Continence Guidelines

Recommendations

Identify and Treat the Cause
1 Take a careful history from the person identified to have urinary incontinence Level of Evidence
5


Address Patient-centered Concerns
2 Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life Level of Evidence
5
3 Provide information and advice on treatment options available in both primary and secondary care Level of Evidence
5
4 Use a validated quality of life and incontinence severity questionnaire, e.g., ICIQ, BFLUTS, I-QOL, SUIQQ, UISS, SEAPI-QMM, ISI and KHQ. Level of Evidence
2


Provide Local Care
5 Recommend containment products and reassess their suitability Level of Evidence
5
6 Consider absorbent products as:- a coping strategy pending definitive treatment- an adjunct to other ongoing therapy- long term management of urinary incontinence only after other treatment options have been explored Level of Evidence
5
7 Inspect genital-perineal area daily to identify signs of contact dermatitis and skin excoriation. Level of Evidence
5
8 Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams. Level of Evidence
5


Provide Organizational Support
9 Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information Level of Evidence
5


Background

The topics ostomy and continence have been combined in this stream. The literature about them is quite separate, but the common thread is protection and management of the skin. Therefore, in searching the literature and making recommendations, skin care is the focus.

Injury may be caused by excreted bodily fluids due to fecal or urinary incontinence or to stoma complications. Stoma complications have been classified into five categories according to etiology or location: poor sitting, stoma proper, peri-intestinal area, mucocutaneous junction, and iatrogenic. In addition to chemical injury, stoma complications may result in mechanical injury, infection, and disease-related lesions. Patients with incontinence or an ostomy, and the associated potential complications can expect a significant impact on their quality of life.

A systematic literature search for clinical practice guidelines on ostomy continence and skin care was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

Fifty-one (51) ostomy continence skin care clinical practice guidelines were found in the English literature from 2002 until May 2007. 43 (84%) of these published articles were excluded because they were: studies (8), irrelevant (20), case series (2), narrative reviews or systematic reviews (4), education pieces (5), unable to locate (3), conference program (1),

Of the identified papers, eight (8) guidelines were appraised by a minimum of three reviewers using the AGREE instrument (http://www.agreecollaboration.org/instrument/). The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this ostomy continence skin care stream.

The most highly ranked guidelines were two versions of the Registered Nurses Association of Ontario (RNAO) on promoting continence (2002 and 2005); one by the National Institute for Clinical Excellence (NICE) on the management of incontinence in women (2006) and a summary version; one by the Scottish Intercollegiate Guidelines Network on the management of urinary incontinence in primary care (2004); one by Dowling-Castronovo and Bradway on urinary incontinence; one by the Singapore Ministry of Health on management of urinary incontince (2003); and one by Braathen et al on photodynamic therapy for non-melanoma skin cancer (2007). Figure I illustrates the domain scores for these guidelines.

The focus of the recommendations from the guidelines is management of skin when there is excess moisture due to incontinence. Since no guidelines were found about the management of ostomies, recommendations about ostomies are not in this overview. Recommendations in relation to ostomy are based on individual studies and expert knowledge and are found under specific topics within the stream.

References

High Ranking Guidelines
1 Management of urinary incontinence in women Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Urinary incontinence the management of urinary incontinence in women. National Collaborating Centre for Women’s and Children’s Health. National Institute for Health and Clinical Excellence. October 2006.
This is a well-developed comprehensive guideline that provides information about skin care in relation to urinary incontinence. There is a summary version of this guideline (36 pages instead of 249) that may be considered a quick reference guide. The latter does not contain details of the supporting documentation for recommendations.
2 Continence Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Nursing Best Practice Guideline: Promoting Continence Using Prompted Voiding. Registered Nursing Association of Ontario. March 2005.
This is a very well-developed clinical practice guideline that provides clear and succinct recommendations for clinical practice and indicates their supporting evidence. Although this guideline was developed for nurses, its recommendations would be useful to clinicians from other disciplines, e.g., family physicians, physical and occupational therapists, dietitians. It is the updated version of the 2002 RNAO guideline below.
3 Continence Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Nursing Best Practice Guideline: Promoting Continence Using Prompted Voiding. Registered Nursing Association of Ontario. January 2002.
This very well-developed earlier version of the RNAO guideline is included because, on appraisal, it received higher scores for some domains than the more recent version. This guideline will be of interest to clinicians who want to review in detail.
4 Urinary incontinence Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Management of urinary incontinence in primary care A national clinical guideline. Scottish Intercollegiate Guidelines Network. December 2004. Updated September 2005. http://www.sign.ac.uk/pdf/sign79.pdf
This guideline presents information about skin care. There is a quick reference guide that summarizes the main recommendations, located at the following website: http://www.sign.ac.uk/pdf/qrg79.pdf
5 Urinary incontinence Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Dowling-Castronovo A, Bradway C. Urinary incontinence. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 83-98. [26 references].
The National Guideline Clearinghouse version (9 pages) of this guideline was reviewed for WoundPedia. It provides short concise recommendations on evaluation and treatment or management of urinary incontinence.
6 Nursing management of urinary incontinence Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Singapore Ministry of Health. Nursing management of patients with urinary incontinence. Singapore: Singapore Ministry of Health; 2003 Dec. 40 p. [32 references].
The National Guideline Clearinghouse version (17 pages) of this guideline was reviewed for WoundPedia. It provides a short concise overview of recommendations on this topic.


Enablers for practice

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