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## Complete Summary

#### GUIDELINE TITLE

Management of urinary incontinence in primary care. A national clinical
guideline.

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
urinary incontinence in primary care. A national clinical guideline.
Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network
(SIGN); 2004 Dec. 41 p. (SIGN publication; no. 79). \[128 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [October 17, 2005, Cymbalta (duloxetine
    hydrochloride)](http://www.fda.gov/medwatch/safety/2005/safety05.htm#Cymbalta)
    : Healthcare professionals notified of revision to the
    PRECAUTIONS/Hepatotoxicity section of the prescribing information to
    include precaution against using in patients with chronic liver
    disease.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Urinary incontinence, including:

-   Stress urinary incontinence

-   Urge urinary incontinence

-   Detrusor overactivity incontinence

-   Mixed urinary incontinence

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Internal Medicine\
Nursing\
Obstetrics and Gynecology\
Urology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Patients\
Physical Therapists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To identify opportunities and effective techniques within primary
    care for assessing and treating urinary incontinence in adults

-   To offer the primary care practitioner an indication of the factors
    that should lead to an onward referral

#### TARGET POPULATION

Adults with urinary incontinence

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Risk factor assessment

2.  Assessment via:

    -   Clinical history

    -   Questionnaires

    -   Pelvic floor assessment

    -   Urinalysis

    -   Post void residual volume (via catheterization and/or ultrasound
        bladder scan)

    -   Flow rate

    -   Digital rectal examination

    -   Voiding diaries

    -   Pad tests

**Management/Treatment**

1.  Client counseling regarding treatment options

2.  Pelvic floor muscle exercises (PFME)

3.  Physiotherapy

4.  Biofeedback

5.  Electrical stimulation

6.  Intravaginal devices

7.  Acupuncture

8.  Bladder retraining

9.  Lifestyle interventions including massive (surgically induced)
    weight loss, moderate weight loss, adjustment of fluid intake, and
    reduce caffeine intake

10. Pharmacotherapy

    -   Combined noradrenaline and serotonin reuptake inhibitors:
        Duloxetine

    -   Antimuscarinics (oxybutynin, tolterodine, trospium and
        propiverine)

    -   The following medications were discussed but not recommended:
        flavoxate; oestrogens; adrenoreceptor agonists; antidepressants

11. Containment products including disposable pads, bed pads, sheaths,
    female urinals, catheters, catheter valves, and urine drainage bags

12. Referral to secondary care, when appropriate

#### MAJOR OUTCOMES CONSIDERED

-   Incontinence episode frequency and severity

-   Quality of life

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence base for this guideline was synthesised in accordance with
the Scottish Intercollegiate Guideline Network (SIGN) methodology. A
systematic review of the literature was carried out using an explicit
search strategy devised by the SIGN Information Officer in collaboration
with members of the guideline development group.

Literature searches were initially conducted in Medline, Embase, Cinahl,
and the Cochrane Library using the year range 1995--2003. The literature
search was updated to cover the period up to May 2004. Key Web sites on
the Internet were also used, such as the National Guidelines
Clearinghouse. These searches were supplemented by the reference lists
of relevant papers and group members\' own files. The Medline version of
the main search strategies can be found on the SIGN website.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomized
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies

High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies (e.g. case reports, case series)

**4**: Expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Scottish Intercollegiate Guidelines Network (SIGN) carries out
comprehensive systematic reviews of the literature using customized
search strategies applied to a number of electronic databases and the
Internet. This is often an iterative process whereby the guideline
development group will carry out a search for existing guidelines and
systematic reviews in the first instance and, after the results of this
search have been evaluated, the questions driving the search may be
redefined and focused before proceeding to identify lower levels of
evidence.

Once papers have been selected as potential sources of evidence, the
methodology used in each study is assessed to ensure its validity.
Scottish Intercollegiate Guidelines Network has developed checklists to
aid guideline developers to critically evaluate the methodology of
different types of study design. The result of this assessment will
affect the level of evidence allocated to the paper, which in turn will
influence the grade of recommendation it supports.

Additional details can be found in the companion document titled \"An
Introduction to the SIGN Methodology for the Development of
Evidence-based Clinical Guidelines\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\]).
Available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The process for synthesizing the evidence base to form graded guideline
recommendations is illustrated in the companion document titled \"An
Introduction to the SIGN Methodology for the Development of
Evidence-based Clinical Guidelines.\" (Edinburgh \[UK\]: Scottish
Intercollegiate Guidelines Network. \[SIGN publication; no. 50\],
available from the [SIGN Web
site](http://www.sign.ac.uk/methodology/index.html).

Evidence tables should be compiled, summarizing all the validated
studies identified from the systematic literature review relating to
each key question. These evidence tables form an important part of the
guideline development record and ensure that the basis of the guideline
development group\'s recommendations is transparent.

In order to address how the guideline developer was able to arrive at
their recommendations given the evidence they had to base them on, SIGN
has introduced the concept of considered judgement.

Under the heading of considered judgement, guideline development groups
are expected to summarise their view of the total body of evidence
covered by each evidence table. This summary view is expected to cover
the following aspects:

-   Quantity, quality, and consistency of evidence

-   Generalisability of study findings

-   Applicability to the target population of the guideline

-   Clinical impact (i.e., the extent of the impact on the target
    patient population, and the resources need to treat them.)

Guideline development groups are provided with a pro forma in which to
record the main points from their considered judgement. Once they have
considered these issues, the groups are asked to summarise their view of
the evidence and assign a level of evidence to it, before going on to
derive a graded recommendation.

The assignment of a level of evidence should involve all those on a
particular guideline development group or subgroup involved with
reviewing the evidence in relation to each specific question. The
allocation of the associated grade of recommendation should involve
participation of all members of the guideline development group. Where
the guideline development group is unable to agree a unanimous
recommendation, the difference of opinion should be formally recorded
and the reason for dissent noted.

The recommendation grading system is intended to place greater weight on
the quality of the evidence supporting each recommendation, and to
emphasise that the body of evidence should be considered as a whole, and
not rely on a single study to support each recommendation. It is also
intended to allow more weight to be given to recommendations supported
by good quality observational studies where randomised controlled trials
(RCTs) are not available for practical or ethical reasons. Through the
considered judgement process guideline developers are also able to
downgrade a recommendation where they think the evidence is not
generalisable, not directly applicable to the target population, or for
other reasons is perceived as being weaker than a simple evaluation of
the methodology would suggest.

On occasion, there is an important practical point that the guideline
developer may wish to emphasise but for which there is not, nor is their
likely to be, any research evidence. This will typically be where some
aspect of treatment is regarded as such sound clinical practice that
nobody is likely to question it. These are marked in the guideline as
\"good practice points.\" It must be emphasized that these are
[not]{.underline} an alternative to evidence-based recommendations, and
should only be used where there is no alternative means of highlighting
the issue.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The grade of recommendation relates to the strength of the evidence on
which the recommendation is based. It does not reflect the clinical
importance of the recommendation.

**A**: At least one meta-analysis, systematic review of randomized
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

**Good Practice Points**: Recommended best practice based on the
clinical experience of the guideline development group.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A national open meeting is the main consultative phase of Scottish
Intercollegiate Guidelines Network (SIGN) guideline development, at
which the guideline development group presents its draft recommendations
for the first time. The national open meeting for this guideline was
held on 24^th^ November 2003 and was attended by 168 representatives of
all the key specialties relevant to the guideline. The draft guideline
was available on the SIGN Web site for a limited period at this stage to
allow those unable to attend the meeting to contribute to the
development of the guideline.

The guideline was also reviewed in draft form by a panel of independent
expert referees, who were asked to comment primarily on the
comprehensiveness and accuracy of interpretation of the evidence base
supporting the recommendations in the guideline.

As a final quality control check, the guideline is reviewed by an
Editorial Group to ensure that the specialist reviewers\' comments have
been addressed adequately and that any risk of bias in the guideline
development process as a whole has been minimised.

Each member of the guideline development group then approved the final
guideline for publication.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Note from the Scottish Intercollegiate Guidelines Network (SIGN) and
National Guideline Clearinghouse (NGC): In addition to these
evidence-based recommendations, the guideline development group also
identifies points of best clinical practice in the original guideline
document.*

The strength of recommendation grading (A-D) and level of evidence (1++,
1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the \"Major
Recommendations\" field.

**[Quality of Life, Patient Information, and Health
Promotion]{.underline}**

**Quality of Life**

*Objective Assessment*

B - Health care practitioners should consider using a validated quality
of life and incontinence severity questionnaire to evaluate the impact
of urinary symptoms and to audit the effectiveness of any management
strategy.

**Patient Information, Advice, and Support**

D - Patients with urinary incontinence should be offered information and
advice on the treatment options available to them in both primary and
secondary care.

D - Patients with urinary incontinence should have access to trained
health care professionals who have the relevant knowledge and skills to
offer appropriate advice and information.

D - Patients with urinary incontinence should be made aware that they
are able to access specially trained staff in primary care without
general practitioner (GP) referral.

**Health Promotion**

C - Strategies using a number of different approaches and delivery media
should be employed to raise awareness of urinary continence and promote
incontinence services to a range of target audiences.

**[Assessment of Urinary Incontinence]{.underline}**

**Risk Factors for Developing Urinary Incontinence**

*Risk Factors for Women*

B - Health professional should be vigilant and adopt a proactive
approach in consultations with patients who are at greatest risk of
developing urinary incontinence through factors including age, the
menopause, pregnancy and childbirth, high body mass index (BMI), and
experience of continence problems in childhood.

**Initiating an Assessment of Urinary Incontinence**

C - Health care professionals should recognize the difficulty that some
patients have in raising concerns about continence and should be
proactive in questioning patients about continence during consultations.

C - Health professional should have a positive attitude to continence
problems.

B - Assessment, treatment, and referral, as appropriate, should be
offered to all patients with urinary continence problems.

**Primary Care Assessment Tools**

*Assessment Tool Recommendations*

D - Initial assessment of a male patient with urinary incontinence
should include completion of a voiding diary, urinalysis, estimation of
post void residual volume, and digital rectal examination.

D - Initial assessment of a female patient with urinary incontinence
should include completion of a voiding diary, urinalysis, and, where
symptoms of voiding dysfunction or repeated urinary tract infections
(UTIs) are present, estimation of post void residual volume.

**[Physical Therapies]{.underline}**

**Pelvic Floor Muscle Exercises**

A - Pelvic floor muscle exercises should be the first choice of
treatment offered to patients suffering from stress or mixed
incontinence. Exercise programmes should be tailored to be achievable by
the individual patient.

D - Pelvic floor muscle exercises should be considered as part of a
treatment plan for patients with urge urinary incontinence.

D - Digital assessment of pelvic floor muscle function should be
undertaken prior to initiating any pelvic floor muscle exercise
treatment.

A - Where group physiotherapy is available patients should be offered
the choice of attending or being seen individually.

**Pelvic Floor Muscle Exercises in Men Undergoing Radical
Prostatectomy**

B - Pelvic floor muscle exercise treatment should be considered for
patients following radical prostate surgery.

**Bladder Retraining**

C - Bladder retraining should be offered to patients with urge urinary
incontinence.

**[Pharmacotherapy]{.underline}**

**Stress Incontinence**

*Combined Noradrenaline and Serotonin Reuptake Inhibitors*

A - Duloxetine should be used only as part of an overall management
strategy in addition to pelvic floor muscle exercises and not in
isolation. A 4-week trial of duloxetine is recommended for female
patients with moderate to severe stress incontinence. Patients should be
reviewed again after 12 weeks of therapy to assess progress and
determine whether it is appropriate to continue treatment.

**Detrusor Overactivity and Urge Incontinence**

*Antimuscarinics*

A - A trial of oxybutynin, propiverine, tolterodine, or trospium should
be given to patients with significant urgency with or without urge
incontinence. The dose should be titrated to combat adverse effects.

**[Containment]{.underline}**

**Product Evaluation**

D - All patients should undergo a continence assessment before product
issue. Issue of products should not take the place of therapeutic
interventions.

**[Referral]{.underline}**

**Referral to Secondary Care**

*All Patients*

D - Patients should be referred to secondary care if previous surgical
or non-surgical treatments for urinary incontinence have failed or if
surgical treatments are being considered.

*Female Patients*

D - Female patients with suspected voiding dysfunction should be
referred to secondary care.

D - Female patients with symptomatic pelvic organ prolapse should be
referred to secondary care.

*Male Patients*

D - Male patients with reduced urinary flow rates or elevated post void
residual volumes should be referred to secondary care.

**[Definitions]{.underline}**:

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of RCTs, or RCTs
with a very low risk of bias

**1+**: Well-conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies

High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**: Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies (e.g. case reports, case series)

**4**: Expert opinion

**Grades of Recommendation**

**A**: At least one meta-analysis, systematic review of randomized
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

#### CLINICAL ALGORITHM(S)

Algorithms are provided in the original guideline document for the
management of urinary incontinence in male patients and in female
patients.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Effective treatment and management of urinary incontinence resulting in
reduced incontinence episode frequency, reduced urgency, increased
patient satisfaction, improved quality of life, and reduced incidence of
potential harms (e.g., falls and fractures).

#### POTENTIAL HARMS

-   There are inherent risks of trauma and infection with
    catheterisation and there may be issues around patient dignity and
    acceptability that should be considered.

-   Side effects of adrenoreceptor agonists were noted to be minor,
    although rare and potentially serious side effects, such as cardiac
    arrhythmias and hypertension, were reported.

-   Nausea was the most commonly reported adverse event in one study of
    duloxetine.

-   The most common side effects of antimuscarinic drugs are dry mouth,
    blurred vision, abdominal discomfort, drowsiness, nausea, and
    dizziness. Urinary retention is a potentially serious but less
    common side effect. Oxybutynin immediate release (IR) preparation
    has the highest incidence of side effects.

-   Offering disposable pads prematurely can lead to psychological
    dependence upon them and reluctance to accept active treatment.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This guideline is not intended to be construed or to serve as a
    standard of care. Standards of care are determined on the basis of
    all clinical data available for an individual case and are subject
    to change as scientific knowledge and technology advance and
    patterns of care evolve. Adherence to guideline recommendations will
    not ensure a successful outcome in every case, nor should they be
    construed as including all proper methods of care or excluding other
    acceptable methods of care aimed at the same results. The ultimate
    judgement regarding a particular clinical procedure or treatment
    plan must be made by the appropriate health care professional,
    following discussion of the options with the patient, in light of
    the diagnostic and treatment choices available. It is advised,
    however, that significant departures from the national guideline or
    any local guidelines derived from it should be fully documented in
    the patient\'s case notes at the time the relevant decision is
    taken.

-   The guideline cannot take the place of clinical judgment in the
    assessment of each patient as an individual but aims to collate
    research evidence, in as accessible format, to support clinical
    decision making.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation of national clinical guidelines is the responsibility of
local National Health Service (NHS) organisations and is an essential
part of clinical governance. It is acknowledged that not every guideline
can be implemented immediately on publication, but mechanisms should be
in place to ensure that the care provided is reviewed against the
guideline recommendations and the reasons for any differences assessed
and, where appropriate, addressed. These discussions should involve both
clinical staff and management. Local arrangements may then be made to
implement the national guideline in individual hospitals, units and
practices, and to monitor compliance. This may be done by a variety of
means including patient-specific reminders, continuing education and
training, and clinical audit.

**Implementation in Primary Care**

The Scottish Programme for Improving Clinical Effectiveness in Primary
Care (SPICE-PC) will develop a criteria set based on this guideline to
assist with its implementation in primary care. The criteria set will be
incorporated into a GPASS care management screen, combining computer
based management prompts with appropriate, automated data collection.
SPICE-PC criteria sets are available from
[http://www.spice.scot.nhs.uk/pdf/Management%20of%20Urinary%20Incontinence.pdf](http://www.spice.scot.nhs.uk/pdf/Management of Urinary Incontinence.pdf).

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
urinary incontinence in primary care. A national clinical guideline.
Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network
(SIGN); 2004 Dec. 41 p. (SIGN publication; no. 79). \[128 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Dec

#### GUIDELINE DEVELOPER(S)

Scottish Intercollegiate Guidelines Network - National Government Agency
\[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Scottish Executive Health Department

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Guideline Development Group*: Mrs Linda Morrow (*Chair*) Professional
Adviser Continence, The Care Commission, Musselburgh; Mrs Joyce
Wilkinson (*Secretary*) Registered Health Visitor, Doctoral Candidate,
University of St. Andrews; Mrs Mary Ballentyne, Senior Clinical Nurse
Specialist, Southern General Hospital, Glasgow; Mrs Mary Brown,
Continence Nursing Team Manager, Lothian Primary Care Trust, Edinburgh;
Ms Jane Camp, Clinical Governance Practice Development Nurse, Gartnavel
Royal Hospital, Glasgow; Dr Paul Dewart, Consultant
Obstetrician/Gynaecologist, St. John\'s Hospital, Livingston; Mrs Ann
Gilchrist, Superintendent Physiotherapist/Clinical Lead, Falkirk Royal
Infirmary; Sister Chris Harris, Urology Nurse Specialist, Western
General Hospital, Edinburgh; Mrs Linda Haworth, Superintendent
Physiotherapist/Clinical Specialist, Carnegie Clinic, Dunfermline; Ms
Fiona Lamont, Patient Representative, Glasgow; Mr David Lyth, Consultant
Urologist, Queen Margaret Hospital, Dunfermline; Mrs Jan MacCallum,
Continence Adviser, Broxburn, West Lothian; Dr David Marshall,
Professional Adviser-Pharmacy, The Care Commission, Hamliton; Ms Cathy
McKerrell, INCONTACT Project Manager (Scotland); Dr Simon Nicholson,
Consultant Gynaceologist, St John\'s Hospital, Livingston; Mr Duncan
Service, Senior Information Officer, SIGN; Dr Lorna Thompson, Programme
Manager, SIGN

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Declarations of interests were made by all members of the guideline
development group. Further details are available from the Scottish
Intercollegiate Guidelines Network (SIGN) executives.

#### GUIDELINE STATUS

This is the current release of the guideline.

Any amendments to the guideline in the interim period will be noted on
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/pdf/sign79.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Quick reference guide: Management of urinary incontinence in primary
    care. Scottish Intercollegiate Guidelines Network. 2004 Dec. 2 p.
    Available in Portable Document Format (PDF) from the [Scottish
    Intercollegiate Guidelines Network (SIGN) Web
    site](http://www.sign.ac.uk/pdf/qrg79.pdf).

-   SIGN 50: A guideline developer\'s handbook. Edinburgh (Scotland):
    Scottish Intercollegiate Guidelines Network. (SIGN publication; no.
    50). Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/index.html).

-   Appraising the quality of clinical guidelines. The SIGN guide to the
    AGREE (Appraisal of Guidelines Research & Evaluation) guideline
    appraisal instrument.  Edinburgh (Scotland): Scottish
    Intercollegiate Guidelines Network, 2001. Available from the [SIGN
    Web site](http://www.sign.ac.uk/methodology/agreeguide/index.html).

Additional implementation tools, including an incontinence questionnaire
and a sample frequency voiding volume chart/voiding diary can be found
in the Annexes of the [original guideline
document](http://www.sign.ac.uk/pdf/sign79.pdf).

#### PATIENT RESOURCES

The following are available:

-   Information for discussion with patients and carers. In: Management
    of urinary incontinence in primary care. A national clinical
    guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines
    Network (SIGN); 2004 Dec. 41 p. (SIGN publication; no. 79).
    Electronic copies: Available in Portable Document Format (PDF) from
    the [Scottish Intercollegiate Guidelines Network (SIGN) Web
    site](http://www.sign.ac.uk/pdf/sign79.pdf).

-   Advice to patients -- incontinence. Edinburgh (Scotland): Scottish
    Intercollegiate Guidelines Network (SIGN); 4 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [SIGN Web
    site](http://www.sign.ac.uk/pdf/pat79.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
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#### NGC STATUS

This NGC summary was completed by ECRI on March 3, 2005. The information
was verified by the guideline developer on March 17, 2005. This summary
was updated by ECRI on October 20, 2005, following the U.S. Food and
Drug Administration advisory on Cymbalta (duloxetine hydrochloride).
This summary was updated by ECRI Institute on November 9, 2007,
following the U.S. Food and Drug Administration advisory on
Antidepressant drugs.

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Date Modified: 11/3/2008