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Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness

Comparative Effectiveness Reviews, No. 36

Investigators: , MD, MS, , PhD, and , MD.

Minnesota Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 11(12)-EHC074-EF

Structured Abstract

Objectives:

Our objectives were to assess methods to diagnose urinary incontinence (UI) and monitor treatment effectiveness in community-dwelling adult women, and to assess clinical efficacy and comparative effectiveness of pharmacological and nonsurgical treatments for UI.

Data Sources:

We searched major electronic bibliographic databases, the FDA (Food and Drug Administration) reviews, trial registries, and research grant databases up to December 30, 2011.

Review Methods:

A systematic review of diagnostic studies and therapeutic randomized and nonrandomized studies published in English was performed to synthesize diagnostic accuracy; minimally clinically important differences in validated tools for diagnosing UI; and rates of continence, improvements in UI, and harms of examined treatments. We calculated pooled absolute risk differences to estimate the number needed to treat (NNT) to achieve continence or avoid harms with random effects models.

Results:

From a total of 905 eligible references, 99 studies showed minimal diagnostic value of tests to distinguish urodynamic stress or urgency UI; 57 studies suggested specific ranges of improvement in UI frequency (based on voiding diaries) that women considered important, as well as the value of quality-of-life assessment with validated checklists or scales. Pretreatment urodynamic diagnoses were not associated with better predictions of nonsurgical treatment outcomes. Continence was achieved in one woman with urgency UI for every eight women treated with fesoterodine (NNT 8, 95 percent CI [confidence interval], 5 to 17), 12 with tolterodine (NNT=12, 95 percent CI, 8 to 25), nine with oxybutynin (NNT=9, 95 percent CI, 6 to 16), nine with solifenacin (NNT=9, 95 percent CI, 6 to 17), and nine with trospium (NNT=9, 95 percent CI, 7 to 12). Discontinuation of treatment due to adverse effects occurred in one woman for every 33 treated with fesoterodine (NNT=33, 95 percent CI, 18 to 102), 16 with oxybutynin (NNT=16, 95 percent CI, 8 to 86), 56 with trospium (NNT=56, 95 percent CI, 30 to 228), and 78 with solifenacin (NNT=78, 95 percent CI, 39 to 823). Discontinuation due to adverse effects occurred more often with fesoterodine or oxybutynin than with tolterodine. Continence was achieved in one woman for every three treated with pelvic floor muscle training (NNT=3, 95 percent CI, 2 to 5), six with pelvic floor muscle training combined with bladder training (NNT=6, 95 percent CI, 4 to 16), and six with intravaginal electrical stimulations (NNT=6, 95 percent CI, 4 to 16). Weight loss improved UI in obese women. Improvement in UI and quality of life were examined using different definitions, which hampered the synthesis of evidence. Evidence was insufficient from which to conclude prediction of treatment effects by age, race, baseline severity of UI, and comorbidities.

Conclusions:

Clinical evaluation with validated tools for diagnosis of UI, its type, frequency, severity, and impact on quality of life informs nonsurgical treatment decisions. Women determine treatment satisfaction and success according to clinically important reductions in UI frequency as recorded in voiding diaries and with clinically important improvements on condition-specific quality-of-life scales. Benefits from pelvic floor muscle training, bladder training, and electrical stimulation are large, and adverse effects are uncommon. Benefits from drugs are small. Drugs for urgency UI have comparable effectiveness. Evidence about long-term adherence to and safety of all available treatments is insufficient.

Contents

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10064-I, Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, Minnesota

Suggested citation:

Shamliyan T, Wyman J, Kane RL. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Comparative Effectiveness Review No. 36. (Prepared by the University of Minnesota Evidence-based Practice Center under Contract No. HHSA 290-2007-10064-I.) AHRQ Publication No. 11(12)-EHC074-EF. Rockville, MD. Agency for Healthcare Research and Quality. April 2012. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA 290-2007-10064-I). The findings and conclusions in this document are those of the author(s), who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

1

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

Bookshelf ID: NBK92960PMID: 22624162
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