with stress incontinence (Grade B) in women with symptoms of mixed incontinence. (Grade C). (Grade A) cones Some women with significant should be treated at initial assessment and then reassessed after a suitable interval. (Grade B). Antimuscarinics A); duloxetine incontinence (Grade If oestrogen deficiency therapies, scheduled voiding regimes, behavioural therapies and medication. In particular: Advice Supervised pelvic floor muscle training Supervised bladder training treated by vaginal devices that treat both incontinence and prolapse (incontinence rings and dishes). stress urinary incontinence (Grade B) Duloxetine is not approved for use in United States. It * in Europe for severe stress incontinence (see committee report on adverse pharmacological management for information regarding efficacy, Administration of the events, and 'black box' warning by the Food Drug United States). • • • • • first ➦ Initial treatment should be maintained for reassessment improvement. if the patient has had insufficient Clinicians are likely to wish treat the NITIAL MANAGEMENT A. I III. WOMEN urinary incontinence, on physical activity with or without urgency of patients should be identified by urgency and stress incontinence mixed stress, urgency or mixed stress incontinence urgency, frequency urgency, incontinence omen with omen with initial assessment. Three other main groups “Complicated” incontinence group. For women with W W initial treatment should include appropriate lifestyle advice, physical Those women with 1. Initial assessment should identify : 2. Treatment • ➦ Those with pain or haematuria, recurrent infections, suspected proven voiding problems, significant pelvic organ prolapse or who have persistent incontinence or recurrent after pelvic or previous incontinence surgery, irradiation, radical pelvic surgery, who have a suspected fistula, for specialist referral. ➦ • Abdominal, pelvic and perineal examinations should be a routine part should be asked to perform a of physical examination. Women “stress test” ( and strain to detect leakage likely be due Any pelvic organ prolapse or uro-genital sphincter incompetence). or rectal examination allows atrophy should be assessed. Vaginal the assessment of voluntary pelvic floor muscle function, an important step prior to the teaching of pelvic floor muscle training. ➦ •

1784 found e.g. void residual organ prolapse • If other abnormality • Significant post • Significant pelvic • Pelvic mass symptoms - Pain - Hematuria - Recurrent infection - Significant voiding - Pelvic irradiation - Radical pelvic surgery - Suspected fistula Complicated incontinence • Recurrent incontinence • Incontinence associated with: presumed due to urgency detrusor overactivity OAB -with or without Incontinence / frequency with URGENCY INCONTINENCE symptom first) Failure symptoms with mixed MIXED INCONTINENCE (treat most bothersome aginal devices, urethral inserts Incontinence Other adjuncts, such as electrical stimulation V SPECIALIZED MANAGEMENT • • activity volume chart and questionnaire) If appropriate on physical Incontinence • Life style interventions. • Pelvic floor muscle training for SUI or OAB • Bladder retraining for OAB • Duloxetine* (SUI) or antimuscarinic (OAB ± urgency incontinence) • General assessment (see relevant chapter) • Urinary symptom assessment (including frequency- • Assess quality of life and desire for treatment • Physical examination: abdominal, pelvic and perineal • Cough test to demonstrate stress incontinence if appropriate • Urinalysis ± urine culture -> if infected, treat and reassess • Assess oestrogen status and treat as appropriate • Assess voluntary pelvic floor muscle contraction • Assess post-void residual urine presumed due to STRESS INCONTINENCE sphincteric incompetence Initial Management of Urinary Incontinence in Women HISTORY CLINICAL DIAGNOSIS PRESUMED ASSESSMENT MANAGEMENT Subject to local regulatory approval (see black box worning). *

1785 pelvic some then the include the full bladder neck sling leading to significant correction of symptomatic (overactive bladder) secondary to voiding dysfunction limited bladder neck mobility, Urgency incontinence If urodynamic stress incontinence is confirmed Those patients with degree of bladder-neck and urethral mobility treatment options that are recommended for patients with range of non-surgical treatments, as well retropubic suspension A) and bladder neck/sub-urethral sling procedures, (Grade operations:(Grade A). The organ prolapse may be desirable at the same time. idiopathic detrusor overactivity may be treated by neuromodulation A) or bladder augmentation (Grade C). Botulinum toxin can (Grade be used in the treatment of symptomatic detrusor overactivity unresponsive to other therapies (Grade C).* post-void residual urine (for example, >30% of total bladder capacity) may have bladder outlet obstruction or detrusor Prolapse is a common cause of voiding dysfunction. underactivity. with caution. 2. Treatment ➦ For patients with procedures, (Grade A) injectable bulking agents (Grade B) and the procedures, (Grade artificial urinary sphincter (Grade B) can be considered. ➦ ➦ * At the time of writing, botulinum toxin is being used “off-label” and * is highly and whose PECIALIZED MANAGEMENT III. WOMEN B. S Prior to intervention (see initial algorithm) pelvic organ prolapse failed initial management is highly recommended, when the results may complicated” incontinence Systematic assessment for Those women who have recommended and it is suggested that the POPQ method should with co-existing pelvic organ be used in research studies. Women prolapse should have their treated as appropriate urodynamic testing change management. It is used to diagnose the type of incontinence and therefore inform the management plan. Within the urodynamic investigation urethral function testing by pressure profile or leak point is optional. quality of life is impaired are likely to request further treatment. If initial management has been given an adequate trial then interventional therapy may be desirable. omen who have “ 1. Assessement ➦ may need to have additional tests such as cytology, cystourethroscopy may need to have additional tests such as cytology, or urinary tract imaging. If these tests are normal then they should be treated for incontinence by the initial or specialized management options as appropriate. ➦ W

1786 pathology Lower urinary tract anomaly / • Correct anomaly pathology • Treat Consider: • Urethrocystoscopy • Further imaging • Urodynamics with: “Complicated” incontinence: • Recurrent incontinence • Incontinence associated - Pain - Hematuria - Recurrent infection symptoms - Voiding - Pelvic irradiation - Radical pelvic surgery - Suspected fistula detrusor Underactive emptying poor bladder associated with INCONTINENCE bladder outlet obstruction (e.g. genito-urinary prolapse) catheterization • Correct anatomic • Intermittent frequency Incontinence with urgency / obstruction Bladder outlet (DOI) DETRUSOR OVERACTIVITY INCONTINENCE symptoms with mixed Incontinence If initial therapy fails : • Botulinum toxin • Neuromodulation • Bladder augmentation MIXED (USI/DOI) (Treat. most bother- (Treat. INCONTINENCE some symptom first) activity on physical Incontinence • Assess for pelvic organ mobility / prolapse • • Consider imaging of the UT/ pelvic floor • Urodynamics (see notes) surgery STRESS - bulking agents - tapes and slings - colposuspension If initial therapy fails : • Stress incontinence URODYNAMIC INCONTINENCE (USI) Specialized Management of Urinary Incontinence in Women HISTORY/ HISTORY/ SYMPTOM DIAGNOSIS CLINICAL TREATMENT ASSESSMENT ASSESSMENT

1787 IV. VESICOVAGINAL FISTULA IN THE DEVELOPING WORLD

I. INTRODUCTION III. TREATMENT

• Obstructed labour is the main cause of The treatment for vesicovaginal fistula is surgical. vesicovaginal fistula in the developing world. The (Grade A) obstructed labour complex not only induces the vesicovaginal fistula and fetal death in most cases, ➦ Simple fistula but can also have urological, gynaecological, neurological, gastro-intestinal, musculoskeletal, A vaginal approach is preferred, since most simple dermatological and social consequences. fistula can be reached vaginally and since spinal • Other aetiologies such as sexual violence or anaesthesia carries less risk than general anaesthesia genital mutilation are less frequent. For these needed for an abdominal approach. A trained surgeon causes the general principles listed here should be should be able to manage these simple fistula. adapted according to the patient’s need. After wide dissection a tension-free single layer closure of the bladder wall and closure of the vaginal wall in • Patients with vesicovaginal fistula should be a separate layer are advocated. A Martius flap in treated as a person, and they deserve the right to adequate counseling and consent to the treatment primary simple obstetric fistula repair is optional. they will eventually undergo, despite language and A care program for failed repairs and for persisting cultural barriers that may exist. incontinence after a successful repair needs to be installed. • Surgeons embarking on fistula surgery in the developing world should have appropriate ➦ Complex fistula training in that setting and should be willing to take on a long-term commitment. Complex fistulae should be referred to a fistula expert • Prevention of fistula is the ultimate goal. in a fistula centre. (Grade B) Collaboration between fistula initiatives and In principle, most complex fistulae can be dealt with maternal health initiatives must be stimulated. by the vaginal approach, but an abdominal approach may be needed in some cases ( e.g. concommittant II. ASSESSMENT reconstructive procedures). Advanced training and surgical skills are prerequisites for treating this type of fistula. It is important to make a distinction between simple If the urethra and/or the urethral closure mechanism fistulae, which have a good prognosis, and complex is involved, a sling procedure, using an autologous fistulae, which have a less favourable outcome. sling, should be performed at the same time as the Careful clinical examination will allow the type of fistula correction. There is no place for synthetic fistula to be determined, although no generally sling material in this setting. (Grade B) accepted classification system is available. Key items are the size and location of the fistula, the ➦ After care extent of the involvement of the urethra and the urethral closure mechanism, and the amount of vaginal The majority of patients with a simple fistula will be scarring. cured after the repair. However, a proportion of them, Associated pathologies should be actively searched and an even larger proportion of the patients after for and should be taken into account in the treatment complex fistula repair, will remain incontinent. plan: all components of the ‘obstructed labour injury Depending on the local possibilities an after care complex’ should be examined and defined. program should be installed.

1788 SURGICAL MANAGEMENT OF OBSTETRIC FISTULA

CONSTANT URINARY HISTORY/SYMPTOM CONSTANT URINARY LEAKAGE AND/OR ASSESSMENT LEAKAGE FECAL INCONTINENCE

• Single vesico-vaginal fistula • Fistula > 4 cm • Urethral involvement CLINICAL • No urethral involvement • Intravaginal ASSESSMENT • Fistula < 4 cm • Acceptable vaginal access • Rectovaginal fistula • Poor vaginal access • Secondary fistula repair

DIAGNOSIS SIMPLE FISTULA COMPLEX FISTULA

If urethral involvement with stress incontinence add autologous sling

Refer to fistula Primary vaginal fistula TREATMENT specialist/ Fistula repair by trained surgeon center

1789 that concurrently Support should aim to optimise anatomy and function (see is reserved for selected women who agree to permanent may benefit hypoestrogenic women for the prevention is appropriate when medically safe and preferred by the patient when successfully fitted, may improve protrusion symptoms reduce the symptoms of urogenital prolapse (Grade B), although topographic change is not expected prevent or slow deterioration of anterior urogenital prolapse (Grade B) - - full text for grades of recommendation specific surgical techniques). Pre and postoperative pelvic floor muscle training may promote quality of life fewer symptoms after surgery for urogenital prolapse (Grade C). Observation (Grade C). Pelvic floor muscle training may: Pessaries, (Grade B). Regular follow up is mandatory. treat stress incontinence should be considered when appropriate. Local oestrogens and/or treatment of vaginal epithelial ulceration (Grade C). Reconstructive surgery Obliterative surgery vaginal closure (Grade B). 2. MANAGEMENT • • • • • • is may not , except in prolapse. Treatment for prolapse. Treatment rectal Imaging of the upper tract symptomatic women and PELVIC ORGAN PROLAPSE PELVIC

V. urogenital I. INTRODUCTION includes should be measured; nearly all elevated post void residuals with the severity of anatomic changes. define the severity of maximum anatomic support defect, assess pelvic muscle function and determine if epithelial/mucosal ulcertion is present. 1. ASSESSMENT indicated when treatment of vaginal prolapse beyond the hymen is observation only (i.e. no or surgery). Pelvic organ prolapse Physical examination should: • • • pelvic organ prolapse should be reserved for Post void residual resolve with treatment of urogenital prolapse. rare, selected, cases. Symptom enquiry may reveal a variety of symptoms. severity correlate

1790 Specialist management Investigation by specialist Complex or recurrent prolapse PELVIC SYMPTOMS PELVIC OR WITHOUT OTHER • observation • lifestyle interventions • transperineal surgery • transabdominal surgery RECTAL PROLAPSE WITH Sufficient to determine the site and Sufficient assess bothersomeness, frequency Endoscopy, lower GI tract Endoscopy, PVR, cough stress test, urinalysis. Bothersome pelvic organ prolapse Selective use of urodynamics when results would alter planned treatment Selective use of upper tract imaging when observation is planned PELVIC SYMPTOMS PELVIC - - Ano-Rectal: Urinary: Physical Examination: severity of prolapse and detect other significant findings UROGENITAL PROLAPSE • observation • lifestyle interventions • pelvic floor muscle training • pessary • reconstructive surgery • obliterative surgery WITH OR WITHOUT OTHER • Symptoms Screening: ano-rectal, genital and sexual and severity of urinary, symptoms • • Management of Pelvic Organ Prolapse (including urogenital prolapse, and recta prolapse) HISTORY CLINICAL DIAGNOSIS ASSESSMENT MANAGEMENT

1791 (A) distinguish cord lesions (e.g. suprapontine pathol- specialised management ( e.g. denervation after pelvic sur- (cerebro-vascular accidents, stroke, (suprasacral infrapontine spinal cord are important in helping suprasacral infrapontine spinal (as after major pelvic surgery) including those with III. INITIAL TREATMENT peripheral nerve lesions physical examination and , like stroke; need to be assessed for degree of mobility and ability peripheral lesions lesions of the cauda equina (eg.lumbar disc prolapse); central lesions below the pons central lesions above the pons disease). Parkinson’s lesions); - - - Patients with traumatic spinal cord lesions) should get Initial treatment for patients with incontinence due to gery) and patients with ogy cooperate. Initial recommended treatments are behavioural therapy (C) and anti-muscarinic drugs for presumed detrusor overactivity (A). Appliances (B) or catheters (C) may be necessary for non-cooperative less mobile patients. : History these groups. • ➦ ➦ ANAGEMENT M may to the This can NITIAL A. I together bowel not necessarily relate and s producing incontinence. such as prostate pathology, pelvic such as prostate pathology, has a high prevalence in this disease (for bladder is ofter useful and necessary only to tailor e.g. patients with suprapontine lesions or in patients does cause of “ idiopathic incontinence should always Other diseases I. STRONG GENERAL RECOMMENDATIONS RECOMMENDATIONS site and extent of the nervous system abnormality. site and extent of the nervous system abnormality. II. INITIAL ASSESSMENT neurogenic bladder VI. NEUROGENIC URINARY INCONTINENCE possible neurologic be considered. Diagnostic steps to evaluate this include basic assessments, such as history and physical examination, urodynamics specialised tests. Patients with known neurologic disease often need evaluation to exclude but as a standard diagnostic not only if symptoms occur, neurologic bladder, approach as A Incontinence in neurologic neurologic pathology. Extensive diagnostic workout This an individual treatment based on complete neurofunctional data. not be needed in every patient patients where treatment will consist merely of bladder drainage due to bad medical condition or limited life expectancy. There is often a need to manage The management of neurologic urinary incontinence depends on an understanding of the likely mechanism Therefore neurogenic incontinence patients can be divided into those having organ prolapse, et al might have an influence. These have to be ruled out. organ prolapse, et al might have an influence. prevalence figures see chapter) in turn depend on the • • • • • • •

1792 Failure ith Negligible PVR W and mobility : • Depending on cooperation • Behavioural modification, • Antimuscarinics, • External appliances, • Indwelling catheter Peripheral nerve lesion (e.g. lumbar disc prolapse) Conus/cauda equina lesion (e.g. radical pelvic surgery) emptying ith Poor bladder (Significant PVR) Failure Urinary incontinence due to detrusor overactivity W sclerosis) with or without • Intermittent catheterisation • Antimuscarinics (e.g. trauma, multiple Suprasacral infrapon- tine spinal cord lesion incompetence disease, stroke, Failure due to sphincter multiple sclerosis tone and voluntary contraction of anal sphincter, bulbocavernosus and anal reflexes, gait tone and voluntary contraction of anal sphincter, Suprapontine cerebral lesion (e.g. Parkinson’s This assessment will give basic information, but does not permit a precise neurourological diagnosis • Further history • General assessment including home • Urinary diary and symptom score Assessment of functional level, quality life and desire for treatment • • Physical examination: assessment of sensation in lumbosacral dermatomes, anal • Urine analysis + culture (if infected: treat as necessary) • Urinary tract imaging, serum creatinine : if abnormal specialised management • Post void residual (PVR) by abdominal examination or optional ultrasound • Behavioural modification • External appliances Stress urinary incontinence Specialised management preferable for more " tailored treatment Initial Management of Neurogenic Urinary Incontinence HISTORY, CLINICAL DIAGNOSIS PRESUMED level of lesion ASSESSMENT MANAGEMENT

1793 (often in combination) III. TREATMENT MODALITIES III. TREATMENT Conservative Surgical treatment imed voiding (C) riggered voiding (C) ANAGEMENT Intermittent catheterization (A) Behavioural treatment(C) T Ext. Appliances (B) Antimuscarinics(A) Alpha 1 blockers (C) Intravesical electrical stimulation (C) Bladder expression (B) T Indwelling catheter (C) Artificial sphincter (A) Bladder neck Sling (B) Sub-urethral tapes (D) Bulking agents (D) Bladder neck closure (D) Stents intraurethral (B) TUI sphincter (B) Botulinum toxin for : sphincter(C) detrusor (A) (B) Sacral deafferentation Sacral anterior root stimulator (B) Enterocystoplasty (B) Autoaugmentation (D) ➦ ➦ • • • • • • • • • • • • • • • • • • • • • • M may if both sys- must depend PECIALIZED together B. S with videourodynamics function neurophysiological testing bowel (low pressure, complete emptying) clinical and . One should always ascertain that the used II. TREATMENT urinary I. ASSESSMENT is needed in most patients and more detailed renal peripheral lesions urodynamic studies are mandatory urodynamically safe urodynamic findings VI. NEUROGENIC URINARY INCONTINENCE Management of neurogenic urinary incontinence has several therapeutic be helpful for better definition of the lesion Most patients with neurogenic urinary incontinence require specialized assessment : Upper tract imaging function studies will be desirable if the upper tract is considered in danger: high LUT pressure, UUT dilatation, recurrent or chronic upper tract infection, (major) stones, reflux. In patients with if available As therapeutical approach can differ in various As therapeutical approach can differ neurological diseases, the most prevalent dis- eases are discussed separately in the chapter Also for specialized management conservative treatment is the mainstay (A). types of The algorithm details the recommended options for different options. The dysfunction does not nec- neurologic dysfunction of the lower urinary tract. essarily correspond to one type/level of neurologic lesion but mostly on • • • tems are affected, as symptoms and treatment of one system can influence the tems are affected, other and vice versa (A). management is It is recommended to look at

1794 No DSD detrusor • Botulinum toxin to • Enterocystoplasty • Autoaugmentation • Behavioural AM • IC + voiding • Triggered AM • Indwelling cath. + AM Appliances + • Ext. overactivity (e.g. Parkinson’sdisease, stroke, multiple sclerosis) Suprapontine cerebral lesion UI due to detrusor ith DSD W cath. + AM cath. + • IC + AM • IC + • Indwelling • SDAF + IC • SDAF + SARS sclerosis) spinal cord lesion (e.g. trauma, multiples Suprasacral infrapontine sphincter overactivity sphincter detrusor underactivity / -1 blockers Botulinum toxin is currently beeing used off label α • Stents intraurethral • TUI sphincter • *Botulinum toxin to * • IC • • Intravesical ES • Bladder expression Incontinence associated with poor bladder emptying due to Stoma/diversion may be an option in selected cases imed voiding sphincteric Peripheral nerve lesion T incompetence Ext. Appliances • Artificial sphincter • Bladder neck Sling • Sub-urethral tapes • Bulking agents • Bladder neck closure (e.g. lumbar disc prolapse) conus cauda equina lesion Stress UI due to (e.g. radical pelvic surgery) • Urodynamic testing (consider the need for simultaneous imaging / EMG) • Urinary tract imaging : if abnormal renal ultrasonography. • Neurophysiological testing in peripheral lesions SURGICAL Specialized Management of Neurogenic Urinary Incontinence CLINICAL TREATMENT LEVEL AND dyssynergia TREATMENT HISTORY AND ASSESSMENT SPECIALIZED ASSESSMENT CONSERVATIVE DIAGNOSIS EXTENT OF LESION, AM = antimuscarinics SDAF = sacral deafferentation SARS = sacral anterior -roots stim IC = intermittent catheterization intermittent IC = residual PVR = incision postvoid transurethral TUI = DSD = Detrusor sphincter

1795 in (Grade may be bladder diary Clostridium difficile rial with catheter T ; oedema on exam) (Grade C) long-term care residents (PVR) testing is impractical in many care may reduce PVR. in this population is uncertain (Grade D). with: diabetes mellitus (especially longstanding), II. CLINICAL DIAGNOSIS (Grade D), and it may cause harm by increasing the risk of can assess UI frequency in treatment of otherwise asymptomatic bacteriuria/pyuria is is recommended for all patients, primarily to screen hematuria Assessment of frail elders with bothersome nocturia should identify clinical stress test contributing comorbidity et checks potential underlying cause(s) including nocturnal (by [frequency-volume chart] or wet checks and primary sleep problem (e.g., apnoea); low voided volumes from high PVR). settings, and there is no consensus for the definition of “high” PVR in any there is compelling clinical experience for PVR testing Yet, population. selected frail older persons considered for PVR > 200–500 ml if the is felt to contribute UI or frequency (Grade C). prior urinary retention or high PVR; recurrent UTIs; medications that impair bladder emptying (e.g., opiates); severe constipation; persistent or worsening urgency UI despite antimuscarinic treatment; or prior urodynamics showing Treatment detrusor underactivity and/or bladder outlet obstruction (Grade C). of antibiotic resistance and severe adverse effects, e.g., antibiotic resistance and severe adverse effects, Urinalysis (Grade C); not beneficial colitis (Grade C). Utility of W Post Voiding Residual volume Post Voiding Nocturia C). • • • • • The most common types of UI in frail older persons are urgency, stress, and mixed The most common types of UI in frail older persons are urgency, UI. Frail elderly with urgency UI also may have detrusor underactivity and high PVR (without outlet obstruction), called detrusor hyperactivity with impaired There is no evidence that antimuscarinics are less effective contractility (DHIC). or cause retention in DHIC (Grade D). of UI goals (Grade . Effective functional management overall prognosis and different approach different should not be treated degree of bother cognitive assessment (Grade C), comorbid conditions and require a to the patient and/or carer, to the patient and/or carer, similar range of treatment options for UI should be done in all frail older (Grade B), and OLDER MEN AND WOMEN AND OLDER MEN (Grade C). extent of investigation (dryness, decrease in specific symptom[s], should include ASSESSMENT . The degree of bother (UTI) are poorly sensitive and specific in nursing overall prognosis and life expectancy frail older persons does not itself cause UI and History should receive the OLDER MEN AND WOMEN OLDER MEN I. HISTORY AND SYMPTOM (Grade B) ; and 2) current consensus diagnostic criteria for that could cause or worsen UI. The physical should include that could cause or worsen UI. VII. URINARY INCONTINENCE IN FRAIL URINARY INCONTINENCE IN FRAIL potential role of comorbid disease, current medications goals for UI care , cooperation, and atrophic vaginitis screening test for depression (Grade B), lesser care burden) (Grade B), likely quality of life, reduction comorbidity, cooperation with management (Grade C), and the patient’s and remaining life expectancy Active case finding and screening A). persons (Grade The patient and/or carer should be asked about the rectal exam for faecal loading or impaction medications assessment ability to toilet) transfers, manual dexterity, (mobility, A), (to assist in planning management, Grade C). The mnemonic DIAPPERS (to assist in planning management, Grade C). (see algorithm) covers some of these comorbid factors, with two alterations : 1) for this purpose home residents. should take into account the for care (prescribed, over-the-counter, and/or naturopathic), and functional (prescribed, over-the-counter, cognitive impairment in UI addressing the management to meet the goals of care should be possible for most frail elderly. as younger persons, but Healthy older persons • •

1796 UI other goals of care, should be considered. (Grade C), but before (e.g., pain, haematuria), estimated remaining life and should consider insufficient response to initial insufficient as urgency, stress, or mixed, as urgency, specialist referral and perioperative care to establish risk for for any comorbidity, medications, and cognitive for any comorbidity, which the primary clinician cannot address (e.g., because clinical diagnosis may be inaccurate (Grade other significant factors Referral decisions SPECIALIZED MANAGEMENT V. (including the carer) to insure that anticipated surgical outcome . Type of specialist will depend on local resources and the reason Type . trial of conservative therapy (Grade C) . B) Evaluation and treatment and/or functional impairments contributing to UI that could compromise surgical outcome (e.g., dementia that precludes patient ability to use artificial sphincter) (Grade C) Adequate Discussion remaining life is consistent with goals of care in the context patient’s expectancy (Grade C) Urodynamic testing, Preoperative assessment minimise common geriatric post-operative complications such as delirium A) and dehydration falls (Grade C). and infection (Grade symptoms that cannot be classified dementia, functional impairment), then complicated comorbidity Referral also may be appropriate for for referral: surgical specialists (urologists, gynecologists); geriatrician or physical therapist (functional and cognitive impairment); continence nurse specialists (homebound patients). patient/carer desire for invasive therapy, management • • • • • If frail elderly have either expectancy Age per se is not a contraindication to UI surgery surgery is considered, all patients should have: If initial , as well goals of care, are reassessment and and influenced by for UI include lifestyle changes pelvic muscle exercises may be next steps (Grade C). In some frail elders the only estimated remaining life expectancy , and III. INITIAL MANAGEMENT clinical diagnosis may be cautiously considered in frail men with suspected to acheive desired goals, (vasopressin) has a high risk of severe hyponatremia in frail persons IV. ONGOING MANAGEMENT AND REASSESSMENT ONGOING MANAGEMENT IV. (Grade C), bladder training for more fit alert patients B), and prompted A). more impaired patients (Grade voiding for frailer, Antimuscarinics may be considered, but there are few studies (Grade C). A-C, depending on added to conservative therapy of urgency UI (Grade agent). All drugs should be started at the lowest prostatic outlet obstruction (Grade C). dose and titrated with regular review until either care goals are met or adverse are intolerable. effects Initial treatment should be individualized Conservative and behavioural therapy For select cognitively intact patients, Alpha-blockers DDAVP and should not be used (Grade A). and should not be used (Grade treatment preferences as the most likely possible outcome may be contained UI (managed with pads), especially for persons with minimal mobility (require assistance of ≥ 2 to transfer), advanced dementia (unable to state their name), and/or nocturnal UI. Optimal UI management is usually possible with the above approaches. management fails • • • • • treatment of contributing comorbidity and/or functional impairment.

1797 * Other hymen (women) UTI UI associated with: • Pain • Haematuria • Recurrent symptomatic • Pelvic mass • Pelvic irradiation • Pelvic / LUT surgery • Prolapse beyond • Suspected fistula STRESS UI* exercises • Lifestyle interventions • Pelvic floor muscle SIGNIFICANT PVR* alpha-blocker (men) PVR 200-500 ml, then reassess (see text) ± functional impairment • Treat constipation • Treat • Review medications • Consider trial of • Catheter drainage if Active Case Finding in Frail Elderly specialist referral as appropriate per patient preferences and comorbidity (see tex) URGENCY UI* including relevant comorbidities and ADLs (see text) including relevant comorbidities and neurological and rectal exams nocturia present trial of antimuscarinic drug If insufficient improvement, reassess for treatment of contributing comorbidity If continued insufficient improvement, or severe associated symptoms are present, consider • Assess, treat and reassess potentially treatable conditions, • Assess Qol, desire for Rx, goals pt & caregiver preference • physical exam including cognition, mobility, • Targeted • Urinalysis • Consider frequency volume chart or wet checks, especially if • Lifestyle interventions • Behavioral therapies • Consider addition and Management of Urinary Incontinence in Frail Older Persons INITIAL ONGOING CLINICAL CLINICAL ASSESSMENT DIAGNOSIS MANAGEMENT void overtreatment of ASSESSMENT HISTORY/SYMPTOM REASSESSMENT A asymptomatic bacteriura MANAGEMENT and (if Mixed UI, initially treat other factors These diagnoses may overlap in various combinations, e.g., Mixed UI, DHIC (see text) • Delirium • Infection • Pharmaceuticals • Psychological • Excess urine output • Reduced Mobility • Stool impaction and most bothersome symptoms) *

1798 VIII. BLADDER PAIN SYNDROME

Properly defined, the term Bladder Pain Syndrome I. DEFINITION appears to fit in well with the taxonomy of the International Association for the Study of Pain (IASP), and focuses on the actual symptom complex. There Bladder Pain Syndrome (In the absence of a is at this time no universally accepted nomen- universally agreed definition, the European Society clature. for the Study of –ESSIC - definition is given along with a slight modification 2. HISTORY / INITIAL ASSESSMENT made at a recent international meeting held by the Society for Urodynamics and Female Urology Males or females with pain, pressure, or discomfort, – SUFU) that they perceive to be related to the bladder, with • ESSIC : Chronic pelvic pain, pressure or discomfort at least one urinary symptom, such as frequency not of greater than 6 months duration perceived to be obviously related to high fluid intake, or a persistent related to the urinary bladder accompanied by at need to void should be evaluated for possible bladder least one other urinary symptom like persistent pain syndrome. The diagnosis of associated “urge” to void or urinary frequency. Confusable disorders including irritable bowel syndrome, chronic diseases as the cause of the symptoms must be fatigue syndrome, and fibromyalgia in the presence excluded. of the cardinal symptoms also suggests the diagnosis. • Consensus Definition from SUFU International Abnormal gynecologic findings in women and well- Conference (Asia, Europe, North America) held in characterized “confusable” diseases that may explain Miami, Florida February 2008: An unpleasant the symptoms must be ruled out, for example UTI. sensation (pain, pressure, discomfort) perceived ➦ The initial assessment consists of a frequency- to be related to the urinary bladder, associated volume chart, focused physical examination, with lower urinary tract symptom(s) of more than urinalysis, and urine culture. Urine cytology and 6 weeks duration, in the absence of infection or cystoscopy are recommended if clinically indicated. other identifiable causes. Patients with urinary infection should be treated and reassessed. Those with recurrent urinary II. BLADDER PAIN SYNDROME (BPS) infection, abnormal urinary cytology, and/or hematuria are evaluated with appropriate imaging and endoscopic procedures, and only if findings are unable to explain the symptoms, are they 1. NOMENCLATURE diagnosed with BPS. (Grade of recom- mendation: C). The scientific committee of the International Consultation voted to use the term “bladder pain 3. INITIAL TREATMENT syndrome” for the disorder that has been commonly referred to as interstitial cystitis (IC). The term painful bladder syndrome was dropped from the lexicon. The • Patient education, term IC implies an inflammation within the wall of the • dietary manipulation, urinary bladder, involving gaps or spaces in the bladder tissue. This does not accurately describe the majority • non-prescription analgesics, and of patients with this syndrome. Painful Bladder • pelvic floor relaxation techniques Syndrome, as defined by the International Continence Society, is too restrictive for the clinical syndrome. comprise the initial treatment of BPS.

1799 The treatment of pain needs to be addressed directly, 5. REFRACTORY BPS and in some instances concurrent consultation with an anesthesia/pain center can be an appropriate early step in conjunction with ongoing treatment ➦ Those patients with persistent, unacceptable of the syndrome. symptoms despite oral and/or intravesical ther- apy are candidates for more aggressive Treatment should be focused on the most modalities. Many of these are best adminis- bothersome or distressing symptoms(s). tered within the context of a clinical trial if pos- ➦ When conservative therapy fails or symp- sible. These may include neuromodulation, toms are severe and conservative manage- intravesical botulinum toxin, or newly described ment is unlikely to succeed, pharmacologic management techniques. At this point, most patients will benefit from the expert- • oral medication, ise of an anaesthesia pain clinic. • intravesical treatment, or ➦ The last step in treatment is usually some type of surgical intervention aimed at increasing • physical therapy the functional capacity of the bladder or diverting can be prescribed. the urinary stream. It is recommended to initiate a single form of therapy • Urinary diversion with or without cystectomy has and observe results, adding another modality or been used as a last resort with good results in substituting another modality as indicated by degree selected patients. of response or lack of response to treatment. (Grade of recom-mendation: C ). • Augmentation or substitution cystoplasty seems less effective and more prone to recurrence of 4. SECONDARY ASSESSMENT chronic pain in small reported series. (Grade of recommendation: C).

➦ If initial oral or intravesical therapy fails, or before beginning such therapy, it is reasonable to consider further evaluation which can include urodynamics, pelvic imaging, and cys- toscopy with bladder distension and possible bladder biopsy under anaesthesia. Findings of detrusor overactivity suggest a trial of antimuscarinic therapy is indicated. The presence of a Hunner’s lesion diagnosed at any stage in the evaluation suggests therapy with transurethral resection or fulguration of the lesion. Distension itself can have therapeutic benefit in 30- 50% of patients, though benefits rarely persist for longer than a few months. (Grade of recommenda- tion: C ).

1800 Bladder Pain Syndrome

Pain, pressure or discomfort SYMPTOM perceived to be related to the bladder with at least one other urinary symptom (eg freqency, nocturia) test and reassess

• History UTI BASIC • Frequency / Volume Chart • "Complicated PBS" ASSESSMENT • Focused Physical • Incontinence Examination • Urinary infection • Urinalysis, Culture, Cytology • Haematuria • Gynecologic signs / symptoms "SIMPLE BPS" Conservative therapy FIRST LINE • Patient education Consider: TREATMENT • Dietary manipulation • urine cytology • Non-prescription analgesics • further imaging • Pelvic Floor Relaxation NORMAL • endoscopy • urodynamics

BPS : requiring more active ABNORMAL SECOND LINE intervention TREATMENT when treatment response inadequate Treat as indicated

Consider : • Oral therapies • Intravesical therapies Improved with • Physical therapy acceptable quality of life: Consider : Follow and THIRD LINE • Cystoscopy under anesthesia Support TREATMENT with hydrodistention; • Fulgeration of Hunner's lesion

Consider in context of clinical trial: • Neuromodulation • Botulinum toxin intramural • Pharmacologic management

FOURTH LINE Consider: TREATMENT • Urinary diversion with or without cystectomy • Substitution cystoplasty

1801 IX. FAECAL INCONTINENCE

INITIAL MANAGEMENT

• Simple exercises to strengthen and enhance I. INITIAL ASSESSMENT awareness of the anal sphincter (Grade C). • Anti-diarrhoeal medication can help if stools are loose (Grade B). Patients present with a variety of symptom complexes. • Irrigation is helpful in a small number of patients As many people are reluctant to admit to symptoms (mainly neurological - Grade C). of FI, it is important to proactively enquire in known high risk groups (such as women with obstetric injuries, • Initial management can often be performed in patients with loose stool and neurological patients). primary care. If this is failing to improve symptoms after 8-12 weeks, consideration should be given • Serious bowel pathology needs to be considered to referral for further investigations. if the patient has symptoms such as an unexplained change in bowel habit, weight loss, anaemia, rectal bleeding, severe or nocturnal III. INVESTIGATIONS diarrhoea, or an abdominal or pelvic mass. • History will include bowel symptoms, systemic A variety of anorectal investigations, including disorders, local anorectal procedures (e.g. manometry, EMG, and anal ultrasound can help to haemorrhoidectomy), childbirth for women, define structural or functional abnormalities of anorectal medication, diet and effects of symptoms on function. lifestyle. • Examination will include anal inspection, IV. FURTHER MANAGEMENT abdominal palpation, a brief neurological examination, digital rectal examination and usually anoscopy and proctoscopy. • BIOFEEDBACK therapy is usually a package of measures designed • Two main symptoms are distinguished: to enhance the patient’s awareness of anorectal urgency faecal incontinence (FI) which is often function, improve sphincter function and coordination a symptom of external anal sphincter dysfunction and retrain the bowel habit (Grade C). or intestinal hurry; and passive loss of stool may indicate internal anal sphincter dysfunction. Both • PRODUCTS urgency and passive FI may be exacerbated in the to manage severe faecal incontinence are ineffective presence of loose stool. in most cases. • SEVERE FAECAL INCONTINENCE II. INITIAL MANAGEMENT which fails to respond to initial management requires specialised investigations and a surgical opinion. ➦ Once local or systemic pathology has been excluded, initial management includes : V. SPECIAL PATIENT GROUPS • Discussion of options with the patient • Patient information and education, The main chapter (refer to the book) also gives algorithms for the management of complex vesico- • Diet and fluid advice, adjusting fibre intake (Grade vaginal fistulae and faecal incontinence in frail older A), and establishing a regular bowel habit with adults. Committees 10 and 16 gives information on complete rectal evacuation and neurogenic FI.

1802 Initial Management of Faecal Incontinence

Active Screening in High Risk Groups

Patient presents with FI

Basic assessment (history, examination, medication and diet review)

Take out of pathway: Address reversible risk factors e.g. Medication; toilet access; • Alarm signals: referral for investigation loose stools • Impaction: treat then evaluate • Surgical evaluation needed: e.g. rectal prolapse, recent sphincter injury, recto-vaginal fistula, cloacal deformity • Patient and / or carer education • Bowel habit and training • Manage constipation • Diet (e.g. soluble fibre for loose stool) • Medication (e.g. loperamide for loose stool) • PFMT / anal sphincter exercises • Adequate containment (e.g. pads or plugs) and practical management advice (Committee 20)

If initial management fails to achieve adequate symptom relief consider: Diagnostic testing; Biofeedback; Irrigation

Surgical evaluation or symptom management if adequate relief not obtained from conservative management, depending on symptom severity and patient preference

1803 IX. FAECAL INCONTINENCE

SURGERY FOR FAECAL INCONTINENCE

many patients with sphincter defects, there is a I. INITIAL ASSESSMENT AND trend towards SNS if initial evaluation by PNE is MANAGEMENT successful. ➦ The reader is referred to the relevant sections on Patients with sphincter defects of greater “Dynamic Testing” and “Conservative Treatment for than 180° or major pereneal tissue loss require Faecal Incontinence.” In general, patients referred individualized treatment. In some cases, initial for surgical management of faecal incontinence must reconstruction can be performed. Should incon- either have failed conservative therapy or not be tinence persist, alternatives include stimulated candidates for conservative therapy due to severe muscle transposition, artificial anal sphincter anatomic, physiologic or neurologic dysfunction. implantation, or sacral nerve stimulation. [GRADE OF RECOMMENDATION C] Prior to surgical management of faecal incontinence, the morphological integrity of the anal sphincter complex should be assessed. This assessment is III. SALVAGE MANAGEMENT best performed with endoanal ultrasound (EAUS), though pelvic MRI may also be useful. Ancillary tests For patients who remain incontinent following include anal manometry, electromyography (EMG), sphincteroplasty, repeat endoanal ultrasound should and defecography. [GRADE OF RECOMMENDATION be undertaken to reassess the status of the repair. If C] there is a persisting sphincter defect, repeat ➦ Patients with rectal prolapse, rectovaginal fis- sphincteroplasty can be considered. Alternatively, tulae, and cloacas often have associated faecal such patients can undergo individualized therapy, incontinence. Initial therapy should be directed including sacral nerve stimulation. [GRADE OF at correction of the anatomic abnormality (in RECOMMENDATION C]. For patients who remain the case of rectovaginal fistula or cloaca, this incontinent despite an anatomically satisfactory surgical repair may include overlapping sphinc- sphincte-roplasty, sacral nerve stimulation is teroplasty.) If the patient has persisting faecal recommended. incontinence, he or she should undergo repeat Patients who have failed sacral nerve stimulation assessment, including especially endoanal can be considered for sphincteroplasty if a sphincter ultrasound. defect is present. Other alternatives include stimulated muscle transposition and implantation of an artificial II. SPECIALIZED MANAGEMENT anal sphincter. [GRADE OF RECOMMENDATION C] Patients who fail surgical therapy for faecal The surgical approach to the incontinent patient is incontinence, or who do not wish to undergo extensive dictated by the presence and magnitude of an pelvic reconstruction, should consider placement of an anatomic sphincter defect. end sigmoid colostomy. [GRADE OF RECOM- MENDATION C]. While this procedure does not restore ➦ If no defect is present, the patient should continence, it does restore substantial bowel control and undergo percutaneous nerve evaluation (PNE), appears to improve social function and quality of life. which, if successful, should lead to sacral nerve stimulation (SNS). [GRADE OF RECOMMEN- DATION B] IV. SPECIAL SITUATIONS ➦ For patients with sphincter defects of less than 180°, sphincteroplasty has been conven- Individuals with severe spinal cord dysfunction tional therapy. [GRADE OF RECOMMENDA- (due, e.g., to injury or congenital abnormality) should TION B] However, as long-term outcome of be considered for an Antegrade Continence Enema sphincteroplasty appears to deteriorate with (ACE) procedure or colostomy. [GRADE OF time, and SNS has been proven effective in RECOMMENDATION C]

1804 Surgical Management of Faecal Incontinence

Surgical Candidate EVALUATION Persistent for EAUS± Manometry, EMG, treatment for surgery for FI MRI, Defecography anatomical abnormality

RECTAL PROLAPSE, COMPLETE SPINAL CLOACA, CORD IMPAIRMENT RECTOVAGINAL FISTULA

ACE SPHINCTER DEFECT Colostomy

>180°or perineal tissue None < 180° loss

Individualized treatment: Sphincteroplasty * Repeat • Sphincteroplasty SNS EAUS • Muscle transposition • Artificial sphincter * = inadequate symptom relief • Sacral nerve stimulation FI: fecal incontinence; • Biomaterial injection ACE: antegrade continence enema; EAUS: endoanal ultrasonography; • ACE EMG: electromyography; • Colostomy MRI: magnetic resonance imaging SNS: sacral nerve stimulation • Conservative therapy

1805 ; appropriate trigger according to : - complete defecation on a regular basis : – stool softener, laxative, prokinetic– stool softener, agents, anti- III. INITIAL TREATMENTS II. BASIC INVESTIGATIONS: II. BASIC INVESTIGATIONS: defecation – irrigation for incontinence – anal plug. Functional assessment Environmental factors assessment - - hand and arm use, fine mobility – maintaining body position, transfer and walking ability. toilet accessibility; assistive devices for bowel care and mobility; carer’s support and attitude; Patient education and goals-setting and faecal continence based on right time, place, trigger consistency Adequate fibre diet and fluid intake preservation of sacral (anorectal) reflex – digital rectal stimulation; suppository and enema; if no anorectal reflex, manual evacuation; abdominal massage can also be helpful Prescribe medications diarrhea drugs as neccessary Assistive techniques may be necessary for ➦ ➦ • • Stool exam, plain XRay • • • • The diagram does not apply to management in acute neurologic patients that need regular bowel emptying. NITIAL MANAGEMENT A. I may present with symptoms : I. INITIAL ASSESSMENT : this includes known neurologic disease X. FAECAL INCONTINENCE IN NEUROLOGICAL PATIENTS Physical examination History taking Patients with in defecation, constipa- related to neurologic bowel dysfunction – difficulty tion and faecal incontinence which disturb their activities of daily living quality of life. Many have permanent impairments and functional limitations and disabilities, which are due to neurological deficits complications Neurological diagnosis and functional level; Previous and present lower gastrointestinal (LGIT) function disorders Severity of neurogenic bowel dysfunction Current bowel care and management including diet, fluid intake, medications bowel functions affecting Co-morbidity / complication e.g., urinary incontinence, autonomic dysreflexia, pressure sores, sexual dysfunction satisfaction, needs, restrictions and quality of life Patient’s Environmental factors and barriers facilitators to independent bowel management. sensory and sacral reflexes – voluntary anal Cognitive functions; motor, sphincter contraction, deep perianal sensation, anal tone, and bulbo- cavernosus reflexes Spasticity of the lower limbs Abdominal palpation for faecal loading and rectal examination ➦ ➦ • • • • • • • • • • ➦

1806 lesions Suprapontine (e.g. Parkinson) Faecal disimpaction " False incontinence due to faecal impaction Suprasacral spinal cord lesion (e.g. trauma, multiple sclerosis,) softener, laxative; softener, Chemical stimulant: untary anal contraction Digital rectal stimulation transanal/transrectal irrigation suppository, mini-enema, stool suppository, tive function, sensory awareness Incontinence due to lack of cogni- disorders, unable to control by vol- anal plug incompetence Assistive device – disorders, current bowel and bladder programme, co-morbid diseases/disorders, QOL and needs sensation, sacral reflexes, per rectal examination, abdominal palpation for faecal impaction in the colon support and attitude not felt on rectal examination) Manual evacuation lesion (e.g. radical pelvic surgery) bar disc prolapse) Peripheral nerve • History taking including diagnosis, pre-morbid bowel function and sensation their • Physical & neurological examination including cognitive function, voluntary anal contraction, • Functional assessment including hand and arm use, fine balance, transfer walk assistive device, carer’s • Environmental factors assessment including toilet accessibility, • Basic investigation: stool exam, plain film abdomen in selected patients (diarrhea, impaction This assessment will give basic information but does not permit a precise diagnosis of neurogenic bowel dysfunction Patient education, adequate fibre diet and fluid intake; regular bowel care, preferable ± 3 times a week Conus/cauda equina lesion (e.g. lum- Incontinence due to sphincter Specialised management preferable for more " tailored treatment Initial Management of Neurogenic Faecal Incontinence in all Necessary HISTORY, CLINICAL DIAGNOSIS PRESUMED TREATMENT level of lesion ASSESSMENT

1807 ransanal irrigation (C) T Surgical management of neurogenic faecal incontinence has different options Surgical management of neurogenic faecal incontinence has different which need a very strict patient selection ACE (C) Antegrade Continence Enema Graciloplasty (C) Artificial sphincter (C ) Anterior Root Stimulation SARS (C ) Sacral (C ) Toxin Botulinum Neuromodulation (C ) It is recommended to look at urinary and bowel function together if both as symptoms and treatment of one system can influ- systems are affected, ence the other and vice versa (A). neurological diseases, the in different As therapeutical approach can differ most prevalent diseases are discussed seperately in the chapter. Electrical stimulation sphincter, (C) Electrical stimulation sphincter, Percutaneous neuromodulation : further research is required • • • • • • • ➦ ➦ ➦ • • specialized PECIALISED MANAGEMENT e.g. women with B. S due to neuropathy, as their value in neurologic pathology is incontinence does not include very extensive optional I. ASSESSMENT II. TREATMENTS : manometry, endoanal ultrasound, (dynamic) MRI, : manometry, that all symptoms are with neurogenic faecal incontinence will need especially if initial management is unsuccesful to look for X. FAECAL INCONTINENCE IN NEUROLOGICAL PATIENTS Also for specialized management, conservative treatment for neurogenic faecal incontinence is the mainstay not sufficiently demonstrated so far. demonstrated so far. not sufficiently (needle) EMG These specific bowel functional tests and electro-diagnostic (needle) EMG tests must be considered Management of neurogenic treatment modalities and many conservative are still empirical. Some patients assessment, comorbidity and certainly before performing invasive treatment Do not assume neurologic pathology might have had childbirth injury to the sphincter ➦ • ➦ • • Special investigations • Special

1808 lesions Suprapontine (e.g. Parkinson) Faecal disimpaction Faecal impaction ACE = Antegrade Continence Enema ACE = Anterior Root Stimulation SARS = Sacral Failure consider Suprasacral spinal cord lesion (e.g. trauma, multiple sclerosis,) Failure consider • ACE • Graciloplasty • Artificial sphincter • SARS • Botulinum Toxin • Neuromodulation • Transanal irrigation • Transanal • Electrical stimulation sphincter, • Percutaneous neuromodulation : further study electromyography, in addition to anorectal manometry, to identify or confirm in addition to anorectal manometry, electromyography, neurogenic cause of faecal incontinence. lesion (e.g. radical pelvic surgery) • Functional bowel testing / functional imaging • Neurophysiological testing especially external anal sphincter needle bar disc prolapse) Peripheral nerve Faecal Incontinence through loss of bowel sensation, sphincter Conus/cauda equina lesion (e.g. lum- deficiency or, severe rectum, prolaps no anal control, comorbidity, severe rectum, prolaps no anal control, comorbidity, deficiency or, Stoma/diversion may be an option in selected cases Specialised Management of Neurogenic Faecal Incontinence SURGICAL TREATMENT DIAGNOSIS TREATMENT SPECIALIZED extent of lesion, ASSESSMENT history, level and history, CONSERVATIVE clinical assessment Primary assessment,

1809 4. Recommendations for Continence Promotion, Education and Primary Prevention

Continence promotion, education and primary • No single model for continence services can be prevention involves informing and educating the public recommended. Because of the magnitude of UI and health care professionals that urinary incontinence prevalence, detection and basic assessment will and faecal incontinence are not inevitable, but are need to be performed by primary care providers. treatable or at least manageable. In addition, other Specialist consultation should generally be bladder disorders such as bladder pain syndrome reserved for those patients where appropriate and pelvic organ prolapse can be treated successfully. conservative treatments have failed, or for Progress has been made in the promotion of specified indications. (Grade D) continence awareness through advocacy programs, • There is a need for research on patient-focused organization of the delivery of care, and public access outcomes, should include evaluation of the to information on a worldwide basis. These have also outcomes for all sufferers who present for care, been advocated in the education of professionals and use validated audit tools/outcome measures and primary prevention of mainly urinary incontience. longitudinal studies of the outcomes of services However, not much has changed in help-seeking behaviour for these disorders. This chapter updates provided. (Grade D) previous International Consultation on Incontinence • There is a need for cost-effectiveness studies of (ICI) chapters on three areas: continence promotion, current services. (Grade D) education and primary prevention and the following are the recommendations in these individual areas. PROFESSIONAL EDUCATION CONTINENCE AWARENESS AND PROMOTION • There remains a need for rigorously evaluated continence education programmes which adhere • Continence awareness should be included in any to defined minimum standards for continence national advocacy program that is working towards specialists and, generalists, utilizing web-based an effective health literacy system, as it is and distance learning techniques alongside audit consistent with and requires the involvement of and feedback, train-the trainer models and many levels of educational, health-care, and leadership models as well as traditional methods. community service providers.(Grade D) (Grade D) • Continence awareness should be part of the main • There is a need for research on the most effective stream and on-going health education and means to educate professional groups on advocacy programs with emphasis on eliminating continence issues.(Grade D) stigma, promoting disclosure and help-seeking behaviour and improving quality of life. (Grade D) PRIMARY PREVENTION • There is a need for research to provide higher level of evidence on the effectiveness of continence • Primary prevention studies efforts should be aimed promotion programs to increase awareness, be it at interventions to promote a healthy body weight for primary prevention, treatment or management. to assist in the prevention of incontinence (Grade (Grade D) A). • There is a need for research on the most effective • Primary prevention studies should not be limited means to educate the public and professional to individual interventions, but also test the impact groups on continence issues. (Grade D) of population-based public health strategies (Grade C) CONTINENCE ADVOCACY • PFMT should be a standard component of prenatal and postpartum care and to instruct women who • Government support and co-operation are needed experience incontinence prior to pregnancy PFMT to develop services, and responsibility for this (Grade C) should be identified at a high level in each Health Ministry. Incontinence should be identified as a • Randomised controlled trials (RCTs) should be separate issue on the health care agenda. There conducted to test the preventative effect of PFMT is a need for funding as a discrete item and for for men post-prostatectomy surgery (Grade B) funding, not to be linked to any one patient group • Further investigation is warranted to assess the (e.g. elderly or disabled), and should be mandatory. efficacy of PFMT and BT for primary prevention (Grade D) of UI in well older adults (Grade B) 1810 5. Recommendations for Further Basic Science Research

1. Integrate data from reductionist experiments to encourage translational approaches to research. formulate better systems-based approaches in 6. Bring about a greater emphasis on the importance the investigation of the pathology of the lower of research to medical trainees through: urinary tract (LUT), the genital tract (GT) and the • establishing research training as a core lower gastro-intestinal tract (LGIT). component of medical training 2. Generate and improve experimental approaches • increased access to support funds, especially to investigate the pathophysiology of the LUT and scholarships and personal awards LGIT by: • organisation of focussed multidisciplinary • The development of fully characterised animals research meetings, either stand-alone or as models • part of larger conferences • Use of human tissue from well-characterised • greater interaction between medical centres patient groups and HEIs 3. Encourage greater emphasis on basic research into our understanding of tissues receiving relatively 7. Increase emphasis on research into lower urinary little attention: ie the lower gastrointestinal tract; the tract and gastro-intestinal tract in HEIs through: bladder neck and urethra. • greater representation on grant-funding 4. Generate a more disciplinary approach to agencies investigate the function of the lower urinary tract • encouragement of submission to high impact- through collaborations between biological, physical factor journals and recognition of research and mathematical sciences. published in specialty journals 5. Increase interaction between higher education • more integrated teaching and training institutions (HEIs), industry and medical centres to opportunities 6. Recommendations for Further Research in Epidemiology

1. Longitudinal study designs are needed to estimate between UI, AI and POP and specific diseases like the incidence of urinary incontinence (UI), anal stroke, diabetes, and psychiatric diseases. incontinence (AI) and pelvic organ prolapse (POP) 5. The variation of disease occurrence in groups of and to describe the natural course of these different racial origin yet similar environmental conditions and to investigate risk factors and exposures, lend support to the presumed genetic possible protective factors. In addition similar studies influence on the causation of UI, AI and POP. This regarding other lower urinary tract symptoms again provides circumstantial evidence for a genetic (LUTS) should be initiated. contribution to pelvic floor disorders since most of 2. There is still little knowledge regarding prevalence, these studies have been unable to control for incidence, and other epidemiological data in heritability in relation to the complex interaction of developing countries. It is recommended that environmental factors. fundamental research regarding prevalence, 6. The ethiology of UI, AI and POP is widely incidence and other epidemiological data in recognised to be multifactorial, yet the complex developing countries should be encouraged, and interaction between genetic predisposition and tailored to the cultural, economic and social environmental influences is poorly understood. environment of the population under study. Genetic components require further investigation. 3. Some potential risk and protective factors deserve Twin studies provide a possible means of studying more attention. For example, the role of pregnancy the relative importance of genetic predisposition and childbirth in the development of UI, AI and and environmental factors. By comparing mono- POP must be studied in a fashion that links zygotic female twins with identical genotype, and population-based methods to clinical assessment dizogytic female twins who on average share 50 of pregnancy, delivery and the birth trauma and percent of their segregating genes, the relative follows women over many years. Such a design is proportions of phenotypic variance resulting from necessary because the effect of pregnancy and genetic and environmental factors can be estimated. childbirth may become clear only years later when A genetic influence is suggested if monzygotic the woman is older and because the woman will twins are more concordant for the disease than not then be able to report the exact nature of the dizygotic twins whereas evidence for environmental tear and episiotomy, etc. effects comes from monozygotic twins who are 4. There should be more emphasis on the associations discordant for the disease. 1811 7. Recommendations for Clinical Research Methodology

PART I: GENERAL II. RECOMMENDATIONS ON RECOMMENDATIONS OBSERVATIONS DURING INCONTINENCE RESEARCH I. RECOMMENDATIONS ON STUDY • One or more high quality, validated symptom CONDUCT AND STATISTICAL instruments should be chosen at the outset of a METHODS clinical trial representing the viewpoint of the patient, accurately defining baseline symptoms • Randomized controlled trials (RCTs) eliminate as well as any other areas in which the treatment most of the biases that can corrupt research and may produce an effect. The objective severity and provide the strongest level of evidence to direct subjective impact or bother should be reflected. clinical care. The primacy of RCTs in incontinence • Whenever relevant, observations of anatomic research should be fully acknowledged by support and pelvic muscle/voluntary sphincter researchers, reviewers, and editors. function should be recorded using standardized, • Careful attention to the planning and design of all reproducible measurements. research is of the utmost importance. This should • All observations should be repeated after begin with a structured literature review which intervention and throughout follow-up and their should be described in the manuscript. High quality, relationships with primary clinical outcome systematic reviews on many topics in incontinence measures investigated. Most research follow-up have been published by the Cochrane Incon- has been inadequate in the past. Given the nature tinence Group (www.otago.ac.nz/cure) and provide of the disorder, short term follow-up in incontinence a valuable starting point. trials should begin with all participants having • The design, conduct, analysis and presentation of reached one year. RCTs must be fully in accordance with the Consolidated Standards of Reporting Trials III. RECOMMENDATIONS ON TESTS (CONSORT) guidelines. Statistical expertise is USED IN URINARY required at the start of the design of a RCT and INCONTINENCE RESEARCH: thereafter on an ongoing basis.

• Equivalence trials are underutilized. Failing to find • Clinical trials of incontinence and LUTS should a difference between two treatments is not the include a validated frequency volume chart or same as proving equivalence if the correct design bladder diary as an essential baseline and is not used. outcome measure. Pad tests are a desirable adjunctive measure and should be considered in • Inclusion and exclusion criteria inherently reflect clinical trials when practical. a conflict between detecting a specific treatment effect and generalizability of the results. It is • Urodynamic studies have not been proven to have recommended that the study population in RCTs adequate sensitivity, specificity or predictive value comprise a sample that is representative of the to justify routine use of testing as entry criteria or overall population. All patients who have the outcome measures in clinical trials. Most large disorder in question, who could benefit from the scale clinical studies should enroll subjects by treatment under investigation, and who are carefully defined symptom driven criteria when evaluable should be eligible. Exclusion criteria the treatment will be given based on an empiric should be limited and related to clearly defined, diagnosis. supportable hypotheses. • High quality, hypothesis driven research into the utility of using urodynamic studies to define patient populations or risk groups within clinical trials is greatly needed.

1812 • In all trials employing urodynamics, standardized • Entry into RCTs should be defined by performance protocols (based on ICS recommendations) are status rather than an arbitrary age limit. defined at the outset. In multicenter trials, urodynamic tests should be interpreted by a central • Establishing the safety of incontinence treatment reader to minimize bias unless inter- and intrarater is even more important in the frail elderly than in reliability has already been established by other populations standardized procedures within the trial. IV. RECOMMENDATIONS FOR PART II : CONSIDERATIONS FOR RESEARCH IN CHILDREN SPECIFIC PATIENT GROUPS • We support the NIH statement (http:// grants. nih.gov/ grants/guide/notice-files/ not98-024.html) I. RECOMMENDATIONS FOR calling for increased clinical research in children. RESEARCH IN MEN All investigators that work with children should be aware of the details of the document. • High quality, gender specific quality of life and • Long-term follow-up is of critical importance in bother scores should be employed when the pediatric population with a primary focus of assessing outcome in male incontinence research. establishing safety of chronic treatments. • Uroflow and measurement of post-void residual urine should be recorded pre-treatment and the V. RECOMMENDATIONS FOR effect of therapy on these parameters should be RESEARCH IN NEUROGENIC documented simultaneously with assessment of PATIENTS the primary outcome variables. The value of invasive pressure-flow urodynamics in stratifying • Detailed urodynamic studies are required for patients deserves further investigation. classification of neurogenic lower urinary tract • Measurement of prostate size (or at least PSA, as disorders in clinical trials because the nature of the a surrogate) should be performed before and after lower tract dysfunction cannot be accurately treatment (synchronous with other outcome predicted from clinical data. measures) whenever prostate size is expected to change due to the treatment. Patients should • Change in detrusor leak point pressure should be stratified by prostate size at randomization be reported as an outcome as appropriate, and when size is considered to be a potentially can be considered a primary outcome for spina important determinant of treatment outcome. bifida patients. • An area of high priority for research is the II. RECOMMENDATIONS FOR development of a classification system to define RESEARCH IN WOMEN neurogenic disturbances. Relevant features would include the underlying diagnosis, the symptoms, • Specific information about the menopausel, and the nature of the urodynamic abnormality. hysterectomy, and hormonal status, parity and obstetric history should be included in baseline VI. RECOMMENDATIONS FOR clinical trial data RESEARCH IN FAECAL • Strict criteria for cure / improve / fail should be INCONTINENCE defined based on patient perception as well as objective and semi-objective instruments such as • Data should be collected on fecal incontinence validated questionnaires, diaries and pad tests. whenever practical as part of research in urinary incontinence. III. RECOMMENDATIONS FOR RESEARCH IN FRAIL OLDER • Well designed and adequately powered studies are needed to define best practice in investigation AND DISABLED PEOPLE and for all treatment modalities currently available

• “Clinically significant” outcome measures and • Further considertion should be given to new relationships of outcome to socioeconomic costs approaches and adoption of technologies/ are critically important to establishing the utility interventions that are of established value in of treating urinary incontinence in the frail elderly. treating urinary incontinence

1813 VII. RECOMMENDATIONS FOR PART III : CONSIDERATIONS FOR RESEARCH IN BLADDER PAIN SPECIFIC TYPES OF RESEARCH SYNDROME

• The patient population for BPS trials must be I. RECOMMENDATIONS FOR carefully defined. When appropriate, relaxed entry BEHAVIORAL AND criteria should be used to reflect the full spectrum PHYSIOTHERAPY RESEARCH of the BPS patient population

• The primary endpoint of BPS trials should be • Treatment protocols must be detailed to the degree patient driven and the Global Response that the work can easily be reproduced Assessment is recommended. A rich spectrum of secondary endpoints will be useful in defining the • The highest practical level of blinding should be effect of treatments used.

• Investigation of antiproliferative factor as an entry • More work is needed to separate the specific and criteria for clinical research is desirable. non-specific effects of treatment

VIII. RECOMMENDATIONS FOR II. RECOMMENDATIONS FOR RESEARCH IN PELVIC ORGAN SURGICAL AND DEVICE PROLAPSE RESEARCH

• There should be a focus on patient reported • Safety and serious side effects of new devices outcomes with the goal of determining “clinically must be adequately defined with adequate follow- significant” prolapse. The implications of stage 2 up, especially for use of implantable devices and prolapse in terms of natural history and treatment biologic materials, so that risks can be weighed outcome are key issues. against efficacy. All new devices and procedures require independent, large scale, prospective, multicenter case series when RCTs are not IX. RECOMMENDATIONS FOR feasible. RESEARCH IN NOCTURIA • Valid informed research consent is required in all trials of surgical interventions, which is separate • Research is needed to define the epidemiology of from the consent to surgery. nocturia and how the symptom relates to normal aging • Reports of successful treatment should be limited to subjects with a minimum (not mean) of one • Clinical research in treatment of nocturia should year follow-up and should include a patient begin with classification of patients by voiding perspective measure. Specific assumptions about diary categories, 24 hour polyuria, nocturnal patients lost to follow-up should be stated; last polyuria, and apparent bladder storage disorders. observation carried forward is generally not the If desired, patients with low bladder capacity can appropriate method of handling this data. be further divided into those with sleep disturbances and those with primary lower urinary tract dysfunction. III. RECOMMENDATIONS FOR PHARMACOTHERAPY TRIALS

• In urinary incontinence safe, effective non-invasive therapy is available for the vast majority of patients. Most trials should offer “standard therapy” rather than a pure placebo where efficacy is established.

• Effective drug therapy is available for most forms of incontinence. Comparator arms are recom- mended for most trials.

1814 IV. RECOMMENDATIONS FOR ETHICS IN RESEARCH

• Continuity in clinical direction from design through authorship is mandatory. Investigators should be involved in the planning stage and a publications committee should be named at the beginning of the clinical trial. The Uniform Requirements for Manuscripts Submitted to Biomedical Journals, from the International Committee of Medical Journal Editors should be followed. Authorship requires:

• Substantial contributions to conception and design or acquisition of data or analysis and interpretation of data,

- Drafting the article or revising it critically for important intellectual content,

- Final approval of the version to be published

• Authors should provide a description of what each contributed and editors should publish that information.

• Authors should have access to all raw data from clinical trials, not simply selected tables Clinical trial results should be published regardless of outcome. The sponsor should have the right to review manuscripts for a limited period of time prior to publication but the manuscript is the intellectual property of its authors, not the sponsor.

• All authors should be able to accept responsibility for the published work and all potential conflicts of interest should be fully disclosed.

1815 ICIQ-UI on Urinary Incontinence Questionnaire (short form)

ICIQ-UI Short Form

Initial number CONFIDENTIAL DAY MONTH YEAR Today’s date Many people leak urine some of the time. We are trying to find out how many people leak urine, and how much this bothers them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.

1 Please write in your date of birth: DAY MONTH YEAR 2 Are you (tick one): Female Male

3 How often do you leak urine? (Tick one box) never 0 about once a week or less often 1 two or three times a week 2 about once a day 3 several times a day 4 all the time 5

4 We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? (Tick one box) none 0 a small amount 2 a moderate amount 4 a large amount 6

5 Overall, how much does leaking urine interfere with your everyday life? Please ring a number between 0 (not at all) and 10 (a great deal) 0 1 2 3 4 5 6 7 8 9 10 not at all a great deal

ICIQ score: sum scores 3+4+5

6 When does urine leak? (Please tick all that apply to you) never – urine does not leak leaks before you can get to the toilet leaks when you cough or sneeze leaks when you are asleep leaks when you are physically active/exercising leaks when you have finished urinating and are dressed leaks for no obvious reason leaks all the time

Thank you very much for answering these questions.

1816 International Consultation on Incontinence Modular Questionnaire (ICIQ)

The scientific committee which met at the end ICIQ-UI Short Form has been translated into of the 1st ICI in 1998 supported the idea that 30 languages to date. Two further, newly a universally applicable questionnaire should developed and fully validated, modules have be developed, that could be widely applied been finalised since the third consultation and both in clinical practice and research. are now being incorporated into clinical practice and research, and translated The hope was expressed that such a accordingly for international use. The ICIQ-VS questionnaire would be used in different [7] provides evaluation of vaginal symptoms settings and studies and would allow cross- and the ICIQ-B [3] can be used to assess comparisons, for example, between a drug bowel symptoms including incontinence. Both and an operation used for the same condition, questionnaires also provide assessment of in the same way that the IPSS (International the impact of these symptoms on quality of life Prostate Symptoms Score) has been used. (Table 1).

An ICIQ Advisory Board was formed to steer Where high quality questionnaires already the development of the ICIQ, and met for the existed within the published literature, first time in 1999. The project’s early progress permission was sought to include these within was discussed with the Board and a decision the ICIQ in order to recommend them for use. made to extend the concept further and to Eleven high quality modules have been develop the ICIQ Modular Questionnaire to adopted into the ICIQ which are direct include assessment of urinary, bowel and (unchanged) derivations of published vaginal symptoms. The first module to be questionnaires (Table 1). developed was the ICIQ Short Form Questionnaire for urinary incontinence: the www.ICIQ.net provides details of the validation ICIQ-UI Short Form. The ICIQ-UI Short Form status of the modules under development for has now been fully validated and published [2]. urinary symptoms, bowel symptoms and vaginal symptoms and provides information Given the intention to produce an inter- regarding the content of existing modules. nationally applicable questionnaire, requests Information regarding production of were made for translations of the ICIQ-UI translations and the ICIQ development Short Form at an early stage, for which the protocol is also available for those interested Advisory Board developed a protocol for the in potential collaborations to continue production of translations of its modules. The development of the project.

1817 Table 1. Fully validated ICIQ modules and derivation

MODULES AVAILABLE FOR USE

ICIQ – MLUTS Urinary symptoms (male) (ICSmale Short Form [4])

ICIQ – FLUTS Urinary symptoms (male) (BFLUTS Short Form [5]) ICIQ-VS [2] Vaginal symptoms ICIQ-B [3] Bowel symptoms ICIQ - UI Short Form [1] Urinary incontinence short form ICIQ – N Nocturia (ICSmale [6]/ BFLUTS [7]) ICIQ – OAB Overactive bladder (ICSmale [6]/ BFLUTS [7]) ICIQ – MLUTS Long Form Urinary symptoms long form (male) (ICSmale [6]) ICIQ – FLUTS Long Form Urinary symptoms long form (female) (BFLUTS [7]) ICIQ – LUTSqol Urinary symptoms quality of life (KHQ [8]) ICIQ – Nqol Nocturia quality of life (N-QOL [9]) ICIQ – OABqol Overactive bladder quality of life (OABq [10]) ICIQ – MLUTSsex Sexual matters related to urinary symptoms (ICSmale [6]) (male) ICIQ – FLUTSsex Sexual matters related to urinary symptoms (BFLUTS [7]) (female)

6. Donovan J, Abrams P, Peters TJ, Kay H, Reynard J, et al. REFERENCES The ICS-'BPH' study: the psychometric validity and reliability of the ICSmale questionnaire. BJU International 1996. 77: 554-562. 1. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, et al. ICIQ: 7. Jackson S, Donovan J, Brookes ST, Eckford S, Swithinbank a brief and robust measure for evaluating symptoms and L, et al. The bristol female lower urinary tract symptoms impact of urinary incontinence. Neurourology and questionnaire: development and psychometric testing. BJU urodynamics 2004. 23: 322-330. International 1996. 77: 805-812. 2. Price N, Jackson SR, Avery K, Brookes ST, Abrams P. 8. Kelleher CJ, Cardozo L, Khullar V, Salvatore S. A new Development and psychometric evaluation of the ICIQ vaginal questionnaire to assess the quality of life of urinary incontinent symptoms questionnaire: the ICIQ-VS. BJOG 2006. 113: 700- women. British Journal of Obstetrics and 712. 1997. 104: 1374-1379. 3. Cotterill N, Norton C, Avery K, Abrams P, Donovan J. A 9. Abraham L, Hareendran A, Mills I, Martin M, Abrams P, et patient-centrered approach to developing a comprehensive al. Development and validation of a quality-of-life measure symptom and quality of life assessment of anal incontinence. for men with nocturia. Urology 2004. 63: 481-486. Diseases of the colon and rectum 2008. 51: 82-87. 10. Coyne KS, Revicki D, Hunt TL, Corey R, Stewart WF, et al. 4. Donovan J, Peters TJ, Abrams P, Brookes ST, De La Rosette Psychometric validation of an overactive bladder symptom JJMCH, et al. Scoring the short form ICSmaleSF and health-related quality of life questionnaire the OAB-q. questionnaire. Journal of Urology 2000. 164: 1948-1955. Quality of life research 2002. 11: 563-574. 5. Brookes ST, Donovan J, Wright M, Jackson S, Abrams P. A scored form of the Bristol Female Lower Urinary Tract Symptoms questionnaire: data from a randomized controlled trial of surgery for women with stress incontinence. American Journal of Obstetrics and Gynaecology 2004. 191: 73-82.

1818 Annex 1 : Bladder Charts and Diaries

Three types of Bladder Charts and Diaries can be used 2. The time, eg. 7.30am when you pass your urine. Do to collect data :- this every time you pass urine throughout the day MICTURITION TIME CHART and also at night if you have to get up to pass urine. 3. Each time you pass urine, collect the urine in a • times of voiding and measuring jug and record the amount (in mls or fluid • incontinence episodes ozs) next to the time you passed the urine, eg. 1.30pm FREQUENCY VOLUME CHART - 320 mls. • times of voiding with voided volumes measured, 4. If you leak urine, show this by writing ‘W’ (wet) on the • incontinence episodes and number of changes of diary at the time. incontinence pads or clothing. 5. If you have a leak, please add ‘P’ if you have to change a pad and ‘C’ if you have to change your underclothes BLADDER DIARIES or even outer clothes. So, if you leak and need to • the information above, but also change a pad, please write ‘WP’ at the time you • assessments of urgency, leaked. • degree of leakage (slight, moderate or large) and 6. At the end of each day please write in the column on descriptions of factors leading to symptoms such as the right the number of pads you have used, or the stress leakage, eg. running to catch a bus number of times you have changed clothes. When you go to bed at the end of the day show it on the It is important to assess the individual’s fluid intake, remembering that fluid intake includes fluids drunk plus diary - write ‘Went to Bed’ the water content of foods eaten. It is often necessary to INSTRUCTIONS FOR USING THE explain to a patient with LUTS that it may be important BLADDER DIARY to change the timing of a meal and the type of food eaten, particularly in the evenings, in order to avoid troublesome This diary helps you and us to understand why you get nocturia. trouble with your bladder. The diary is a very important The micturition time and frequency volumes charts can part of the tests we do, so that we can try to improve your be collected on a single sheet of paper (Fig. 1). In each symptoms. On the chart you need to record:- chart/diary, the time the individual got out of bed in the 1. When you get out of bed in the morning, show this on morning and the time they went to bed at night should the diary by writing ‘GOT OUT OF BED’. be clearly indicated. 2. During the day please enter at the correct time the Each chart/diary must be accompanied by clear instructions drinks you have during the day, eg. 8.00am - two for the individual who will complete the chart/diary: the cups of coffee (total 400 ml). language used must be simple as in the suggestions given 3. The time you pass your urine, eg. 7.30am. Do this for patient instructions. There are a variety of designs of every time you pass urine throughout the day and charts and diaries and examples of a detailed bladder night. diary are given. The number of days will vary from a single 4. Each time you pass urine, collect the urine in a day up to one week. measuring jug and record the amount (in mls or fluid INSTRUCTIONS FOR COMPLETING THE ozs) next to the time you passed the urine, eg. MICTURITION TIME CHART 1.30pm/320ml. 5. Each time you pass your urine, please write down This chart helps you and us to understand why you get how urgent was the need to pass urine: trouble with your bladder. The diary is a very important ‘O’ means it was not urgent. part of the tests we do, so that we can try to improve your + means I had to go within 10 minutes. symptoms. On the chart you need to record:- ++ means I had to stop what I was doing and go to the 1. When you get out of bed in the morning, show this on toilet. the diary by writing ‘GOT OUT OF BED’. 2. The time, eg. 7.30am, when you pass your urine. Do 6. If you leak urine, show this by writing an ‘W’ on the diary this every time you pass urine throughout the day at the time you leaked. and also at night if you have to get up to pass urine. 7. If you have a leak, please add ‘P’ if you have to change 3. If you leak urine, show this by writing a ‘W’ (wet) on a pad and ‘C’ if you have to change your underclothes the diary at the time you leaked or even outer clothes. So if you leak and need to 4. When you go to bed at the end of the day show it on change a pad, please write ‘WP’ at the time you the diary - write ‘WENT TO BED’. leaked. 8. If you have a leakage please write in the column INSTRUCTIONS FOR USING THE called ‘Comments’ whether you leaked a small amount FREQUENCY VOLUME CHART or a large amount and what you were doing when This chart helps you and us to understand why you get you leaked, eg. ‘leaked small amount when I sneezed trouble with your bladder. The diary is a very important three times’. part of the tests we do, so that we can try to improve your 9. Each time you change a pad or change clothes, please symptoms. On the chart you need to record:- write in the ‘Comments’ column. 1. When you get out of bed in the morning, show this on 10. When you go to bed at the end of the day show it on the chart by writing ‘Got out of bed’. the diary - write ‘Went to Bed’. 1819 1820