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Urinary incontinence in neurological disease overview

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Urinary incontinence in neurological disease

About

What is covered

This pathway covers the management of lower urinary tract dysfunction resulting from neurological disease and injury in adults and children (from birth). The recommendations on assessment apply to people who have a neurological condition. If the assessment shows the incontinence to be non-neurogenic, please refer to lower urinary tract symptoms (NICE guideline CG97) and urinary incontinence (NICE guideline CG40).
Assessment applies to new patients, those with changing symptoms and those requiring periodic reassessment of their urinary tract management. The interval between routine assessments will be dictated by the person's particular circumstances (for example, their age, diagnosis and type of management) but should not exceed 3 years.
Urinary symptoms resulting from neurological disease can occur because of damage to the brain, the suprasacral spinal cord, the sacral spinal cord (the conus medullaris) or the peripheral nervous system. Damage within each of these areas tends to produce characteristic patterns of bladder and sphincter dysfunction.
Symptoms of neurological lower urinary tract dysfunction may be related to impaired urine storage (such as increased frequency of urination and urinary incontinence) and/or bladder emptying difficulties. Incontinence can arise as a result of an overactive bladder, dysfunction of the urethral sphincters or a combination of the two.
Secondary effects can also arise as a result of neurological lower urinary tract dysfunction. For example, there is an increased risk of urinary tract infection in people with neurological lower urinary tract dysfunction, and kidney function can be lost as a result of abnormally high pressures within the bladder, from the effects of urinary tract infection and as a result of kidney stones.
Urinary symptoms have a significant impact on quality of life, causing embarrassment, leading to social isolation and impairing activities of daily living. Medical interventions often do not restore normal urinary function, and quality of life may be affected by the medical management of neurological lower urinary tract dysfunction. The economic cost of managing neurological lower urinary tract dysfunction is considerable.

Updates

Updates to this pathway

17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
10 June 2015 Urinary tract infections in adults (NICE quality standard 90) added to this pathway.
7 October 2014 Minor maintenance updates.
22 July 2014 Minor maintenance updates.
8 March 2013 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Management of lower urinary tract dysfunction in neurological disease

What is covered

This pathway covers the management of lower urinary tract dysfunction resulting from neurological disease and injury in adults and children (from birth). The recommendations on assessment apply to people who have a neurological condition. If the assessment shows the incontinence to be non-neurogenic, please refer to lower urinary tract symptoms (NICE guideline CG97) and urinary incontinence (NICE guideline CG40).
Assessment applies to new patients, those with changing symptoms and those requiring periodic reassessment of their urinary tract management. The interval between routine assessments will be dictated by the person's particular circumstances (for example, their age, diagnosis and type of management) but should not exceed 3 years.
Urinary symptoms resulting from neurological disease can occur because of damage to the brain, the suprasacral spinal cord, the sacral spinal cord (the conus medullaris) or the peripheral nervous system. Damage within each of these areas tends to produce characteristic patterns of bladder and sphincter dysfunction.
Symptoms of neurological lower urinary tract dysfunction may be related to impaired urine storage (such as increased frequency of urination and urinary incontinence) and/or bladder emptying difficulties. Incontinence can arise as a result of an overactive bladder, dysfunction of the urethral sphincters or a combination of the two.
Secondary effects can also arise as a result of neurological lower urinary tract dysfunction. For example, there is an increased risk of urinary tract infection in people with neurological lower urinary tract dysfunction, and kidney function can be lost as a result of abnormally high pressures within the bladder, from the effects of urinary tract infection and as a result of kidney stones.
Urinary symptoms have a significant impact on quality of life, causing embarrassment, leading to social isolation and impairing activities of daily living. Medical interventions often do not restore normal urinary function, and quality of life may be affected by the medical management of neurological lower urinary tract dysfunction. The economic cost of managing neurological lower urinary tract dysfunction is considerable.

Updates

Updates to this pathway

17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
10 June 2015 Urinary tract infections in adults (NICE quality standard 90) added to this pathway.
7 October 2014 Minor maintenance updates.
22 July 2014 Minor maintenance updates.
8 March 2013 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Infection control (2012) NICE guideline CG139

Quality standards

Quality statements

Diagnosing urinary tract infections in adults aged 65 years and over

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Adults aged 65 years and over have a full clinical assessment before a diagnosis of urinary tract infection is made.

Rationale

The accuracy of dipstick testing in adults aged 65 years and over can vary. It is therefore important that factors other than the results of dipstick testing are taken into consideration when diagnosing urinary tract infections in older people to ensure appropriate management and avoid unnecessary use of antibiotics.

Quality measures

Structure
Evidence of local arrangements to ensure a full clinical assessment is undertaken before a diagnosis of urinary tract infection is made in adults aged 65 years and over.
Data source: Local data collection.
Process
Proportion of adults aged 65 years and over who received a full clinical assessment before being diagnosed with a urinary tract infection.
Numerator – the number in the denominator diagnosed with a urinary tract infection based on a full clinical assessment.
Denominator – the number of adults aged 65 years and over diagnosed with a urinary tract infection.
Data source: Local data collection.
Outcome
Antibiotic prescription rates for urinary tract infections.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services and GPs) ensure that adults aged 65 years and over receive a full clinical assessment before being diagnosed with a urinary tract infection.
Healthcare professionals ensure they perform a full clinical assessment before diagnosing urinary tract infections in adults aged 65 years and over.
Commissioners (such as clinical commissioning groups and NHS England area teams) ensure that all providers are aware that adults aged 65 years and over with a suspected urinary tract infection are diagnosed based on a full clinical assessment. NHS England area teams should be aware that achieving this quality statement could be incorporated into GP surgeries ‘Avoiding Unplanned Admissions’ Enhanced Service, as per local arrangements.

What the quality statement means for patients, service users and carers

Adults aged 65 years and over who have symptoms that are typical of a urinary tract infection have a full clinical assessment before a diagnosis of a urinary tract infection is made.

Source guidance

Definitions of terms used in this quality statement

Symptoms of urinary tract infection
These include dysuria, increased frequency of urination, suprapubic tenderness, urgency and polyuria (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).
Clinical assessment
A full clinical assessment should be a face to face review of the person’s medical history, physical examination, assessment of pulse, blood pressure, temperature and recording of symptoms (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).

Diagnosing urinary tract infections in adults with catheters

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters.

Rationale

Dipstick testing is not an effective method for detecting urinary tract infections in catheterised adults. This is because there is no relationship between the level of pyuria and infection in people with indwelling catheters (the presence of the catheter invariably induces pyuria without the presence of infection). To ensure that urinary tract infections are diagnosed accurately and to avoid false positive results, dipstick testing should not be used.

Quality measures

Structure
Evidence of local arrangements to ensure healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters.
Data source: Local data collection.
Process
Proportion of episodes of suspected urinary tract infection in adults with urinary catheters that are investigated using dipstick testing.
Numerator – the number in the denominator assessed using dipstick testing.
Denominator – the number of episodes of suspected urinary tract infection in adults with urinary catheters.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services, care homes and GPs) ensure that training and education programmes are kept up to date so that healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary catheters.
Healthcare professionals ensure that dipstick testing is not used to diagnose urinary tract infections in adults with urinary catheters.
Commissioners (such as clinical commissioning groups, NHS England area teams) ensure that providers are aware that adults with urinary catheters should not have urinary tract infections diagnosed by dipstick testing.

What the quality statement means for patients, service users and carers

Adults with urinary catheters do not have urinary tract infections diagnosed by dipstick testing.

Source guidance

Referring men with upper urinary tract infections

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Men who have symptoms of an upper urinary tract infection are referred for urological investigation.

Rationale

Upper urinary tract infections can indicate the presence of lower urinary tract abnormalities. It is important that men with symptoms of an upper urinary tract infection have urological investigations to ensure that any possible abnormalities are diagnosed and treated.

Quality measures

Structure
Evidence of local arrangements to ensure that men with symptoms of an upper urinary tract infection are referred for urological investigations.
Data source: Local data collection.
Process
Proportion of episodes of suspected upper urinary tract infection in men that are referred for urological investigations.
Numerator – the number in the denominator referred for urological investigations.
Denominator – the number of episodes of suspected upper urinary tract infection in men.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services and GPs) ensure that they have processes in place so that men with symptoms of an upper urinary tract infection are referred for urological investigation.
Health and social care practitioners ensure that they are aware of local referral pathways for urological investigations so that men with symptoms of an upper urinary tract infection can be referred for urological investigation.
Commissioners (such as clinical commissioning groups and NHS England area teams) should seek evidence of practice from providers that men with symptoms of an upper urinary tract infection are referred for urological investigation. This can be achieved through carrying out local audits.

What the quality statement means for patients, service users and carers

Men with symptoms of an upper urinary tract infection are referred to a specialist for urological tests.

Source guidance

Definitions of terms used in this quality statement

Upper urinary tract infection
Characterised by evidence of urinary tract infection with symptoms suggestive of pyelonephritis (loin pain, flank tenderness, fever, rigors or other manifestations of systemic inflammatory response (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).

Urological investigations

These include urodynamic techniques such as pressure/flow cystography to detect lower urinary tract abnormalities (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012], recommendation 5.3).

Urine culture for adults with a urinary tract infection that does not respond to initial antibiotic treatment

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture.

Rationale

Some urinary tract infections are resistant to initial antibiotic treatment and a urine culture is needed (or a repeat where an initial urine culture was taken) to determine which antibiotic will work against the specific strain of bacteria causing the urinary tract infection. A urine culture is needed to guide a change in antibiotic treatment in people who do not respond to initial treatment with antibiotics.

Quality measures

Structure
Evidence of local arrangements to ensure adults with urinary tract infections who do not respond to initial antibiotic treatment have a urine culture.
Data source: Local data collection.
Process
Proportion of episodes of a urinary tract infection not responding to initial antibiotic treatment investigated with a urine culture.
Numerator – the number in the denominator investigated with a urine culture.
Denominator – the number of episodes of a urinary tract infection not responding to initial antibiotic treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services and GPs) ensure that processes and referral pathways are in place so that adults with a urinary tract infection not responding to treatment with initial antibiotic treatment have a urine culture.
Healthcare professionals ensure that adults with a urinary tract infection not responding to treatment with initial antibiotic treatment have a urine culture.
Commissioners (such as clinical commissioning groups) ensure that service specifications with local providers indicate that adults with a urinary tract infection not responding to treatment with initial antibiotic treatment have a urine culture.

What the quality statement means for patients, service users and carers

Adults with a urinary tract infection that is not responding to initial antibiotic treatment have their urine tested to see if other antibiotics should be tried.

Source guidance

Definitions of terms used in this quality statement

Urine culture
A sample of urine is taken to identify bacteria and their sensitivity to antibiotics (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).
Not responding
There is no response to treatment within the follow-up period as agreed with the healthcare professional (expert consensus).

Antibiotic treatment for asymptomatic adults with catheters and non-pregnant women

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

Quality statement

Healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.

Rationale

Antibiotics are not effective for treating asymptomatic bacteriuria in adults with catheters or non-pregnant women. Unnecessary treatment with antibiotics can also increase the resistance of bacteria that cause urinary tract infections, making antibiotics less effective for future use.

Quality measures

Structure
a) Evidence of local arrangements to ensure healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.
Data source: Local data collection.
b) Evidence of local arrangements to ensure healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.
Data source: Local data collection.
Process
a) Proportion of episodes of asymptomatic bacteriuria in adults with catheters treated with antibiotics.
Numerator – the number in the denominator treated with antibiotics.
Denominator – the number of episodes of asymptomatic bacteriuria in adults with a catheter.
Data source: Local data collection.
b) Proportion of episodes of asymptomatic bacteriuria in non-pregnant women treated with antibiotics.
Numerator – the number in the denominator treated with antibiotics.
Denominator – the number of episodes of asymptomatic bacteriuria in non-pregnant women.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, community services, care homes, GPs) ensure that processes are in place so that healthcare professionals do not prescribe antibiotics to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women. Internal training and education may be required, according to local need.
Healthcare professionals ensure that antibiotics are not prescribed to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women.
Commissioners (such as clinical commissioning groups, local authorities and NHS England area teams) ensure that providers are aware that antibiotic treatment should not be prescribed to treat asymptomatic bacteriuria in adults with catheters and non-pregnant women. This could be included in local service specifications and pathways.

What the quality statement means for patients, service users and carers

Adults with catheters and non-pregnant women who have bacteria in their urine but no symptoms of urinary tract infection are not prescribed antibiotics.

Source guidance

Definitions of terms used in this quality statement

Asymptomatic bacteriuria
Bacteria in a urine sample taken from a person who does not have any of the typical symptoms of lower or upper urinary tract infection. Asymptomatic bacteriuria should be confirmed by 2 consecutive urine samples (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).

Treatment of recurrent urinary tract infection: placeholder statement

This quality statement is taken from the urinary tract infections in adults quality standard. The quality standard defines clinical best practice in urinary tract infections in adults care and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence‑based guidance to be developed in this area.

Rationale

Recurrent urinary tract infections are common and it is important that they are managed and prevented effectively.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Offer urodynamic investigations before performing surgical treatments for neurogenic lower urinary tract dysfunction.

Glossary

Paths in this pathway

Pathway created: August 2012 Last updated: August 2015

© NICE 2015

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