This is the current release of the guideline.

Urinary incontinence

Diagnosis
Management
Treatment

Family Practice
Internal Medicine
Obstetrics and Gynecology
Surgery
Urology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To consider the best available evidence for evaluating and treating urinary incontinence in women

Women with urinary incontinence

Diagnosis

1. Medical and medication history
2. Voiding diary
3. Physical examination, including gynecologic and lower neurologic examinations
4. Measurement of urethral mobility
5. Urinalysis
6. Blood tests (blood urea nitrogen, creatinine, glucose, calcium) for suspected renal compromise
7. Urine cytology, in limited cases
8. Voiding assessment of urinary bladder (transurethral catheterization, ultrasound)
9. Urodynamic tests (cystometry, uroflowmetry, postvoid residual urine volume, pressure flow voiding study, electromyography)
10. Cystourethroscopy
11. Urethral pressure profilometry and leak point pressure measurement – not recommended

Management

1. Absorbent products
2. Behavioral modification (lifestyle intervention, scheduled or prompted voiding, bladder training, pelvic muscle rehabilitation)
3. Medical management (estrogen, anticholinergic agents [oxybutynin chloride, tolterodine], tricyclic antidepressants [imipramine], musculotropic drugs)
4. Surgical treatments (retropubic laparoscopic or open Burch colposuspension and sling procedures, tension-free vaginal tape procedure, anterior colporrhaphy, pubovaginal fascial bladder neck sling)
5. Injection of bulking agents (collagen, carbon-coated beads, fat) as second-line therapy or for women ineligible for surgery
6. Pessaries
7. Hysterectomy (for concomitant uterine prolapse or specific uterine pathology)
8. Paravaginal defect repair (not recommended as primary treatment of urodynamic stress incontinence)

• Cure rate
• Relapse rate
• Duration of improvement
• Quality of life
• Patient satisfaction
• Complication rates of surgery

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and February 2005. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

• Behavioral therapy, including bladder training and prompted voiding, improves symptoms of urge and mixed incontinence and can be recommended as a noninvasive treatment in many women.
• Pelvic floor training appears to be an effective treatment for adult women with stress and mixed incontinence and can be recommended as a noninvasive treatment for many women.
• Pharmacologic agents, especially oxybutynin and tolterodine, may have a small beneficial effect on improving symptoms of detrusor overactivity in women.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

• Cystometric testing is not required in the routine or basic evaluation of urinary incontinence.
• Bulking agents are a relatively noninvasive method of treatment for stress incontinence and can be used in women for whom any form of operative treatment is contraindicated.
• Long-term data suggest that Burch colposuspension and sling procedures have similar objective cure rates; therefore, selection of treatment should be based on patient characteristics and the surgeon's experience.
• The combination of a hysterectomy and a Burch colposuspension does not result in higher continence rates than a Burch procedure alone.
• Tension-free vaginal tape and open Burch colposuspension have similar success rates.
• Anterior colporrhaphy, needle urethropexy, and paravaginal defect repair have lower cure rates for stress incontinence than Burch colposuspension.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• After the basic evaluation of urinary incontinence, simple cystometry is appropriate for detecting abnormalities of detrusor compliance and contractibility, measuring postvoid residual volume, and determining capacity.
• Patients with urinary incontinence should undergo a basic evaluation that includes a history, physical examination, measurement of postvoid residual volume, and urinalysis.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate evaluation and management of patients with urinary incontinence

Medical Intervention

• The response to pharmacologic treatment often is unpredictable, and side effects are common with effective doses.
• The most typical side effect of anticholinergic therapy is dry mouth; other side effects most frequently reported were blurred vision, constipation, nausea, dizziness, and headache.

Surgical Intervention

• Intraoperative or immediate postoperative complications of surgery for stress incontinence include direct surgical injury to the lower urinary tract, hemorrhage, bowel injury, wound complications, retention, and urinary tract infection. Gynecologic surgeons may perform cystoscopy during or after retropubic and sling procedures to verify ureteral patency and the absence of sutures or sling material in the bladder. Most of the chronic complications after Burch colposuspension and sling procedures relate to voiding dysfunction and urge symptoms (see Table 2 in the original guideline document).
• Retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.
• A multicenter randomized trial found no difference between Burch colposuspension and tension-free vaginal tape procedures, with objective cure rates for urodynamic stress incontinence of 57% and 66%, respectively. Bladder injury was more common during the tension-free vaginal tape procedure (P = .013); delayed voiding, operation time (P <.001), and return to normal activity (P <.001) were all longer after colposuspension.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2005 Jun

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Gynecology

Not stated

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on October 9, 2007. The information was verified by the guideline developer on December 3, 2007. This summary was updated by ECRI Institute on October 27, 2008 following the U.S. Food and Drug Administration (FDA) advisory on surgical mesh devices.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.