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2. Patient comments 2 Platting legs at front door Key in the door Need to know where all the toilets are: toilet mapping Turning the tap on Worse in cold weather

3. Examination 3 Primarily for pelvic floor function. Apply PERFECT scheme: P: power/strength up to a score of 6 for men E: endurance up to 8 seconds R: repetitions up to 10 times F: fast 10 fast squeezes E: elevation observe elevation of scrotum and retraction of penis C: co-contraction of pelvic floor with transversus abdominis muscle T: timed can they cough and squeeze

4. Pelvic floor exercises 4 Can observe pelvic floor lift as a scrotal lift or penile retraction If you can see a lift generally agreed power = 3 Individualised exercise regime Supervised pelvic floor muscle training for the treatment of UI/OAB wet or dry.

5. Pelvic floor exercises 5 Example patient: P: 4, E: 2, R: 5, F: 8, E: yes, C: yes, T: no Leaking on movement Heavily dependent on abdominal muscles Needed support to localise pelvic floor Exercises: Suggested 6 times per day Long hold: 5 X 2 seconds Fast: 8

6. Lifestyle interventions 6 Type of fluid/diet to avoid caffeine: not everybody sensitive. Wean them off over a period of a week or longer if have very high intake. Includes: coffee. tea, coke, blackcurrant squash Alcohol Smoking: nicotine is a bladder irritant

7. Lifestyle interventions 7 Foods which may irritate the bladder include: tomatoes, citrus fruits Dietary advice regarding fibre: increase or decrease Advise to reduce fluids in the evening whilst maintaining volume 2 hours before going to bed

8. Bladder training 8 Plan voids: If key in the door is a problem void before leaving work Delay voids: start with a few minutes and increase over a period of weeks Sit on a firm seat to reduce urge Standing on tiptoe Distraction: OAB symptoms are enhanced by anxiety about the problem Pelvic floor exercises

9. Treatment options 9 Anticholinergic medication Suggestions for where to start re NICE and risks Tolterodine 2mg BD For older people Oxybutynin not recommended (NICE 2013) Move on to Solifenacin when more powerful drug needed

10. Treatment options 10 When anticholinergics not recommended or have failed Mirabegron 50mg OD: Beta3 receptor agonist Restrict use of Mirabegron in uncontrolled hypertension, end-stage kidney disease or a major liver impairment: 25mg

11. Caution with anticholinergics 11 There is a risk that anticholinergics may cause or enhance retention. If the patient has a condition with a neurological aspect Mild voiding problems

12. Post Radical Prostatectomy 12 If you know your patient is being referred for surgery ensure CCAS receive a referral pre or immediate post op CCAS support: PERFECT assessment Support to maintain exercises Management support

13. Post micturition dribble 13 Urine collects in the bulbar urethral area Teach urethral milking CCAS provide a written leaflet Pelvic floor exercises supporting OAB bladder management: positively reinforces bladder is empty

14. Management options 14 Enable men to maintain daily activities Provide security and promote confidence Improve quality of life Include disposable pads, washable absorbent pants and sheaths

15. Follow up support 15 4 to 6 weeks for bladder training Within 4 weeks for medication Where there is a risk of urinary retention attend clinic within the 4 weeks for bladder scan

16. What patients say 16 Appreciate having the time to talk about something so personal I have learnt a lot about myself I understand what has been happening to me I now know how I can help myself I would have been too embarrassed to talk about bowels to anyone else

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18. References DIONKO A., BROCK B., BROWN M., et al. Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. Journal of Urology. 1986;136:1022. DOREY, G. (2004) Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. British Journal of General Practitioners 1; 54(508): 819–825. DOREY, G. (2003) Pelvic floor exercises for men. Nursing Times 99 (19) 46-48 18

19. References 19 NICE quality standard 45. Lower urinary tract symptoms in men. Sept 2013 NICE 171 Clinical Guideline. The management of urinary incontinence in women Sept 2013 JAFFE, W. and TE, A (2005) Overactive Bladder in the Male Patient: Epidemiology, Etiology, Evaluation and Treatment. Current Urology Reports 6:410–418