Urinary Incontinence: ACP Offers Nonsurgical Options

Laurie Barclay, MD

September 16, 2014

Kegel exercises to strengthen pelvic floor muscles, bladder training, and weight loss and exercise are effective nonsurgical treatment options for women with urinary incontinence (UI), according to a new, evidence-based clinical practice guideline from the American College of Physicians (ACP). The new recommendations, which target all clinicians treating women with UI, were published in the September 16 issue of the Annals of Internal Medicine.

"[UI] is a common problem for women that is often underreported and underdiagnosed," ACP president David Fleming, MD, said in a news release. "Physicians should take an active approach and ask specific questions such as onset, symptoms, and frequency of [UI]; it is estimated that about half of the women with incontinence do not report it to their doctor."

Prevalence of reported UI is about 25% among women aged 14 to 21 years, 44% to 57% among women aged 40 to 60 years, and 75% among women aged 75 years and older. In 2004, US costs of UI care were approximately $19.5 billion, and UI was responsible for 6% of nursing home admissions among elderly women, costing approximately $3 billion.

Risk factors for UI include pregnancy, pelvic floor trauma after vaginal delivery, menopause, hysterectomy, obesity, urinary tract infections, functional and/or cognitive impairment, chronic cough, and constipation.

The authors searched MEDLINE, the Cochrane Library, Scirus, and Google Scholar from 1990 through December 2013 to identify published English-language literature on nonsurgical management of UI in women. Pertinent outcomes were continence, improvement in UI, quality of life, adverse effects, and discontinuation because of adverse effects.

Specific recommendations were as follows:

  • Women with stress UI (incontinence when laughing, coughing, or sneezing) should have first-line treatment with pelvic floor muscle training and Kegel exercises, which involve relaxing and contracting the muscles that control urine flow (strong recommendation, high-quality evidence).

  • Women with urgency UI (incontinence for no apparent reason after suddenly feeling the urge to urinate) should undergo bladder training (strong recommendation, moderate-quality evidence).

  • Women with mixed UI should undergo pelvic floor muscle training with bladder training, which is behavioral therapy that involves urinating on a set schedule and gradually increasing the time between urination (strong recommendation, moderate-quality evidence).

  • Women with stress UI should not be given systemic pharmacologic therapy (strong recommendation, low-quality evidence).

  • Women with urgency UI in whom bladder training was unsuccessful should have pharmacotherapy, with specific agents selected for tolerability, adverse effect profile, ease of use, and cost (strong recommendation, high-quality evidence).

  • Obese women with UI should be treated with weight loss and exercise (strong recommendation, moderate-quality evidence).

"Physicians should utilize non-drug treatments as much as possible for [UI]," Dr. Fleming said in the news release. "Kegel exercises for stress UI, bladder training for urgency UI, and Kegel exercises with bladder training for mixed UI are effective, have few side effects, and are less expensive than medications. Although various drugs can improve UI and provide complete continence, adverse effects often lead many patients to stop taking their medication."

The ACP operating budget provided sole financial support for development of this guideline. Some of the guideline authors reported various financial disclosures involving ACP; Pfizer; Ortho-McNeil; sanofi-aventis; GlaxoSmithKline; Merck; ECRI Institute; US Department of Veterans Affairs; Agency for Healthcare Research and Quality; Centers for Medicare & Medicaid Services; Office of the National Coordinator for Health and Information Technology; UpToDate; National Institute of Diabetes and Digestive and Kidney Diseases; Informed Medical Decisions Foundation; the National Board of Medical Examiners; University of Texas; University of California, San Francisco; American Board of Internal Medicine; Accreditation Council for Graduate Medical Education; the National Heart, Lung, and Blood Institute; National Institutes of Health; Allergan; Bayer; the Blue Cross and Blue Shield Association; General Electric; UBC; and/or Genentech.

Ann Intern Med. 2014;161:429-440. Full text

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