In English – Virtsankarkailun hoitopolku

Overactive
bladder and
incontinence
care path

Seuraava
Sivuston sisältö pohjautuu Käypä hoito -suosituksiin | Virtsankarkailu (naiset): Käypä hoito -suositus, 2017 | Eturauhasen hyvänlaatuinen liikakasvu: Käypä hoito -suositus, 2020

Problems with urinary incontinence?
Leaking urine?

Patient´s story -video

Risk factors

  • Aging (weakened kidney function, frequent nighttime urination)
  • Overweight
  • Pregnancy, childbirth
  • Enlarged prostate / procedures
  • Constipation
  • Excessive ingestion of liquids
  • Smoking
  • Some general diseases weaken the bladder control, such as
    • memory disorders and other neurological diseases
    • diabetes
    • depression
  • Some medicines that cause or worsen urinary incontinence, especially noteworthy with elderly, such as
    • diuretics
    • NSAIDs
    • drugs that effect CNS
    • anticholinergic drugs
Overactive bladder +

Urgency, with or without urge incontince, usually combined with frequency and/or nocturia

About 1/3 of patients have bladder leakage (1)

Urinary incontinence +

Stress urinary incontinence
Involuntary leakage on effort or exertion, or on physical activity

Urge urinary incontinence
Involuntary leakage accompanied by or immediately preceded by urgency

Mixed urinary incontinece
Simulateous stress and urge incontinence

Overflow incontinence
Acute or chronic incontinece caused by urinary retention (unable to completely empty bladder, often no urge to urinate)

 

 

 

Pre-information form +

Load and print the pre-information form

Bladder diary +

The first page in bladder diary contains instructions for completing the measurement chart. The diary contains pages for three days. Should you need the diary only for two days, print instrucions and two diary pages.

Load and print bladder diary from here.

Erottelupiste questionnaire (women) +

The questionnaire is for a doctor/nurse to fill in. The second page contains instructions for interpretation.

Load and print the incontinence “Erottelupiste” questionnaire from here.

Haitta-aste questionnaire (women) +

The first page is for patient to fill in and the second is an instruction page for doctor.

Load and print the incontinence “Haitta-aste” questionnaire from here.

DAN-PSS-1-questionnaire (men) +

Load and print DAN-PSS-1-questionnaire from here.

Jotain potilas kertoo

in English
First contact to nurse

First contact to nurse

Pre-information | women +
  • Diseases
  • Medication
  • Pregnancies, childbirths
    • nursing (if nursing or periods not regular, guidance to physiotherapy)
  • Menopause, systemic or topical hormone replacement therapy
  • Previous treatments for urinary problems (what, when)
    • medication
    • physiotherapy
    • pelvic or spinal surgery
  • Urinary tract infections and gynecological infections
  • Bowel function
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Pre-information | men +
  • Diseases
  • Medication
  • Previous treatments for urinary problems (what, when)
    • medication
    • physiotherapy
    • pelvic or spinal surgery
  • Urinary tract infections
  • Bowel function
Copy

Current status

  • Symptom definition and duration (under 1 month > exclude infection)
    • forms and questionnaires
  • Need for pads/day
  • General condition, performance status e.g. taking care of hygiene, aids
  • RR and BMI
  • Daily coughing, smoking
  • Measurement of residual urine when neccessary (u/s or catheterization <150 ml normal)

Additionally for frailty and patients with mutliple comorbidities:

  • Locomotion, risks for falling, safe route to toilet, mobility aids
  • Weight change within last 3 to 6 months
  • Diet, sufficient protein intake
  • Assessment of muscular strength, e.g. getting up from a chair
  • Memory and mood
  • Recording of medication
  • Measurement of residual urine when neccessary (u/s or catheterization, important that is always under bladder capacity (400 ml), <250 to 300 ml normal) (2,3)

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Plan

Patient is given:

  • Laboratory referral
    • U-KemSeul (urin chemical screening)
    • U-BaktVi (urin bacteria screening)
    • Crea
    • PSA when needed
    • Chlamydia and clap tests if needed
  • Bladder diary to bring home (for 2 to 3 days)

Copy

in English
First contact to doctor

First contact to doctor

When to specialized medical care
Pre-information +
  • Check the data recorded by nurse during the first contact
    • pre-information, current status, plan
    • laboratory results
    • ”Erottelupiste” questionnaire and ”haitta-aste” questionnaire are checked and fulfilled with the patient if needed
  • Bladder diary results (2 to 3 days)
Copy
Status +
  • General condition
  • RR and BMI
  • Measurement of residual urine when neccessary (u/s or catheterization <150 ml normal)
    • frailty and patients with multiple comorbidities: important that is always under bladder capacity (400 ml), <250 to 300 ml normal) (2,3)

Women:

  • Abdominal palpation
  • Condition of genital mucous membrane, cystocele

Men:

  • Abdominal palpation (retention, tumor)
  • Prostate palpation (size, hardness, nodules, pain)
  • Examination of the prepuce (phimosis)
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Plan +
  • Assessment and diagnosis (overactive bladder, benign prostatic hyperplasia, type of incontinence, other reasons)
  • Exclude urinary tract infection, potential chlamydia and clap
  • PSA when necessary
  • Give guidance to lifestyle changes and give self-care instructions
  • Patient´s treatment is chosen based on the diagnosis
  • Remember long enough treatment period before response assessment

Additionally for frailty and patients with mutliple comorbidities:

  • Understanding of patient´s medication and its implementation
  • Anticholinergic burden
  • Renal function (GFR)
  • Effect on conduction time (QT)
  • Effect on orthostatic hypotension
      Copy

       

      Pre-information +
      • Diseases
      • Symptom definition and duration
      • Medication
      • Previous treatments for urinary problems (what, when)
        • medication
        • physiotherapy
        • pelvic or spinal surgery
      • Urinary tract infections
      • Bowel function
      • Need for pads/day
      • General condition, performance status e.g. taking care of hygiene
      • Daily coughing, smoking
      • ”Erottelupiste” questionnaire and ”haitta-aste” questionnaire are checked and fulfilled with the patient if needed

      Additionally from women:

      • Pregnancies, childbirths
        • Nursing (if nursing or periods not regular, guidance to physiotherapy)
      • Menopause, systemic or topical hormone replacement therapy
      • Gynecological infections

      Additionally for frailty and patients with mutliple comorbidities:

      • Locomotion, risks for falling, safe route to toilet, mobility aids
      • Weight change within last 3 to 6 months
      • Diet, sufficient protein intake
      • Assessment of muscular strength, e.g. getting up from a chair
      • Memory and mood
        Copy
        Status +
        • General condition
        • RR and BMI
        • Measurement of residual urine when neccessary (u/s or catheterization <150 ml normal)
          • frailty and patients with multiple comorbidities: important that is always under bladder capacity (400 ml), <250 to 300 ml normal) (2,3)

        Women:

        • Abdominal palpation
        • Condition of genital mucous membrane, cystocele

        Men:

        • Abdominal palpation (retention, tumor)
        • Prostate palpation (size, hardness, nodules, pain)
        • Examination of the prepuce (phimosis)
          Copy
          Plan +
          • Assessment and diagnosis (overactive bladder, benign prostatic hyperplasia, type of incontinence, other reasons)
          • Exclude urinary tract infection, potential chlamydia and clap
          • PSA when necessary
          • Give guidance to lifestyle changes and give self-care instructions
          • Patient´s treatment is chosen based on the diagnosis
          • Remember long enough treatment period before response assessment

          Additionally for frailty and patients with mutliple comorbidities:

          • Understanding of patient´s medication and its implementation
          • Anticholinergic burden
          • Renal function (GFR)
          • Effect on conduction time (QT)
          • Effect on orthostatic hypotension
            Copy

            ICD-10 diagnosis codes

            R35 Polyuria (frequency of micturition, nocturia)

            R33 Retention of urine

            N39.3 Stress incontinence

            N39.4 Other specified urinary incontinece (reflex, urge, overflow)

            N32.82 Other specified disorders of bladder (calcified, contracted, overactive)

            N31.0 Uninhibited neuropathic bladder, not elsewhere classified

            When to specialized medical care +

            Referral to specialized medical care if:

            • macrohematuria
            • residual urine over 150 ml (u/s or catheterization)
              • frailty: even 250 to 300 ml accepted
            • cystocele with symptoms
            • pelvic tumor
            • neurological problem
            • disturbing urinal incontinence after surgery
            • suspicion of fistula
            • urinary incontinence unresponsive to treatment
            • if a man, especially under 50 years, has severe urinary symptoms
            • overflow incontinence (especially in men)
            • stress urinary incontinence in men (usually related to previous urologic procedure)
            • suspicion of urinary track infection or prostate cancer in men
              Copy
              Remember in referral +
              • Patient´s name, phone number and address
              • If patient can manage in Finnish or will need an interpreter (mention which language)

              Anamnesis

              General anamnesis:

              • Diseases
              • Current medication
              • Smoking
              • Allergies
              • Performance
              • Previous surgeries

              Gynecological anamnesis:

              • Pregnancies and childbirth
              • Menopause, systemic or topical hormone treatment
              • General gynekological examination (prolapses, evaluation of pelvic floor muscles, cough stress test)

              Examinations in men

              • Urologic examination, e.g. palpation of the prostate gland and examination of the fore skin

              Urinary incontinence

              • Type of urinary incontinence: stress, urge, mixed, overflow
              • “Erottelupiste”, “haitta-aste” questinnoaires
              • Bladder diary (2 to 3 days)
              • (or to referral: the amount of liquids drank per day, volume of urin (min/max), the amount of micturitions per day and per night)

              Performed physiotherapy treatments

              Tried medications

              Current status

              • Height
              • Measured weight
              • Muscosal condition
              • Coughs stress test with full bladder +/-
              • Prolapses spontaniously/with straining
              • Gynecological or urologic abnormalities
              • CCU and the amount of residual urine
              • Urinary track u/s, IPSS or DAN-PSS questionnaire, crea, PSA
              • Bladder diary (2 to 3 days), “erottelupiste” and “haitta-aste” questionnaires
              • List of medication
              Copy
              in English
              Treatment options

              Treatment

              Lifestyle changes +

              Lifestyle changes that improve bladder control

              • Bladder training (e.g. prolongation of urinary frequency)
              • Pelvic floor muscles training
              • General muscular strength exercises
              • Weight loss
              • Quitting smoking
              • Avoiding constipation by necessary diet changes
              • Reducing the use of excessive liquids and decaffeinated drinks
              • Avoiding alcohol consumption
              Copy
              Overactive bladder and urge incontinence +

              Medication

              Mixed urinary incontinence can also be treated with medication, if urge incontinence is the predominant symptom.

              • Topic estrogen therapy
                • estradiol
                • estriol
              • Anticholinergic or antimuscarinic drugs
                • darifenacin
                • fesoterodine
                • oxybutynin
                • solifenacine
                • tolterodine
                • trospium chloride
              • Beta-3-agonist
                • mirabegron

              Other treatments

              • electrical stimulation

              In specialized medical care

              • injection treatment with botulinum toxin A
              • sacral nerve root neuromodulation
              • surgical treatments (clam cystoplasty and urinary stoma)

              Additionally about medication for frailty and patients with mutliple comorbidities:

              • Side effects on the anticholinergics must be taken into account and special precautions should be taken during use. Anticholinergics are not to be used with other strongly anticholinergic drugs or with acetylcholinesterase inhibitors. Oxybutynin is most likely to cause central nervous system adverse reactions, so it should not be used with elderly.
              • Topical estrogen is suitable also for elderly.
              • Mirabegron may allay the symptoms of overactive bladder without typical side effects of anticholinergics, but no reliable evidence exists.
              • Starting dose should preferably be lower than with younger adult patients (use as in SmPc).

              Familiarize also with Lääke 75+ database by Fimea.

                Copy
                Stress incontinence +

                Muscle training for the pelvic floor

                Guided muscle training for the pelvic floor reduces urinary leakage in stress incontinence.

                • Finger test for pelvic floor muscles (professional)
                • If the muscle recognition and practice fail, patient should be referred to physiotherapy for biofeedback-assisted training
                • To increase the strength in pelvic floor muscles, practice should be done five days a week for at least three months
                • 8 to 12 pelvic floor muscle contractions each lasting 6 to 8 seconds are recommended. The series is repeated 3 times.
                • To maintain pelvic floor muscle strength the practice should be continued permanently 2 to 3 times.

                Medication

                Current Care guideliness do not mention any drug with evidence-based efficacy.

                Surgical procedures in specialized medical care

                • Midurethral sling procedure
                • Polyacrylamide hygrogel

                Aids and care accessories

                • Urinary catheters (overflow incontinence), repeat catheterization recommended
                • Tampons and urethra pessaries supporting and elevating urethra (stress incontinence)
                • Urinal, urine bottle or urine bag for men
                • Incontinence pads (model, size, absorbency, change interval)

                Additionally for frailty and patients with mutliple comorbidities:

                The same treatment may be considered, taking into account the patient’s general condition.

                Remember to facilitate toilet access:

                • Clothing that is easy to open and remove
                • Toilet seat riser, movable seat
                • Bedpan, urine bottle
                • Home remodeling and mobility aids (physio- and occupational therapist makes an assessment)
                Copy
                Overflow incontinence +

                Re-catheterization is best suited for the treatment of overflow urinary incontinence. Permanent catheterization should be avoided. The permanent catheterization is suitable for temporary use in chronic urinary retention before the patient is treated with surgery. Silicone catheters should be used primarily. This is particularly important if the catheter is to be kept for a long time. Repetitive catheterization is a good treatment for chronic urinary retention in appropriate cases (requires patient or relative to perform catheterization).

                A suprapubic catheter (suprapubic cystostomy) is the only option if catheterization through the urethra is not possible. However, the insertion of a catheter carries a significant risk of serious complications and its necessity should be carefully evaluated. If the patient has undergone an abdominal surgery, the suprapubic catheter is placed by using ultrasound guidance.

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                Self-care instructions +

                You can print different self-care instructions from here.

                in English
                Follow-up

                Follow-up
                (contact or appointment)

                When to specialized medical care

                Current status

                • About 3 months trial period in implemented medication or physiotherapy
                • Current state of the patient, quality of life compared to previous situation
                • If necessary, bladder diary results vs. previous results

                Plan

                • If symptoms have alleviated and no problems during treatment, continuation according to treatment plan by doctor
                • Motivate the patient to continue the chosen treatment
                • New follow-up contact with a nurse in about a year, when re-check of the symptoms using necessary questionnaires (ask the patient to bring with the completed urinary questionnaire)

                Copy

                Assessment of current care

                • Treatment impact evaulation (efficacy, tolerability, adherence)
                • Treatment change or enhancement
                • Assessment of specialized medical care

                Copy

                When to specialized medical care +

                Referral to specialized medical care if:

                • macrohematuria
                • residual urine over 150 ml (u/s or catheterization)
                  • frailty: even 250 to 300 ml accepted
                • cystocele with symptoms
                • pelvic tumor
                • neurological problem
                • disturbing urinal incontinence after surgery
                • suspicion of fistula
                • urinary incontinence unresponsive to treatment
                • if a man, especially under 50 years, has severe urinary symptoms
                • overflow incontinence (especially in men)
                • stress urinary incontinence in men (usually related to previous urologic procedure)
                • suspicion of urinary track infection or prostate cancer in men
                  Copy
                  Remember in referral +
                  • Patient´s name, phone number and address
                  • If patient can manage in Finnish or will need an interpreter (mention which language)

                  Anamnesis

                  General anamnesis:

                  • Diseases
                  • Current medication
                  • Smoking
                  • Allergies
                  • Performance
                  • Previous surgeries

                  Gynecological anamnesis:

                  • Pregnancies and childbirth
                  • Menopause, systemic or topical hormone treatment
                  • General gynekological examination (prolapses, evaluation of pelvic floor muscles, cough stress test)

                  Examinations in men

                  • Urologic examination, e.g. palpation of the prostate gland and examination of the fore skin

                  Urinary incontinence

                  • Type of urinary incontinence: stress, urge, mixed, overflow
                  • “Erottelupiste”, “haitta-aste” questinnoaires
                  • Bladder diary (2 to 3 days)
                  • (or to referral: the amount of liquids drank per day, volume of urin (min/max), the amount of micturitions per day and per night)

                  Performed physiotherapy treatments

                  Tried medications

                  Current status

                  • Height
                  • Measured weight
                  • Muscosal condition
                  • Coughs stress test with full bladder +/-
                  • Prolapses spontaniously/with straining
                  • Gynecological or urologic abnormalities
                  • CCU and the amount of residual urine
                  • Urinary track u/s, IPSS or DAN-PSS questionnaire, crea, PSA
                  • Bladder diary (2 to 3 days), “erottelupiste” and “haitta-aste” questionnaires
                  • List of medication
                  Copy
                   
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