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CLINICIAN’S CORNER
Management of Urinary Incontinence
in Women
Scientific Review
Context Urinary incontinence is a common health problem among women that nega-
tively impacts quality of life. Therefore, it is important that primary care physicians have an understanding of how to manage urinary incontinence effectively.
Objective To review the most recent, high-quality evidence regarding the etiology
and management of urinary incontinence in women.
tary leakage of urine,1 is acommon health problem Data Sources and Study Selection Searches of MEDLINE, EMBASE, The Coch-
rane Library, and the ACP Journal Club were performed to identify English-language
articles published between 1998-2003 that focused on the etiology or treatment of uri- nary incontinence in adult women. The references of each retrieved article were re- viewed and an expert in the field was contacted to identify additional relevant articles.
Data Extraction Using a combination of more than 80 search terms, we included
articles of etiology that were cohort studies, case-control studies, cross-sectional stud- ies, or systematic reviews of cohort, case-control, and/or cross-sectional studies. Stud- ies of treatment had to be randomized controlled trials or systematic reviews of ran- domized controlled trials. The quality of each article was assessed independently by each author and inclusion (n=66) was determined by consensus.
Data Synthesis Multiple factors have been found to be associated with urinary in-
continence, some of which are amenable to modification. Factors associated with in- continence include age, white race, higher educational attainment, pregnancy- and overflow incontinence. Stress in- related factors, gynecological factors, urological and gastrointestinal tract factors, continence is involuntary leakage from comorbid diseases, higher body mass index, medications, smoking, caffeine, and func- tional impairment. There are several effective nonpharmacological treatments includ- ing pelvic floor muscle training, electrical stimulation, bladder training, and promptedvoiding. Anticholinergic drugs are effective in the treatment of urge urinary inconti- nence. Several surgical interventions are effective in the management of stress incon- intrinsic sphincter function. Urge in- tinence, including open retropubic colposuspension and suburethral sling procedure.
continence is involuntary leakage ac- Conclusion Urinary incontinence in women is an important public health concern,
and effective treatment options exist.
by urgency,1 and it usually indicates de- trusor overactivity. Mixed incontinenceis the complaint of involuntary leak-age associated with urgency and also flow incontinence, which is associated Author Affiliations: San Francisco Veterans Affairs Medi-
cal Center, San Francisco and Division of Geriatrics, De- partment of Medicine, University of California, San Fran- cisco (Dr Holroyd-Leduc) and Division of General Internal nary incontinence in women is over- Medicine, University Health Network, University of Toronto, Toronto, Ontario (Dr Straus).
Corresponding Authors: Jayna M. Holroyd-Leduc,
See also p 996.
MD, SFVAMC (181G), 4150 Clement St, Bldg 1, SanFrancisco, CA 94121 ( Jayna.Holroyd-Leduc@med.va .gov); Sharon E. Straus, MD, Department of Medi- CME available online at
cine, University Health Network, Toronto General Hos-pital, 200 Elizabeth St, ENG 248, Toronto, Ontario, www.jama.com
Canada, M5G 2C4 (sstraus@mtsinai.on.ca).
986 JAMA, February 25, 2004—Vol 291, No. 8 (Reprinted)
2004 American Medical Association. All rights reserved.
MANAGEMENT OF URINARY INCONTINENCE IN WOMEN ported by other trials.20,21 The associa- Clinical Issues
What Factors Increase the Risk of De-
Cochrane Library, and the ACP Jour- veloping Urinary Incontinence? Mul-
gardless of the age of the patient at the nal Club were performed by using more fication, so clinicians can focus on iden- delivery (hazard ratio [HR], 3.5; 95% CI, Pregnancy, Mode of Delivery, and Par- ity. After adjusting for the length of the liveries (HR, 3.5; 95% CI, 1.2-9.8) after and duration of labor.22 The risk of stress cross-sectional studies, or systematic re- cross-sectional studies. Studies of treat- CI, 1.5-13.2).9 Increased parity also ap- ery, vaginal laceration or episiotomy, and tion, the reference lists of retrieved ar- factor (OR, 10.43; 95% CI, 1.17-93.42).23 development of urinary incontinence.
tion between fetal weight and urinary in- tempt to retrieve additional articles. For delivery, perineal trauma, duration of la- OR, 2.1; 95% CI, 1.7-2.6, respectively).
2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, February 25, 2004—Vol 291, No. 8 987
MANAGEMENT OF URINARY INCONTINENCE IN WOMEN Hysterectomy and Other Gynecologi- cal Factors. A systematic review found Comorbid Diseases. The presence of p o r t e d b y a l a r g e c o h o r t s t u d y uria in the past 12 months.14 This study, en.2 After adjusting for age, parity, and Parkinsonism,39 arthritis,16,36 back prob- Medications, Smoking, Alcohol, and Age. Advancing age is associated with Caffeine. Several medications have been 2.86; P = .001),31 and poor pelvic floor Urological and Gastrointestinal Fac- tional attainment, financial assets, age, tors. Recurrent urinary tract infection functional status, vision and hearing ca- ated with urinary incontinence.12,16,30,32,33 In one study, recurrent urinary tract in- 988 JAMA, February 25, 2004—Vol 291, No. 8 (Reprinted)
2004 American Medical Association. All rights reserved.
MANAGEMENT OF URINARY INCONTINENCE IN WOMEN Table 1. Comparison of Pelvic Floor Muscle Training vs Other Physical Therapies in the
Self-reported Cure
Reduction in Urinary
PFMT Alone
or Improvement,
Leakage Episodes per
Compared With
RR (95% CI)
24 h, WMD* (95% CI)
Abbreviations: CI, confidence interval; PFMT, pelvic floor muscle training; RR, relative risk; WMD, weighted mean differ- Socioeconomic Status. Higher levels of *Based on data from Hay-Smith et al.42†Based on data from Burgio KL.48 ‡Represents results for cure only.
ticularly mild incontinence and stressincontinence.10,21,37 Although the rea-son for this association is unclear, it re- factors such as age, race, assets, comor- pelvic floor muscles to prevent the cones tors (eg, natural history of the disease), from slipping out of the vagina. Electri- but the placebo effect might have a small tion between a person’s financial assets pelvic floor musculature or to inhibit de- Body Mass Index. Many studies have training, which aims to increase the time nence10-14,16,21,30,31,33,37 (OR per unit Functional Status. Functional impair- Pelvic Floor Muscle Training. Stud- nence.30,32,34,37,39 The presence of trunk ied in terms of the duration of each con- tion in urinary leakage with pelvic floor not significantly different between elite What Nonpharmacological Manage-
ment Strategies Are Effective? There are
or placebo (TABLE 1).42 The placebo
intervention used in the different trials alter the pelvic floor musculature).
vidual isolate the relevant muscles.
2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, February 25, 2004—Vol 291, No. 8 989
MANAGEMENT OF URINARY INCONTINENCE IN WOMEN training (RR, 1.41; 95% CI, 1.09-1.81).53 suggested that there is no difference be- Vaginal Cones. Use of weighted vagi-
nal cones theoretically requires that the ter than pelvic floor training alone (rela- ing resulted in fewer self-reported cures sion, and the weight is increased as tol- surgery group had a significantly greater reduction (PϽ.01). All reported ad- Electrical Stimulation. Electrical
nificantly better than regular social vis- fectiveness of electrical stimulation may Bladder Training. Bladder training
tinence, there was no difference in self- Ͼ50 mL).54 There was no significant to experience a subjective cure vs those tion was not significantly different from [WMD], −0.41; 95% CI, −0.79 to −0.03).
enced dry mouth and inability to void.
990 JAMA, February 25, 2004—Vol 291, No. 8 (Reprinted)
2004 American Medical Association. All rights reserved.
MANAGEMENT OF URINARY INCONTINENCE IN WOMEN ticipants.61 In particular, the risk of dry Prompted Voiding. There are a num-
intervals. Several of these trials (includ- tynin was associated with a significantly participants in the control groups, there currence of at least 1 adverse event (eg, Adrenergic Drugs. ␣-Adrenoceptor
provement, 0.59; 95% CI, 0.31-1.14)while more in the intervention groupshad significantly fewer incontinent epi- Table 2. Comparison of the Pharmacological Treatments for Urinary Incontinence
Medication
Benefits
Potential Adverse Reactions*
CI, −1.32 to −0.53).57 One trial found For Urge Incontinence
a statistically significant increase in in- Abnormal vision, dry eyesNausea, dyspepsia, abdominal pain least 1 object out of 2 on 3 separate oc- HypotensionHeadacheDiarrhea, GI tract symptoms What Are the Risks and Benefits
of Pharmacological Therapies?
Bone marrow suppressionHypotension, hypertension (TABLE 2).
Anticholinergic Drugs. Anticholin-
Dry mouth, rashConstipation, GI tract symptoms For Stress Incontinence
Confusion, anxietyUrinary symptoms, retention Abbreviations: ECG,electrocardiogram; GI, gastrointestinal.
*Based on information in the included trials and the Physicians’ Desk Reference, 56th ed, 2002.
−0.56; 95% CI, −0.73 to −0.39).58 The †These medications need to be used with caution in elderly patients because of the increased risk of adverse events ‡Phenylpropanolamine and clenbuterol have also been studied but are not approved by the US Food and Drug 2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, February 25, 2004—Vol 291, No. 8 991
MANAGEMENT OF URINARY INCONTINENCE IN WOMEN ␣-1A adrenoceptors have been found nence. Doxepin as been found to re- incontinence, voiding difficulties, re-to mediate the contractile response of renergic drugs have also been studied.
not available in the United States. Phen- matic activity. A controlled trial of du- Open Retropubic Colposuspen-
sion. Open retropubic colposuspen-
vealed a significant dose response in the P=.6; 40 mg, 59%; P=.02; 80 mg, 58%; P = .04).69 However, there was no sig- in any single adverse-effect category, the What Are the Risks and Benefits
(TABLE 3).70 Open retropubic colpo-
of Surgical Interventions?
Other Drug Treatments. Because of
the individual patient, the choice of pro- their benefit.66 A recently published pla- sion differed in the rates of repeat sur- 2-91).68 The only reported adverse effect 992 JAMA, February 25, 2004—Vol 291, No. 8 (Reprinted)
2004 American Medical Association. All rights reserved.
MANAGEMENT OF URINARY INCONTINENCE IN WOMEN Table 3. Comparative Failure Rates (Not Cured) Within 1 Year for Surgical Procedures for
Relative Risk (95% Confidence Interval)
dence to identify differences in rates ofde novo urge symptoms, urge inconti- Subjective Failure
Objective Failure†
Bladder Neck Needle Suspension.
*Based on data from Lapitan MC.70†Failure to be cured based on objective tests such as stress test, pad test, and/or urodynamic parameters.
the sutures through to the paraure-thral tissue on each side of the bladderneck to support it. There are 3 main 3-11).75,76 There was also a death in the there is a paucity of data, there does not appear to be a difference in failure rates Suburethral Sling Procedure. Sub-
sion and anterior vaginal repair.71 There b i n e d a b d o m i n a l a n d v a g i n a l injection (RR, 1.69; 95% CI, 1.02-2.79).
Anterior Vaginal Repair. During an-
are placed in the periurethral tissue and on their quality of life. Therefore, it is dure and Kelly plication. As already out- Periurethral Injections. The injec-
artificial urethral cushions that can help lowest risk for adverse complications.
Laparoscopic Colposuspension.
fat) with placebo (injection of saline).
ever, there are technical differences in- this field in an attempt to bridge the gap cal practice. Part 2 of this series will fo- 2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, February 25, 2004—Vol 291, No. 8 993
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2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, February 25, 2004—Vol 291, No. 8 995

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