Clinical Practice Guidelines

Clinical Practice Guidelines

Urinary Incontinence

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reviewed at least every two (2) years and updated as needed.

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member population served by CareMore.

April 15, 2013 ◆

Volume 87, Number 8

543

Diagnosis of Urinary Incontinence

CHRISTINE KHANDELWAL, DO, and CHRISTINE KISTLER, MD, MASc

University of North Carolina, Chapel Hill, North Carolina

U

rinary incontinence affects

mil-lions of persons, and the

preva-lence increases with age. Roughly

20 million American women and

6 million American men experience urinary

incontinence at some time in their lives.

Although women report incontinence

more often than men,

_{after 80 years of}

age, both sexes are affected equally.

_Women

commonly experience stress or urge

incon-tinence (i.e., overactive bladder), or a

com-bination of the two, with approximately

equal frequency.

_{In men, prostate problems,}

which lead to overflow incontinence, and

their treatments, which lead to stress

incon-tinence, are the most common causes.

Despite what many patients believe,

uri-nary incontinence is not a normal result of

aging. It is a pathologic condition that affects

quality of life. Patients who have incontinence

are more likely to have depression, limited

social and sexual function, and dependence

on caregivers.

_{Guidelines for diagnosis}

and treatment of urinary incontinence were

published in 2012 by the American Urological

Association.

_{This article reviews the}

diagno-sis; a separate article in an upcoming issue of

AFP reviews management options in women.

Classification

Incontinence can be classified as

tran-sient or chronic.

_{Transient incontinence}

is urinary leaking that spontaneously

reverses after the underlying cause is

resolved.

_{Chronic urinary incontinence}

does not typically resolve spontaneously,

and is classified into five types: stress, urge,

mixed, overflow, or functional.

Character-istics of each type are shown in Table 1.

Stress incontinence is caused by sphincter

weakness, which leads to ineffective

func-tion. It is the most common cause of urinary

incontinence in younger women and the

sec-ond most common cause in older women.

It also occurs in men after prostate surgery.

Urge incontinence is a result of detrusor

overactivity, and can be further divided into

two subtypes: sensory (a result of local

irri-tation, inflammation, or infection within the

bladder) or neurologic (most often caused by

loss of cerebral inhibition of detrusor

con-tractions).

_{Aging increases the prevalence}

of urge and stress incontinence, and the two

often coexist, leading to mixed incontinence.

This occurs in about one-third of adults who

have incontinence.

Overflow incontinence is caused by

impaired detrusor contractility, bladder

out-let obstruction, or both, resulting in

overdis-tension of the bladder.

_{Chronic overflow}

incontinence is common in men because

of prostatic hyperplasia, but it is

uncom-mon in women.

_{Functional incontinence is}

caused by cognitive, functional, or mobility

Urinary incontinence is common, increases in prevalence with age, and affects quality of life for men and women.

The initial evaluation occurs in the family physician’s office and generally does not require urologic or gynecologic

evaluation. The basic workup is aimed at identifying possible reversible causes. If no reversible cause is identified, then

the incontinence is considered chronic. The next step is to determine the type of incontinence (urge, stress, overflow,

mixed, or functional) and the urgency with which it should be treated. These determinations are made using a patient

questionnaire, such as the 3 Incontinence Questions, an assessment of other medical problems that may contribute to

incontinence, a discussion of the effect of symptoms on the patient’s quality of life, a review of the patient’s completed

voiding diary, a physical examination, and, if stress incontinence is suspected, a cough stress test. Other components

of the evaluation include laboratory tests and measurement of postvoid residual urine volume. If the type of urinary

incontinence is still not clear, or if red flags such as hematuria, obstructive symptoms, or recurrent urinary tract

infec-tions are present, referral to a urologist or urogynecologist should be considered. (

Am Fam Physician

.

2013;87(8):543-550. Copyright © 2013 American Academy of Family Physicians.)

More online at http://www. aafp.org/afp.

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2013 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.

Urinary Incontinence: Diagnosis

544

April 15, 2013

difficulties that impair patients’ ability to use the toilet,

but without a failure of bladder function or neurologic

control of urination.

_{This type of incontinence is also}

referred to as toileting difficulty.

Evaluation

Patients can be evaluated for urinary incontinence in a

family physician’s office. Although most incontinence

research excludes men and children, a standardized

approach is recommended for guiding the initial

evalua-tion.

_{An algorithm for the diagnosis of}

uri-nary incontinence is shown in Figure 1.

The patient history is often the most

important factor in identifying the type,

severity, and burden of incontinence for

patients.

_{Generally, more than one office}

visit is required to perform the physical

examination and necessary tests.

Transient Urinary Incontinence

The first step in the evaluation is to

iden-tify transient or reversible causes of urinary

incontinence.

_{Reversible incontinence}

usually has a sudden onset and has been

present for less than six weeks at the time of

evaluation.

_{The mnemonic DIAPPERS is}

useful for recalling the common reversible

causes of urinary incontinence (Table 2).

Physicians should take note of patients’

medications, especially those started recently.

Medication-induced incontinence often

can be reversed by stopping the medication.

Table 3 lists the most important medications

to consider.

_{Certain drugs (e.g., diuretics,}

alcohol) have no pharmacologic action on

the lower urinary tract, but may contribute to

incontinence by increasing urine production

or impairing nervous system function.

If the incontinence is determined to be related to an

acute condition, correcting the transient causes may

resolve the symptoms.

_{However, if symptoms persist,}

further evaluation is needed.

Chronic Urinary Incontinence

Several questionnaires are available to determine which

type of chronic urinary incontinence is present.

_The

3 Incontinence Questions is a reliable questionnaire

Clinical recommendation

Evidence

rating References Comments The 3 Incontinence Questions tool, which asks patients if, when, and

how often they experience urine leakage, should be used to help categorize the type of urinary incontinence.

C 20 Good-quality prospective cohort study with follow-up

A three-day voiding diary can be used as part of the initial assessment for urinary incontinence symptoms.

C 27 Systematic review of lower-quality studies

A positive cough stress test result is the most reliable clinical assessment for confirming the diagnosis of stress incontinence.

C 2, 32 Systematic review of good-quality cohort studies

Postvoid residual urine measurement should be performed in select high-risk patients (e.g., those with overflow incontinence).

C 5, 15 Consensus opinion, no high-quality evidence is available to support the recommendation

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Table 1. Types of Chronic Urinary Incontinence

Type Prevalence Pathophysiology Symptoms History Etiology

Stress 24 to 45 percent in women older than 30 years

Sphincter weakness (urethral sphincter and/or pelvic floor weakness)

Loss of small amount of urine during physical activity or intra-abdominal pressure (coughing, sneezing jumping, lifting, exercise); can occur with minimal activity, such as walking or rising from a chair

Patient usually can predict which activities will cause leakage

Childbirth and obesity in women; may occur after prostatectomy in men

Urge 9 percent in women 40 to 44 years of age 31 percent in women

older than 75 years 42 percent in men

older than 75 years

Detrusor overactivity (uninhibited bladder contractions) caused by irritation within the bladder or loss of inhibitory neurologic control of bladder contractions

Loss of urine preceded by a sudden and severe desire to pass urine; patient typically loses urine on the way to the toilet

Bladder contractions may also be stimulated by a change in body position (i.e., from supine to upright) or with sensory stimulation (e.g., running water, hand washing, cold weather, arriving at the front door)

Volume of urine loss is variable, ranging from minimal to flooding (if entire bladder volume is emptied) Frequency and nocturia are common Symptoms of urgency may also occur

without urinary loss, which is known as overactive bladder

Bladder irritation caused by cystitis, prostatitis, atrophic vaginitis, bladder diverticuli, prior pelvic radiation therapy

Loss of neurologic control caused by stroke, dementia, spinal cord injury, Parkinson disease

Mixed 20 to 30 percent of patients with chronic incontinence

Combination of stress and urge incontinence

Involuntary leakage associated with symptoms of urgency; loss of urine with exertion, effort, sneezing, or coughing

Patient should determine which symptom is predominant and most bothersome

Combination of the etiologies for stress and urge incontinence Overflow (urinary retention) 5 percent of patients with chronic incontinence

Overdistention of the bladder caused by impaired detrusor contractility or bladder outlet obstruction; leads to urine leakage by overflow

Dribbling of urine, inability to empty bladder, urinary hesitancy, urine loss without a recognizable urge or sensation of fullness/pressure in lower abdomen

Does not usually occur unless bladder emptying is poor (postvoid residual volumes > 200 to 300 mL)

Anticholinergic medications, benign prostatic hyperplasia, pelvic organ prolapse, diabetes mellitus, multiple sclerosis, spinal cord injuries Functional Uncertain Variable leakage of urine, usually

caused by environmental or physical barriers to toileting

Caused by nongenitourinary factors, such as cognitive or physical impairments that result in the patient’s inability to void independently

Impaired physical function (immobility) and/or impaired cognition

Possible lower urinary tract deficits

Severe dementia, physical frailty or inability to ambulate, mental health disorder (e.g., depression)

Urinary Incontinence: Diagnosis

April 15, 2013 ◆

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545

available free of charge (Figure 2).

_{It asks three}

mul-tiple choice questions about if, when, and how often

patients experience urine leakage. This questionnaire

has been validated in studies that show it to be

reason-ably accurate in categorizing urinary incontinence in

middle-aged to older women.

_{It has a sensitivity of 0.86}

and 0.75, and a specificity of 0.60 and 0.77, for

classify-ing stress and urge incontinence, respectively.

ASSESSMENT OF MEDICAL PROBLEMS

The patient history should include an assessment of other

medical conditions and symptoms, with their temporal

relationship to urinary incontinence.

_{For example, a}

history of bowel, back, gynecologic, or bladder surgery

could affect the anatomy and innervation of the lower

urinary tract, leading to incontinence.

_Gynecologic

history can assess estrogen status; estrogen deficiency

may result in atrophic vaginitis or atrophic urethritis, a

potentially reversible cause of urinary incontinence.

Physicians should also inquire about other

comor-bidities, such as chronic obstructive pulmonary disease

(chronic cough can result in stress incontinence);

car-diovascular disease (volume status or diuretic therapy

can increase urine flow and cause incontinence in

patients with an overactive bladder); neurologic

condi-tions (central nervous system dysfunction can impair

inhibition of detrusor contractions, or lead to

denerva-tion of the detrusor muscle with resultant retendenerva-tion and

overflow incontinence); and musculoskeletal conditions

(impaired mobility can cause functional incontinence).

Treating these conditions may not eliminate

inconti-nence, but it may lessen the severity.

ASSESSMENT OF QUALITY OF LIFE

The severity of symptoms and their effect on quality

of life determines the aggressiveness of treatment.

Patients should be asked about the effects of

inconti-nence on work, activities of daily living, sleep, sexual

activity, social interactions, interpersonal relationships,

and general perception of health and quality of life.

Identifying the most bothersome symptom will help

direct management. For example, one patient may be

most concerned about managing nocturia (often caused

by urge incontinence), whereas another patient may be

most concerned about incontinence that occurs during

exercise (typically caused by stress incontinence).

Table 1. Types of Chronic Urinary Incontinence

Type Prevalence Pathophysiology Symptoms History Etiology

Stress 24 to 45 percent in women older than 30 years

Sphincter weakness (urethral sphincter and/or pelvic floor weakness)

Loss of small amount of urine during physical activity or intra-abdominal pressure (coughing, sneezing jumping, lifting, exercise); can occur with minimal activity, such as walking or rising from a chair

Patient usually can predict which activities will cause leakage

Childbirth and obesity in women; may occur after prostatectomy in men

Urge 9 percent in women 40 to 44 years of age 31 percent in women

older than 75 years 42 percent in men

older than 75 years

Detrusor overactivity (uninhibited bladder contractions) caused by irritation within the bladder or loss of inhibitory neurologic control of bladder contractions

Loss of urine preceded by a sudden and severe desire to pass urine; patient typically loses urine on the way to the toilet

Bladder contractions may also be stimulated by a change in body position (i.e., from supine to upright) or with sensory stimulation (e.g., running water, hand washing, cold weather, arriving at the front door)

Volume of urine loss is variable, ranging from minimal to flooding (if entire bladder volume is emptied) Frequency and nocturia are common Symptoms of urgency may also occur

without urinary loss, which is known as overactive bladder

Bladder irritation caused by cystitis, prostatitis, atrophic vaginitis, bladder diverticuli, prior pelvic radiation therapy

Loss of neurologic control caused by stroke, dementia, spinal cord injury, Parkinson disease

Mixed 20 to 30 percent of patients with chronic incontinence

Combination of stress and urge incontinence

Involuntary leakage associated with symptoms of urgency; loss of urine with exertion, effort, sneezing, or coughing

Patient should determine which symptom is predominant and most bothersome

Combination of the etiologies for stress and urge incontinence Overflow (urinary retention) 5 percent of patients with chronic incontinence

Overdistention of the bladder caused by impaired detrusor contractility or bladder outlet obstruction; leads to urine leakage by overflow

Dribbling of urine, inability to empty bladder, urinary hesitancy, urine loss without a recognizable urge or sensation of fullness/pressure in lower abdomen

Does not usually occur unless bladder emptying is poor (postvoid residual volumes > 200 to 300 mL)

Anticholinergic medications, benign prostatic hyperplasia, pelvic organ prolapse, diabetes mellitus, multiple sclerosis, spinal cord injuries Functional Uncertain Variable leakage of urine, usually

caused by environmental or physical barriers to toileting

Caused by nongenitourinary factors, such as cognitive or physical impairments that result in the patient’s inability to void independently

Impaired physical function (immobility) and/or impaired cognition

Possible lower urinary tract deficits

Severe dementia, physical frailty or inability to ambulate, mental health disorder (e.g., depression)

Urinary Incontinence: Diagnosis

VOIDING DIARY

Because many patients provide an unclear voiding

his-tory, a voiding diary can be helpful (eFigure A). The

simplest voiding diaries ask patients to record the

fre-quency of incontinence episodes, but diaries also can

be used to assess the situations in which incontinence

occurs, which can help clarify the type of incontinence.

For example, the diary may reveal leakage during times

of increased abdominal pressure, suggestive of stress

incontinence, or dribbling that is indicative of overflow

incontinence.

_{Patients with stress incontinence usually}

wake once or not at all at night to void; patients with urge

incontinence usually wake more than twice and as often

as every hour.

A voiding diary can also serve as a baseline for

com-paring the severity of incontinence after treatment,

thereby assessing the effectiveness of management.

Table 2. Differential Diagnosis of Transient

Causes of Urinary Incontinence (DIAPPERS

Mnemonic)

Delirium

Infection (acute urinary tract infection) Atrophic vaginitis

Pharmaceuticals(Table 3)

Psychological disorder, especially depression Excessive urine output (e.g., hyperglycemia)

Reduced mobility (i.e., functional incontinence) or reversible (e.g., drug-induced) urinary retention

Stool impaction

Adapted with permission from Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med. 1985;313(13):801.

Diagnosis of Urinary Incontinence

Figure 1. Algorithm for the diagnosis of urinary incontinence. (PVR = postvoid residual.) Patient presents with urinary incontinence

Assess for transient incontinence: Apply DIAPPERS mnemonic (Table 2) Review medications (Table 3)

Assess for chronic incontinence:

Obtain history and give 3 Incontinence Questions questionnaire (Table 1 and Figure 2)

Review voiding diary (eFigure A)

Perform physical examination (Table 4); include cough stress test if stress incontinence is suspected Measure PVR urine

Obtain laboratory evaluation

Presumed type of incontinence after history, physical examination, and laboratory evaluation (may require return visit or referral if diagnosis is inconclusive or red flags are found)

Stress (only or predominantly) Symptoms with coughing,

sneezing, or exercise; no nocturia Voiding diary: small

volume leakage (5 to 10 mL) with activity Cough stress test: leakage

coincides with coughing PVR urine < 50 mL

Urge (only or predominantly) Symptoms of urgency Voiding diary: variable

volume loss; frequency and nocturia noted Cough stress test: may

show delayed leakage after cough PVR urine < 50 mL

Mixed

Symptoms equally as often with physical activity as with a sense of urgency Voiding diary: varies Cough stress test: may

show leakage with coughing PVR urine < 50 mL Overflow No symptoms with physical activity or urgency Voiding diary: varies Cough stress test: no

leakage PVR urine > 200 mL

No

Treat reversible causes

Incontinence resolved?

No further intervention Yes

Functional

Symptoms may include cognitive impairment and degree of immobility Voiding diary: may show

pattern in circumstances of incontinence Cough stress test: no

leakage PVR urine: varies

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A three-day diary is as informative as a longer-term

assessment, has good reliability, and may be more

fea-sible than longer diaries in routine clinical settings.

More sophisticated diaries, such as a frequency-

volume voiding diary for assessing bladder activity,

can also be used.

_{A frequency-volume voiding diary}

requires recording the amount of fluid intake, the volume

of urine voided (in mL) of each continent episode (using a

measuring cup or plastic hat placed below the toilet seat),

and an estimation of the volume of each incontinent

epi-sode.

_{This approach can reliably discriminate between}

urge and stress incontinence. Urge incontinence

typi-cally involves a large volume of urine loss, whereas stress

incontinence is often a smaller volume and is associated

with increased abdominal pressure.

_A

frequency-voiding diary can reveal whether the patient is

experi-encing frequent large volume voids, which are typically

associated with conditions causing polyuria

(e.g., excess fluid intake, diabetes mellitus).

The physical examination can identify

ana-tomic abnormalities or transient causes that

may not have been considered after

apply-ing the DIAPPERS mnemonic. Findapply-ings

associated with incontinence are listed in

Table 4.

_{In particular, the cardiovascular}

examination should look for evidence of

vol-ume overload (e.g., rales, pedal edema) that

might result in increased urine flow, which

aggravates urge incontinence. The abdomen

should be palpated for masses and tenderness,

and the bladder percussed for distention that

would indicate overflow.

_{The extremities}

should be examined for joint mobility and

function (impairment of which might

indi-cate functional incontinence), and peripheral

edema that might indicate volume overload.

In men, a prostate examination should be

included to identify prostate enlargement,

which may contribute to an outlet

obstruc-tion.

_{In women, an external}

gyneco-logic examination can assess for atrophic

vaginitis or other vulvar signs of irritation

caused by incontinence.

_Estrogen

defi-ciency may predispose women to urinary

frequency, urgency, or both, and can cause

or exaggerate sensory urge incontinence.

Pelvic organ prolapse (with cystocele,

ure-thral polyps, or rectocele) may not lead to

incontinence, but it often accompanies

atro-phic vaginitis.

_{A rectal examination is important}

to assess for fecal impaction, which can exert pressure

on the urethra, impair bladder emptying, and

precipi-tate overflow incontinence caused by retention.

_In

select patients, primarily older adults, a cognitive and

functional assessment should be included to evaluate for

functional incontinence.

COUGH STRESS TEST

If stress incontinence is suspected, the cough stress test

is the most reliable clinical assessment for confirming

the diagnosis.

_{When compared with more}

sophis-ticated multichannel urodynamic studies, the cough

stress test demonstrates good sensitivity and specificity

for stress incontinence,

_{although it requires further}

confirmatory urodynamic evaluation if the results are

inconclusive.

Table 3. Common Medications and Substances That Can

Cause Urinary Incontinence

Class Mechanism of effect Antihypertensives

Alpha-adrenergic antagonists

Decrease sphincter tone, causing stress incontinence

Angiotensin-converting enzyme inhibitors

May increase coughing, causing stress incontinence

Calcium channel blockers Relax the bladder, causing retention and overflow incontinence

Diuretics High urine flow that leads to bladder contractions, causing urge incontinence

Pain relievers

Cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs

Increase fluid retention, causing nocturnal diuresis and functional incontinence Opioids Relax the bladder, causing fecal impaction,

sedation, retention, and overflow incontinence Skeletal muscle relaxants Inhibit bladder contractions, causing sedation,

retention, and overflow incontinence

Psychotherapeutics

Antidepressants, antiparkinsonian agents, antipsychotics

Inhibit bladder contractions, causing retention and overflow incontinence

Sedatives and hypnotics Lead to sedation and impaired cognition, causing functional or overflow incontinence

Others

Alcohol Leads to diuretic effect and depressed central inhibition, causing urge incontinence, overflow incontinence, or both

Antihistamines, anticholinergics

Inhibit bladder contractions, causing sedation, retention, and overflow incontinence Medications for urinary

urgency

Inhibit bladder contractions, causing sedation, retention, and overflow incontinence Thiazolidinediones Increase fluid retention, causing nocturnal

diuresis and functional incontinence

548

April 15, 2013

With a full bladder (although not to the point of

abrupt urination), the patient should be in the lithotomy

position. Women should separate the labia.

_The

patient should relax the pelvic muscles and forcibly

cough once.

_{If the test is initially performed supine}

and no leakage is observed, the test should be repeated

in the standing position. The patient stands while

wear-ing a pad or with his or her legs shoulder-width apart

over a cloth or paper sheet on the floor to see the

leak-age. If urine leaks with the onset of the cough and

ter-minates with its cessation, the test is positive for stress

incontinence.

A negative test shows no leak or a delayed leak by five

to 15 seconds, and rules out most cases of stress

incon-tinence.

_{False-negative results may occur if a patient’s}

bladder is empty, if the cough is not forceful enough,

if the pelvic floor muscles contract to override urethral

sphincter incompetence, or if severe prolapse masks

the leakage.

_{Furthermore, a delayed leak may}

sug-gest a bladder spasm triggered by the cough, and not a

weakness of the sphincter. This indicates possible urge

incontinence.

LABORATORY TESTS

Laboratory tests should include a serum

cre-atinine level, which may be elevated if there is

urinary retention (overflow bladder) caused

by bladder outlet obstruction or denervation

of the detrusor. If not already performed to

exclude acute urinary tract infection as a

cause of reversible incontinence, a

urinaly-sis should be obtained to rule out hematuria,

proteinuria, and glycosuria, any of which

require a diagnostic workup.

POSTVOID RESIDUAL URINE

A measurement of postvoid residual (PVR)

urine is recommended to diagnose overflow

incontinence.

_{Although overflow}

incon-tinence is present in only a minority of

patients with incontinence, it is important

to exclude this diagnosis because chronic

failure of bladder emptying can lead to

hydronephrosis and irreversibly impaired

renal function. Overflow is more common

in older persons, but it can also occur in

young adults as a manifestation of

neu-rologic disorders, such as multiple

sclero-sis. Expert opinion recommends that PVR

urine always be measured in patients who

may have overflow incontinence, and some

experts recommend measuring PVR urine

when another cause is not obvious.

To measure PVR urine, the patient empties the

bladder, and then the amount of urine remaining in

the bladder is measured. This can be performed with

a handheld ultrasound unit, which is the preferred

method if available. The alternative is in-and-out

ure-thral catheterization.

_{In-and-out catheterization}

requires training to decrease the risk of infection and

urethral trauma, which is important in men with

sig-nificant prostate enlargement.

_{If PVR urine cannot be}

measured in the office setting and if overflow

inconti-nence is strongly suspected, further urodynamic

evalu-ation is warranted.

A PVR urine measurement less than 50 mL is negative

for overflow; 100 to 200 mL is considered indeterminate

(and the measurement should be repeated on another

occasion); and greater than 200 mL is suggestive of

over-flow as a main contributing factor of incontinence.

Referral for Further Evaluation

If the cause of urinary incontinence is unclear after the

assessment, referral to a urologist or urogynecologist is

The 3 Incontinence Questions

1. During the past three months, have you leaked urine (even a small amount)?

❏ Yes

❏ No (questionnaire completed)

2. During the past three months, did you leak urine: (check all that apply)

❏ A. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercising?

❏ B. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough?

❏ C. Without physical activity and without a sense of urgency?

3. During the past three months, did you leak urine most often: (check only one)

❏ A. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercising?

❏ B. When you had the urge or feeling that you needed to empty your bladder, but you could not get to the toilet fast enough?

❏ C. Without physical activity and without a sense of urgency?

❏ D. About equally as often with physical activity as with a sense of urgency? Definitions of type of urinary incontinence are based on responses to question 3:

Response to question 3 Type of incontinence

A. Most often with physical activity Stress only or stress predominant B. Most often with the urge to

empty the bladder

Urge only or urge predominant C. Without physical activity or

sense of urgency

Other cause only or other cause predominant

D. About equally with physical activity and sense of urgency

Mixed

Figure 2. Questionnaire for the evaluation of urinary incontinence. Adapted with permission from Brown JS, Bradley CS, Subak LL, et al.; Diagnostic Aspects of Incontinence Study (DAISy) Research Group. The sensitivity and specificity of a sim-ple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006;144(10):716.

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549

recommended (Table 5

₎

_{. Patients with typical stress}

or urge incontinence usually do not have any of the red

flags of hematuria, obstructive symptoms (straining to

void or sensation of incomplete bladder emptying), or

recurrent urinary tract infections. If any of these are

present, further evaluation is recommended.

Routine referral for urodynamic testing is not

recom-mended, even if a patient is a candidate for surgical

treat-ment of stress incontinence. Studies show that routine

preoperative urodynamic testing in patients who have

uncomplicated stress incontinence does not result in

better surgical outcomes.

The authors thank Anthony Viera, MD, MPH, assistant professor in the Department of Family Medicine, University of North Carolina at Chapel Hill, for his assistance with this article.

Data Sources: A literature search for scientific evidence supporting evaluation of urinary incontinence was performed in PubMed Clinical

Table 5. Indications for Urologic Referral

Incontinence associated with relapse or recurrent symptomatic urinary tract infections

Incontinence with new-onset neurologic symptoms, muscle weakness, or both

Marked prostate enlargement Pelvic organ prolapsed past the introitus Pelvic pain associated with incontinence Persistent hematuria

Persistent proteinuria

Postvoid residual volume > 200 mL Previous pelvic surgery or radiation Uncertain diagnosis

Information from references 18 and 36.

Table 4. Physical Examination Findings Associated with Urinary Incontinence

Organ system Finding or comorbidity Mechanism of effect Type of incontinence Abdominal Masses Chronic outflow obstruction from detrusor overactivity Overflow

Palpable bladder Detrusor overactivity from a neurologic or obstructive cause

Overflow Cardiac Arteriovascular disease Detrusor underactivity or areflexia from ischemic

myopathy or neuropathy

Urge Volume overload (congestive

heart failure)

Fluid excretion shift toward increased volume of urine Urge Musculoskeletal Mobility restriction, pain,

arthritis

Postponement of voiding and/or detrusor overactivity Urge, functional, or both Neurologic Cerebral vascular accident,

normal pressure hydrocephalus

Detrusor overactivity from central cause; failure to recognize need to void or to use toilet; environmental barriers

Urge, functional, or both Impaired mental status

(delirium), dementia

Failure to recognize need to void or to use toilet; environmental barriers

Urge, functional, or both Spinal stenosis Detrusor underactivity; damage to detrusor upper motor

neurons (cervical stenosis) or areflexia (lumbar stenosis)

Overflow Pelvic Enlarged prostate, pelvic mass Chronic outflow obstruction from detrusor overactivity Overflow

Following prostatectomy Sphincter and/or nerve damage Stress Vulvar or vaginal atrophy Diminished estrogen effects on periurethral tissues can

contribute to inflammation-induced detrusor overactivity

Stress, urge, or mixed Weak pelvic floor muscles Denervation of pelvic floor and/or striated sphincter trauma Stress Pulmonary Chronic cough from chronic

obstructive pulmonary disease or bronchitis

Increase in intra-abdominal pressure overcomes sphincter closure mechanisms in the absence of a bladder contraction

Stress

Rectal Fissures may indicate chronic constipation from fecal impaction

Intravesical pressure exceeds maximum urethral pressure, detrusor underactivity

Overflow

Reduced or absent anal sphincter tone; peripheral neuropathy caused by diabetes mellitus, alcoholism

Detrusor underactivity Overflow

Urinary Incontinence: Diagnosis

550

April 15, 2013

incontinence, and causes. The search included meta-analyses, random-ized controlled trials, clinical trials, and reviews. We also searched the Agency for Healthcare Research and Quality evidence reports, Clinical Evidence, the Cochrane database, Essential Evidence Plus, and the National Guideline Clearinghouse database. Search date: June 6, 2012.

The Authors

CHRISTINE KHANDELWAL, DO, is a clinical assistant professor in the Department of Family Medicine at the University of North Carolina, Cha-pel Hill.

CHRISTINE KISTLER, MD, MASc, is an assistant professor in the Depart-ment of Family Medicine at the University of North Carolina.

Address correspondence to Christine Khandelwal, DO, University of North Carolina, 590 Manning Dr., Chapel Hill, NC 27599 (e-mail: [email protected]). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations. REFERENCES

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2. Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have? JAMA. 2008;299(12): 1446-1456.

3. Gibbs CF, Johnson TM II, Ouslander JG. Office management of geriatric urinary incontinence. Am J Med. 2007;120(3):211-220.

4. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteris-tics, and study type. J Am Geriatr Soc. 1998;46(4):473-480.

5. DuBeau CE, Kuchel GA, Johnson T II, Palmer MH, Wagg A; Fourth International Consultation on Incontinence. Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence. Neurourol Urodyn. 2010;29(1):165-178.

6. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician. 1998;57(11):2675-2684, 2688-2690. 7. Coyne KS, Sexton CC, Irwin DE, Kopp ZS, Kelleher CJ, Milsom I. The

impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int. 2008;101(11):1388-1395.

8. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188(6 suppl):2455-2463.

9. McKertich K. Urinary incontinence-assessment in women: stress, urge or both? Aust Fam Physician. 2008;37(3):112-117.

10. Dowling-Castronovo A, Specht JK. How to try this: assessment of tran-sient urinary incontinence in older adults. Am J Nurs. 2009;109(2):62-71. 11. Frank C, Szlanta A. Office management of urinary incontinence among

older patients. Can Fam Physician. 2010;56(11):1115-1120.

12. Ouslander JG. Management of overactive bladder. N Engl J Med. 2004;350(8):786-799.

13. Imam KA. The role of the primary care physician in the management of bladder dysfunction. Rev Urol. 2004;6(suppl 1):S38-S44.

14. Chapple CR, Manassero F. Urinary incontinence in adults. Surgery (Oxford). 2005;23(3):101-107.

15. DuBeau CE. Clinical presentation and diagnosis of urinary incontinence. http://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-urinary-incontinence [subscription required]. Accessed January 31, 2012.

16. Yap P, Tan D. Urinary incontinence in dementia - a practical approach. Aust Fam Physician. 2006;35(4):237-241.

17. Goode PS, Burgio KL, Richter HE, Markland AD. Incontinence in older women. JAMA. 2010;303(21):2172-2181.

18. Cefalu CA. Urinary incontinence. In: Ham RJ, ed. Primary Care Geriatrics: A Case-Based Approach. 5th ed. Philadelphia, Pa.: Mosby Elsevier; 2007:306-323.

19. Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med. 1985;313(13):800-805.

20. Brown JS, Bradley CS, Subak LL, et al.; Diagnostic Aspects of Inconti-nence Study (DAISy) Research Group. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006;144(10):715-723.

21. Moore KN, Saltmarche B, Query A. Urinary incontinence. Non-surgical management by family physicians. Can Fam Physician. 2003;49:602-610. 22. Wyman JF, Choi SC, Harkins SW, Wilson MS, Fantl JA. The urinary diary in evaluation of incontinent women: a test-retest analysis. Obstet Gyne-col. 1988;71(6 pt 1):812-817.

23. Bryan NP, Chapple CR. Frequency volume charts in the assessment and evaluation of treatment: how should we use them? Eur Urol. 2004; 46(5):636-640.

24. Abrams P, Klevmark B. Frequency volume charts: an indispensable part of lower urinary tract assessment. Scand J Urol Nephrol Suppl. 1996; 179:47-53.

25. Homma Y, Ando T, Yoshida M, et al. Voiding and incontinence fre-quencies: variability of diary data and required diary length. Neurourol Urodyn. 2002;21(3):204-209.

26. Nygaard I, Holcomb R. Reproducibility of the seven-day voiding diary in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(1):15-17.

27. Yap TL, Cromwell DC, Emberton M. A systematic review of the reliability of frequency-volume charts in urological research and its implications for the optimum chart duration. BJU Int. 2007;99(1):9-16.

28. Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2000;62(11):2433-2444, 2447, 2452. 29. Fink D, Perucchini D, Schaer GN, Haller U. The role of the frequency- volume chart in the differential diagnostic of female urinary inconti-nence. Acta Obstet Gynecol Scand. 1999;78(3):254-257.

30. Brown JS, et al. Measurement characteristics of a voiding diary for use by men and women with overactive bladder. Urology. 2003;61(4):802-809. 31. Bachmann GA, Nevadunsky NS. Diagnosis and treatment of atrophic

vaginitis. Am Fam Physician. 2000;61(10):3090-3096.

32. Videla FL, Wall LL. Stress incontinence diagnosed without multichannel urodynamic studies. Obstet Gynecol. 1998;91(6):965-968.

33. Scotti RJ, Myers DL. A comparison of the cough stress test and single-channel cystometry with multisingle-channel urodynamic evaluation in genu-ine stress incontgenu-inence. Obstet Gynecol. 1993;81(3):430-433. 34. Wall LL, Wiskind AK, Taylor PA. Simple bladder filling with a cough

stress test compared with subtracted cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol. 1994;171(6):1472-1477. 35. Ghoniem G, Stanford E, Kenton K, et al. Evaluation and outcome

mea-sures in the treatment of female urinary stress incontinence: Interna-tional Urogynecological Association (IUGA) guidelines for research and clinical practice. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(1):5-33. 36. Weidner AC, Myers ER, Visco AG, Cundiff GW, Bump RC. Which

women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol. 2001;184(2):20-27.

37. Nager CW, Brubaker L, Litman HJ, et al.; Urinary Incontinence Treat-ment Network. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987-1997.

Nonsurgical Management of Urinary Incontinence in Women: A

Clinical Practice Guideline From the American College of Physicians

Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD; Mary Ann Forciea, MD, MS; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD; and Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*

Description:The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recom-mendations on the nonsurgical management of urinary inconti-nence (UI) in women.

Methods: This guideline is based on published English-language literature on nonsurgical management of UI in women from 1990 through December 2013 that was identified using MEDLINE, the Cochrane Library, Scirus, and Google Scholar. The outcomes eval-uated for this guideline include continence, improvement in UI, quality of life, adverse effects, and discontinuation due to adverse effects. It grades the evidence and recommendations by using ACP’s guideline grading system. The target audience is all clinicians, and the target patient population is all women with UI.

Recommendation 1: ACP recommends first-line treatment with pelvic floor muscle training in women with stress UI. (Grade: strong recommendation, high-quality evidence)

Recommendation 2:ACP recommends bladder training in women with urgency UI. (Grade: weak recommendation, low-quality evi-dence)

Recommendation 3:ACP recommends pelvic floor muscle training with bladder training in women with mixed UI. (Grade: strong recommendation, high-quality evidence)

Recommendation 4:ACP recommends against treatment with sys-temic pharmacologic therapy for stress UI. (Grade: strong recom-mendation, low-quality evidence)

Recommendation 5:ACP recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful. Cli-nicians should base the choice of pharmacologic agents on tolera-bility, adverse effect profile, ease of use, and cost of medication. (Grade: strong recommendation, high-quality evidence)

Recommendation 6: ACP recommends weight loss and exercise for obese women with UI. (Grade: strong recommendation, moderate-quality evidence)

Ann Intern Med.2014;161:429-440. doi:10.7326/M13-2410 www.annals.org

For author affiliations, see end of text.

U

rinary incontinence (UI), the involuntary loss of

urine, has a prevalence of approximately 25% in

young women (aged 14 to 21 years) (1), 44% to 57%

in middle-aged and postmenopausal women (aged 40 to 60

years) (2), and 75% in elderly women (aged

ⱖ

75 years)

(3). However, these statistics may be underestimated

be-cause one study showed that at least half of incontinent

women do not report the issue to their physicians (4). Risk

factors for UI include pregnancy, pelvic floor trauma after

vaginal delivery, menopause, hysterectomy, obesity,

uri-nary tract infection, functional and/or cognitive

impair-ment, chronic cough, and constipation (5). The effects of

UI range from slightly bothersome to debilitating. Urinary

incontinence also contributes to high medical spending—

approximately $19.5 billion was spent in the United States

in 2004 —and it accounts for 6% of nursing home

admis-sions for elderly women, costing approximately $3 billion

(6).

The 2 types of UI are based on the dysfunctional

mechanism: stress and urgency. However, the distinction is

not always clear, particularly for older women. Stress UI is

related to urethral sphincter failure associated with

intra-abdominal pressure and results in the inability to retain

urine when laughing, coughing, or sneezing (7). Urgency

UI is the involuntary loss of urine associated with a sudden

and compelling urge to void (7).

Mixed UI is a combination of stress and urgency UI.

Overactive bladder is a constellation of symptoms that

in-cludes urinary urgency (with or without UI), usually

ac-companied by frequency, and nocturia (5).

The primary goal of treatment is to achieve or improve

continence (8, 9). Clinically successful treatment has been

defined as that which reduces the frequency of UI episodes

by at least 50% (10). Treatments addressed in this

guide-line include lifestyle changes, pelvic floor muscle training

(PFMT), and various approved drugs (

Table 1

) (8).

Sur-gical treatments, available for women in whom

conserva-* This paper, written by Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD; Mary Ann Forciea, MD, MS; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD; and Paul Shekelle, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its approval were Paul Shekelle, MD, PhD (Chair); Michael J. Barry, MD; Roger Chou, MD; Molly Cooke, MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD, MS; Russell P. Harris, MD, MPH; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schu¨nemann, MD, PhD; J. Sanford Schwartz, MD; Donna E. Sweet, MD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 25 September 2013.

See also:

Summary for Patients. . . I-34

Web-Only

Supplement CME quiz

Clinical Guideline

© 2014 American College of Physicians 429

This article has been corrected. The specific correction appears on the last page of this document. The original version (PDF) is available at www.annals.org. Downloaded From: http://annals.org/ on 07/30/2015

tive therapy has failed or who have anatomical

abnormali-ties, are not addressed in this guideline.

This guideline from the American College of

Physi-cians (ACP) presents the available evidence on the

nonsur-gical (pharmacologic and nonpharmacologic) treatment of

UI in women in the primary care setting. It does not fully

evaluate nonsurgical treatments, such as botulinum toxin

or percutaneous nerve, magnetic, or electrical stimulation,

because they are not typically used by or available to

pri-mary care physicians. The target audience includes all

cli-nicians, and the target patient population is all women

with UI. This guideline is based on a systematic evidence

review sponsored by the Agency for Healthcare Research

and Quality (11) and an updated literature search (

Supple-ment

, available at www.annals.org).

M

This guideline is based on a systematic evidence review

(11) that addressed the following key questions related to

the diagnosis and nonsurgical management of UI:

1. How effective is the nonpharmacologic treatment of

UI in women?

1a. How do nonpharmacologic treatments affect

in-continence, severity and frequency of UI, and quality of

life compared with no active treatment?

1b. How do combined methods of nonpharmacologic

treatments with drugs affect incontinence, severity and

fre-quency of UI, and quality of life compared with no active

treatment or monotherapy?

1c. What is the comparative effectiveness of different

nonpharmacologic treatments?

1d. What are the harms of nonpharmacologic

treat-ments compared with no active treatment?

1e. What are the comparative harms of different

non-pharmacologic treatments?

1f. Which patient characteristics, including age, type

and severity of UI, baseline disease that affects UI,

adher-ence to treatment recommendations, and comorbid

condi-tions, can modify the effects of nonpharmacologic

treat-ments on patient outcomes, such as continence, quality of

life, and harms?

2. How effective is the pharmacologic treatment of UI

in women?

2a. How do pharmacologic treatments affect

conti-nence, severity and frequency of UI, and quality of life

compared with no active treatment or combined treatment

methods?

2b. What is the effectiveness of pharmacologic

treat-ments compared with each other or with

nonpharmaco-logic treatments of UI?

2c. What are the harms of pharmacologic treatments

compared with no treatment?

2d. What are the harms of pharmacologic treatments

of UI compared with each other or with nonpharmacologic

tr

e

atments?

2e. Which patient characteristics, including age, type

and severity of UI, baseline disease that affects UI,

adher-ence to treatment recommendations, and comorbid

condi-tions, can modify the effects of pharmacologic treatments

on patient outcomes, such as continence, quality of life,

and harms?

The systematic evidence review was done by the

Minnesota Evidence-based Practice Center. The literature

search included English-language studies published

be-tween 1990 and December 2011 identified using

MEDLINE, the Cochrane Library, Scirus, and Google

Scholar as well as manual searches of reference lists from

systematic reviews. Literature was updated through

De-cember 2013, focusing on treatments most relevant to

pri-mary care (see the

Supplement

for details). Data were

ex-tracted using a standardized form, and study quality was

assessed according to the

Methods Guide for Effectiveness

and Comparative Effectiveness Reviews

(12). This guideline

focuses on treatments most relevant to primary care

clini-cians; the full report (11) and published article (13)

con-tain more details.

This guideline rates the evidence and

recommenda-tions by using ACP’s guideline grading system (

Table 2

).

Details of the guideline development process can be found

in the methods paper (14).

D

Because most women with UI do not report it to their

physicians (4), physicians should proactively ask female

pa-tients about bothersome UI symptoms as part of a routine

review of systems. Clinicians should take a focused history

and ask specific questions, such as the time of onset,

symp-toms, and frequency (4). Clinicians should also do a

fo-cused physical examination and evaluate neurologic

symp-toms. Asking such questions as “Do you have a problem

with urinary incontinence (of your bladder) that is

bother-some enough that you would like to know more about how

it could be treated?” as part of a quality improvement

in-tervention has been shown to increase appropriate care by

15% in patients aged 75 years or older (15).

Table 1. Nonpharmacologic Treatments for UI

Treatment Description

PFMT Instruction on the voluntary contraction of pelvic floor muscles (Kegel exercises)

PFMT with biofeedback using vaginal EMG

PFMT with EMG probe used to give patients visual feedback on when they are properly contracting the pelvic floor muscles Bladder training Behavioral therapy that includes extending the

time between voiding

Continence service Treatment program involving nurses and clinicians trained in identifying, diagnosing, and appropriately treating patients with UI

EMG⫽electromyography; PFMT⫽pelvic floor muscle training; UI⫽urinary incontinence.

Clinical Guideline

43016 September 2014 Annals of Internal Medicine Volume 161 • Number 6 www.annals.org

T

Complete continence, a clinically important

improve-ment in UI (defined as reducing UI frequency by

ⱖ

50%),

and quality of life were the primary outcomes assessed in

the systematic review to evaluate the effectiveness of

non-pharmacologic and non-pharmacologic treatments.

Nonpharmacologic Treatment

Appendix Table 1

(available at www.annals.org)

sum-marizes nonpharmacologic treatments.

Stress UI: Nonpharmacologic Treatment

PFMT Versus No Active Treatment.

High-quality

evi-dence showed that PFMT is an effective UI treatment

compared with no active treatment. Pooled data from

stud-ies that included women with stress UI (16 –18) showed

increased continence rates with PFMT compared with no

active treatment (number needed to treat for benefit

[NNT

], 3 [95% CI, 2 to 5]). High-quality evidence

showed that PFMT was more than 5 times as effective as

no active treatment in improving UI (NNT

, 2 [CI, 2 to

6]) (16, 19 –23). In addition, studies reported improved

quality of life (11).

PFMT With Biofeedback Using a Vaginal

Electromyog-raphy Probe Versus No Active Treatment.

Low-quality

evi-dence showed that PFMT with biofeedback using a vaginal

electromyography probe increased continence compared

with no active treatment (16, 20). High-quality evidence

showed that this treatment improved UI compared with

no active treatment (NNT

, 3 [CI, 2 to 6]) (16, 19, 20,

24).

Other Treatments.

Evidence was insufficient to

deter-mine the effectiveness of vaginal cones and pessaries or of

intravaginal and intraurethral devices versus no active

treat-ment (11).

Urgency UI: Nonpharmacologic Treatment

Bladder Training Versus No Active Treatment.

Low-quality evidence showed that bladder training improved UI

compared with no active treatment (NNT

, 2 [CI, 2 to 4])

(25, 26). However, evidence on bladder training for

achieving complete continence was insufficient (11).

PFMT Versus No Active Treatment.

Pooled data from

studies that included women with mixed UI (18, 20, 27)

showed increased continence rates with PFMT compared

with no active treatment.

PFMT Plus Bladder Training Versus No Active

Treatment.

High-quality evidence showed that PFMT

combined with bladder training achieved continence

(NNT

, 6 [CI, 4 to 16]) (28 –32) and improved UI

(NNT

, 3 [CI, 2 to 6]) (28, 30 –32) compared with no

active treatment.

Continence Service Versus No Active Treatment.

Con-tinence service involves nurses and clinicians trained to

identify, diagnose, and appropriately treat patients with

UI. Moderate-quality evidence showed that this service

yielded no statistically significant improvement in

conti-nence compared with no active treatment (33–35).

Low-quality evidence showed no consistent statistically

signifi-cant improvement in UI (35, 36).

Weight Loss and Physical Activity Versus No Active

Treatment.

Moderate-quality evidence indicated that

weight loss and exercise improved UI in obese women

(NNT

, 4 [CI, 2 to 18]) (37, 38).

Other Treatments.

Evidence was insufficient to

deter-mine the effectiveness of behavioral modification

pro-grams, a soy-enriched diet, or acupuncture for improving

UI in women with mixed UI (11).

Comparative Effectiveness of Nonpharmacologic Treatments

No evidence showed that one nonpharmacologic

treat-ment was superior to another in the various comparisons

assessed for stress, urgency, or mixed UI. Further details

are available in the full systematic review (11) and the

Supplement

.

Pharmacologic Treatment

Appendix Table 2

(available at www.annals.org)

sum-marizes pharmacologic treatments.

Stress UI: Pharmacologic Treatment

Nonsystemic Estrogen Therapy Versus Placebo.

Overall

evidence was insufficient to determine the effectiveness of

topical estrogen therapies at improving UI. Evidence

showed increased continence and improved UI with

vagi-nal estrogen formulations, but transdermal patches were

associated with worsened UI. Studies used a range of

estro-gen applications.

Urinary incontinence improved with vaginal estrogen

tablets (39) and vaginal ovules (40) compared with

pla-cebo. Vaginal estrogen tablets increased continence

com-pared with placebo (NNT

, 5 [CI, 3 to 12]) (39 – 42). An

Table 2. The American College of Physicians’ Guideline Grading System*

Quality of Evidence

Strength of Recommendation Benefits Clearly Outweigh Risks

and Burden or Risks and Burden Clearly Outweigh Benefits

Benefits Finely Balanced With Risks and Burden

High Strong Weak

Moderate Strong Weak

Low Strong Weak

Insufficient evidence to determine net benefits or risks

*Adopted from the classification developed by the GRADE (Grading of Recom-mendations, Assessment, Development, and Evaluation) workgroup.

Clinical Guideline

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estradiol implant did not improve UI compared with

pla-cebo (41).

Intravaginal Estriol Plus PFMT Versus Intravaginal

Estriol.

Low-quality evidence from 1 study showed that a

combination of intravaginal estriol plus PFMT more

effec-tively achieved continence than intravaginal estriol alone

(NNT

, 1 [CI, 1 to 2]) (43).

Duloxetine Versus Placebo.

Low-quality evidence

showed that continence was reduced less with duloxetine

than placebo (44, 45). High-quality evidence showed that

duloxetine did not statistically significantly improve UI

compared with placebo (NNT

, 13 [CI, 7 to 143]) (44,

46 – 49). Low-quality evidence showed that duloxetine

im-proved quality of life (45, 49, 50). However, quality of life

did not improve in women with severe stress UI or

over-active bladder (46, 51).

Urgency UI: Pharmacologic Treatment With Antimuscarinics

Darifenacin Versus Placebo.

High-quality evidence

showed that darifenacin improved UI compared with

pla-cebo (NNT

, 9 [CI, 6 to 18]) (52–54). Achieving

com-plete continence was not studied as an outcome with

dar-ifenacin treatment. High-quality evidence also showed that

darifenacin improved quality of life (11).

Fesoterodine Versus Placebo.

Moderate-quality evidence

showed that fesoterodine achieved continence more than

placebo (NNT

, 8 [CI, 6 to 11]) (55–57). High-quality

evidence also showed an improvement in UI (NNT

, 10

[CI, 7 to 18]) (56, 58 – 60). Low-quality evidence showed

that fesoterodine also improved quality of life (11).

Oxybutynin Versus Placebo.

High-quality evidence

showed that oxybutynin achieved continence more than

placebo (NNT

, 9 [CI, 6 to 16]) (61– 65).

Moderate-quality evidence showed that this agent also improved UI

(NNT

, 6 [CI, 4 to 11]) (24, 61, 62, 64, 66 –73).

Propiverine Versus Placebo.

Low-quality evidence

showed that propiverine achieved continence more than

placebo (NNT

, 6 [CI, 4 to 12]) (74, 75), and

moderate-quality evidence showed that it improved UI (NNT

, 5

[CI, 4 to 8]) (74 –76) compared with placebo.

Solifenacin Versus Placebo.

High-quality evidence

showed that solifenacin achieved continence more than

placebo (NNT

, 9 [CI, 6 to 17]) (77– 81), and low-quality

evidence indicated that it resolved UI compared with

pla-cebo (NNT

, 6 [CI, 4 to 10]) (81, 82). Low-quality

evi-dence from 1 study showed that higher doses of solifenacin

(10 mg/d vs. 5 mg/d) did not decrease the frequency of UI

episodes and were associated with increased risk for adverse

effects (83).

Tolterodine Versus Placebo.

High-quality evidence

showed that tolterodine achieved continence (NNT

, 12

[CI, 8 to 25]) (55, 56, 84, 85) and improved UI (NNT

,

10 [CI, 7 to 24]) (55, 56, 59, 86 –90) more than placebo.

Low-quality evidence showed that tolterodine improved

quality of life (11).

Trospium Versus Placebo.

High-quality evidence

showed that trospium achieved continence more than

pla-cebo (NNT

, 9 [CI, 7 to 12]) (91–94). Low-quality

evi-dence did not show a statistically significant improvement

in UI compared with placebo (94, 95). Individual studies

showed that trospium improved quality of life (11).

Agonists

Mirabegron Versus Placebo.

Moderate-quality evidence

showed that mirabegron achieved continence more than

placebo (NNT

, 12 [CI, 7 to 29]) and improved UI

com-pared with placebo (NNT

, 9 [CI, 6 to 17]) (96).

Low-quality evidence showed that higher doses of mirabegron

improved treatment satisfaction and quality of life

com-pared with lower doses (150 mg/d vs. 100 mg/d) (97).

Solabegron Versus Placebo.

Evidence was insufficient to

determine the effect of solabegron on continence or

im-proving UI, but low-quality evidence showed that it

de-creased the frequency of UI episodes in a dose-dependent

manner (98).

Urgency UI: Other Pharmacologic Treatments

Evidence was insufficient to determine the clinical

ef-fectiveness of resiniferatoxin or nimodipine compared with

placebo for treatment of UI (11).

Urgency UI: Comparative Effectiveness of Pharmacologic Treatments

Fesoterodine Versus Tolterodine.

Moderate-quality

evi-dence showed that fesoterodine achieved continence more

often than tolterodine (NNT

, 18 [CI, 11 to 52]) (55, 56,

99). High-quality evidence showed that fesoterodine

im-proved UI more than tolterodine (NNT

, 36 [CI, 17 to

1000]) (55, 56, 59, 90).

Oxybutynin Versus Tolterodine.

Low-quality evidence

showed no difference between oxybutynin and tolterodine

for achieving continence (100). Moderate-quality evidence

showed no difference for improving UI (66, 68, 100, 101).

Tolterodine Versus Trospium.

Low-quality evidence

from 1 study showed that tolterodine and trospium were

similarly effective at treating urgency UI (100).

Solifenacin Versus Tolterodine.

Evidence was

insuffi-cient to compare solifenacin with tolterodine for effects on

continence or improvement of UI (11).

Trospium Versus Oxybutynin.

Low-quality evidence

showed no differences between trospium and oxybutynin

for effects on continence or improvement of UI (100).

Other Comparisons.

Evidence was insufficient to

de-termine the comparative effectiveness on continence or

im-provement of UI for darifenacin, propiverine, solifenacin,

or

flavoxate

versus

oxybutynin;

solifenacin

versus

darifenacin; or tolterodine or solifenacin versus propiverine

(11).

Clinical Guideline

43216 September 2014 Annals of Internal Medicine Volume 161 • Number 6 www.annals.org