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Urinary incontinence guidelines recommend nonpharmacologic therapy as first line

Key clinical point: Consider pelvic floor muscle training as a first-line therapy for women with urinary incontinence.

Major finding: New guidelines on nonsurgical management of urinary incontinence recommend pelvic floor muscle training as first-line therapy for stress urinary incontinence, and bladder training as first line therapy for urgency urinary incontinence.

Data source: Guidelines from the American College of Physicians

Disclosures: Some authors declared conflicts of interest including stock options, fees, royalties from a range of private and public organizations.


 

FROM ANNALS OF INTERNAL MEDICINE

References

Women with stress urinary incontinence should be managed with pelvic floor muscle training as the first-line therapy, according to new guidelines from the American College of Physicians, which also recommended against systemic pharmacologic therapy for the condition.

The review of all English-language literature from 1990 to 2013 on nonsurgical management of urinary incontinence in women found there was high-quality evidence in favor of nonpharmacologic therapy with pelvic floor muscle training as the first-line treatment for both stress and mixed urinary continence.

Defining ‘clinical success’ as a 50% reduction in the frequency of urinary incontinence episodes, the guidelines concluded there was evidence to make a strong recommendation for bladder training in women with urgency urinary incontinence (UI). The addition of pelvic floor muscle training was not found to result in any additional benefit, compared with bladder training alone, for those with urgency incontinence.

While the guidelines advised against pharmacologic therapy for stress incontinence, they did find evidence in favor of pharmacologic therapy as a second-line option for urgency urinary incontinence if bladder training had been unsuccessful, with the choice of agent to be based on tolerability, adverse effect profile, ease of use, and cost.

“Pharmacologic therapies were effective and equally efficacious at managing urgency UI and had a moderate magnitude of benefit in achieving continence rates but were associated with adverse effects,” Dr. Amir Qaseem from the American College of Physicians and his colleagues wrote in the Sept. 15 issue of the Annals of Internal Medicine.

For urgency urinary incontinence, the guidelines found oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium chloride increased continence rates. However patients were less likely to experience adverse events resulting in discontinuation with solifenacin, and the highest risk of discontinuation was found with oxybutynin.

“Evidence was insufficient to evaluate the comparative effectiveness of nonpharmacologic versus pharmacologic treatments for UI, and nonpharmacologic treatment should be considered first-line therapy.”

The authors also strongly recommended weight loss and exercise to improve continence in obese women, pointing out that the benefits would extend beyond relief of urinary incontinence (Ann. of Intern. Med. 2014 Sept. 15 [doi:10.7326/M13-2410]).

The prevalence of urinary incontinence ranges from one in four women aged 14-21 years, to three-quarters of all women older than 75 years; however, the authors suggested that these figures underestimated the true incidence because at least half of all incontinent women do not tell their physicians.

Because of this fact, the guidelines also suggested that physicians take the lead in routinely asking female patients about troublesome UI symptoms, and following up with a focused history, physical examination, and evaluation of neurologic symptoms.

“Asking such questions as “Do you have a problem with urinary incontinence (of your bladder) that is bothersome enough that you would like to know more about how it could be treated?” as part of a quality-improvement intervention has been shown to increase appropriate care by 15% in patients aged 75 years or older,” the authors wrote.

Some authors declared conflicts of interest including stock options, fees, royalties from a range of private and public organizations. Disclosures can be viewed on the ACP website.

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