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Table of Contents

• Focus of Research for Clinicians
• Background
• Conclusion
• Clinical Bottom Line
• Gaps in Knowledge
• What To Discuss With Your Patients
• Resource for Patients
• Source

Focus of Research for Clinicians

In response to a request from the public, a systematic review of the clinical research was undertaken to determine what is known about the comparative effectiveness, benefits, and adverse effects of urinary incontinence (UI) interventions for women and the utility of methods for diagnosis and treatment evaluation. The systematic review included 905 publications presenting the results of clinical studies published from January 1990 through December 2011. The full report, listing all studies, is available at www.effectivehealthcare.ahrq.gov/ui.cfm. This summary, based on the full report of research evidence, is provided to clinicians to inform discussions of options with patients and to assist in decisionmaking along with consideration of a patient’s values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.

Background

UI affects women of all ages, but its prevalence increases with age. The severity of the physical, psychological, and social burdens of UI can range from mildly bothersome to debilitating.

Two predominant forms of UI are stress incontinence (sphincter failure during increases in intra-abdominal pressure, as when coughing or sneezing or with exertion) and urgency incontinence (involuntary loss of urine accompanied by a compelling urge to void, often associated with bladder detrusor muscle overactivity). Both forms can appear in one individual as the “mixed” type. Patient reports of symptoms are the typical basis for diagnosing UI, after exclusion of underlying causes (e.g., infection, urogenital prolapse). Urodynamic evaluation is not typically used in primary care, but is used for differential diagnosis, especially for patients considering surgical treatment. The comparative reliability of diagnostic methods and their value for individualizing treatment are not well understood. Non-surgical treatments include lifestyle changes, pelvic floor muscle training (PFMT), bladder training, and drugs for urgency incontinence from overactive bladder. Effectiveness of UI interventions is typically measured by reduction in frequency of UI episodes and amounts of urine in absorbent pads, although the treatment goals valued by women with UI are not clearly established.

Conclusion

Nonpharmacological interventions (notably, PFMT or bladder training) lessen the severity of urgency, stress, and mixed UI, and promote continence in patients with stress and mixed UI, with low risk of adverse effects. For nonpharmacological interventions, reasons for discontinuation and methods to improve adherence are not understood or systematically investigated. Drug treatments for urgency UI show similar small benefits but may be differentiated by their adverse effects profiles. Withdrawal from drug treatment is typically due to adverse effects. Dry mouth and constipation are common. The long-term safety of drugs for UI has not been evaluated in clinical trials, but serious adverse effects have been associated with their use (e.g., among the elderly and in combination with other commonly prescribed drugs). Diagnosis using clinical tools available in primary care is comparable to urodynamic evaluation. Urodynamic evaluation is not associated with better outcomes with non-surgical treatments. Currently available validated tools (voiding diaries, scales measuring perception of improvement and quality of life) are effective for measuring success with treatment targets that are valued by women with UI.

Clinical Bottom Line

Strength of Evidence Scale

High:
There are consistent results from good-quality studies. Further research is very unlikely to change the conclusions.

Moderate:
Findings are supported, but further research could change the conclusions.

Low:
There are very few studies, or existing studies are flawed.

Insufficient:
Research is either unavailable or does not permit estimation of a treatment effect.

Table 1. Outcomes of Nonpharmacological Interventions for UI

The ability of interventions to achieve continence or clinically important improvement was compared with placebo or no active treatment. Meta-analytic results are presented as the number of reported events attributable to treatment per 1,000 patients (calculated from the difference between treatment-group and control-group event rates).

Indication	Intervention	Continence (Reports per 1,000 treated)	Improvement (Reports per 1,000 treated)
NSD = no statistically significant difference; NR = not reported
Stress UI	PFMT	299	412
	PFMT plus biofeedback	NSD	390
	Electrical stimulation	162	156
	Magnetic stimulation	NSD	265
Urgency UI	Bladder training		430
	Percutaneous tibial nerve stimulation	NR	308
Mixed UI	PFMT plus bladder training	166	387
	Maintained weight loss and exercise		273
All training regimens of PFMT increase rates of continence and improvement in stress UI.

Gaps in Knowledge

The systematic review identified areas where evidence about treatments for UI is limited or absent, including:

• Evidence is insufficient to permit conclusions about the effectiveness of nonpharmacological interventions when compared with drugs or combined modalities.
• The reasons for discontinuation from treatment with nonpharmacological interventions and methods to improve adherence are not understood nor well investigated.
• Evidence is inadequate to determine whether increasing drug dosage leads to greater improvement or likelihood of achieving continence.
• Evidence about how patient characteristics influence treatment benefits or adverse effects is incomplete and of limited value to guide decisionmaking (e.g., baseline frequency, age, race, type of UI, prior treatment, comorbidities, and obesity).

What To Discuss With Your Patients

• The roles of nonpharmacological, pharmacological, and surgical interventions.
• The trade-offs between the likelihood of benefits and the types and severity of adverse effects associated with UI drug treatments.
• The importance of adherence to exercise protocols to achieve continence or improve severity of UI.
• The benefits and low risk of adverse effects from nonpharmacological UI treatments, such as special exercises.

Resource for Patients

Non-surgical Treatments for Urinary Incontinence, A Review of the Research for Women is a free companion to this clinician research summary. It covers:

• The types of UI and procedures for diagnosis
• The types of drug and nondrug interventions that are available for treating stress, urgency, and mixed UI
• The potential for benefits and the risks of adverse effects when drug or nondrug treatments are chosen
• Questions to ask when making decisions about UI treatment options

Source

The information in this summary is based on Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness, Comparative Effectiveness Review No. 36, prepared by the Minnesota Evidence-based Practice Center under Contract No. 291-2007-10064-I for the Agency for Healthcare Research and Quality, April 2012. 

This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Diane Markesich, Ph.D., Aimee Roundtree, Ph.D., Thomas Workman, Ph.D., Ursula Braun, M.D., and Michael Fordis, M.D.  

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