Clinical update: Continence care

Urinary incontinence is a common problem affecting up to one third of women at some time in their lives. Prevalence increases with age. Data also show that mild to moderate incontinence is more common in younger women, with moderate to severe incontinence being more common in older women. It is not a life-threatening condition and healthcare professionals can dismiss it as being ‘normal’, but leaking urine can have a devastating effect on an individual’s psychological state, general health and wellbeing. Referral pathways vary, and referral to a healthcare professional with the specialist knowledge and skills to offer the best help and advice, is not always made. In Scotland, a CSP campaign has led to a pledge that more woman will be offered physio rather than surgery. See www.csp.org.uk/node/883329

The National Institute for Health and Care Excellence (NICE) has published a quality standard on managing female urinary incontinence. The seven quality statements are designed to be specific, concise and measurable, and are based on the corresponding NICE guideline. 

 

I was a specialist committee member of both the update of the NICE guideline CG171 and the recently-published quality standard 77. Implementing these standards across primary and secondary care should help to raise the quality of continence care. This is an ideal opportunity for specialist continence physiotherapists to promote their role in the initial assessment and management of these women.

 

Statement 1 says that the healthcare professional performing the initial assessment (ideally in a primary care setting) should aim to categorise the type of incontinence as this will form the basis of the initial management. GPs and practice nurses, to whom the patient may initially present, do not always have enough time or specialist knowledge to correctly classify the type of incontinence. Typically, a specialist continence physio or continence nurse will ask a questions to gain an accurate insight into the main problem, which is often complex and consists of mixed symptoms.  

 

A bladder diary is an important part of the initial assessment and aids categorisation of the incontinence (see statement 2). Again, most generalists would not have time to discuss the bladder diary with the patient or the knowledge to interpret the bladder diary correctly to gain any useful information on which to base management. If referrals are made in a timely fashion into specialist continence service the highly-trained physiotherapist or nurse would be able to use the information from the bladder diary as a diagnostic tool and to initiate appropriate lifestyle changes and treatment. The aim is to treat the condition, thus improving the symptoms and not to offer containment products in a routine fashion (see statement 3). 

Statements 4 and 5 highlight the importance of conservative measures as first-line treatment for stress, urgency and mixed incontinence. For symptoms of overactive bladder (frequency, urgency, urgency incontinence, nocturia) and mixed incontinence, six weeks of bladder training is recommended. This consists of lifestyle advice such as reducing caffeine and fizzy drinks, trying to defer voiding if frequency is a problem, and pelvic floor muscle exercises as an aid to reduce urgency and incontinence. For stress incontinence (leaking with coughing, sneezing and physical activity) and mixed incontinence, at least three months supervised pelvic floor muscle training is recommended as first-line treatment for women who are able to contract their pelvic floor muscles. 

 

This must, of necessity, involve a vaginal examination of the pelvic floor muscles to confirm the correct contraction. Without this it is impossible to initiate and plan an individualised exercise programme, and this is explained in the full version of the quality standard. Some women, however, cannot contract their pelvic floor muscles. This does not mean that quality statement 4 excludes these women from having any treatment for their incontinence. They are an important group, who with input from a highly-skilled continence physiotherapist can, in the majority of cases, learn to produce the correct contraction. Once this is learned they can then enter a three-month pelvic floor muscle training programme.

There are a number of highly skilled physios, many of whom have attended courses run by the Pelvic, Obstetric and Gynaecological Physiotherapy professional network, or master’s level modules in incontinence. I suggest they are best placed to assess and treat women with stress or mixed urinary incontinence who require pelvic floor muscle training, and implement the NICE quality standards. We need to produce more evidence to support the use of physiotherapy in this condition and sell our services to providers or our place in the patient pathway may be eroded by other continence providers with less expertise in muscle rehabilitation. fl

Quality standards draw on NICE guidelines CG171 Urinary incontinence: the management of urinary incontinence in women, September 2013.