• Finnish Medical Society Duodecim. Urinary incontinence in women. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Aug 8 [Various].

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Urinary incontinence in women. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2005 Aug 31 [Various].

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Aim

• It is important to differentiate stress incontinence from other types of incontinence which may also be caused by different treatable gynaecological, urological or neurological illnesses.

Types of Incontinence

1. In stress incontinence, involuntary loss of urine occurs during physical exertion or strain (e.g., coughing or sneezing), and it affects approximately three quarters of adult patients who present with incontinence.
2. Urge incontinence is characterised by a sudden urge to urinate followed by involuntary loss of urine, either during the urge or immediately afterwards. It is typically seen in elderly post-menopausal women and also in young women.
3. Mixed incontinence is a combination of the two above types. It is most common in women aged over 70 years.
4. Incomplete voiding and urinary retention, whether acute or chronic, may lead to overflow incontinence.

Epidemiology

• In epidemiological studies, the prevalence of female urinary incontinence in the adult population has ranged between 5% and 58% (median 28% [Cheater & Castleden, 2000]). More than 50% of patients conceal the problem.
• Approximately 6% of the population suffers from urinary incontinence of sufficient severity to interfere with their quality of life.
• Urinary incontinence increases in frequency with age. Around 60% of women over 70 years of age suffer from it.

Aetiology

• Stress incontinence is caused by weakness of the structures supporting the urethra or by sphincter insufficiency. The risk factors for stress incontinence include obesity (>20%), pregnancy and giving birth as well as heavy smoking. Congenital connective tissue weakness may also be a risk factor for stress incontinence.
• In urge incontinence bladder muscles contract inappropriately, the cause of which may be
  • Neurogenic (multiple sclerosis [MS], dementia, disturbances in cerebral circulation, Parkinson's disease, diabetes)
  • Non-neurogenic (acute or recurrent urinary tract infection, history of complicated urinary tract infections, tumour, disease affecting the bladder wall, bladder calculus, local oestrogen deficiency in postmenopausal women, fast bladder filling, diuretics, hysterectomy (Brown et al., 2000; Altman et al., 2007) [C]
  • Idiopathic; in approximately 80% of cases the cause remains unknown.
• Overflow incontinence is caused either by impaired micturition reflex (e.g., a neurogenic aetiology, post surgery, a drug adverse effect) or by a mechanical obstruction (tumour, prolapse).

Investigations

History

• In what situations does incontinence occur?
  • Standardised symptom questionnaires are suitable for clinical practice.
• For how long has incontinence lasted?
  • Moderately severe urge incontinence with a fairly sudden onset may be suggestive of an organic aetiology, e.g., bladder disease, inflammation or pelvic tumour.
• Severity?
  • How many times a week does the patient experience urinary incontinence, does she need to use protective pads and what impact does incontinence have on her life?
• A frequency/volume chart is a simple tool for monitoring bladder function and the type and severity of incontinence.
• Gynaecological history: deliveries, surgery, menstrual cycle
• Systemic illnesses and medication that may potentially affect bladder function (diuretics, anticholinergics)

Clinical Examination

• General clinical examination: general health status, mobility, weight, neurological abnormalities.
• Gynaecological examination: mucous membranes, prolapses, palpation to exclude tumours, cough stress test and measurement of residual urine ([see the Finnish Medical Society Duodecim guideline "Determining the volume of residual urine by ultrasonography") in case of incomplete voiding.

Laboratory Investigations and Imaging Studies

• In case of urge incontinence or mixed incontinence, urine chemistry should be carried out and, if indicated, microscopic examinations and culture.
  • Occasional microscopic haematuria may be associated with physical exercise, menstruation, sexual intercourse or minor trauma.
  • Recurrent microscopic haematuria ([see the Finnish Medical Society Duodecim guideline "Hematuria". Note; a reagent strip test alone is not sufficient) warrants a cytological examination of the urine, cystoscopy and urinary tract ultrasonography.

Indications for a Referral to Specialist Care

• Haematuria or a suspicion of a bladder disease (interstitial cystitis, bladder calculus, bladder cancer)
• Residual urine volume more than 100 mL (measured if the patient has difficulties passing urine or if overflow incontinence is suspected)
• Symptomatic prolapse
• Pelvic tumour
• Neurological problems
• Troublesome incontinence that has already been treated with surgery
• Suspicion of a fistula
• Treatment-resistant urge incontinence
• Stress incontinence if physiotherapy fails to provide adequate relief
• Problems in differential diagnosis

Conservative Treatment

• Lifestyle changes may alleviate both urge and stress incontinence.
  • Weight loss (5% to 10%) alleviates incontinence symptoms and improves the quality of life.
  • Fluid restriction is recommended only if daily fluid intake exceeds 3,000 mL.
  • Treatment of constipation
• Pelvic floor muscle training and physiotherapy:
  • Supervised regular pelvic floor muscle training of 2–6 months' duration is an effective form of therapy for all types of urinary incontinence (Hay-Smith & Dumoulin, 2006; Berghams et al., 2000; de Kruif & van Wegan,1996) [A].
  • Pelvic floor muscle training is also beneficial in postpartum incontinence (Hay-Smith et al., 2008) [A].
  • If the outcome of self-directed training is not satisfactory after 2 months, the patient should be referred to an appropriately trained physiotherapist.
• Electrical stimulation in order to reduce the overactivity of the bladder muscle (Bo, 1998) [D] as well as bladder training (Wallace et al., 2004; Berghams et al., 2000) [C] may also be employed in urge incontinence.

Pharmacotherapy

• Stress incontinence: drug therapy only plays a minor role
• Urge incontinence
  • Local oestrogen therapy appears to cure or alleviate symptoms in postmenopausal women (Moehrer, Hextall, & Jackson, 2003; Fantl, Cardozo, & McClish, 1994; Zullo et al., 1998) [B]. Bladder irritation will reduce as urogenital atrophy reverses and urinary tract infections reduce in number. The patient should be informed that itching and burning may occur at the beginning of treatment.
  • Anticholinergic drugs are used widely in the treatment of urge incontinence (Nabi et al., 2006; Alhasso et al., 2006) [A]. Drugs in this group include oxybutynin, tolterodine, trospium chloride, solifenacin and darifenacin.
    • Contraindications: urinary retention, uncontrolled narrow-angle glaucoma, myasthenia gravis, severe colitis.
    • Interactions must be borne in mind.
    • The most common adverse effects: dry mouth, blurred vision, postural hypotension, constipation and urinary retention. Moreover, the patient may experience central nervous system effects, such as cognitive disorders and confusion, which may be particularly troublesome in elderly patients.
    • The efficacy of the medication should be assessed at regular intervals (after about 2 months) because only a proportion of patients will benefit from the treatment and, on the other hand, if the adverse effects are only mild a dose increase may be attempted.
    • There is no difference in efficacy between the different agents. Adverse effect profiles are individual: try different preparations.

Surgical Treatment

• Should conservative treatment not yield adequate response stress incontinence may be treated surgically, if considered appropriate by a urogynaecologist.
  • Mini-invasive suburethral sling procedures are effective (Bezerra, Bruschini, & Cody, 2005; Valpas et al., 2004; Ward & Hilton, 2004; Paraiso et al. 2005; Cody et al., 2003; "Tension-free vaginal tape," 2004) [A] and can be carried out under local anaesthesia.
    • Tension-free vaginal tape (TVT) made of polypropylene mesh may be inserted retropubically underneath the midurethral region.
    • In transobturator tape procedures (TOT, TVT-O) the mesh is tunnelled from the vaginal side to the top of the thigh or vice versa.
    • At the postoperative check-up the patient must be checked for urinary retention, retropubic haematoma (usually resorbs spontaneously), poor healing of the vaginal incision or visible tape ends.
    • In pure stress incontinence the long-term outcome is good (at a 7-year follow-up 81% of the patients were continent) (Nilsson, Falconer, & Rezapour, 2004).
    • In mixed incontinence the results are poorer (Holmgren et al., 2005).
• Surgery is of no help in pure urge incontinence. In extreme cases, intradetrusor injections of botulinum toxin A (Duthie et al., 2007) [D], sacral nerve root neuromodulation or augmentation cystoplasty may be considered.
• The treatment for mixed incontinence is chosen according to the dominant type of incontinence.

Incontinence Protection

Absorbent pads, pants and protective bedding will provide protection. Vaginal cones and tampons prevent incontinence during short-lasting physical exercise. A trained incontinence nurse will be in charge of patient education and supplying incontinence products.

Related Evidence

Refer to the original guideline document for related evidence, including Cochrane reviews and other evidence summaries.

Definitions:

Classification of the Quality of Evidence

GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).

None provided

Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are. The type of supporting evidence is identified and graded for select recommendations (see the "Major Recommendations" field).

• Finnish Medical Society Duodecim. Urinary incontinence in women. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2008 Aug 8 [Various].

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

2001 Jan 4 (revised 2008 Aug 8)

Finnish Medical Society Duodecim - Professional Association

Finnish Medical Society Duodecim

Editorial Team of EBM Guidelines

Primary Author: Beata Stach-Lempinen

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Urinary incontinence in women. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2005 Aug 31 [Various].

None available

None available

This summary was completed by ECRI on December 17, 2002. The information was verified by the guideline developer as of February 7, 2003. This summary was updated by ECRI on April 2, 2004, October 5, 2004, February 22, 2005, June 10, 2005, and November 3, 2005. This summary was updated by ECRI on March 8, 2006, following the U.S. Food and Drug Administration advisory on Cymbalta (duloxetine hydrochloride). This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on January 9, 2009. This summary was updated by ECRI Institute on May 26, 2009, following the U.S. Food and Drug Administration advisory on Botox, Botox Cosmetic (Botulinum toxin Type A), and Myobloc (Botulinum toxin Type B). This summary was updated by ECRI Institute on August 17, 2009, following the updated FDA advisory on Botox and Botox Cosmetic (Botulinum toxin Type A), and Myobloc (Botulinum toxin Type B).

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