Scoping question: Do non-pharmacological interventions (prompted voiding, timed voiding, toilet training, habit retraining, pelvic floor muscle training) produce any benefit and/or harm for older people with urinary incontinence? The full ICOPE guidelines and complete set of evidence profiles are available at: who.int/publications/i/item/9789241550109# Background
Urinary incontinence, the involuntary loss of urine, is a highly prevalent condition in older people aged 60 years and over (1). The common types of urinary incontinence in older people are stress incontinence and urge incontinence. Stress incontinence is the involuntary leaking of urine during efforts or exertion, or while sneezing or coughing. Urge incontinence, or overactive bladder syndrome, involves a constellation of symptoms including frequency, urgency and leakage immediately preceded by urgency. The prevalence of urinary incontinence reported in populationbased studies ranges from 9.9% to 36.1% (2)(3)(4), and is twice as high in older women as in older men. Urinary incontinence has a profound impact on the quality of life of older people, their subjective health status (5,6), levels of depression (7) and need for care (8).
Several chronic conditions and environmental factors increase the risk of urinary incontinence in older people. Chronic diseases that are associated with urinary incontinence include diabetes mellitus, Parkinson's disease, dementia, stroke, prostatic cancer, chronic obstructive pulmonary disease (COPD) and arthritis. Environmental factors such as inaccessible or unsafe toilet facilities, and the absence of caregivers for toileting assistance are also associated with urinary incontinence. Nonpharmacological interventions are mostly preferred and remain the mainstay of urinary incontinence management for patients with mild urinary incontinence. The primary goal of urinary incontinence interventions is to improve continence by reducing the frequency of urinary incontinence episodes. incontinence, change in mean proportion of hourly checks that are wet, number of patients with reductions in incidence of daytime incontinence, number of patients with reductions in incidence of night-time incontinence, incontinent episodes in 24 hours, mean urinary incontinence incidence per 24 hours, urinary incontinence symptoms - Important: Perceived cure, self-initiated toileting, median percentage of checks wet, number of incontinent episodes, urinary incontinence urgency, urinary incontinence frequency, nocturia, quality of life ICOPE guidelines -World Health Organization

# Search strategy
A systematic literature search for reviews was conducted in Ovid MEDLINE, Embase, PsycINFO and Cochrane databases. The details of the search terms used for retrieving studies are provided in Annex 1. The search retrieved 188 reviews and 798 randomized controlled trials (RCTs). After initial screening for eligibility, 111 reviews and 161 RCTs were considered for full-text review.
Ultimately, five systematic reviews that included 25 RCTs and two additional studies investigating the benefits of non-pharmacological interventions were included in this review (see Annex 2).

# List of systematic reviews identified by the search process

# Narrative description of the systematic reviews included in the analysis
The Cochrane systematic review by Wallace et al. (updated in 2009) aimed to synthesise evidence for effectiveness of bladder training for urinary incontinence in adults (9) (19,20). Both compared timed voiding plus additional intervention with usual care. Most of the participants from the two selected trials were cognitively impaired elderly women (mean age 86.7 years) and all resided in facilities that provided nursing care. The majority of participants (82%) in one study were older women (19) while the other study did not report the sex of participants (20).  (15 April 2013), and hand searches were done in the journals and reference lists of relevant articles to identify potential studies. Twenty-one trials involving 1281 women (665 PFMT, 616 controls) met the inclusion criteria. Seven of them recruited older people aged over 60 years or had mean participant age of more than 60 years (21)(22)(23)(24)(25)(26)(27).
Two additional RCTs, not listed in the above-mentioned Cochrane systematic reviews, were identified in an independent literature search and were also included (28,29).

# Brief descriptions of the included nonpharmacological interventions
Prompted voiding is administered for older people with or without cognitive impairment to initiate their own toileting through requests for help, and includes the use of positive reinforcement from carers when they do this. This is distinct from some other therapies because of the participation of the individual in the process. In contrast, habit retraining attempts to determine the micturition pattern for an individual, which can be used to achieve continence but does not necessarily rely on the individual's participation. Timed voiding is fixed by time or event, and is carer led and is not an individualized intervention. Bladder training actively includes the individual in attempting to increase the interval between the desire to void and the actual void, and hence would not be suitable for those who are cognitively impaired. It comprises three components: (a) patient educationinformation about the bladder and how continence is usually maintained; (b) scheduled voidinga "timetable for voiding" which may be fixed or flexible to suit the participant's rate of increase in the interval between voids (the aim is usually to achieve an interval of 3-4 hours between voids); and (c) positive reinforcementpsychological support and e. Imprecision: Downgraded twice as sample size was very small (smaller than 50). f. Risk of bias: Downgraded once as allocation concealment method was unclear in two trials. g. Inconsistency: Downgraded once as considerable heterogeneity was observed: Chi 2 = 18.07, df = 1 (P = 0.00002); I 2 = 94%. h. Indirectness: Downgraded once as included trials were conducted in nursing home settings and generalizing the interventions to other settings is doubtful. i.
Risk of bias: Downgraded once as allocation concealment was unclear. j.
Indirectness: Downgraded once as trial was conducted in nursing home setting and generalizing the interventions to other settings is doubtful. k. Imprecision: Downgraded once as sample size was small (smaller than 200). a. Risk of bias: Downgraded once as allocation concealment method and procedure for masking outcome assessor was unclear in one trial. b. Inconsistency: Downgraded once as moderate heterogeneity was observed: Chi 2 = 7.56, df = 2 (P = 0.02); I 2 = 74%. c. Risk of bias: Downgraded once as outcome assessor was not masked and method applied for allocation concealment was unclear. d. Imprecision: Downgraded twice as sample size was very small (smaller than 100). e. Risk of bias: Downgraded once as allocation concealment method was unclear in one trial.

# ICOPE guidelines -World Health Organization

# ICOPE guidelines -World Health Organization

# Evidence-to-recommendations table Problem Explanation
Is the problem a priority?
The prevalence of urinary incontinence reported in population-based studies ranges from 9.9% to 36.1%, and is twice as high in older women as in older men. Urinary incontinence has a profound impact on the quality of life of older people, their subjective health status, levels of depression and need for care.

# Benefits and harms Explanation
Do the desirable effects outweigh the undesirable effects?

# Yes No Uncertain
No studies reported harm associated with non-pharmacological management of urinary incontinence.
There is limited low-quality evidence which suggests that prompted voiding may benefit older people in managing urinary incontinence. Eight trials included in this analysis investigated the benefit of prompted voiding compared with no prompted voiding for older people with urinary incontinence. All of the analysed trials were conducted in the United States. Seven of the eight studies were carried out in nursing home settings.
- Apart from one study, all of the trials were conducted in high-income countries.
- Although the majority of PFMT trials involved older women, the recommendation for PFMT may be applicable to older men. - The duration of the PFMT intervention trials ranged from 6 to 12 weeks and most of the trials administered the interventions on a daily regimen. - Using continence products should be considered for older people who are bedridden or experiencing severe declines in mental and/or physical capacities. - Health care providers should take a detailed history and ask specific questions about urinary incontinence, such as the time of onset, symptoms and frequency.

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ICOPE guidelines -World Health Organization
- At least half of women with urinary incontinence do not report this issue to their general practitioner; therefore, health care professionals should routinely check for urinary incontinence in older women and men. - Identifying and managing conditions that may cause urinary incontinence, including urinary tract infections, metabolic disorders, excess fluid intake and impaired mental conditions (e.g. delirium), are important and should not be neglected. - Clinicians should review current medications that may cause or worsen urinary incontinence. - Although pharmacological therapy can reduce urinary incontinence and even provide complete continence, many older people discontinue medication because of adverse effects. Specialist care providers should be consulted when initiating pharmacological treatment. - As a first-line treatment, provide advice on bladder training for a minimum of six weeks.
Bladder training involves advising the older people to follow a strict schedule for bathroom visits. The schedule starts with bathroom visits every 2 hours, but the time between visits should be gradually increased to improve bladder control.