The Urological Society of India Guidelines for the Evaluation and Management of Nonneurogenic Urinary Incontinence in Adults (Executive Summary)

These guidelines have been drafted by the Urological Society of India Urinary Incontinence (UI) Guidelines Panel and address “Nonneurogenic urinary incontinence in adults.” The guidelines are intended for urologists and the recommendations are updated till October 2018. These will remain valid until the next update or for a maximum period of 5 years. The guidelines should not be regarded as a rigid clinical pathway for every patient and are not intended to replace clinical judgment. This executive summary includes some salient aspects of the guidelines and the guideline statements. The guidelines document includes additional details regarding epidemiology, new definitions, a discussion on the guidelines recommendations, a position statement on mesh for stress incontinence, and a section on healthcare and cost of drugs in India. The complete guidelines document can be accessed from the Urological Society of India website at www.usi.org.in

Literature search was conducted on PubMed, Cochrane Central Register of Controlled Trials (including randomized and quasi-randomized trials from Embase and PubMed), Mendeley, and Directory of Open Access Journals. Each set of search was conducted twice, once for high level evidence (randomized trials and systematic reviews) and another time for all levels of evidence (LE) with geographical area restricted to “India.” Secondary evidence sources included citations from all published English language guidelines and reviews. LE was evaluated by the Centre for Evidence-Based Medicine method.[1]

The guidelines panel based its final recommendations on the best available global evidence, Indian data as well as the socioeconomics of healthcare in India. Grades of recommendation (GR) (strong/moderate/weak) are the strength of mandate based on the extent of risk–benefit ratio of either taking or not taking an action. Clinical principle is a statement that is widely agreed upon by clinicians, for which there may or may not be evidence in the medical literature. Expert opinion is a statement agreed upon by the guidelines panel in the absence of evidence.

This guideline follows the joint International Urogynecology Association-International Continence Society terminology document of 2010.[2] UI is defined as “the complaint of any involuntary leakage of urine.” Stress UI is “complaint of involuntary loss of urine with effort or physical exertion, or on sneezing or coughing.” Urgency UI is “complaint of involuntary loss of urine associated with urgency.” Mixed UI is “complaint of involuntary loss of urine with urgency and also with effort or physical exertion or on sneezing or coughing.”

UI has been noted in 25%–45% of adult women in global studies.[3] Studies from India show a prevalence of 10%–42% in nine population-based door-to-door epidemiological studies, with stress UI being the most common type.[4,5,6,7,8,9,10,11,12] Age-adjusted prevalence progressively increased from the 3^rd to 7^th decade (5.6%, 14.2%, 27.3%, 34.3%, and 39.0%, respectively). This finding has important implications for health planning since the population of Indians older than 60 years is set to double from 117 million in 2015 to 246 million by 2040.[13] Two noteworthy risk factors were delivery at home and pregnancy at young age.[4,7,9] About 40% of women attributed incontinence to a natural consequence of aging.[4,6,9] Social embarrassment (about 25%) was possibly more important than financial constraint (3%–14%) in determining help-seeking behavior.[4,8,9]

In general, the prevalence of UI in men has been noted to be lower than women; however, the age-related trend is similar. A systematic review of 21 studies showed a prevalence of 3%–5% in young and middle-aged men and 11%–34% in older men.[14] The guidelines committee could not find any study that looked at the prevalence in Indian men.

The committee examined the issue of access and usage of toilets in India. Inability to access a toilet facility in time can convert urgency in an individual with limited ambulation into UI.[15] Although there has been a dramatic increase in toilet availability under the Swachh Bharat Mission,[16] usage remains clouded by misplaced beliefs regarding personal hygiene and household sanctity.[17]

Historical reports of postprostatectomy incontinence after radical prostatectomy ranging from 2.5% to 87% have improved with refinements in technology and technique. Currently, about 6%–9% of men undergoing radical prostatectomy are expected to require surgery for incontinence.[18,19] In contrast, the risk of incontinence after benign prostate surgery is 1% or less.

GUIDELINE STATEMENTS

Evaluation of urinary incontinence

1.1 Carry out a clinical evaluation to categorize the type of UI (stress, urgency, mixed or incontinence associated with chronic retention) (Clinical Principle)

1.2 Baseline clinical evaluation should include clinical history, physical examination, and degree of bother (Clinical Principle), complete urine examination (LE-3, GR-strong), voiding diary (LE-2, GR-strong), and postvoid residual urine measurement (Expert Opinion)

1.3 Do not perform invasive urodynamics testing before initiating noninvasive treatment (LE-1 GR-strong)

1.4 Invasive urodynamics may be omitted before surgery in women with uncomplicated stress UI (LE-1, GR-moderate). All other women should undergo urodynamics before stress UI surgery (LE-3, GR-strong)

1.5 Invasive urodynamics is recommended in men and women with urgency UI before invasive therapies (LE-3, GR-weak)

1.6 Invasive urodynamics is recommended in men with postprostatectomy incontinence before surgical therapy (LE-4, GR-moderate)

1.7 A diagnostic cystoscopy is not recommended in the evaluation of UI in women (LE-4, GR-moderate). In men with PPI, a diagnostic cystoscopy should be performed before surgical intervention (LE-4, GR-moderate).

Conservative therapies

2.1 Patient education regarding lower urinary tract function and implications of UI should be an integral part of management (Clinical Principle)

2.2 Counsel patients that moderation of caffeine consumption (LE-2, GR-moderate), modification of fluid intake (LE-2, GR-moderate), treatment of constipation (LE-3, GR-moderate), and reduction of obesity (LE-1, GR-strong) can benefit patients with UI

2.3 Comorbid conditions and medications that may influence UI should be addressed as appropriate (Clinical Principle)

2.4 Pelvic floor muscle training (PFMT) is recommended for women with UI as initial treatment or in combination with other treatments (LE-1, GR-strong)

2.5 Routine use of biofeedback, pelvic floor stimulation therapy, vaginal cones, or continence pessary is not recommended (LE-2, GR-moderate)

2.6 PFMT is effective in the prevention and treatment of UI during pregnancy and postpartum (LE-2, GR-moderate)

2.7 Bladder training is effective in women with UI (LE-1, GR-strong)

2.8 Percutaneous tibial nerve stimulation is effective for the short-term treatment of women with urgency UI (LE-2, GR-moderate)

2.9 PFMT is recommended for men with PPI for more rapidly attaining their final continence status (LE-1, GR-strong). Routine use of biofeedback or pelvic floor stimulation therapy is not recommended (LE-2, GR-moderate).

Pharmacotherapy

3.1 Antimuscarinics (darifenacin, oxybutynin, solifenacin, tolterodine, trospium, fesoterodine, and propiverine) are appropriate for patients with urgency UI (LE-1, GR-strong)

3.2 Exercise caution while prescribing antimuscarinics in the elderly (LE-1, GR-strong)

3.3 Mirabegron is appropriate for patients with urgency UI (LE-1, GR-strong)

3.4 Combination of mirabegron with antimuscarinics is more efficacious than either drug alone (LE-1, GR-strong)

3.5 Consider propantheline in patients with financial constraint (LE-2, GR-weak)

3.6 Duloxetine may offer some benefit in the treatment of stress UI in women and PPI in men (LE-1, GR-moderate), but caution is advised in view of the potential for serious side effects (LE-2, GR-strong).

Invasive therapy for urgency urinary incontinence

4.1 Offer onabotulinum toxin A (LE-1, GR-strong) or sacral neuromodulation (LE-2, GR-moderate) in patients with refractory urgency UI, or when drug therapy is contraindicated or not tolerated.

Invasive therapy for stress urinary incontinence

5.1 Mid-urethral slings (MUS), autologous pubovaginal slings, and the open retropubic colposuspension are standard surgical options for a woman with uncomplicated stress UI (LE-1, GR-strong). Both transobturator and retropubic tapes using macroporous polypropylene mesh are appropriate (LE-1, GR-strong)

5.2 In women with mixed UI, initial treatment should be conservative with or without pharmacotherapy for urgency component (LE-1, GR-strong). Stress UI surgery is appropriate treatment in women with stress-predominant mixed UI (LE-1; GR-strong). Counsel regarding unpredictable resolution or worsening of urgency

5.3 Single-incision slings are a less invasive but less effective alternative to MUS (LE-2, GR-moderate)

5.4 Consider the use of customized mesh using established surgical principle in patients with financial constraint who desire MUS (LE-3, GR-weak)

5.5 Bulking agents are weakly effective in women with stress UI (LE-1, GR-moderate) and should be considered only when surgery is inappropriate or refused

5.6 Laser therapies are not recommended for the treatment of stress UI in women outside a research protocol (LE-2, GR-strong).

Surgery for postprostatectomy incontinence

6.1 Surgery should be offered after a minimum interval of 6 months following the initial prostate surgery (LE-4, GR-moderate). Confirm stable patency of any anatomical narrowing before offering PPI surgery (Clinical Principle)

6.2 For mild-to-moderate PPI, artificial urinary sphincter (LE-2, GR-moderate) and slings (LE-3, GR-moderate) are appropriate surgeries

6.3 For severe PPI, artificial urinary sphincter is appropriate (LE-2, GR-strong)

6.4 Inform patients that reoperation rates are significant with all the current surgical options for PPI (LE-3, GR-moderate)

6.5 Bulking agents are appropriate for short-term relief in men with mild PPI (LE-3, GR-weak).