8 . Management recommendations: clean intermittent self catheterisation (CISC) 8 .1 Overview

Link to Appendix 3
Link to Section 2
8. Management recommendations: clean intermittent
self catheterisation (CISC)
Section 8 has been developed using non-systematic, narrative methodology.
8.1 Overview
The main aims of clean intermittent self catheterisation (CISC) are to empty the bladder and
prevent bladder over distension in order to avoid complications and to improve urological
conditions (Cottenden, Bliss, Fader et al., 2005). Infrequent emptying leads to excessive
bladder volumes, with long periods of urine stagnation. As residual urine plays a role in
infection, attention must be made to complete emptying of the bladder (Cottenden, Bliss,
Fader et al., 2005). It is generally recommended that total emptying be performed at least
four times per day. Catheterising more than six times in 24 hours is inconvenient and should
be discouraged. If catheterising six times in 24 hours still produces any single volume over
500mL, fluid intake should be investigated. Reducing fluid in the evening will minimise
excessive urine volumes during the night (Heard, 2005).
When low urine volumes are produced (<1200mL per day), clients have been found to be less
inclined to empty as frequently as recommended, causing stagnation and bladder distension
(Heard, 2005). Clients should be advised to drink 1.5 to 2 litres of water daily (Sullivan, 2006)
unless otherwise indicated.
If persistent difficulty with catheter insertion occurs, the client should be referred on for
urological evaluation. In the short term, observe technique and help correct faulty insertion
techniques. Catheters with alternative tip designs, (eg. Coudé, Tiemann), may be useful for
difficult insertions (Heard, 2005).
8.2 Definition of clean intermittent self catheterisation
CISC is a clean, non-sterile, technique that can be used independently by the individual, a
carer or clinician to facilitate emptying the bladder (Williams, 2005).
8.3 Indications for clean intermittent self catheterisation
CISC should be used where there is a clinical indication to empty the bladder and the client
is unable to do so (Hirst, 2006). The June 2004 National Health Service Quality Improvement
Scotland Best Practice Statement on Urinary Catheterisation and Catheter Care states that
“intermittent catheterisation is the preferred alternative to indwelling catheterisation for
individuals in whom bladder emptying is incomplete, providing this is safe and acceptable
to them” (NHSQIS, 2004). It has fewer complications and gives a better outcome (Cottenden,
Bliss, Fader et al., 2005).
CISC may be used short term or long term in a variety of circumstances, including:
• Neuropathic disorders where the bladder loses the ability to empty completely, providing
that bladder capacity is sufficient, bladder pressure can be kept low and urethral resistance
is high enough to maintain continence (Cottenden, Bliss, Fader et al., 2005).
• Where there is an obstruction to the outflow of urine and the bladder can’t empty itself
(Hirst, 2006).
• Post operative urinary retention (Williams, 2005).
• Following surgery for incontinence (colposuspension) if obstruction occurs in short or
long term (Getliffe & Dolman, 2003).
• When a continent urinary diversion such as Mitrofanoff diversion is performed to create
a continent catheterisable channel into the bladder from the abdominal surface (Getliffe
& Dolman, 2007).
• Following bladder substitution or augmentation (Sullivan, 2006).
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8. Management recommendations: clean intermittent self catheterisation (CISC)
8.4 Client selection criteria
Physiological requirements to be met include:
• Adequate bladder capacity to enable sufficient urine storage so that catheterisation can
be restricted to only every four hours (Hirst, 2006)
• Adequate sphincter mechanism (Sullivan, 2006).
The person undertaking CISC must have good manual dexterity, mobility, motivation, and
the ability to learn and carry out the procedure correctly (NHSQIS, 2004). As a general
rule, a person who is able to write and feed him/herself has the manual dexterity to self
catheterise. The presence of a disability does not necessarily preclude CISC. Indeed, success
in the technique has been achieved by people with blindness, lack of perineal sensation,
tremor, mental disability, and paraplegia (Getliffe & Dolman, 2007). If a person has problems
with balance or hip abduction, help from a physiotherapist or other health professional is
recommended (Sullivan, 2006).
8.5 Advantages and disadvantages of clean intermittent self catheterisation
Advantages of CISC include the following:
• Urinary tract complications are reduced by improving bladder drainage
• Continence should be achieved unless co-existing detrusor overactivity is present
• Improved quality of life and empowerment through greater independence and personal
control over bladder function
• Greater freedom for expression of sexuality as compared with use of an indwelling
catheter
• Reduced burden on hospital and community resources, especially cost factors
• Reduced common indwelling catheter associated problems, including urethral trauma,
UTI and encrustation
• Improved sleep for those with nocturia and nocturnal enuresis
(Getliffe & Dolman, 2007; Shaw, Logan, Webber et al., 2008; Sullivan, 2006).
Disadvantages of clean intermittent self catheterisation have been reported to include:
• Difficulty finding hygienic facilities and privacy away from the home environment
• The time involved in the process
• Increased risk of urinary tract infections
• Shorter sleep due to client staying up late for final catheterisation, and rising early for
first catheterisation in the morning
• Perceived stigma and embarrassment
• Fear of pain/discomfort in the early phase
• Physical and technical difficulties
• Disposal issues
(Shaw, Logan, Webber et al., 2008).
8.6 Complications of clean intermittent self catheterisation
As with indwelling catheterisation, some complications may occur when using intermittent
catheters (Cottenden, Bliss, Fader et al., 2005). These include the following:
• Urinary tract infections (UTI)
If catheterisation is begun by clients with recurrent or chronic UTI and urinary retention,
the incidence of infection decreases and some patients may become totally free of infection.
If symptomatic infections occur, improper CISC technique often can be identified as the
cause. Recurrent infection persists if the primary cause is not addressed.
8. Management recommendations: clean intermittent self catheterisation (CISC)
55
•
Other complications
Urethral bleeding may be seen in clients new to CISC. Trauma of the urethra may
very rarely cause false passage and meatal stenosis in men. The incidence of urethral
strictures increases with the number of years of CISC. Forceful manipulation during
catheter insertion and significant bleeding are important contributing factors for the
development of urethral strictures in clients on CISC (Cottenden, Bliss, Fader et al.,
2005)
Rare complications from CISC include bladder calculi caused by introduction of pubic hair,
loss of the catheter in the bladder, bladder perforation and bladder necrosis (Cottenden,
Bliss, Fader et al., 2005). Clinical practice feedback indicates excessive bladder volumes
(>500mL at each CISC) may also be a complication (Sullivan, 2006).
8.7 Managing and treating complications
Link to Section 14.6
For clients using CISC, there are inconsistent findings regarding the effect of antibiotic
prophylaxis on symptomatic UTI, and there is only limited evidence that receiving antibiotics
reduces the rate of bacteriuria (asymptomatic and symptomatic) (Niel-Weise & van den Broek,
2005). While there is weak evidence that prophylactic antibiotics are better in terms of fewer
symptomatic bacteriurias (Niel-Weise & van den Broek, 2005), there is usually no place
for prophylactic antibiotics or treatment of the asymptomatic UTI (Hirst, 2006). There is,
however, often a client expectation that an antimicrobial response is required, despite scant
evidence in some cases to support such treatment (Brown & Nay, 2006).
The use of prophylactic antibiotics either orally or by installation poses a significant risk
for the development of resistance to antibiotics. The risk of side effects from antibiotics, the
expense, and the risk to other clients from cross-infection with resistant organisms are strong
arguments against prophylactic antibacterials. The need for alternatives to broad spectrum
antibiotic treatment should encourage further investigation of options such as ingesting
large amounts of fluid to flush out harmful bacteria (Brown & Nay, 2006).
Link to Section 14.6
Ascorbic acid has been found to be useful only when used together with other antibacterial
drugs (Cottenden, Bliss, Fader et al., 2005). Cranberry juice may inhibit Escherichia Coli from
attaching to the bladder wall; however the juice may have little value in the presence of other
bacteria (Brown & Nay, 2006). There is inconclusive evidence about the role cranberry juice
or tablets play in preventing urinary tract infections (Cottenden, Bliss, Fader et al., 2005) and
until the evidence for using cranberry juice is stronger, it should, at the very least, be used
with caution. An awareness of its potential for neutral or even adverse effects needs to be
brought to the attention of all health care workers (Brown & Nay, 2006).
Urethral strictures occur infrequently and can be avoided by gentle introduction of a well
lubricated or hydrophilic catheter (Cottenden, Bliss, Fader et al., 2005).
Point of Interest
Urethral trauma with false passages has been treated with six weeks of indwelling
catheterisation and five days of antibiotics. The false passages disappeared and CISC was
restarted. In a small study of only six people, urethral strictures were effectively treated with
urethral dilatation in four cases, while two were treated with optical internal urethrotomy,
followed by urethral stenting for two weeks (cited in Cottenden et al, 2005).
56
8. Management recommendations: clean intermittent self catheterisation (CISC)
8.8 Catheters - properties
A catheter without a retention balloon is used for intermittent catheterisation (AUNS, 2006;
Getliffe & Dolman, 2007; Sullivan, 2006). The catheters come in different lengths for men
(approximately 40cm long) and women (approximately 22cm long).
To aid insertion, intermittent catheters are more rigid than indwelling ones. The longer length
male catheters are made from PVC with variable rigidity (Sullivan, 2006), while the majority
of female catheters have the same degree of rigidity. Some women, particularly those in
wheelchairs, may prefer to use the longer male catheter (Sullivan, 2006).
The catheter has an eyelet on either side of the tip, and a funnel at the other end, which may
help people with poor eyesight to distinguish between the two ends. The funnels are colour
coded to indicate the size of the catheter.
8.8.1 Catheters - size
The correct catheter diameter is the smallest size capable of providing adequate drainage. Too
large a diameter can cause urethral irritation and subsequent damage. The size of the catheter
can be determined by looking at the size of external meatus (Sullivan, 2006). The most
common sizes are 10–12 Fg/Ch for women and 12-14 Fg/Ch for most males, with 1Fg/Ch
equalling 1/3 mm (AUNS, 2006). The size of the catheter also influences how fast the bladder
is drained. A smaller size catheter may be contraindicated for clients who are unwilling to
spend sufficient time catheterizing, resulting in a larger post void residual volume (Hirst,
2006).
8.8.2 Catheters - lubricant
The catheters used for intermittent catheterisation are either single-use pre-lubricated catheters
or polyvinyl chloride (PVC) catheters, which can be used with a water-based lubricant for men
where needed (NHSQIS, 2004). Petroleum jelly is not suitable for catheter insertion (Sullivan,
2006). Hydrophilic catheters have been found to be easier to use and better tolerated by
people using CISC who have had difficulties with conventional catheters (Cottenden, Bliss,
Fader et al., 2005). When immersed in water, the water molecules bind to the surface so no
additional lubricant is necessary. Hydrophilic catheters are more expensive than some PVC
catheters and are single use only products (Sullivan, 2006). The surface of the catheter is
claimed to be an important factor with less stricture development when hydrophilic catheters
are used, however results are not conclusive (Cottenden, Bliss, Fader et al., 2005).
While overseas research indicates that local anaesthetic gel can be inserted 5-10 minutes
before inserting the catheter (Cottenden, Bliss, Fader et al., 2005), other evidence suggests
that anaesthetic gel is ineffective and is rarely used in Queensland (Hirst, 2006).
8.9 Valsalva and Credé manoeuvres
Adequate voiding can be attained by employing Valsalva and gentle Credé manoeuvre at the
conclusion of catheterisation before the catheter is removed (Heard, 2005). These techniques
can cause irreversible damage to the upper urinary tract if used as a primary approach to
bladder emptying, or if undertaken without the catheter in place (Hirst, 2006). Therefore,
discussion with the treating general medical practitioner and/or medical specialist is necessary
before recommending either practice to an individual client.
The Valsalva manoeuvre (inhaling deeply and then exhaling forcefully against a closed
glottis) greatly increases intra-abdominal pressure, and may enable bladder emptying by
straining. In some people it also may trigger a bladder contraction. As this manoeuvre
increases intracranial pressure, it only has a place at the end of catheterisation while the
catheter is still in place (Hirst, 2006).
8. Management recommendations: clean intermittent self catheterisation (CISC)
57
The Credé manoeuvre, or manual expression, involves applying considerable pressure,
usually with the ball of the hand, over the bladder. It assists in emptying the bladder in much
the same way as use of the Valsalva technique, by raising bladder pressure or triggering a
bladder contraction. These manoeuvres may be used in conjunction with the ‘double voiding’
technique, or voiding again to ensure emptying of the bladder.
8.10 Education for use of clean intermittent self catheterisation
CISC will not be successful without the client’s full cooperation, and cannot be started unless
the client is willing (Sullivan, 2006). Education is very important. Clients and caregivers
must understand what is wrong with the bladder/sphincter, what the cause is and why CISC
is proposed for treatment. They need to learn how to catheterise correctly (Cottenden, Bliss,
Fader et al., 2005).
Good Practice Point
Clean intermittent self catheterisation
Key points to cover in client education (Getliffe & Dolman, 2003; Sullivan, 2006)
•
Acknowledge any anxiety before starting to teach the technique.
•
Discuss the client’s bladder dysfunction and reasons for CISC.
•
Discuss the technique, and issues such as how long the client will need to catheterise, any
long-term effects, and the possibility of causing injury to oneself.
Acknowledge any embarrassment at touching the genitals. Discuss personal anatomy and
•
identification of urethral orifice.
•
Be positive, optimistic, and patient, and provide encouragement at every step.
•
Discuss alternatives to CISC, such as voiding techniques, IDC, surgery or drugs, continuing
voiding difficulties or overflow incontinence. Indicate the advantages and disadvantages of
each option.
Discuss the possibility of initial discomfort. Taking urinary alkalinisation tablets (eg.
•
sodium citrotartrate) and increasing water intake may help. Identify what to do if there is an
infection, and who to contact if there are any problems.
•
Discuss hygiene.
•
Provide dietary advice for avoidance of constipation.
•
Check manufacturer’s instructions for use.
•
Discuss storage of new catheters including :
- Lie catheters flat, preferably in manufacturer’s box, away from heat or sunlight
- Do not bend
- Do not group with rubber bands
- Check the expiry date before use.
8.11 Frequency of clean intermittent self catheterisation
Regular, timely catheterisation prevents over-distension of the bladder, avoids incontinence
whenever possible and helps to reduce infection (NHSQIS, 2004). One study found a five-fold
increase in infection when CISC was done three times a day compared to six times a day
(Cottenden, Bliss, Fader et al., 2005).
Frequency varies with individual needs and depends on the reasons for CISC. It is generally
not necessary more than four hourly during the day – greater frequency will significantly
impact on the individual’s social freedom (Hirst, 2006). Those who are in complete retention
may need to catheterise five to six times a day. One author (Alderman, 1988) suggests the
guideline of voided urinary volume plus residual urine should be no more than 400 -500mL
(Getliffe & Dolman, 2007).
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8. Management recommendations: clean intermittent self catheterisation (CISC)
Where inefficient voiding leads to a gradual increase in post-void volume during the day,
CISC may be needed only once a day or every couple of days. The client may choose to
perform CISC before some activity that may limit access to toilet, or before sexual activity.
Sleep should be as undisturbed as possible (Getliffe & Dolman, 2007), and modifying timing
of fluid intake and/or use of night-time Desmopressin (DDAVP) may assist in achieving this
(Fonda, DuBeau, Harari et al., 2005; Heard, 2005). However, the risks of this medication,
including the reduced frequency of catheterisation, needs to be considered.
Link to Section 14.8
8.12 Catheter cleaning
In Australia, there are strict rules from the Therapeutics Goods Act 1989 regarding use of
products in accordance with the product information. Any health professional who provides
advice contrary to the manufacturer’s single use labelling may be professionally liable for
any harm to the client as a result of the advice given with respect to cleaning and reuse.
In a case of negligence, the health professional may be required to provide the evidence on
which his/her recommendations for cleaning were based (TGA, 2006). In Australia, only one
manufacturer claims to have a catheter for repeat use. All catheters should be used as per the
manufacturer’s information.
Point of Interest
A Cochrane review found no convincing evidence that any specific technique (sterile or clean),
catheter type (coated or uncoated), method (single use or multiple use), person (self or other)
or strategy is better than any other for all clinical settings. This reflects a lack of reliable
evidence rather than evidence of no difference. Thus, clinicians must base decisions about
which technique and type of catheter to use on clinical judgement, in conjunction with clients
and medical practitioners. Differential costs of catheters/techniques may also inform decision
making (Moore, Fader & Getliffe, 2007).
8.13 Contraindications for clean intermittent self catheterisation
Use of CISC may be contraindicated in the following circumstances (Cottenden, Bliss, Fader
et al., 2005):
• Spasticity interfering with catheterisation
• Incontinence despite anticholinergic agents
• Unhygienic environment prohibiting clean procedure
• Limited dexterity
• Poor technique.
Good Practice Point
•
•
•
•
•
CISC is the first choice of treatment for those with an inability to empty the bladder adequately
and safely.
Proper education and teaching are necessary to permit a good outcome (Cottenden, Bliss,
Fader et al., 2005).
To prevent and reduce complications, a non-traumatising technique with adequate frequency
of catheterisation and complete emptying should be strictly performed (Cottenden, Bliss,
Fader et al., 2005).
Minimal requirements for regular follow-up are history taking, physical examination,
imaging, laboratory results and urodynamics tests, for early detection of risk factors and
complications.
Long-term results, cost and quality of life need to be further documented (Cottenden, Bliss,
Fader et al., 2005).
8. Management recommendations: clean intermittent self catheterisation (CISC)
Link to Appendix 3
59
9. Management recommendations: indwelling
catheterisation - urethral and suprapubic
Link to Section 2
Section 9 has been developed using non-systematic, narrative methodology.
9.1 Indwelling catheters
Indwelling urinary catheters are generally fed into the bladder via the urethra or, in the
case of suprapubic, via the anterior abdominal wall. The term ‘indwelling’ implies that the
catheter will remain in position for a defined period and that a balloon catheter will be used
to anchor the catheter in the bladder (Oliver, 2006). Indwelling urinary catheters (urethral and
suprapubic) can provide effective bladder management for either short (generally considered
up to 14 days) or long periods. Indications for long term use of indwelling catheters include
bladder outlet obstruction, chronic urinary retention, or restricted movements, eg. paralysis
or coma (Cottenden, Bliss, Fader et al., 2005).
There are potential complications associated with long-term indwelling catheters, including
urinary tract infection, bacteraemia, tissue trauma, bladder spasms, calculi and encrustation
thereby necessitating effective care and monitoring within the community setting. The decision
to manage bladder dysfunction by long term catheterisation should consider the quality of
life and benefits against the potential risks and complications. Long term catheterisation may
be the preferred management strategy for people with intractable urinary incontinence as a
means of promoting quality of life (Cottenden, Bliss, Fader et al., 2005), but the probability
of a catheter acquired urinary tract infection must be considered. Good hand washing is
essential when providing catheter care, and the correct technique (use running water, wet
hands, soap up, rinse off soap, and dry hands thoroughly with clean towel or air drier) must
be followed.
Point of Interest
Catheter materials
Silicone elastomer coated latex, hydrophilic polymer coated latex, and all silicone catheters
cause minimal friction and tissue reaction, and are therefore the catheters of choice for longterm use. Hydrogels absorb aqueous fluids to produce a soft slippery surface that reduces
trauma on insertion or during withdrawal of the catheter. Silicone can allow slow diffusion of
water, which could lead to deflation of the balloon and the catheter falling out.
Frequency of changing the catheter depends on local catheter policy and manufacturer’s
guidelines, and may be up to 12 weeks if problem-free.
Silver coating of the exterior and interior of catheters has been developed to reduce the risk
of bacterial infections. Silver ions are bactericidal and non-toxic to humans. The silver may be
present as a silver alloy or as silver oxide, with the silver alloy being superior in protecting
against bacteriuria (Cottenden, Bliss, Fader et al., 2005).
The internal diameter of a catheter varies from brand to brand, depending on the manufacturing
method. The urinary flow rate therefore depends on the internal diameter, but 12-16 Fg/Ch
catheters are adequate to drain normal quantities of urine, including larger volumes produced
by diuresis. Larger sizes are associated with increased bladder irritability and spasms. Small
balloon sizes are recommended for all patients (10mL for adults) for reasons of comfort,
reduced irritation and spasm causing possible expulsion of the inflated balloon.
9.1.1 Indwelling suprapubic catheters (SPC)
The suprapubic catheter is inserted into the bladder via a surgical incision into the anterior
60
9. Management recommendations: in-dwelling catheterisation - urethral and suprapubic
abdominal wall (Cottenden, Bliss, Fader et al., 2005). The catheter is generally held in place
by an inflated balloon. The placement of the SPC is a relatively minor procedure however
there remains the remote possibility of damage to other abdominal structures during the
course of placement (Oliver, 2006).
Indwelling suprapubic catheterisation may offer advantages over indwelling urethral
catheterisation for the following reasons (Cottenden, Bliss, Fader et al., 2005):
• Minimised risk of urethral trauma during insertion and withdrawal
• Minimised risk of urethral damage and necrosis caused by the weight of poorly supported
urine collection bags, expulsion of the catheter, or sitting on the catheter (which is a
particular problem for women using wheelchairs)
• Ease of catheter access for those with reduced mobility or who use a wheelchair, have
restricted hip mobility or experience urethral pain
• Less impact of indwelling catheter on sexuality and sexual function, although the impact
of altered body image must be considered
• Avoidance of urethritis, epididymitis or epididymo-orchitis and prostatitis in elderly
men
• Management of urinary retention or voiding problems caused by prostatic obstruction or
urethral stricture
• Following urethral or pelvic trauma.
The client or carer may regard the suprapubic catheter as more invasive than regular
indwelling catheter. The continence clinician may need to reinforce the advantages listed
above, particularly those of reduced infection, greater comfort and less restriction on sexual
activities (Oliver, 2006).
Suprapubic catheter (SPC) insertion is generally contraindicated in people with hematuria of
unknown origin, bladder tumour, or small contracted bladders resulting from free drainage
or long term urethral catheterisation. For obese or immobile people, where the traditional
stoma site may become concealed by an apron of excess anterior abdominal wall fatty tissue,
the catheter should be inserted through the apron itself, not in it’s crease (Hirst, 2006).
Although the neurogenic bladder is not covered within the scope of this guideline, it is
important to note that the use of SPC is controversial in this area, with some reports showing
accelerated renal deterioration in people with a spinal injury, and the risk of autonomic
dysreflexia at catheter change. However, there is a high level of client satisfaction with this
procedure.
Not all urethral catheters are licensed for suprapubic use. Short-term catheters may be plastic,
but all-silicone or coated latex catheters are the best materials for long-term suprapubic
catheterisation (Cottenden, Bliss, Fader et al., 2005).
There is limited published evidence regarding frequency of catheter change, with reports
varying widely from monthly to quarterly if the catheter is causing no problems (Cottenden,
Bliss, Fader et al., 2005). When changing suprapubic catheters, the new one should be inserted
as soon as possible after the removal of the old one, as a delay of only a few minutes can
result in partial obliteration of the tract. It is important that the continence clinician discusses
with the client, family and carer what happens if the SPC falls out at home. In practice, the
carer may be given a catheter with the advice to replace such a catheter loss immediately and
thereby preserve the tract (Hirst, 2006). Care must be taken to avoid inserting the catheter too
far through the bladder and into the urethra; observing the length and angle of protrusion of
the catheter prior to catheter change can help with correct positioning of the new catheter.
Some people, particularly women, may have continued urethral leakage with SPC, and
therefore may require closure of the urethra (Cottenden, Bliss, Fader et al., 2005).
9. Management recommendations: in-dwelling catheterisation - urethral and suprapubic
61
9.2 Complications of long term indwelling catheters
Effective care and monitoring within the community setting are key factors in preventing
the risks and complications associated with long term catheterisation. Primary preventative
measures may include ongoing assessment and evaluation of catheter management and
drainage system, maintenance of adequate hydration, prevention of constipation, and
appropriate cleansing.
Complications which may occur include catheter associated infection, tissue trauma, catheter
encrustation leading to blockage, formation of calculi, histological changes, and an increased
risk of bladder cancer after 5-10 years.
Catheter encrustation is a common feature affecting up to 50% of all long-term indwelling
catheter users. Encrustation can occur without any infection present, and may be influenced
by catheter surface properties. Heavy encrustation on the catheter tip and balloon can cause
painful tissue trauma on catheter removal. The encrustation is a combination of calcium
phosphates and magnesium ammonium phosphate, and is dependent on the acidity of the
urine. Women with reduced mobility together with high urinary pH and ammonia concentrates
are also prone to encrustation (Getliffe & Fader, 2007).
Catheter complications such as blockage and encrustation are best managed by early
intervention and preventative care including monitoring of urine pH, examination of the
catheter for signs of encrustation, replacement of the catheter if necessary, and ensuring
adequate fixation of the catheter and drainage system to prevent trauma and facilitate
drainage. Problems need to be identified early, acted upon and appropriately documented.
If a client is susceptible to recurrent catheter encrustation, aim for planned care not crisis care.
Monitor the life of the catheter so a pattern of blockage can be established, and recatheterisaton
can be implemented before the problem develops (Getliffe & Dolman, 2007).
Due to lack of evidence from randomised controlled trials, clear recommendations for
management and treatment of encrustation in clinical practice are limited, but some strategies
include oral cranberry juice/capsules, increasing fluid intake and taking urease inhibitors
(Cottenden, Bliss, Fader et al., 2005). Bladder irrigation is not the preferred intervention within
the community setting and should not be used as a substitute for changing the catheter if this
is required. However, if other measures fail to rectify blockage then bladder irrigation may
be one option. Oral acidification of urine through diet and oral medication (ascorbic acid and
methenamine) is a more popular method of encrustation prevention (Getliffe & Fader, 2007).
There are potential risks associated with the incorrect instillation of irrigation fluid into the
bladder for catheter blockage or encrustation, including the physical force of flushing the
bladder and the type of solution used. Breakage of the closed drainage system inevitably
increases the risk of introducing infection and this should be considered when determining a
need for the procedure (Colpman & Welford, 2005).
Point of Interest
Bladder irrigation with pre-boiled tap or sterile room temperature water may prevent stone
and debris accumulation and may be an important element in the prevention of symptomatic
infections and catheter blockages (Hirst, 2006). Further research is required in this
area. Normal saline may be used for flushing of debris and small blood clots, but it is not
recommended as a suitable effective irrigation solution for catheter encrustation, due to its
neutral pH (Getliffe & Fader, 2007).
On appraisal of current literature there is a lack of evidence to provide clear guidelines on
bladder irrigation in the clinical setting. A systematic review protocol titled “Washout
policies for the management of long-term indwelling catheterisation in adults” 2008, has
been registered with The Cochrane Collaboration. Results of this research may guide the best
practice for bladder irrigation.
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9. Management recommendations: in-dwelling catheterisation - urethral and suprapubic
‘Deflation cuff’ formation can be a particular problem for all-silicone suprapubic catheters,
and although cuffs can form with other catheters such as hydrogel coated latex, the retention
force is less than with all-silicone material. Slow deflation of the silicone balloon may be
helpful, as is reinsertion of 0.5-1mL water to fill the catheter inflation lumen and eliminate
the balloon cuff. Subsequent use of a lubricant with gentle removal of the catheter can
reduce tissue trauma and pain.
Recommendations vary for assessment of people with catheters including a schedule of
medical imaging of urinary tract, eg. cystoscopy, urinalysis, biopsy, urodynamics studies,
and assessment of renal function (refer also to Table 6). However, the consensus appears to
be that annual cystoscopy and/or biopsy should be instigated between 5-10 years after initial
catheterisation, and suggested for people displaying hematuria or for those with chronic
urinary tract infection resistant to standard therapy (Oliver, 2006).
Good Practice Point
Indwelling catheterisation
•
•
•
•
•
•
•
•
•
•
•
•
Indwelling catheters should only be used after alternative management strategies have
been considered.
Ongoing assessment and evaluation of catheter care is the key factor in prevention of
problems and risks associated with catheterisation.
All-silicone or hydrogel-coated catheters are preferable to other materials for long-term
use.
A closed drainage system should be maintained to reduce risk of catheter-associated
infection.
Meatal cleansing by simple washing with soap and water during routine bathing or
showering is recommended. Antiseptic agents are no advantage.
Bladder irrigation and antibiotic prophylaxis are not recommended as routine infection
control measures.
The addition of disinfectants to drainage bags is not recommended as an infection control
strategy.
Asymptomatic bacteriuria should not be treated with antibiotics unless urological
instrumentation is planned. All people with an IDC, especially a long term one, will have
bacteruria and therefore culturing of the urine is not recommended.
Identification of a characteristic pattern of catheter life can facilitate pre-emptive catheter
changes in patients with recurrent catheter encrustation and blockage.
Bladder cancer is a significant risk in long-term catheterised patients. Investigations should
be case-specific rather than routine screening.
If indwelling catheterisation is being considered, the suprapubic method should be
considered alongside urethral catheterisation, following appropriate risk assessment.
Suprapubic insertion should be carried out only by appropriately trained and skilled
practitioners (Cottenden, Bliss, Fader et al., 2005).
9.3 Closed drainage systems
Maintaining a sterile, continuously closed drainage system is important in the prevention
of catheter-associated infection (CHRISP, 2004). A link drainage system such as attaching
an overnight drainage bag to the leg bag can be used to maintain the integrity of the closed
system (Schofield, 2001). Due to lack of evidence-based studies and involvement of other
issues (such as cost-effectiveness), further studies on closed systems have been recommended
(Dunn, Pretty, Reid et al., 2000). Clinicians are referred to the recommendations of the
manufacturers and policy guidelines for each workplace.
9. Management recommendations: in-dwelling catheterisation - urethral and suprapubic
Link to Section 8.12
63
10. Management recommendations: toileting
programs, pelvic floor muscle training, bladder
training, and combined approaches
Link to Section 2
Section 10 has been developed using systematic review methodology.
10.1 Outline of interventions
Link to Section 2.1 and
Appendix 2
Recommendations in this section are divided into those for clients with cognitive impairment
and those without. In general clinical practice, cognitive impairment is frequently defined by
a Mini Mental State Examination (MMSE) score of 23 or below. For this guideline, relevant
research studies have been systematically identified, critically appraised, the findings
synthesised, and recommendations formed according to the GRADE system.
10.1.1 Interventions: people with cognitive impairment
Link to Appendix 4
Link to Appendix 5
Interventions for clients with cognitive impairment include toileting programs such as
prompted voiding and habit retraining (refer to Table 12, Section 10.2). These are described
in detail in Appendix 4. Timed voiding is not discussed in this guideline because research in
this area involves older people in residential care rather than those living in the community.
The findings therefore cannot be generalised to the target group of community-dwelling
older people.
10.1.2 Interventions: people without cognitive impairment
Interventions for clients without cognitive impairment include pelvic floor muscle training (for
women and for men post-prostatectomy), bladder training and a combination of approaches
(refer to Table 12, Section 10.3, and Appendix 5). Additional interventions commonly used
include biofeedback (pressure or electromyograph) as an adjunct to pelvic floor muscle
training, and electrical stimulation. These two approaches are not explicitly considered in
this guideline due to time limitations. Less common approaches include complementary
therapies such as acupuncture, herbal medicine, nutritional therapy, and magnet therapy.
These interventions are not considered in this guideline and the reader is encouraged to
undertake evidence-based critical appraisal of the research in these areas.
Point of Interest
A study of 771 community-dwelling men and women (mean age 82.1 years for women and 80.6
years for men), classified participants into two groups according to level of independence. The
independent group needed help in personal, instrumental or technical daily activities less than
once a week or not at all, while those who were dependent needed ADL assistance at least once
per week.
The study found that, when controlled for age, the presence of both daytime frequency and
nocturia was a predictor of the need for help in daily activities in both men and women. Although
voiding symptoms were reported as being less bothersome than storage symptoms, both had
a similar influence on daily life, causing people to avoid places and situations, to modify fluid
intake and to limit social life (Stenzelius, 2006).
64
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
65
Evidence statement
Quality of
evidence
(GRADE)
These articles were
reviewed by authors
of this guideline
Colling, Owen,
McCreedy et al.,
2003.
Engberg, Sereika,
McDowell et al.,
2002.
Jirovec & Templin,
2001.
10.2.1 Prompted
voiding and
habit retraining
Evidence shows a low
level of support for
the benefit of toileting
programs for older,
frail, communitydwelling adults with
incontinence and
cognitive impairment
LOW
10.2 Interventions for those with cognitive impairment
Topic
PROBABLY DO:
Continence clinicians probably should implement toileting programs for
selected older, frail, community-dwelling adults with incontinence and
cognitive impairment, under the following circumstances:
• The client’s carer has had the toileting program explained fully
to him/her, including realistic estimation of the impact on time,
laundering and so on
• The client’s carer is motivated and has adequate social support
mechanisms in place
• The client’s carer is willing and able to follow the protocol
Specifically, the clinician should:
• Ensure that the first steps in incontinence management have been
assessed, i.e. screening for ‘red flags’ and treating potentially
reversible conditions associated with incontinence (DIAPPERS)
(MASS 2007)
• Ensure that the client has been screened for significant post-void
residual using a bladder scan, and if present, that this is being
managed
• Encourage the program to be commenced as early as possible
after the diagnosis of cognitive impairment, in order to establish a
routine
• Provide ongoing support and review for the client and their carer
• Monitor the level of strain/burden on the carer
Recommendation and rationale
Table 12: Recommendations for toileting programs, pelvic floor muscle training, bladder training and combined approaches
Link to Good
Practice Point
within Section
4.4.8
Link to Section 4.2
Link to Appendix 2
66
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
10.2.1 Prompted
voiding and habit
retraining (cont).
Topic
Evidence statement
Quality of
evidence
(GRADE)
Rationale:
Although the limited available evidence does not demonstrate benefit of
this intervention, it is recommended for selected clients (see above) for
the following reasons:
• The high economic and personal costs of incontinence to the
community and the individual
• The high burden of incontinence to the community and the
individual
• The need for proactive approaches to avoid or delay admission to
residential care due to incontinence
• The relatively low burden and cost of the intervention to the
individual, providing their carer is motivated and supported
See Appendix 4 for specific guidelines on implementation of toileting
programs – Habit Retraining and Prompted Voiding
Recommendation and rationale
Link to Appendix 4
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
67
Evidence statement
Quality of
evidence
(GRADE)
These articles were
reviewed by the
authors of this
guideline
Miller, Ashton-Miller,
& DeLancey, 1998.
Burgio, Locher,
Goode et al., 1998.
10.3.1 Pelvic floor
muscle training
Evidence shows a very
low level of support for
the benefit of teaching a
specifically timed pelvic
floor muscle contraction
to a select group of
older, frail, cognitively
intact communitydwelling women with
incontinence
VERY LOW
10.3 Interventions for those who are cognitively intact
Topic
Rationale:
Although the evidence for this intervention is low, it is recommended
for the following reason:
• Resource implications (cost, time and equipment) are insignificant,
especially if done opportunistically during a vaginal examination
PROBABLY DO:
Continence clinicians probably should teach a pelvic floor muscle
contraction that is precisely timed with the activity that provokes
incontinence (eg a cough) in a select group of older, cognitively intact
women with stress incontinence in the following circumstances:
• Opportunistically, when performing a vaginal examination, and an
effective voluntary pelvic floor muscle contraction is confirmed;
• The client has stress incontinence that is associated with particular
activities (eg coughing), but not urge incontinence alone
• The client does not have a neurological disorder
Recommendation and rationale
Link to Section 11
and Appendix 2
68
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
These articles were
reviewed by the
authors of this
guideline
Excluded studies:
Jarvis & Millar, 1980.
Jarvis & Millar, 1981.
Colombo, Zanetta,
Scalambrino et al.,
1995.
Fantl, Wyman,
McClish et al., 1991.
Mattiasson, Blaakaer,
Hoye et al., 2003.
10.3.2 Bladder
training
Topic
There is a low level of
evidence for the benefit
of bladder training
in older communitydwelling, cognitively
intact clients
Evidence statement
LOW
Quality of
evidence
(GRADE)
See Appendix 5 for specific guidelines on carrying out a bladder
training program
Rationale:
Although the limited available evidence does not demonstrate benefit of
this intervention, it is recommended for the following reasons:
• The high economic costs of incontinence to the community and the
individual
• The high burden of incontinence to the community and the
individual
• The need for proactive approaches to avoid or delay admission to
residential care due to incontinence
DO
Continence clinicians should implement a bladder training program
with older community-dwelling, cognitively intact clients with urinary
frequency and incontinence
Recommendation and rationale
Link to Appendix 5
Link to Appendix
2 and Table 2,
Section 2
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
69
LOW
Evidence shows a low
level of support for the
benefit of a combined
approach of pelvic floor
muscle training and
bladder training in older
community-dwelling,
cognitively intact
clients
10.3.3 Pelvic floor
muscle training
combined with
bladder training
These articles were
reviewed by the
authors of this
guideline
Burgio, Goode,
Locher et al., 2002.
Dougherty, Dwyer,
Pendergast et al.,
2002.
Holtedahl, Verelst, &
Schiefloe, 1998.
McDowell, Engberg,
Sereika et al., 1999.
Subak, Quesenberry,
Posner et al., 2002.
Wyman, Fantl,
McClish et al., 1998.
Quality of
evidence
(GRADE)
Evidence statement
Topic
Rationale:
• There is a lack of evidence for biofeedback plus PFMT over PFMT
alone in this group
• There is evidence at the level of a systematic review (albeit from a
younger age group) that adding biofeedback provides no further
benefit over PFMT alone
• Vaginal biofeedback equipment, if available, may be used,
providing that correct pelvic floor muscle contraction has been
confirmed on vaginal examination, and the clinician continues
to monitor that correct pattern of pelvic floor muscle contraction
occurs (MASS 2007). Vaginal biofeedback probes are for single
patient use only. Sterilisation and re-use is not recommended
DO
Continence clinicians should use a combined approach of pelvic floor
muscle training and bladder training with older community-dwelling,
cognitively intact clients where both interventions are appropriate
Specifically:
• Ensure that the first steps in incontinence management have
occurred, i.e. screening for ‘red flags’ and treating potentially
reversible conditions associated with incontinence (DIAPPERS)
(MASS 2007)
• Ensure that the client has been screened for significant post-void
residual using a bladder scan, and if present, that this is being
managed
Recommendation and rationale
Link to Good
practice Point
within Section
4.4.8
Link to Appendix
2 and Table 2,
Section 2
70
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
These articles were
reviewed by the authors
of this guideline
Exclude studies:
Parekh, Feng, Kirages
et al. 2003.
Bales, Gerber, Minor
et al. 2000.
Burgio, Goode, Urban
et al. 2006.
Filocamo, Li Marzi, Del
Popolo et al. 2005.
Floratos, Sonke, Rapidou
et al. 2002.
Franke, Gilbert, Grier
et al. 2000.
Joseph & Chang 2000.
Matthewson-Chapman 1997.
Overgard, Angelsen,
Lydersen et al. 2008.
Porru, Campus, Caria
et al. 2001.
Van Kampen 2000.
Wille, Sobottka,
Heidenreich et al. 2003.
10.3.4 Management
of post-prostate
surgery incontinence
with pelvic floor
muscle training
Topic
Evidence shows a
moderate level of
support for the benefit
of pelvic floor muscle
training following
prostate surgery for
earlier attainment of
urinary continence
Evidence statement
MODERATE
Quality of
evidence
(GRADE)
Rationale:
• A proactive approach to continence is required when the aim is to
prevent or delay residential care.
• The associated costs and resource implications are not significant
when compared with the potential cost savings
• Although most of the studies used biofeedback to teach PFMT,
it is not possible to identify the relative contributions of the
exercises and the biofeedback assistance to the benefit of the
treatment. None of the studies that compared biofeedback-taught
PFMT and verbally-taught PFMT showed a difference between
the two methods. Thus there is insufficient evidence to warrant
recommending biofeedback as a routine tool in this population
• There is no evidence from the available studies that electrical
stimulation adds further benefit to PFMT in this population so the
purchase of electrical stimulation equipment is not warranted
DO
Continence clinicians should implement a pelvic floor muscle exercise
program as early as possible after removal of the catheter post-prostate
surgery. Close liaison with the client’s urologist and/or general medical
practitioner should occur
Recommendation and rationale
Link to Section 11
and Appendix 2
Point of Interest
A Cochrane review sought to assess the effectiveness of vaginal cones (Herbison, Plevnick
& Mantle, 2002), and found some evidence that weighted cones are better than no active
treatment in women with stress urinary incontinence. Cones may be of similar effectiveness to
pelvic floor muscle therapy and electrostimulation, but this conclusion must remain tentative
owing to the inadequate size of the studies reviewed, and different outcome measures used.
Some women do not like using vaginal cones.
10. Management recommendations: toileting programs, pelvic floor muscle training, bladder training, and combined approaches
71
11. Pelvic floor muscle function assessment and
rehabilitation
As indicated in its title, this guideline is written for continence clinicians. Continence
physiotherapists are recognised as being the ideal health professionals to undertake pelvic floor
muscle function assessment and rehabilitation. If other health professionals are interested in
developing their skills and knowledge in this area, they are encouraged to undertake further
training.
Link to Section 2
Section 11 has been developed using non-systematic, narrative review.
11.1 Assessment of pelvic floor muscle function
11.1.1 Correct activation
A correct contraction of the pelvic floor muscles (PFM) involves an inward and upward
movement of the genital openings. This can be discerned via direct observation of the
perineum. The “lift” of the bladder base can also be imaged using transabdominal ultrasound.
A correct contraction of the PFM avoids co-contraction of the gluteals and adductors but
includes contraction of the deep abdominal muscles (transversus abdominis and internal
oblique) (Sapsford, Hodges, Richardson et al., 2001). More than 30% of women do not perform
a correct “lifting” contraction of the PFM when given verbal instruction (Bump, Hurt, Fantl et
al., 1991). This has also been confirmed via imaging of the bladder base using transabdominal
ultrasound. A study of women with incontinence and/or prolapse found only 38% were able
to produce a lift of the bladder base – that is, an effective pelvic floor muscle contraction. In
43% of the women, pelvic floor muscle contraction resulted in a depression of the bladder
base (Thompson & O’Sullivan 2003).
Good Practice Point
An incorrect pattern of contraction that involves a “bearing down” manoeuvre has the potential
to compromise pelvic floor function (Bump, Hurt, Fantl et al., 1991). It is therefore essential to
determine correct lifting pattern of contraction when providing pelvic floor muscle exercises.
11.1.2 Strength
A variety of methods for assessing the pelvic floor muscles via a digital vaginal muscle
test have been documented (Bo & Sherburn, 2005). Two key differences are the use of one
versus two fingers, and the scale used to record findings. It has been hypothesized that the
use of two fingers in digital palpation could stretch the PFM and either inhibit their activity
or conversely, increase their activity by providing increased proprioceptive feedback (Bo
& Sherburn 2005). Therefore, number of fingers used in assessment should be documented
and should be consistent within the one client. Health professionals are referred to their
postgraduate training course content for advice on these and other issues; however, a short
summary of the modified Oxford Scale, a commonly used scale, follows (table 13).
The Oxford Scale can be used for either per vaginam or per rectum assessment, and therefore
in both males and females. Use of the Scale assumes a correct contraction has been verified via
visual observation of perineum. Usually, the best of three maximum voluntary contractions
(MVCs), held for 3-5 seconds, is recorded. This helps to negate the problem that, in some
women, the first contraction is better than subsequent contractions due to fatigue, whereas
in other women, subsequent contractions are better as a learning effect takes place (Bo &
Sherburn 2005).
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11. Pelvic floor muscle rehabilitation
Good Practice Point
It is important to note that grading PFM via the Oxford Scale is not appropriate for clients with
pelvic or perineal pain, vaginismus or other related disorders (Frawley, 2006).
Results of studies on reliability of digital muscle testing are conflicting (Bo & Sherburn 2005).
A recent study suggests that intra-therapist reliability is good for grading strength, but not
endurance (Frawley, Galea, Phillips et al., 2006).
Table 13: Laycock’s modified Oxford Scale
Level
Descriptor
0
No discernible muscle contraction
1
Flicker or pulsation is felt under the examiner’s finger
2
An increase in tension is detected, without any discernible lift
3
Muscle tension is further enhanced and characterized by lifting of the
muscle belly and also elevation of the posterior vaginal wall. A grade 3 and
stronger can be observed as an in-drawing of the perineum and anus
4
Increased tension and a good contraction are present which are capable
of elevating the posterior vaginal wall against resistance (digital pressure
applied to the posterior vaginal wall)
5
Strong resistance can be applied to the elevation of the posterior vaginal
wall; the examining finger is squeezed and drawn into the vagina
(Laycock & Jerwood 2001)
Other documented forms of assessing pelvic floor muscle strength include MRI, EMG, vaginal
dynamometers and vaginal weighted cones. The reader is referred to a summary article
for more information and discussion of validity and reliability of these methods (Bo and
Sherburn 2005).
11.1.2.1 Importance of position and documentation of position in assessment
Variations in body position can affect the function of the pelvic floor muscles and, therefore,
assessment findings. A study comparing continent and incontinent women investigated the
timing of superficial versus deep pelvic floor muscles with PFM contraction (Devreese, Staes,
De Weerdt et al., 2004). Continent women, when performing a PFM contraction, were more
likely to contract the superficial before the deep PFM, in contrast to incontinent women. Some
timing variation was also seen in different positions. In crook lying and upright sitting, the
“suboptimal” pattern of deep before superficial contraction was seen in incontinent women
more often than in supine, forward-lean standing and forward-lean sitting.
11. Pelvic floor muscle rehabilitation
73
A study of continent women by found that:
• Vaginal squeeze pressure was highest in lying and crook lying (versus sitting and
standing)
• The measured grade tended to be lower in standing versus crook lying and supine
• Displacement of the pelvic floor on trans-abdominal ultrasound, however, was higher in
standing than supine and sitting
• Women preferred the lying position over any upright position for digital muscle
testing.
(Frawley, Galea, Phillips et al., 2006)
Good Practice Point
The traditional lying position should be used for performing a digital muscle assessment, as it is
practical, as well as preferred by the client. Crook lying and supine lying may produce differing
assessment findings. Therefore, the specific position in lying, including the positioning of the
legs, should be recorded and kept consistent on reassessment.
Similarly, the client’s position should be recorded when assessing bladder base movement via
trans-abdominal ultrasound.
11.1.2.2 Manometry
Manometry involves the use of a device commonly called a perineometer. Using a pressure
sensor, the intra-vagina or intra-anal pressure is measured while performing a pelvic floor
contraction. However, evidence indicates that it is the urethral pressure that is of critical
relevance in measuring closure pressure (Bo & Sherburn 2005). Use of a perineometer requires
precise placement of the pressure probe for test-retest reliability. Inaccurate readings may
result from the use of different diameters of vaginal probe. Also, measured increases in
pressure may equally reflect intra-abdominal pressure rise. Contraction of other muscles such
as the hip external rotators, gluteals and adductors may affect measurement (Bo & Sherburn
2005).
Point of Interest
While manometry may be useful in the research environment, it is unlikely to provide reliable
information in the clinical setting.
11.1.3 Endurance
Muscle endurance is defined as the length of time a maximum voluntary contraction (MVC)
can be sustained before strength is reduced by >35%. In the pelvic floor, this is commonly
tested as the length of contraction or the number of repetitions at set intervals before fatigue.
Clinically, fatigue can be accompanied by initiation of extraneous muscle contractions
including adductors and gluteals (Laycock & Jerwood, 2001).
11.1.4 Displacement
Transabdominal ultrasound assessment of pelvic floor muscle function involves the use of
a curved-array ultrasound probe, 3.5 or 5 MHz, placed suprapubically (either sagitally or
transversely), and is undertaken to assess displacement of the bladder base during PFM
contraction. It does not correlate with PFM strength (Sherburn, Murphy, Carroll et al., 2005).
It is therefore not used to measure strength, but rather to confirm or teach correct contraction
of the pelvic floor muscles.
74
11. Pelvic floor muscle rehabilitation
Bladder base motion on transabdominal ultrasound cannot be measured from a fixed bony
landmark, unlike perineal ultrasound which uses the pubic symphysis. However, bladder
base motion during PFM contraction has been shown to correlate closely with bladder neck
movement as measured with perineal ultrasound (Thompson, O’Sullivan, Briffa, et al, 2004a)
and a lift of the bladder base on contraction of the PFM is the normal pattern of movement
shown on MRI (Mikuma, Tamagawa, Morita et al., 1998).
With a correct PFM contraction, a sagittal plane view displays displacement of the posterior
bladder wall in an anterocephalic direction. For reliability of the sagittal plane view, it is
important that the transducer is directly in the midline, aligned with the pubic symphysis
(Sherburn, Murphy, Carroll et al., 2005).
Point of Interest
A concern with the use of transabdominal ultrasound is that a greater lift may not necessarily
correlate with better PFM function, but rather, may reflect the degree of connective tissue
laxity in the pelvic floor (Bo & Sherburn 2005). This technique is therefore best used to teach or
confirm correct contraction; quantifying the displacement may not be clinically useful.
11.1.5 Integration with abdominal, respiratory and deep spinal muscle function
A recent study in five healthy females and one healthy male provided some indications of the
role of the pelvic floor muscles in breathing and postural control (Hodges, Sapsford & Pengel,
2007). By measuring EMG response of the PFM with breathing and rapid and repetitive
arm movements, the study demonstrated a number of findings. The PFM were continually
(tonically) active during the breathing cycle, the PFM activity increased in preparation for
the postural challenge imposed by upper limb movement, and in association with abdominal
muscle activity (rather than simply with increased intra-abdominal pressure). It seems likely
that the PFM have an important tonic role and an anticipatory role in postural adjustment,
probably contributing to control of the spinal and pelvic joints.
Research has shown that a proportion of both continent and incontinent women demonstrate
an abnormal increase in activation of chest and superficial abdominal wall muscles when
attempting a pelvic floor muscle contraction (Thompson, O’Sullivan, Briffa, et al., 2004c).
Women with urge incontinence and prolapse were significantly more likely to demonstrate
abnormal patterns of muscle activation (Thompson & O’Sullivan, 2003; Thompson, O’Sullivan,
Briffa, et al., 2004c). Increased PFM activity in women with incontinence was associated with
greater activity of the external oblique abdominal muscles, resulting in increased intraabdominal pressure (Smith, Coppieters & Hodges 2007). This effect was even greater with
severe incontinence.
Good Practice Point
Assessment of pelvic floor muscle function should include assessment of breathing pattern and
abdominal and respiratory muscle use.
11.2 Treatment of pelvic floor muscle dysfunction in urinary incontinence
Readers are referred to table 12, Sections 10.3.1, 10.3.3 and 10.3.4 of this guideline for a
systematic review of management recommendations for pelvic floor muscle training.
11. Pelvic floor muscle rehabilitation
75
11.2.1 Importance of position
Variations in body position have been demonstrated to affect the function of muscles
important to continence (see Section 11.1 in this guideline). The PFM are able to produce a
stronger contraction in upright, unsupported sitting compared to slumped sitting (Sapsford,
Richardson & Stanton 2006).
Variation in sequencing of the superficial and the deep pelvic floor muscles occurs in different
positions. Continent women, unlike incontinent women, contract the superficial PFM before
the deep PFM (Devreese, Staes, Janssens, et al., 2007). This pattern is more likely to occur
in sitting leaning forward, standing leaning forward or lying with legs outstretched, whereas
the opposite pattern is more likely to occur when lying with knees bent or sitting upright
(Devreese, Staes, Janssens, et al., 2007).
Point of Interest
Choice of body position for teaching pelvic floor muscle activation should consider research
findings, as well as the client’s functional ability and the daily activities that provoke
symptoms.
Good Practice Point
•
•
•
•
Side lying should be chosen over crook lying and supine (due to tendency to recruit gluteal
muscles in this position).
While it may be easiest to gain PFM contraction in the recumbent position (supine, crook
lying or side lying), the more functional upright position should be tried early, but adapted
to recruit the muscles most effectively (forward-lean sitting, standing or forward-lean
standing). Standing is a position used regularly by most people, so it is important to
practise PMF contraction in standing, even though it has been associated with a suboptimal
recruitment pattern.
Clients demonstrating suboptimal muscle recruitment patterns or breathing patterns should
practise PFME in side lying or supine with support under the knees until they master the
correct pattern before progressing to upright positions.
Slumped sitting should be avoided, and lumbar spine posture in sitting should be monitored
closely when exercises are performed in sitting (see Section 11.2.2).
11.2.2 Importance of lumbar spine posture
EMG activity of transversus abdominis on contraction has been found to be greater in
extension compared to a flexed lumbar spine posture (Sapsford & Hodges, 2001). Transversus
abdominis activation has also been shown to produce PFM contraction (Sapsford, 2001).
Good Practice Point
Considering the evidence for interaction between muscles of the lumbar spine and the PFM, clients
should avoid a flexed lumbar spine during PFME, aiming for a neutral to extended posture.
11.2.3 Functional integration with abdominal capsule
11.2.3.1 Abdominal muscle recruitment
EMG studies have shown that during a correct pelvic floor muscle contraction in lying, there
is increased activation of the pelvic floor muscles and the lower fibres of internal oblique,
with minimal activation of external oblique and chest wall muscles (Thompson, O’Sullivan,
Briffa et al., 2004c).
76
11. Pelvic floor muscle rehabilitation
Good Practice Point
Lower abdominal wall movement should not be discouraged when performing PFME.
Physiotherapists may use deep abdominal muscle activation to facilitate contraction of the pelvic
floor muscles where assessment has indicated suboptimal pelvic floor muscle activation.
11.2.3.2 Breathing pattern
Research has shown that a proportion of both continent and incontinent women demonstrate
an abnormal increase in activation of chest and superficial abdominal wall muscles when
attempting a pelvic floor muscle contraction (Thompson, O’Sullivan, Briffa, et al., 2004c).
Clients should be encouraged to maintain a normal breathing pattern when performing
PFME. Features of an incorrect breathing pattern include:
• Breath holding
• Shallow breathing
• Increased rate of breathing
• Excessively deep breathing
• Recruitment of accessory muscles of respiration (upper chest and neck)
• Decreased abdominal wall and lower rib movement.
Good Practice Point
If the client is using an incorrect breathing pattern when performing pelvic floor muscle exercises,
the correct breathing pattern should be taught.
11.2.4 Retraining motor patterns
11.2.4.1 Timing
Timing is a critical issue in pelvic floor muscle contraction. Postural activation of the PFM is
delayed in women with stress urinary incontinence; in fact, in some women the activity of
the muscles actually decreases just before the movement (Smith, Coppieters & Hodges 2006).
Retraining of prolonged gentle (tonic) holds of the tranversus abdominis and/or the pelvic
floor muscles may restore the normal pattern (Sapsford, 2001). This may need to occur prior
to strength training of the pelvic floor (Sapsford, 2004).
Training of a PFM contraction prior to and during a cough has been shown to reduce
incontinence in women (Miller, Ashton-Miller & DeLancey 1998). Training of PFM contraction
with appropriate abdominal muscle recruitment can also occur with nose blowing, laughing
and sneezing, and if relevant, with high impact activities (Sapsford, 2004).
Contemporary muscle rehabilitation focuses on retraining normal patterns of movement
rather than specific muscles. For example, restoring optimal function of the lumbo-pelvic
joints involves training correct stabilization strategies and movement patterns (Lee, 2004).
In the same way, correct muscle activation patterns that avoid bladder descent, as identified
in research, should be taught to achieve and maintain continence (Lee & Lee, 2004). These
include:
• Co-activation of the deep abdominals without excessive activity of the superficial
abdominals and without gluteals and adductors
• Maintenance of a diaphragmatic breathing pattern without excessive use of the accessory
muscles of respiration,
• Coughing without bulging of the abdominal wall.
11. Pelvic floor muscle rehabilitation
77
In addition to motor control deficits, other musculoskeletal factors contributing to incontinence
should also be treated (Grewar & McLean, 2008). For example, manual compression through
the pelvis has been shown to eliminate the increased descent of the bladder and pelvic floor
muscles in women with sacroiliac joint pain. Specific rehabilitation of muscles of the pelvis
and other strategies to restore adequate sacro-iliac joint compression may be helpful in clients
with these deficits along with continence problems. Similarly, articular, muscular or fascial
restrictions that contribute to postures and movement patterns that promote incontinence
should be treated (Grewar & McLean, 2008).
Good Practice Point
Both motor control deficits and musculoskeletal factors that compromise the client’s continence
should be treated.
11.2.5 Strength training/endurance training
Strength of the PFM is not well correlated with a decrease in incontinence episodes or
decreased pad weight (Devreese, Staes, De Weerdt et al., 2004). Additionally, women with
stress incontinence produce greater PFM activity with challenges to their postural control
(postural perturbations) than continent women (Smith, Coppieters & Hodge, 2007).
Point of Interest
It is clear that PFM strength is not the only factor in stress incontinence and may not even
be the most important factor. However, it is often appropriate to provide clients with a PFM
strength training program based on assessment findings.
When providing a strength training program for the PFM, teaching PFM contraction as
opposed to transversus abdominis muscle contraction will result in a greater upward
displacement of the pelvic floor, which probably represents a stronger PFM contraction (Bo,
Sherburn & Allen, 2003).
Good Practice Point
Structuring a PFME program
•
Teach correct activation pattern including best cue for individual client based on assessment,
substitution manoeuvres to avoid, etc.
78
•
Utilise whole abdomino-pelvic capsule concept to facilitate optimal activation patterns with
other muscles for spinal and pelvic joint stabilization
•
Provide appropriate positions for exercise based on client function and assessment findings.
Consider using forward-lean sitting or standing, especially for clients having difficulty
•
Provide recommendations for number of sessions per day, number of contractions, rest
periods, number of sets – minimum 25 contractions total per day (Choi, Palmer & Park,
2007)
•
Treat, or refer for treatment, conditions that may be compromising the function of PFM and/
or abdominal wall or spinal muscles, including constipation and obstructed defecation,
spinal or pelvic pain, etc.
•
It has been suggested there be a rest interval of four seconds between contractions. Once
ten contractions with ten second holds have been achieved, the rest interval should be
shortened (Laycock & Jerwood, 2001).
11. Pelvic floor muscle rehabilitation
Point of Interest
The following summary articles provide further reading on different approaches to pelvic floor
muscle assessment and treatment.
• Sapsford, R. (2004). Rehabilitation of pelvic floor muscles utilizing trunk stabilization.
Manual Therapy 9: 3-12
• Grewar, H. and McLean, L. (2008). The integrated continence system: A manual therapy
approach to the treatment of stress urinary incontinence. Manual Therapy article in press.
Available online 12 March 2008
• Bo, K. and Sherburn, M. (2005). Evaluation of female pelvic floor muscle function and
strength. Physical Therapy 85: 269-282).
11.3 Pelvic floor muscle rehabilitation for men
There is some evidence that pelvic floor muscle rehabilitation in men is an effective form of
conservative management for:
Link to Sections
6.5.4 and 13
• Post prostatectomy urinary incontinence
• Post micturition dribble
• Erectile dysfunction.
A smaller study of 55 men found post-micturition dribble in 36 subjects (Dorey, 2004). After
three months of pelvic floor muscle exercises and three months of home exercises, 27 of
the 36 subjects (75%) were cured, three (8%) improved, five (14%) dropped out and one still
experienced leakage. Use of this ‘squeeze out’ technique (performing a strong contraction of
the pelvic floor muscles after voiding) may facilitate a contraction of the bulbocavernosus
muscle, thereby eliminating urine from the bulbar portion of the urethra.
Erectile dysfunction increases with age, with two thirds of men at the age of 70 years having
this problem. A randomised control trial (n=55) has shown that after three months, subjects
in the treatment group had a significant improvement in their dysfunction. It should be noted
that lifestyle changes can also improve erectile dysfunction, including reducing alcohol
intake, quitting smoking, reducing weight, getting fit, and avoiding saddle pressure for pushbike riders (Dorey, Speakman, Feneley et al., 2004).
A Cochrane systematic review of 17 trials of conservative management for post prostatectomy
urinary incontinence found conflicting information about the benefit of pelvic floor muscle
training, for either prevention or treatment of urine leakage after prostate surgery, whether
for cancer or benign enlargement of the prostate (endoscopic resection). The review
noted three trials that recruited pre-operatively and included all men undergoing radical
prostatectomy, and suggests that men presenting with persistent urinary incontinence are a
different population, who may not achieve the same level of benefit from pelvic floor muscle
rehabilitation as those undergoing radical prostatectomy (Hunter, Moore & Glazener, 2007).
Another systematic review of 11 papers evaluating the effectiveness of PFMT for treating
urinary incontinence after radical prostatectomy found that PFMT with or without biofeedback
enhancement hastens the return to continence more than no PFMT in men with urinary
incontinence after radical prostatectomy (MacDonald, Fink, Huckabay et al., 2007).
11. Pelvic floor muscle rehabilitation
79
12. Adherence issues relating to pelvic floor muscle
rehabilitation management
Link to Section 2
Link to Table 14 in this
Section
Section 12 has been developed using non-systematic, narrative methodology.
There are a number of theories and models that underpin thinking and research in this area.
This guideline does not address all of these in detail, but provides a summary of three models.
Table 14 provides information on studies which address adherence in this context.
12.1 Outline of the importance of adherence to treatment
Adherence (compliance) to programs to treat incontinence, such as a pelvic floor muscle
exercise program, is important to optimise outcome. Several studies have demonstrated
a relationship between adherence to continence programs and improved outcome (Bo &
Talseth, 1996; Chen, Chang, Lin et al., 1999; Lagro-Jansenn, Debruyne, Smits et al., 1991;
Siu, Chang, Yip et al., 2003).
12.2 Psychosocial models to promote adherence
There are numerous psychosocial models of behaviour and behaviour change. The following
is a selection of models that have been cited in the pelvic floor muscle exercise literature.
12.2.1 Transtheoretical (Stages of Change) Model
Link to Table 14 in
this Section
The Transtheoretical Model outlines five stages through which an individual progresses to
successfully change behaviour (Prochaska & DiClemente, 1983). Progression through these
stages occurs at varying rates. This is not necessarily a linear process, as the individual may
regress and move back into an earlier stage (Marcus, Rossi, Selby et al., 1992). The model
describes ten different strategies, or ‘processes of change’ that are applied to varying degrees
in each of these five stages. Using a technique that is targeted at the particular stage of
behaviour change of an individual can help to promote successful behaviour change (Marcus,
Rossi, Selby et al., 1992). Table 14 outlines specific strategies that can be used to promote
adherence to pelvic floor muscle exercises according to the client’s stage of change.
The ten processes of change are broadly divided into experiential processes and behavioural
processes. Experiential processes refer to the cognitive strategies people use, such as
consciousness raising (seeking out information), while behavioural processes (taking actions)
includes strategies such as counter conditioning (replacing an undesirable behaviour with a
more favourable one).
The model was originally applied to addictive behaviours such as smoking (Prochaska &
DiClemente, 1983) but has also been applied to exercise behaviour (Marcus, Rossi, Selby et
al., 1992).
80
12. Adherence issues relating to pelvic floor muscle rehabilitation management
12. Adherence issues relating to pelvic floor muscle rehabilitation management
81
Not currently
practising the
behaviour but
intending to
within six months
Contemplation
Less likely to
use behavioural
processes
• Teach facts, myths about incontinence, PFM and PFME. Provide handouts with
information, diagrams, debunking myths
• Weigh up pros and cons of PFME
• Explore client’s beliefs around continence and their ability to perform PFME. Ask
them to rate how much their incontinence bothers them /10, rate their confidence
in PFME being able to help them /10, and their confidence in being able to stick
to the program /10
• Encourage client to identify people who have successfully incorporated PFME, or
give case studies of people in similar circumstances
• Encourage discussion about how they would feel about themselves if they were
able to incorporate PFME into their lives
• Encourage identification of barriers and solutions
• Encourage confiding in partner/friend and asking for support/reminders to do PFME
• Establish rapport with client
• Explore client’s beliefs around continence and their ability to perform PFME. Ask
them to rate how much their incontinence bothers them /10, rate their confidence
in PFME being able to help them /10, and their confidence in being able to stick
to the program /10
• Teach facts, myths about incontinence, PFM and PFME. Provide handouts with
information, diagrams, debunking myths
• Weigh up pros and cons of doing PFME
Less likely than
those in other
stages to use any
change processes
Not currently
practising the
behaviour and
not intending to
within six months
Pre-contemplation
Likely to use
experiential
processes
Example strategies for PFME
Adapted from (Alewijnse, Mesters, Metsemakers et al., 2002; Marcus, Selby, Niaura et
al., 1992; Prochaska & DiClemente, 1983)
Change processes
to be used
(Marcus, Rossi,
Selby et al., 1992)
Definition
Stage of change
(Prochaska &
DiClemente, 1983)
Table 14: Application of the transtheoretical model to a pelvic floor muscle exercise program
82
12. Adherence issues relating to pelvic floor muscle rehabilitation management
Equally likely to
use experiential
processes as in the
previous stage
More likely to
use behavioural
processes than in
the previous stage
Link to Section 7.3
• Discuss impact of incontinence on different aspects of life. Use of QoL
questionnaire may be a useful starting point
• Weigh up pros and cons of regular PFME
• Set short and long-term goals
• Consider rewards for behaviour
• Make a contract
• Assess ability to perform PFME correctly and correct substitution patterns (eg
incorrect breathing, contraction of inappropriate muscles)
• Provide simple technique for self-assessing correct PFME contraction (eg
checking normal breathing, feeling for lift, visual feedback of perineum with
mirror)
• Encourage client to identify people who have successfully incorporated PFME, or
give case studies of people in similar circumstances
• Discuss how other people may successfully incorporate PFME into different
settings and circumstances
Currently
practising the
behaviour but not
regularly
•
•
•
•
Example strategies for PFME
Adapted from (Alewijnse, Mesters, Metsemakers et al., 2002; Marcus, Selby, Niaura et
al., 1992; Prochaska & DiClemente, 1983)
Preparation
Change processes
to be used
(Marcus, Rossi,
Selby et al., 1992)
Encourage active contribution to goal-setting
Encourage brainstorming appropriate rewards
Give examples of positive self-talk
Ask client to identify an outcome that occurred in their life because of their
taking responsibility and taking positive action
• Form a ‘contract’ with the client
• Provide and encourage use of sticker reminders
• Encourage associating PFME with a regular activity, such as washing hands,
having a drink, or after voiding
Definition
Contemplation
(cont.)
Stage of change
(Prochaska &
DiClemente, 1983)
12. Adherence issues relating to pelvic floor muscle rehabilitation management
83
Action
Preparation (cont)
Stage of change
(Prochaska &
DiClemente, 1983)
Currently
practising the
behaviour
regularly, but has
only begun doing
so in the last six
months
Definition
More likely to
use experiential
and behavioural
processes than in
the previous stage
Change processes
to be used
(Marcus, Rossi,
Selby et al., 1992)
• Encourage identification of barriers and solutions
• Encourage confiding in partner/friend and asking for support/reminders to do
PFME
• Encourage active contribution to goal-setting
• Encourage brainstorming appropriate rewards
• Give examples of positive self-talk
• Ask client to identify a positive life outcome due to having taken responsibility
and positive action
• Form a ‘contract’ with the client
• Provide and encourage use of sticker reminders
• Discuss factors that have led to or could lead to relapse
• Re-frame relapse in positive terms
• Reinforce skills through continued feedback
• Reinforce self-efficacy through encouragement
• Teach further cues to monitor that the PFME are being performed correctly
• Encourage keeping an exercise diary
• Provide regular contact (even telephone) to provide encouragement and check
progress
• Discuss how other people may successfully incorporate PFME into different
settings and circumstances
• Encourage identification of barriers and solutions
• Provide and encourage use of sticker reminders
• Encourage associating PFME with a regular activity, such as washing hands,
having a drink, or after voiding
Example strategies for PFME
Adapted from (Alewijnse, Mesters, Metsemakers et al., 2002; Marcus, Selby, Niaura et
al., 1992; Prochaska & DiClemente, 1983)
84
12. Adherence issues relating to pelvic floor muscle rehabilitation management
Definition
Currently
practising the
behaviour and
has been regularly
for longer than
six months
Stage of change
(Prochaska &
DiClemente, 1983)
Maintenance
Less likely to
use experiential
processes, but
still likely to
use behavioural
processes
Change processes
to be used
(Marcus, Rossi,
Selby et al., 1992)
• Encourage identification of barriers and solutions
• Reinforce skills, self-efficacy and self-esteem
• Discuss factors that have led to or could lead to relapse and strategies to counter
them
Example strategies for PFME
Adapted from (Alewijnse, Mesters, Metsemakers et al., 2002; Marcus, Selby, Niaura et
al., 1992; Prochaska & DiClemente, 1983)
12.2.2 Bandura’s Self-Efficacy and Social Influence Theory
The foundation of the Social Cognitive Theory, developed by Bandura, is that human beings
are proactive, rather than reactive organisms shaped by environmental forces or driven by
inner impulses. Human behaviour is therefore the product of a complex interplay of personal,
behavioural and environmental influences. Bandura’s theory highlights the importance of the
role of cognition in human behaviour. A key component influencing cognition is seen to be
self-efficacy, the self-beliefs that enable the individual to exert control over their thoughts,
feelings and actions. These beliefs influence the choices that people make, the amount of
effort that will be expended on an activity, how long they will persevere when confronted
with obstacles, and how resilient they will be in the face of adverse circumstances (Pajares,
2002).
The reader is encouraged to explore this theory further in relation to how to an increase in
self efficacy can improve adherence.
12.2.3 Attitudes - Social Influence – Self-Efficacy (ASE) Model
The ASE model is based on a theory of behavioural intention rather than behavioural change,
which suggests that behavioural change is best predicted by an individual’s intention to
perform that behaviour. The ASE model postulates that behavioural intention is determined
by three key factors: attitudes, social influences and self-efficacy expectations (Alewijnse,
Mesters, Metsemakers et al., 2003). These are seen as the proximal factors that directly affect
the behavioural intention, while distal factors are those which influence the proximal factors
indirectly. Distal factors include socio-demographic, psychological, socio-cultural and
medical variables.
In relation to intention to perform pelvic floor muscle exercises, specific proximal and distal
determinants have been delineated as shown in figure 4.
Specific Proximal Factors (direct effect on behavioural intention)
• Positive and negative outcome expectations regarding adherence to PFME
• Perceived social norms
• Modelling
• Social support
• Self-efficacy beliefs.
Specific Distal Factors (indirect effect on behavioural intention)
• Lay beliefs about incontinence
• Self-care strategies
• Illness representation
• Cultural norms and values
• Risk perception
• Prognosis
• Severity of symptoms
• Symptom impact.
Figure 4: Specific proximal and distal factors affecting adherence to pelvic floor
muscle training
(Alewijnse, Mesters, Metsemakers et al., 2003)
12. Adherence issues relating to pelvic floor muscle rehabilitation management
85
According to this model, barriers can be encountered once the behaviour has commenced,
and can in turn influence the three key factors of attitudes, social influences and self-efficacy
expectations. Barriers to PFM training are outlined in Figure 5.
Barriers to pelvic floor muscle training:
• Lack of discipline
• Lack of time
• Lack of energy
• Forgetting to do exercises
• Stressful situations
• Associations with sex
• Perceiving the pelvic floor as an unfamiliar body area
• Difficulties integrating exercises in daily life
• Fluctuations in effectiveness
• Muscle pain in the bladder
• Self-esteem
• Body esteem
• Verbal feedback or reinforcement from others.
Figure 5: Barriers to pelvic floor muscle training
(Alewijnse, Mesters, Metsemakers et al., 2002; Alewijnse, Mesters, Metsemakers et al., 2003)
12.3 Evidence
12.3.1 Factors associated with adherence
Link to Table 15,
Section 12.3.3
Several studies have specifically examined psychological/behavioural variables and their
association with adherence to treatment programs, and table 15 summarises these studies.
The reader is encouraged to assess the reliability and validity of these studies, bearing in mind
that retrospective studies are less ideal than cross-sectional cohort and case series studies.
• A case-series (Kartha, 1989) that applied a prediction model of adherence to a published
study of 55-90 year-old stress-incontinent women undergoing a PFME program over six
months found that the ‘perception of seriousness’ of their condition was associated with
increased adherence to PFME.
• A cross-sectional cohort study of 55 Taiwanese women with urinary incontinence
tested the hypothesis that adherence to PFME could be predicted by five key concepts:
‘knowledge of PFME’, ‘attitudes towards PFME’, ‘partner cohesion’, ‘perceived benefits of
PFME’ and ‘PFME self-efficacy’ (i.e. confidence in successfully performing PFME). Selfefficacy directly predicted both perceived adherence and adherence behaviour to PFME
(Chen, 2001).
Link to Section 12.2.3
86
• Using the ASE model, a cross-sectional cohort study (Alewijnse, Mesters, Metsemakers
et al., 2001) also found that self-efficacy (perception of ability to perform the exercises
as recommended under various circumstances) predicted intention to adhere to a
physiotherapy program in a sample of 129 women with urinary incontinence.
12. Adherence issues relating to pelvic floor muscle rehabilitation management
12.3.2 Scales predicting adherence
Broome developed a self efficacy scale based on Bandura’s Self-Efficacy and Social Influence
Theory which was tested on a sample of 125 women aged 50 and older with urinary
incontinence, including a subset of women who had completed a course of behavioural
treatment for their incontinence. The scale revealed that the higher the initial self-efficacy,
the greater the likelihood of a positive outcome (Broome, 1999).
Similarly, Chen developed a self-efficacy scale for the performance of PFME (Chen, 2004).
This scale incorporated aspects of Bandura’s Model and the Health Promotion Model (Pender
& Pender, 1986). The scale was tested on 106 Taiwanese women with urinary incontinence,
aged 24 to 89, who had been instructed to perform PFME for at least six weeks, and revealed
a moderate correlation between the scale and the subjects’ perception of outcome; that is,
the higher their self-efficacy as measured by the scale, the better they tended to perceive the
outcome of their program.
Point of Interest
People with higher self-efficacy tend to have an actual or perceived positive outcome to
treatment of their incontinence.
12.3.3 Health education programs and devices to assist adherence
A number of studies have examined the effects of specific health education programs or tools
as supplements to treatment for urinary incontinence, and a table summarising techniques
to promote adherence is included in this section (refer table 15). The reader is encouraged to
assess the reliability and validity of these studies, bearing in mind that retrospective studies
are less ideal than cross-sectional cohort and case series studies.
A randomised controlled trial of 133 women with incontinence (Alewijnse, Mesters,
Metsemakers et al., 2003) compared a “usual patient education and PFME program” provided
by a physiotherapist to the same program supplemented with a health education program.
The health education program was based on the ASE model and hence aimed to influence
adherence through the mediation of attitudes, social expectations and self-efficacy. A self-help
guide was used, which included reminders to exercise (eg. stickers), guidance for adherence
(eg. tips to address barriers to adherence and relapse prevention strategies) and structured
feedback. Data from the 23% who dropped out was not collected. The drop-out group had
more severe and more frequent urinary incontinence episodes. There was no statistically
significant difference found between the two groups. Intention to adhere did not significantly
predict long-term adherence behaviour, a finding not in support of the ASE theory. However,
short-term adherence to the program was a predictor of long-term adherence.
Link to Section 12.2.3
A quasi-randomised controlled trial (i.e. allocation by alternation rather than at random)
of 48 Japanese women with stress urinary incontinence (Kim, 2001) compared the efficacy
of a PFME program (control group) with the addition of a Continence Efficacy Intervention
Program (treatment group). The program consisted of a pamphlet on PFM instruction, a
video, a training diary, a schedule guideline, and a follow-up phone call including further
education and encouragement. Adherence and improvement in condition were measured
subjectively, and showed significantly better results in the treatment group.
12. Adherence issues relating to pelvic floor muscle rehabilitation management
87
A non-randomised controlled trial involving 46 Japanese women with stress urinary
incontinence (Sugaya, Owan, Hatano et al., 2003) compared two approaches to a PFME
program. The control group received a pamphlet about PFME whereas the treatment group
received the pamphlet plus timer that sounded three times a day to cue the subject to perform
her exercises. Its visual display indicated a rhythm to which the subject was encouraged to
perform her PFME. There was no statistically significant difference between groups in number
of incontinence episodes or pad use, but there was a statistically significant improvement in
quality of life in the treatment group compared to the control group.
A quasi-randomised controlled trial of women with stress urinary incontinence (Gallo &
Staskin, 1997) was guided by the Health Promotion Model (Pender & Pender, 1986), which
highlights the importance of cues to action. The trial compared a biofeedback-assisted PFME
program (control group) with the addition of an audiotape (treatment group). The audiotape
contained cues for PFM contraction and ran through a PFME session. A significantly greater
percentage of those in the treatment group demonstrated greater adherence to the program.
Effect of adherence on continence outcomes was not reported.
Good Practice Point
Limited research of variable quality and reliability investigating factors predicting adherence to
continence programs suggests the following:
Encouraging clients to complete a bladder diary, in addition to assisting assessment and
•
monitoring of progress, can give the clinician an indication of the client’s likelihood of
adhering to treatment.
•
Depression itself is a risk factor for some chronic diseases, and can affect adherence to
medical regimes, the effectiveness of care, the potential speed of recovery and it may
increase the risk of poor outcomes (Queensland Health strategy for chronic disease 20052115, 2005). Screening for depression, followed by appropriate referral is essential, as
depression may predict poor adherence to continence programs.
•
Clients should be fully informed of the likely outcomes of untreated urinary incontinence in
order to increase understanding of the seriousness of their condition, as this may improve
adherence with the program.
•
Treatment programs should focus on strategies to improve the client’s self-efficacy, as this
might be associated with improved adherence.
Limited research of variable quality and reliability investigating health education programs to
supplement continence programs and devices to promote adherence suggests the following:
•
Clients who are poorly compliant with their program in the short-term are less likely to be
compliant in the long term. Clinicians should aim to identify poor adherence as early as
possible and focus on strategies to improve it.
•
Use of additional resources, such as pamphlets, videos, DVDs, audiotapes and training
diaries, as well as follow-up support, may help improve adherence.
•
Use of culturally appropriate and gender specific staff and resources.
88
12. Adherence issues relating to pelvic floor muscle rehabilitation management
12. Adherence issues relating to pelvic floor muscle rehabilitation management
89
Study type
Retrospective case
series
Retrospective
statistical analysis
of randomised
controlled trials
Case study
series applying a
prediction model
of adherence
Author
Kincade, Peckous,
& BusbyWhitehead, 2001
Shishani, 2003
Kartha, 1989
55-90 year old
stress incontinent
women 98 men and
women, 50 years
and over
Sample
None stated
None stated
None stated
Control
Treatment
Undergoing PFME
program over 6
months
Biofeedbackassisted PFME
Intervention
Table 15: Summary of studies comparing adherence and pelvic floor muscle training
Perception of
seriousness
Fewer depressed
symptoms at baseline
Increased frequency
of urinary leakage
episodes at baseline
Completion of 7 day
bladder diary
Significant
adherence factors
Age, mobility level, use
of hormone therapy or
diuretics, homebound
status, caregiver status,
living arrangements,
duration of urinary
incontinence
Age, gender, education,
race, incontinence
related variables,
distance client travelled
to clinic, referral source,
previous treatment,
number of comorbidities, prescription
medicines
Non-significant
adherence factors
90
12. Adherence issues relating to pelvic floor muscle rehabilitation management
129 women
with urinary
incontinence
Cross-sectional
cohort study
Self efficacy
scale based on
Bandura’s self
efficacy and social
influence theory
Self efficacy scale
Alewijnse, Mesters,
Metsemakers et al.,
2001
Broome, 1999
Chen, 2004
106 Taiwanese
women with
urinary
incontinence aged
24 – 89 years
125 aged 50 and
older with urinary
incontinence,
including a subset
of women who
had completed
a behavioural
treatment for
incontinence
55 Taiwanese
women with
urinary
incontinence
Cross-sectional
cohort study
Chen, 2001
Sample
Study type
Author
None stated
None stated
Control
Treatment
PFME for at least
6 weeks
Physiotherapy
program
Intervention
The higher the
perception of self
efficacy, the better the
perceived outcome.
The higher the initial
self efficacy, the
greater the likelihood
of a positive outcome
Self efficacy
(perception of
ability to perform
the exercises as
recommended
under various
circumstances)
PFME self efficacy,
namely confidence
in successfully
performing PFME
Significant
adherence factors
Knowledge of PFME
Attitudes towards PFME
Partner cohesion
Perceived benefits of
PFME
Non-significant
adherence factors
12. Adherence issues relating to pelvic floor muscle rehabilitation management
91
Study type
Randomised
control trial
Pseudorandomised
controlled trial
Non-randomised
controlled trial
Pseudorandomised
controlled trial
Author
Alewijnse, Mesters,
Metsemakers et al.,
2003
Kim, 2001
Sugaya, Owan,
Hatano et al., 2003
Gallo & Staskin,
1997
Women with
stress urinary
incontinence
As for control
with addition of
audiotape
Pamphlet plus
device to improve
adherence to
the program
Pamphlet about
PFME
Biofeedback
assisted PFME
program
As for control
but with addition
of a continence
efficiency
intervention
program
PFME program
48 Japanese
women with
stress urinary
incontinence
46 Japanese
women with
stress urinary
incontinence
As for control but
supplemented with
a health education
program based on
ASE model
Treatment
Usual patient
education and
PFME program
provided by a
physiotherapist Control
Intervention
133 women with
incontinence
Sample
Significantly greater
percentage of those
in treatment group
demonstrated greater
adherence to the
program
Statistically
significant
improvement in QoL
in the treatment
group
Subjective adherence
statistically
significantly greater
in treatment group
Subjective
improvement
significantly greater
in treatment group
Short term adherence
was a predictor to
long term adherence
Significant
adherence factors
Effect of adherence on
continence outcomes
was not reported
Number of continence
episodes or pads used.
Intention to adhere
Non-significant
adherence factors
13. Containment management of urinary incontinence
Despite the best treatment of bladder and bowel problems, incontinence commonly persists.
While improving and/or regaining continence should be the ultimate goal, the appropriate
selection and use of continence aids can make incontinence more manageable and
comfortable, and boost confidence and self-esteem. Prescription of continence aids should
follow a thorough continence assessment, appropriate interventions and management (Miller
& Burgin, 2008).
The selection of continence aids should be carried out using a problem solving approach.
Health professionals assessing continence problems should be aware of the many choices
available and ensure clients receive comprehensive advice when selecting and fitting
continence aids to ensure optimal outcomes. Manufacturers are continually updating and
developing new products and it is essential that health professionals regularly update their
knowledge (Miller & Burgin, 2008).
To ensure prescription of the most appropriate continence aid after the comprehensive
assessment, management, and review of management outcomes, product selection should
consider the following points:
• Volume lost in incontinence episodes
• Diurnal pattern of urinary incontinence
• Ease of use and disposal
• Client preference
• Cost.
When choosing a product the EASE mnemonic may assist:
• E - effect of the product to contain odour and urine/faeces
• A - appropriateness for client/carer
• S - safety of product for client
• E - effective cost considerations.
A booklet titled “Continence products: personal characteristics and specific considerations
when selecting continence products” may assist clinicians when considering the functional
implications of most of the commonly prescribed continence products (MASS 2007b).
Point of Interest
Referral to an occupational therapist for a detailed functional assessment should be considered,
as other health professionals will not have the necessary knowledge and skills to assess a
client’s full functional ability.
Increased awareness of functional aspects of continence promotion can often solve the
environmental and functional issues that are causing or contributing to the incontinence. This
includes assisting with the best method of applying and removing the continence aid.
13.1 Skin health and continence products
The healthy skin has a protective acid mantle, with a pH of between 5.4 – 5.9 (Ersser,
Getliffe, Voegeli et al., 2005). With incontinence, decomposition of urinary urea by microorganisms release ammonia to form the alkali, ammonium hydroxide. Chemical irritation of
the skin may arise from both the rise in alkalinity and bacterial proliferation (Ersser, Getliffe,
92
13. Containment management of urinary incontinence
Voegeli et al., 2005). The combination of urine and faeces causes significantly higher levels
of irritation than urine or faeces alone, since the presence of faecal urease results in the
breakdown of urinary urea causing an increase in pH to 8.0 or higher, which increases the
activities of faecal proteases and lipases (Ersser, Getliffe, Voegeli et al., 2005; Gray, Bliss,
Erner-Seltun et al., 2007; Gray, Ratliff & Donovan, 2002). Liquid stool tends to be richer in
digestive enzymes, which, when combined with its elevated water content, is particularly
damaging to the skin (Gray, Bliss, Erner-Seltun et al., 2007).
Prolonged exposure to water alone has been shown to cause hydration dermatitis, and
prolonged occlusion of the skin (as with a continence product) reduces skin barrier function
and significantly raises microbial counts and pH (Ersser, Getliffe, Voegeli et al., 2005; Gray,
Bliss, Erner-Seltun et al., 2007). Even in the absence of incontinence, prolonged exposure
of the perineal skin to perspiration under an incontinence containment brief raises the local
pH to approximately 7.1, increasing the risk for irritant dermatitis (Gray, Ratliff & Donovan,
2002). Prolonged occlusion of the skin under an absorptive incontinence product for five
days has been shown to increase sweat production and compromise barrier function, resulting
in elevated trans-epidermal water loss, CO2 emission, and pH (Gray, Bliss, Erner-Seltun et
al., 2007).
Use of containment aids increases susceptibility to over-hydration and elevated skin
temperatures, both of which compromise the skin barrier (Lekan-Rutledge, Doughty, Moore,
et al., 2003), and contribute to incontinence associated dermatitis (Gray, Bliss, Erner-Seltun
et al., 2007). Excess moisture on the skin will eventually produce mechanical change.
Twice as much energy is required to produce frictional erosions on dry skin as on skin
subjected to 24 hour water exposure (Farage, Miller, Berardesca et al., 2007). Skin hydration
following occlusion is significantly higher and slower to dissipate in aged skin (Farage,
Miller, Berardesca et al., 2007). Thus, continence aids should be firmly fitting but not too
tight, to avoid an occlusive environment (Lekan-Rutledge, Doughty, Moore, et al., 2003), be
sufficiently absorbent to draw urine away from the skin and lock it into the core of the pad,
and should be changed before they become sodden (Ersser, Getliffe, Voegeli et al., 2005;
Nazarko, 2007).
With urinary incontinence, dermatitis begins between the labial folds in women, or the
scrotum in men (Farage, Miller, Berardesca et al., 2007; Gray, Bliss, Erner-Seltun et al., 2007),
while dermatitis associated with faecal incontinence originates in the perianal area (Farage,
Miller, Berardesca et al., 2007; Gray, Bliss, Erner-Seltun et al., 2007) and progresses to the
posterior aspect of the upper thighs. Unusual patterns may reflect occlusion of the skin by
a containment device (Farage, Miller, Berardesca et al., 2007). The prevention of perineal
dermatitis or the restoration of perineal skin integrity and prevention of recurrent damage
are of critical consideration in management of urinary and/or faecal incontinence (LekanRutledge, Doughty, Moore, et al., 2003).
Points of Interest
Three key factors contribute to incontinence associated dermatitis:
•
•
•
Tissue tolerance: affected by age, health status, nutritional status, oxygenation,
perfusion and core body temperature
Perineal environment: affected by the character of the incontinence (urinary, faecal or
double incontinence), the volume and frequency of incontinence, mechanical chafing,
introduced agents such as allergens or irritants, and factors that compromise the
skin’s barrier function such as hydration, pH, faecal enzymes, and fungal or bacterial
pathogens
Toileting ability: mobility, sensory perception, cognitive awareness (Brown, 1995, cited
in Gray, Bliss, Erner-Seltun et al., 2007).
13. Containment management of urinary incontinence
93
Points of Interest cont.
Active preventative care to maintain skin health is essential, including cleansing, moisturising
and protecting skin. The best measures to prevent skin breakdown are by initial thorough
assessment and a consistent approach to client and carer education with ongoing review
(Lekan-Rutledge, Doughty, Moore, et al., 2003).
13.1.1 The perineal assessment tool
The perineal assessment tool has undergone content validation and may be used to assess
incontinence associated dermatitis risk. However, as it has not been extensively used in
research or clinical setting, it should be used in conjunction with regular, descriptive
assessments of skin folds within the perineum, the lower abdomen, between the buttocks and
adjacent skin folds of the inner thighs, scrotum and labia majora.
Table 16: The perineal assessment tool (Nix, 2002)
Factors
Descriptor
Type and intensity of irritant
Formed stool and/or urine
Soft stool with or without urine
Liquid stool with or without urine
0
1
2
Duration of irritant
Linen/pad change at least every 2
hours or less
Linen/pad change at least every 4
hours or less
Linen/pad change at least every 8
hours or less
0
Clear and intact
Erythema/dermatitis with or without
candidiasis
Denuded/eroded skin with or without
dermatitis
0
1
0 – 1 contributing factor
2 contributing factors
3 or more contributing factors
0
1
2
Perineal skin condition
Contributing factors (low albumin,
antibiotics, tube feeding, bacterial
infections causing diarrhoea)
Score
1
2
2
Calculate the cumulative score: higher scores indicate a greater risk for incontinence associated
dermatitis. Cited in Gray, Bliss, Erner-Seltun et al., 2007
13.1.2 Types of skin products
Moisturisers are substances designed to soften and increase the pliability of the stratum
corneum by increasing its hydration. Moisturisers containing occlusives and humectants
can effectively repair the damaged stratum corneum. Barrier enhancing skin cleansers
and moisturisers can both maintain and aid in the restoration of skin health. Petrolatumdepositing liquid cleansers offer therapeutic solutions for both diseased and healthy skin
(Schwartz, Centurion & Draelos, 2008), while those containing humectants such as glycerin,
lanolin or mineral oil, replace oils in the skin and promote its effectiveness as a moisture
barrier. Moisturisers can be applied as a separate step in perineal skin care, but many are
combined with perineal skin cleansers (Gray, Ratliff & Donovan, 2002).
Humectants attract water when applied to the skin, and include glycerin, sorbitol, urea, alpha
hydroxy acids (AHAs) and sugars (Schwartz, Centurion & Draelos, 2008).
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13. Containment management of urinary incontinence
Emollients are soothing to the skin or the mucous membrane. They smooth roughened skin,
lubricate, replace natural skin lipids, and provide occlusion. Emollients are comprised of
water in oil emulsions, so oil is the largest component. The oil concentration affects the ease
of spreading and degree of occlusion required (Schwartz, Centurion & Draelos, 2008).
Lubricants reduce friction, heat or wear when introduced as a film between solid surfaces
(Schwartz, Centurion & Draelos, 2008).
Occlusives (also referred to as moisture barriers or skin protectants), physically block the
surface of the stratum corneum from exposure to irritants or moisture, and reduce transepidermal water loss. They have an emollient effect. Petrolatum is the principal ingredient
used in occlusive formulations (Schwartz, Centurion & Draelos, 2008), with other active
ingredients including dimethicone, lanolin and zinc oxide (Gray, Ratliff & Donovan, 2002).
Hoggarth (2005) found that the most effective barriers are those that contained zinc oxide,
followed by water-in-oil and non-aqueous based formulations. The least effective barrier
product is an oil-in-water based formulation (Hoggarth, Waring, Alexander et al, 2005). A
moisture barrier may be incorporated into skin cleansers or applied separately as a cream or
ointment (Gray, Ratliff & Donovan, 2002). Alternatives to occlusives include:
• Powders, which absorb excessive moisture and reduce friction and erosion when applied
to opposing skin surfaces. Cornstarch is preferred to talcum powder, because using talc
powders in perineal area may increase risk of invasive ovarian cancer (Gray, Ratliff &
Donovan, 2002). Powders should only be applied as a light dusting. Caking exacerbates,
rather than relieves, friction and erosion produced when skin folds in the perineum move
against one another (Gray, Ratliff & Donovan, 2002).
• Pastes, which are ointments with powder added for durability. A barrier paste may
be used if extensive perineal skin erosion is producing exudate. Pastes absorb excess
drainage and block exposure to irritants. Zinc oxide is common ingredient in barrier
pastes. It is important to use an appropriate product such as mineral oil to remove pastes,
as otherwise vigorous scrubbing may be required (Gray, Ratliff & Donovan, 2002).
• Liquid barrier films (skin sealants) comprise a polymer combined with a solvent (usually
alcohol). The solvent evaporates on skin, and polymer dries to form a barrier. Use
judiciously, as alcohol may be irritating or locally cytotoxic to compromised perineal
skin. A liquid film barrier should not be used with a barrier cream or paste because the
products are often incompatible (Gray, Ratliff & Donovan, 2002).
13.1.3 Prevention of incontinence associated dermatitis (IAD)
• Cleanse skin gently with a pH neutral product to remove irritants and pathogens.
Cleansing agents should be pH balanced and contain surfactants to emulsify stool and
lift irritants from the skin surface with minimal force. Added fragrances may contribute
to allergic contact dermatitis (Gray, Bliss, Erner-Seltun et al., 2007; Lekan-Rutledge,
Doughty, Moore, et al., 2003)
• Moisturisers contain emollients that penetrate the skin to restore lipids, and humectants
to bind moisture at the epidermal level. Some cleanser products contain moisturisers
(Gray, Bliss, Erner-Seltun et al., 2007; Lekan-Rutledge, Doughty, Moore, et al., 2003).
• Routine use of a skin protectant is recommended for those at risk of incontinence
associated dermatitis, including those experiencing high volume or frequent incontinence,
or those with double urinary and faecal incontinence. Moisture barriers to protect the
skin against irritants and moisture, by providing a water-repellent coating to the skin.
Many clinicians advocate application of products that incorporate a skin protectant into
a one-step cleansing solution or system, thus reducing the time required to adequately
cleanse and protect the perineal and perigenital skin, particularly in residential care
settings (Gray, Bliss, Erner-Seltun et al., 2007; Lekan-Rutledge, Doughty, Moore, et al.,
2003).
13. Containment management of urinary incontinence
95
13.1.3.1 Cleansing
Repetitive cleansing increases the rate at which the epidermal cells and surface lipids are
removed. This compromises skin barrier properties and increases the risk of dermatitis,
particularly in older people, whose risk is higher due to thinning of the epidermis and reduced
production of skin lipids. Repetitive cleansing and exposure to alkaline urine or stool can
also disrupt the skin’s acid mantle (Lekan-Rutledge, Doughty, Moore, et al., 2003).
Soap is made from a mixture of alkalis and fatty acids, and tends to have a higher pH than
that of normal skin. Its ability to cleanse the skin requires decomposition in water releasing
free alkali and insoluble acid salts that remove dirt and irritating substances from the skin
(Gray, Bliss, Erner-Seltun et al., 2007). Soap may adversely affect the skin by removing
natural sebum oil from the skin and raising its alkalinity (Ersser, Getliffe, Voegeli et al,
2005).
Perineal skin cleaners combine detergents and surfactant ingredients to loosen and remove
dirt or irritants. Many also contain emollients, moisturisers, or humectants to restore or
preserve optimal barrier function, and many are pH neutral, ensuring their pH is close to that
of normal healthy skin (5.0-5.9) (Ersser, Getliffe, Voegeli et al, 2005; Farage, Miller, Berardesca
et al., 2007; Gray, Bliss, Erner-Seltun et al., 2007).There is some evidence suggesting that a
cleanser that matches the pH of the skin and contains moisturisers or humectants may be
preferable to soap and water, especially in aged skin (Ersser, Getliffe, Voegeli et al, 2005;
Gray, 2007). The pH of cleansing products should be verified before use as many common
products have pH outside the recommended range (Farage, Miller, Berardesca et al., 2007).
13.1.3.2 Drying
The mechanical and chemical drying of the skin can adversely affect barrier function. A
minimal rubbing drying technique, such as patting, may reduce the friction damage caused
(Ersser, Getliffe, Voegeli et al, 2005).
13.1.4 Management of incontinence associated dermatitis (IAD)
The principles of a structured skin care regimen comprise gentle cleansing, moisturisation,
and application of a skin protectant or moisture barrier (Gray, 2007).
13.1.4.1 Mild to moderate incontinence associated dermatitis
For mild to moderate IAD, characterised by erythema and tenderness of intact skin, a
structured skin care regimen similar to those recommended for prevention should be used,
with the addition of a skin protectant. Skin care should be provided following each major
incontinence episode, particularly if faecal matter is present. Skin protectant should be used
daily or more frequently if the client has high-volume or frequent episodes of incontinence.
Combination products are usually recommended, particularly in the residential care setting,
as they reduce several steps into a single intervention, maximising time efficiency and
encouraging adherence to a structured skin care regimen. These include moisturising
cleansers, moisturising skin protectant creams, and disposable washcloths that incorporate
cleansers, moisturisers and skin protectants into a single product (Gray, Bliss, Erner-Seltun
et al., 2007).
13.1.4.2 Severe incontinence associated dermatitis
For severe IAD, associated with denudation of the skin, a structured skin care program
combined with regular application of a skin protectant product may provide adequate
protection to promote healing in some clients (Gray, Bliss, Erner-Seltun et al., 2007).
96
13. Containment management of urinary incontinence
Topical antibiotics and antimicrobials should be used only when an infection has been
confirmed (Farage, Miller, Berardesca et al., 2007).
13.1.5 Specific skin care with use of absorbent pads
Skin should be kept dry using absorbent incontinence pads (Farage, Miller, Berardesca et al.,
2007). Absorbent products may actually increase the tissue interface pressures when soaked,
even when used in conjunction with pressure reducing or relieving support surfaces (Gray,
Bliss, Erner-Seltun et al., 2007). Wet or soiled garments should be changed promptly, and
skin cleansing should follow every incontinent episode. Efforts should be made to prevent
further moisture from reaching the skin (Farage, Miller, Berardesca et al., 2007).
Barrier ointments should be used to protect the skin from contact with moisture, while
at the same time preventing friction from continence pads and bed linens (Farage, Miller,
Berardesca et al., 2007). It is important that the barrier cream, ointment or film is suitable
for use with incontinence pads. It is recommended that only water based barrier creams are
used if pads are to be worn. Oil based creams and talcum powder should be avoided as these
clog the pad and affect the absorbency of the pad, allowing urine to sit next to the skin for
longer (Whitely, 2008).
13. Containment management of urinary incontinence
97
14. Pharmacological management
Link to Section 2
Section 14 has been developed using non-systematic, narrative methodology.
14.1 Outline
Pharmacological management of incontinence is used for incontinence resistant to conservative
treatment, or as an adjunct to other management strategies. Use of pharmacological agents
aims to relieve symptoms, reduce complications of incontinence and improve the quality of
life.
Successful treatment depends upon the specific cause of the incontinence and correct
diagnosis. If incorrectly diagnosed, some treatments may actually worsen the incontinence
or cause other problems. It is recommended to treat the most prominent incontinence type
and check for effectiveness before using a second agent.
Link to Appendix 14
Link to Appendix 14
As the elderly are more sensitive to both the beneficial and adverse effects of medication,
appropriate consideration should be given when instituting any medication therapy. Slow
titration and monitoring of effect should be followed. Early cessation is standard practice if
no benefit is provided or adverse effects are suffered.
It is necessary to assess and check for medications that may be contributing to the incontinence.
For further information refer to Appendix 14 in this guideline. It should be remembered that
‘medications’ refers to prescription, over-the-counter, (OTC) and complementary medications.
Continence clinicians must know their professional roles and responsibilities in relation to
pharmacological management.
14.2 Medication reviews
Medication reviews should be an integral part of a continence assessment. The Home Medicines
Review Program (an Australian government funded service) provides the opportunity for any
client, carer or professional to request a medication review. This enables a specially trained
pharmacist to visit the client following consent from the client and the general medical
practitioner. The review facilitates use of the pharmacist’s special skills and knowledge in
supporting and assisting other health professionals, and in contributing to the care of clients
by ensuring optimal use of medicines.
14.3 Medications for stress incontinence
14.3.1 Adrenergic agonists
There is only weak evidence to suggest that the use of an adrenergic agonist (such as
Pseudoephedrine) is better than placebo treatment, and insufficient evidence to assess the
effects of adrenergic agonists when compared to or combined with other treatments. Clients
using adrenergic agonists may suffer from minor side effects, occasionally leading them to
stop treatment. Rare but serious side effects such as cardiac arrhythmias and hypertension have
been reported, and these medications are not widely used for managing stress incontinence
in Australia (Alhasso, Glazener, Pickard et al., 2005).
Link to Section 14.7
14.3.2 Topical oestrogen
Topical oestrogens may prevent urinary tract infections and help female clients with chronic
voiding dysfunction. Topical oestrogens increase urethral vascularity and thickness, and
sensitise alpha adrenergic receptors in bladder neck, both of which theoretically should
improve urethral closure. However, recently Weiss found no objective improvement in
measured urine loss with oestrogen therapy (Weiss, 2005) while Casper reported that some
forms of incontinence showed benefit through oestrogen therapy (Casper, 2006).
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14. Pharmacological management
Good Practice Point
Although the amount of oestrogen absorbed may not be significant, clinicians are advised to
consider the possible risks associated with the use of topical oestrogen products with each client
through reference to manufacturer guidelines, pharmacist advice, and other resources.
Adapted from MIMS on-line as cited by Golding (2006).
14.3.3 Duloxetine
Duloxetine hydrochloride is a combined norepinephrine and serotonin reuptake inhibitor
which increases contraction of urethral sphincters during urine storage. It is the only
medication licensed specifically for stress incontinence and is approved for this use in
the United Kingdom. In the United States of America, incontinence is a non-FDA labelled
indication for duloxetine. Whilst now available in Australia, it is currently only registered
by the Therapeutic Goods Administration (TGA) for use in treating depression. The most
common side effect is nausea (Weiss, 2005).
14.4 Medications for detrusor overactivity and urge incontinence
Link to Section 3.5.1
14.4.1 Oral Oestrogen
The most recent evidence suggests that oestrogen treatment increases the risk of new onset
incontinence in previously continent women, and worsens existing incontinence (Hendrix,
Cochrane, Nygaard et al, 2005; Waetjen, 2006). Therefore, oral oestrogen should not be
prescribed for the treatment of stress or urge incontinence in post-menopausal women (Martin
& Barbieri, 2008). Hormone therapy for bothersome menopausal symptoms may increase
the risk of developing or worsening incontinence, although the absolute risk is small, and
appears to be reversible with cessation of the hormone therapy (Waetjen, 2006).
Points of Interest
The 2005 Women’s Health Initiative study (Hendrix, Cochrane, Nygaard et al., 2005) assessed
the effects of menopausal hormone therapy on the incidence and severity of symptoms
of urinary incontinence in healthy postmenopausal women. This study included two trials
– one examining the effects of oral oestrogen plus progestin (for women who had not had a
hysterectomy) and the other trial examining the effects of oral oestrogen alone (for women
who previously had a hysterectomy). Over 27,000 women in total were enrolled in the studies.
In both trials, oral hormone therapy was associated with an increased incidence of urinary
incontinence and worsening symptoms of pre-existing urinary incontinence, and this effect
persisted at three years.
14.4.2 Oral anticholinergics (antimuscarinics)
Anticholinergics with antimuscarinic effects are among the medications most frequently
prescribed for urge incontinence. A systematic Cochrane review (2005) found that treatment
with these agents compared with placebo resulted in a 40 percent higher rate of cure or
improvement, and an absolute decrease of 0.6 in both incontinent episodes and voids per 24
hours; the rate of dry mouth was more than 2.5 times higher with treatment. The absolute
benefit over placebo was small, in part because patients tended to do well whether they
received active treatment or placebo. This may have been due to patients’ use of concomitant
bladder retraining in some of the underlying studies, whether directed to or not. Thus, although
14. Pharmacological management
Link to Table 23
Appendix 14
99
statistically significant, the differences between anticholinergic drugs and placebo were small,
apart from the increased rate of dry mouth in patients receiving active treatment. For many
of the outcomes studied, the observed difference between anticholinergics and placebo may
be of questionable clinical significance (Hay-Smith, Herbison, Ellis et al., 2005).
Currently in Australia, medications registered for detrusor overactivity and urinary
incontinence include the anticholinergics imipramine, propantheline, oxybutynin and
tolterodine, darifenacin and solifenacin.
Oxybutynin — Oxybutynin has direct antispasmodic effects and inhibits the action of
acetylcholine on smooth muscle. The efficacy of oxybutynin may continue to increase
beyond two weeks, suggesting that physicians should avoid escalating the dose too quickly
or abandoning therapy too soon.
Anticholinergic side effects, especially dry mouth, can limit therapy with oxybutynin.
However, side effects can be minimized by slow titration of the drug. The newer slow release
patch formulation may assist in reducing side effects to some degree (manufacturers claim).
Tolterodine — A meta-analysis found that tolterodine has similar clinical efficacy to
oxybutynin, is better tolerated than oxybutynin , but is considerably more expensive than
generic oxybutynin (Harvey, Baker, & Wells, 2001). There have been case reports of cognitive
side effects mimicking dementia with tolterodine.
Darifenacin and Solifenacin — These are newer anticholinergic agents (recently registered
in Australia) that are more selective for muscarinic receptors in the bladder. However, they
do not have significantly improved efficacy, and patients may still experience adverse effects
(eg dry mouth) (Bochner, 2008).
Constipation and compensatory fluid intake for a dry mouth may exacerbate urinary
incontinence. As a dry mouth predisposes clients to dental caries, regular dental care must be
implemented if they are maintained on the drug.
The post void residual should be monitored in older patients. Worsening of urinary incontinence
can result from subclinical retention that requires lower (not higher) drug dosages (Up-todate, 2006).
14.4.3 Botulinum toxin injections for adults
Intravesical botulinum toxin shows promise as a therapy for overactive bladder symptoms,
but as yet too little controlled trial data exist on benefits and safety compared with other
interventions, or with placebo. At present there is little more than anecdotal evidence in
the form of case reports, to support the efficacy of intravesical botulinum toxin; there is
not much in the way of substantial, robust safety data. Furthermore, the optimal dose of
botulinum toxin for efficacy and safety has not yet been demonstrated. Botulinum toxin
injections into the bladder appeared to give few side effects or complications, but there were
no long-term follow-up studies (Duthie, Wilson, Herbison et al, 2007).
14.4.4 Common side effects of anticholinergics in the older person
Antimuscarinic agents may impair aspects of CNS functioning including memory and sleep,
and may lead to hallucinations, confusion or delirium, although serious CNS disturbances are
uncommon. Cardiac effects (i.e. tachycardia) are also possible (Hijaz & Rackley, 2005).
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14. Pharmacological management
The most common side effects with these medications are constipation and dry mouth. They
may worsen cognitive function and may present an increasing risk of falls. These effects are
said to be less problematic with Tolterodine compared to Oxybutynin, although they are still
present (Hay-Smith, Herbison, Ellis et al., 2005). Urinary retention can be a common side
effect of anticholinergic medications.
Imipramine and propantheline may be poor choices in the elderly due to their increased
side effect profile. Imipramine is a tricyclic antidepressant that works via anticholinergic
effects and by relaxing the dome of the detrusor (Kuteesa & Moore, 2006). It commonly
causes drowsiness, especially in the first three weeks, and is therefore often taken at night
for nocturnal symptoms. Propantheline is a synthetic analogue of atropine that blocks
muscarinic receptors at all sites and therefore may cause significant side effects. However, it
is only approximately 60% of the cost of oxybutynin (Kuteesa & Moore, 2006).
Link to Appendix 14
14.5 Medications for voiding difficulties
Voiding difficulties may be due to Bladder Outlet Obstruction (BOO), poor detrusor
contractility, or detrusor sphincter dyssynergia. These are covered in detail in section five of
this guideline.
Medications indicated for those with voiding difficulties include:
• Alpha-adrenergic antagonists
• Androgen blockage provided by Finasteride
• Saw Palmetto (Serenoa Repens), which provides mild to moderate improvement in
urinary symptoms and flow measures in benign prostatic hyperplasia. It shows a similar
improvement in urinary symptoms and flow when compared to Finasteride, and is
associated with fewer adverse treatment events. While Serenoa Repens may be a useful
treatment option, patients and providers need to be aware that there are no guarantees
regarding product purity and potency (Wilt, Ishani, & Mac Donald, 2002).
Link to Table 10
Section 6.5.2
14.6 Medications for urinary tract infections
Urinary tract infections (UTI) cause urge incontinence due to irritation associated with
cystitis. They should be treated effectively using appropriate antibiotics and, if recurrent,
with appropriate prophylactic use of antibiotic therapy.
There is conflicting data on the risk of UTI with oestrogen use. Oral oestrogen does not
appear to reduce the frequency of UTI, but intravaginal oestrogen may reduce the risk of
recurrence in women with frequent UTIs. The relative efficacy, safety and client tolerability
of intravaginal oestrogen have not been directly compared with antimicrobial prophylaxis
(Martin & Barbieri, 2008).
Post menopausal women who have three or more recurrent UTIs per year, and who do not
take oral oestrogen, may benefit from intravaginal oestrogen, particularly when resistance to
multiple drugs limits the efficacy of antimicrobial prophylaxis (Martin & Barbieri 2008).
A recent Cochrane review of ten studies found some evidence that cranberry juice may
decrease the number of symptomatic urinary tract infections over a 12 month period for
women although the evidence for elderly men and women is inconclusive. There was poor
adherence to the treatment over time. There is evidence that cranberry juice is not effective
in people with a neurogenic bladder. The optimum dose, method of administration (eg.
juice, tablets or capsules) and length of treatment all require further investigation (Jepson,
Mihaljevic & Craig, 2008).
14. Pharmacological management
Link to Section 8.7
101
14.7 Medications for vaginal atrophy
Topical oestrogen applications (creams, pessaries or vaginal ring) have been reviewed
separately all were found to be effective for symptoms of vaginal atrophy. Extremely low
doses of unopposed (i.e. without progestin) transdermal oestrogen do not appear to increase
the risk of urinary incontinence (Martin & Barbieri, 2008). As a treatment choice, women
appeared to favour the oestradiol releasing vaginal ring for ease of use, comfort of product
and overall satisfaction. However the oestradiol ring is not currently available in Australia
and requires approval prior to treatment (Suckling, Lethaby, & Kennedy, 2003). Some women
prefer an oestrogen tablet which adheres to the vaginal wall, while others prefer pessaries
(Hirst, 2006).
14.8 Medications for nocturnal diuresis
Link to Section 8.11
People with excessive nocturnal diuresis may benefit from use of nasal Desmopressin Acetate
(DDAVP) at bedtime (Fonda, DuBeau, Harari et al., 2005). However, the role of DDAVP is very
limited, and its significant risks and side effects (for example, heart failure in older people)
indicate the need for careful consideration before prescribing (Golding, 2006).
14.9 Medications for overactive bladder
A recent Cochrane review has compared the use of anticholinergic drugs with non-drug
therapies for overactive bladder syndrome in adults. Although there is limited evidence
available, it was found that, during initial treatment, the greatest symptomatic improvement
was seen amongst those on a combined therapy of an anticholinergic drug plus bladder
training. Anticholinergic drugs showed more symptomatic improvement compared to
bladder training alone. There was insufficient evidence to determine if there is any sustained
symptomatic improvement after stopping either treatment (Alhasso, McKinlay, Patrick et al.,
2006).
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14. Pharmacological management
15. Indications for referral for further assessment
The ‘First Steps’ CPG (MASS 2007), contains a clinical algorithm referral pathway for primary
level clinicians which highlights significant factors requiring further investigation. These
include:
• Red Flags – as outlined in Section 9.1 of the ‘First Steps’ CPG (MASS 2007). Immediate
medical assessment is needed if the client has pain, recent unexplained weight
loss, recent sudden change in bowel habit, pelvic mass, rectal bleeding, persistent
diarrhoea, hematuria, recurrent symptomatic urinary tract infection, history of
pelvic surgery or irradiation, major pelvic organ prolapse, or recent prostatectomy
surgery.
• DIAPPERS – as outlined in Section 9.2 of the ‘First Steps’ CPG (MASS 2007), the
‘DIAPPERS’ mnemonic alerts health professionals to the following conditions:
* Delirium – any sign
* Infection – positive reagent strip test
* Atrophic Vaginitis – reports vaginal dryness, itching, irritation,
* Pharmaceuticals
* Psychological
* Excess urine output
* Restricted mobility
* Stool impaction.
pain with intercourse or signs present on examination
If further assessment or treatment is indicated, or if the continence clinician is unsure about
appropriate management strategies, the continence clinician can refer to the algorithm shown
as figure 6, and to the flowchart shown in figure 7 on the following pages.
Additional indicators for further assessment by a general medical practitioner include:
• Males: refer for general medical practitioner review if no medical review current
• Neurological examination (dermatome testing/reflex testing) equivocal or not normal,
or secondary level clinician lacks competency to complete specific assessment
• Perineal examination reveals presence of prolapse extending beyond the vaginal
introitus, skin lesions, vaginal epithelium that is pale, smooth, shiny or dry, vaginal
discharge, vaginal malodour
• Rectal examination/observation reveals rectal prolapse, haemorrhoids, presence of
stool in addition to a recent history of bowel function suggesting faecal impaction
• Polyuria or nocturnal polyuria identified on bladder diary
• Poor responses to treatment in women with incontinence in whom voiding difficulties
are also present (recommend referral to a medical specialist for urodynamics/
uroflowmetry)
• No response to treatment in 12 weeks or inadequate response (client not satisfied) by
six months – refer on with view to medical specialist investigations/consideration
for surgical interventions
• Persistent difficulty reported with catheter insertion – refer to general medical
practitioner with view to specialist urology referral.
15. Indications for referral for further assessment
Link to Section 4.4
103
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2:00:59 PM
AL
ME
TITION
E
CONTINENCE ADVISOR
CONTINENCE PHYSIOTHERAPIST
MULTI-DISCIPLINARY TEAM
AC
INDIVIDUAL
R
R
P
STEP 6 - EVALUATE
STEP 7 - REVIEW
IF REQUIRED
RED FLAGS OR
DIAPPERS
AL
STEP 5 - IMPLEMENT
STEP 4 - PLAN
RED FLAGS OR
DIAPPERS
STEP 3 - OBJECTIVE
ASSESSMENT
(MASS 2007)
Figure 6: Clinical algorithm: referral pathway for the care of community-dwelling older people with urinary incontinence
EXIT
IF REQUIRED
STEP 2 - SUBJECTIVE
ASSESSMENT
STEP 1 - BATHE
E
GEN
GENERIC ASSESSMENT
OR SELF REFERRAL
ENTRY
Clinical algorithm: Referral pathway for the care of community-dwelling older people with urinary incontinence
Clinical Algorithm.pdf
IC
R
104
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15. Indications for referral for further assessment
15. Indications for referral for further assessment
105
•
•
•
•
•
•
•
•
CLINICAL
DIAGNOSIS
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals
Psychological
Excess urine output
Reduced mobility
Stool impaction and
other factors
(Abrams, Andersson, Brubaker et al., 2005)
INCONTINENCE
• Double voiding
• Consider cautious addition
and trial of antimuscarinic
drugs
• If PVR>500: catheter
decompression then reassess
UI associated with:
• Pain
• Haematuria
• Recurrent symptomatic UTI
• Pelvic mass
• Pelvic irradiation
• Pelvic/LUT surgery
• Major prolapse (women)
• Post prostatectomy (men)
• ± Topical oestrogens (women)
• Behavioral therapies
• Lifestyle interventions
Stress UI *
If fails, consider need for specialist assessment
Continue conservative methods ± Dependent continence ± Contained continence
• ± Topical oestrogens (women)
• Review medications
• Consider trial of alpha-blocker
(men)
• Treat constipation
• Behavioral therapies
Sigificant PVR *
• Lifestyle interventions
Urge UI *
• Assess, treat and reassess potentially treatable conditions, including relevant
comorbidities and activities of daily living (ADLs)
• Assess QoL, desire for Rx, goals of Rx, patient and caregiver preferences
• Targeted physical exam including cognition, mobility, neurological
• Urinalysis and MSU
• Bladder diary
• Cough test and PVR (if feasible and if it will change management)
Figure 7: Management of urinary incontinence in frail older people
ONGOING MANAGEMENT
and REASSESSMENT
(If Mixed UI, initially treat predominant symptoms)
INITIAL
MANAGEMENT
*These diagnoses may overlap in various
combinations, e.g., MIXED UI
D
I
A
P
P
E
R
S
CLINICAL
ASSESSMENT
HISTORY/SYMPTOM/ASSESSMENT
MANAGEMENT OF URINARY INCONTINENCE IN FRAIL OLDER PEOPLE
`