Guidelines on Urinary Incontinence M.G. Lucas (chair), D. Bedretdinova, J.L.H.R. Bosch, F. Burkhard, F. Cruz, A.K. Nambiar, C.G. Nilsson, D.J.M.K. de Ridder, A. Tubaro, R.S. Pickard © European Association of Urology 2014 TABLE OF CONTENTS PAGE 1. INTRODUCTION 7 1.1 Methodology 7 1.1.1 PICO questions 7 1.1.2 Search strategies 8 1.1.3 Level of evidence and grade of recommendation 9 1.2 Publication history 9 1.3 References 10 1.4 Use in different healthcare settings and by healthcare professionals 10 1.5 Terminology 10 2. ASSESSMENT AND DIAGNOSIS 11 2.1 History and physical examination 11 2.2 Patient questionnaires 11 2.2.1 Questions 11 2.2.2 Evidence 12 2.2.3 Research priorities 13 2.2.4 References 13 2.3 Voiding diaries 14 2.3.1 Questions 14 2.3.2 Evidence 14 2.3.3 References 15 2.4 Urinalysis and urinary tract infection 16 2.4.1 Questions 16 2.4.2 Evidence 16 2.4.3 References 17 2.5 Post-voiding residual volume 17 2.5.1 Question 17 2.5.2 Evidence 17 2.5.3 Research priority 18 2.5.4 References 18 2.6 Urodynamics 20 2.6.1 Question 20 2.6.2 Evidence 20 2.6.2.1 Repeatability 20 2.6.2.2 Diagnostic accuracy 20 2.6.2.3 Does urodynamics influence the outcome of conservative therapy 21 2.6.2.4 Does urodynamics influence the outcome of surgery for SUI? 21 2.6.2.5 Does urodynamics help to predict complications of surgery? 21 2.6.2.6 Does urodynamics influence the outcome of surgery for DO? 21 2.6.2.7 Does urodynamics influence the outcome of treatment for post- prostatectomy UI in men? 21 2.6.3 Research priority 22 2.6.4 References 22 2.7 Pad testing 26 2.7.1 Question 26 2.7.2 Evidence 26 2.7.3 Research priority 26 2.7.4 References 26 2.8 Imaging 27 2.8.1 Questions 28 2.8.2 Evidence 28 2.8.3 Research priority 29 2.8.4 References 29 3. CONSERVATIVE MANAGEMENT 30 3.1 Simple clinical interventions 30 3.1.1 Underlying disease/cognitive impairment 30 3.1.1.1 Question 30 2 URINARY INCONTINENCE - UPDATE APRIL 2014 3.1.1.2 Evidence 30 3.1.1.3 References 31 3.1.2 Adjustment of medication 31 3.1.2.1 Question 31 3.1.2.2 Evidence 31 3.1.2.3 References 32 3.1.3 Constipation 32 3.1.3.1 Question 32 3.1.3.2 Evidence 33 3.1.3.3 Research priority 33 3.1.3.4 References 33 3.1.4 Containment 33 3.1.4.1 Question 33 3.1.4.2 Evidence 34 3.1.4.3 Question 34 3.1.4.4 Evidence 34 3.1.4.5 Question 34 3.1.4.6 Evidence 34 3.1.4.7 Question 34 3.1.4.8 Evidence 34 3.1.4.9 Research Priority 35 3.1.4.10 References 35 3.2 Lifestyle interventions 36 3.2.1 Caffeine reduction 36 3.2.1.1 Question 37 3.2.1.2 Evidence 37 3.2.1.3 References 37 3.2.2 Physical exercise 37 3.2.2.1 Question 37 3.2.2.2 Evidence 37 3.2.2.3 References 38 3.2.3 Fluid intake 39 3.2.3.1 Question 39 3.2.3.2 Evidence 39 3.2.3.3 References 39 3.2.4 Obesity and weight loss 39 3.2.4.1 Question 39 3.2.4.2 Evidence 39 3.2.4.3 References 40 3.2.5 Smoking 41 3.2.5.1 Question 41 3.2.5.2 Evidence 41 3.2.6 Recommendations for lifestyle interventions 41 3.2.7 Research priority 42 3.2.8 References 42 3.3 Behavioural and Physical therapies 42 3.3.1 Bladder Training 42 3.3.1.1 Questions 42 3.3.1.2 Evidence 43 3.3.2 Pelvic floor muscle training (PFMT) 43 3.3.2.1 Question 43 3.3.2.2 Evidence 44 3.3.2.3 Efficacy of PFMT in SUI, UUI and MUI in women 44 3.3.2.4 PFMT in the elderly 44 3.3.2.5 PFMT and Radical prostatectomy 44 3.3.3 Scheduled voiding 45 3.3.4 Electrical stimulation (surface electrodes) 45 3.3.4.1 Question 45 3.3.4.2 Evidence 46 3.3.5 Magnetic stimulation 46 URINARY INCONTINENCE - UPDATE APRIL 2014 3 3.3.5.1 Question 46 3.3.5.2 Evidence 46 3.3.6 Posterior tibial nerve stimulation 47 3.3.6.1 Question 47 3.3.6.2 Evidence 47 3.3.7 Recommendations for behavioural and physical therapies 48 3.3.8 Research priorities 48 3.3.9 References 48 3.4 Conservative therapy in mixed urinary incontinence 52 3.4.1 Question 52 3.4.2 Evidence 52 3.4.3 Recommendations conservative therapy in mixed urinary incontinence 52 3.4.4 References 52 4. DRUG TREATMENT 53 4.1 Antimuscarinic drugs 53 4.1.1.1 Question 53 4.1.1.2 Evidence 53 4.1.1.3 References 54 4.2 Comparison of antimuscarinic agents 55 4.2.1 Question 55 4.2.2 Evidence 55 4.2.3 References 56 4.3 Antimuscarinic drugs versus non-drug treatment 57 4.3.1 Question 57 4.3.2 Evidence 57 4.3.3 References 58 4.4 Antimuscarinic agents: adherence and persistence 58 4.4.1 Question 59 4.4.2 Evidence 59 4.4.3 References 60 4.5 Antimuscarinic agents, the elderly and cognition 60 4.5.1 Question 61 4.5.2 Evidence 61 4.5.2.1 Oxybutynin 61 4.5.2.2 Solifenacin 61 4.5.2.3 Tolterodine 62 4.5.2.4 Darifenacin 62 4.5.2.5 Trospium chloride 62 4.5.2.6 Fesoterodine 62 4.5.2.7 Duloxetine in the elderly 62 4.5.2.8 Mirabegron 62 4.5.2.9 Applicability of evidence to general elderly population 62 4.5.2.10 Anticholinergic load 62 4.5.2.11 Question 63 4.5.2.12 Evidence 63 4.5.3 Research priority 63 4.5.4 References 63 4.6 Adrenergic drugs for UI 66 4.6.1 References 67 4.7 Duloxetine 68 4.7.1 Questions 68 4.7.2 Evidence 68 4.7.3 References 69 4.8 Oestrogen 70 4.8.1 Questions 70 4.8.2 Evidence 70 4.8.3 References 71 4.9 Desmopressin 71 4.9.1 Questions 71 4 URINARY INCONTINENCE - UPDATE APRIL 2014 4.9.2 Evidence 72 4.9.2.1 Improvement of incontinence 72 4.9.2.2 Monitoring for hyponatraemia 72 4.9.3 References 72 4.10 Drug treatment in Mixed urinary incontinence 72 4.10.1 Question 72 4.10.2 Evidence 72 4.10.3 References 73 5. SURGICAL TREATMENT 73 5.1 Women with uncomplicated SUI 74 5.1.1 Open and laparoscopic surgery for SUI 74 5.1.1.1 Question 75 5.1.1.2 Evidence 75 5.1.1.3 References 76 5.1.2 Mid-urethral slings 76 5.1.2.1 Questions 77 5.1.2.2 Evidence 77 5.1.2.3 References 79 5.1.3 Single-incision slings 81 5.1.3.1 Questions 81 5.1.3.2 Evidence 81 5.1.3.3 References 82 5.1.4 Adjustable sling 82 5.1.4.1 Questions 82 5.1.4.2 Evidence 82 5.1.4.3 References 82 5.1.5 Bulking agents 83 5.1.5.1 Question 83 5.1.5.2 Evidence 83 5.1.5.3 Research priorities 85 5.1.5.4 References 85 5.2 Complicated SUI in women 86 5.2.1 Colposuspension or sling following failed surgery 86 5.2.1.1 Question 87 5.2.1.2 Evidence 87 5.2.1.3 References 88 5.2.2 External compression devices 88 5.2.2.1 Question 89 5.2.2.2 Evidence 89 5.2.2.3 Research priorities 90 5.2.2.4 References 90 5.3 Women with both SUI and pelvic organ prolapse 91 5.3.1 Questions 91 5.3.1.1 Evidence 91 5.3.1.2 References 94 5.4 Men with SUI 95 5.4.1 Bulking agents in men 95 5.4.1.1 Question 95 5.4.1.2 Evidence 95 5.4.1.3 References 95 5.4.2 Fixed male sling 96 5.4.2.1 Question 96 5.4.2.2 Evidence 96 5.4.2.3 References 96 5.4.3 Adjustable slings in males 97 5.4.3.1 Question 97 5.4.3.2 Evidence 98 5.4.3.3 References 98 5.4.4 Compression devices in males 99 URINARY INCONTINENCE - UPDATE APRIL 2014 5 5.4.4.1 Question 99 5.4.4.2 Evidence 99 5.4.4.3 Research priorities 100 5.4.4.4 References 100 5.5 Surgical interventions for refractory DO 102 5.5.1 Intravesical injection of botulinumtoxinA 102 5.5.1.1 Question 102 5.5.1.2 Evidence 102 5.5.1.3 Research priorities 103 5.5.1.4 References 103 5.5.2 Sacral nerve stimulation (neuromodulation) 104 5.5.2.1 Question 104 5.5.2.2 Evidence 104 5.5.2.3 Research priority 105 5.5.2.4 References 105 5.5.3 Cystoplasty/urinary diversion 106 5.5.3.1 Augmentation cystoplasty 106 5.5.3.2 Detrusor myectomy (bladder auto-augmentation) 107 5.5.3.3 Urinary diversion 107 5.5.3.4 References 107 5.6 Surgery in patients with mixed urinary incontinence 108 5.6.1 Question 108 5.6.2 Evidence 108 5.6.3 Research priority 109 5.6.4 References 109 5.7 Surgery for UI in the elderly 110 5.7.1 References 111 APPENDIX A: URINARY FISTULA 112 A.1 Introduction 112 A.2 Diagnosis of fistula 112 A.3 Management of vesicovaginal fistula 112 A.3.1 Conservative management 112 A.3.2 Surgical management 112 A.3.2.1 Surgical approaches 112 A.3.3 Postoperative management 113 A.4 Management of radiation fistula 113 A.5 Management of ureteric fistula 113 A.6 Management of urethrovaginal fistula 114 A.6.1 Diagnosis 114 A.6.2 Surgical repair 114 A.6.2.1 Vaginal approach 114 A.6.2.2 Abdominal approach 115 A.7 References 117 6.