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JOGC

No. 397 – Conservative Care of Urinary Incontinence in Women

      Abstract

      Objective

      To outline the evidence for conservative care, including both assessment and management options, for urinary incontinence in women.

      Intended Users

      Relevant primary care providers and medical specialists including but not limited to physicians, nurses, midwives, and pelvic health physiotherapists.

      Target Population

      Women (>18 years of age) with urinary incontinence.

      Options

      Assessment options include gathering of a detailed history, physical examination, laboratory analysis, urodynamic evaluation, and cystoscopy. Conservative management options include lifestyle management, pelvic floor muscle training, behavioural management, and mechanical devices.

      Outcomes

      To provide an evaluation-based summary of current available evidence concerning efficacy of conservative care (assessment and management) strategies for urinary incontinence in women.

      Evidence

      The Cochrane Library and Medline (2013-2018) were searched to find articles related to conservative care of urinary incontinence in women (>18 years). Articles were appraised, and the collective evidence was graded.

      Validation Methods

      The evidence obtained was reviewed and evaluated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Urogynecology Committee under the leadership of the principal authors. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework.

      Benefits, Harms, and Costs

      Evidence for the efficacy of conservative care (assessment and management) options for women with urinary incontinence is strong. Furthermore, these options carry minimal or no harm and confer an established cost benefit.

      Guideline Update

      This SOGC Clinical Practice Guideline will be automatically reviewed 5 years after publication.

      SUMMARY STATEMENTS

      • 1
        Assessment – history (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • History alone is not sufficient to diagnose the full spectrum of urinary incontinence. However, a clear history of urinary leakage with physical activity, in the absence of complicated urinary incontinence features, may be sufficient for stress urinary incontinence diagnosis in conjunction with physical examination.
      • 2
        Assessment – physical examination (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • The cough stress test, if positive, is a reliable test to diagnose uncomplicated stress urinary incontinence when complemented by a history consistent with stress urinary incontinence.
        • Measurement of urethral hypermobility alone has poor reliability and remains controversial in the conservative management of urinary incontinence. However, the presence of an immobile, fixed urethra suggests complex urinary incontinence and may warrant further investigation.
      • 3
        Assessment – urinalysis (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • Urine dipstick testing, microscopic urinalysis and urine culture and sensitivity along with measurement of post-void residual volume when indicated should be performed in all women with urinary incontinence to rule out infections, hematuria, and proteinuria. Further evaluations are indicated when the post-void residual volume is persistently greater than 150 mL.
      • 4
        Assessment – urodynamic studies (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • Urodynamic studies are not indicated in otherwise healthy women with uncomplicated stress urinary incontinence on history and physical examination, as urodynamic study results do not assist with diagnosis or improve treatment outcomes in this group of women. Urodynamic study testing may be warranted in women with complicated urinary incontinence symptoms, urinary incontinence refractory to treatment, or conflicting history and physical examination results.
      • 5
        Assessment – cystoscopy (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • Cystoscopic evaluation of the lower urinary tract may be indicated in women with urge urinary incontinence refractory to treatment, continuous urine leakage suspicious for iatrogenic genitourinary injuries or fistulas, persistent post-void dribbling, and hematuria.
      • 6
        Management – lifestyle (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • Evidence from one randomized controlled trial and one meta-analysis supports lifestyle modification interventions promoting weight loss as a management strategy to reduce urinary incontinence in women who are overweight or obese. A 5% reduction in weight loss has an impact on the reduction of urinary incontinence symptoms. Caffeine reduction demonstrates reduction in symptoms of urgency and frequency.
      • 7
        Management – pelvic floor muscle training (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • Pelvic floor muscle training is an effective therapy for urinary incontinence and can be used alone or as part of a multicomponent therapy that includes lifestyle and behavioural approaches. Progressive programs that are supervised by health care providers are more effective.
      • 8
        Management – adjuncts (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • Although current published studies have limitations, currently there does not appear to be any clear added benefit of using adjunctive therapies (biofeedback, electrical stimulation, or vaginal cones).
      • 9
        Management – behavioural; bladder training (mixed urinary incontinence, urge urinary incontinence):
        • Scheduled voiding regimens represent an important and effective management strategy as a stand-alone therapy or part of a multicomponent therapy that includes lifestyle and pelvic floor muscle training. Women have been more satisfied with voiding regimens compared with no treatment.
      • 10
        Management – intravaginal mechanical devices (stress urinary incontinence, mixed urinary incontinence):
        • There is evidence that intravaginal mechanical devices (incontinence pessaries) are effective and may be preferred for women who have incontinence in specific situations such as exercise. Intravaginal mechanical devices may not be as effective as pelvic floor muscle training.

      RECOMMENDATIONS

      • 1
        Assessment – history (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We recommend eliciting a comprehensive voiding, medical, and surgical history in women with urinary incontinence to distinguish those with uncomplicated stress urinary incontinence from other types of urinary incontinence, in order to better assess the need for further physical examinations and investigations prior to treatment planning (strong, low).
      • 2
        Assessment – physical examination (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We recommend that cough stress test be performed on physical examination to diagnose stress urinary incontinence in conjunction with history taking (strong, low). This cough stress test may have to be done also with reduction of prolapse, if present. While urethral hypermobility may contribute to stress urinary incontinence diagnosis, we recommend against the routine use of Q-tip testing in women with urinary incontinence. The vaginal Q-tip test may be used as an alternative to urethral Q-tip testing in select patients (conditional, moderate).
      • 3
        Assessment – urinalysis (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We recommend that initial investigations include a urinalysis and, if indicated, urine culture and sensitivity and post-void residual assessment for all women with urinary incontinence. Further evaluations such as a hemoglobin A1c, serum creatinine, and imaging may be considered on a case-by-case basis depending on the results of these initial investigations (strong, moderate).
      • 4
        Assessment – urodynamic studies (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We recommend that in women with uncomplicated urinary incontinence on history and physical examination, routine urodynamic studies not be undertaken prior to treatment planning (strong, high).
        • We suggest that urodynamic studies be considered in women with refractory or complicated urinary incontinence symptoms, who have undergone prior incontinence procedures, or with urinary incontinence in the setting of stage 3–4 pelvic organ prolapse (conditional, low).
      • 5
        Assessment – cystoscopy (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We suggest that cystoscopic evaluation be considered in women with hematuria, or refractory and/or complicated urinary incontinence symptoms (conditional, low).
      • 6
        Management – lifestyle (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We recommend counselling to support weight loss as a first-line strategy for all women with urinary incontinence who are overweight or obese (strong, high).
        • We recommend counselling related to reducing caffeine to address symptoms of frequency and urgency (conditional, moderate).
      • 7
        Management – pelvic floor muscle training (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We recommend pelvic floor muscle training (individually tailored, inclusive of digital pelvic floor muscle examination) to be offered to all women with urinary incontinence (strong, high).
      • 8
        Management – adjuncts (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence):
        • We suggest adjunctive pelvic floor muscle therapies be used on an individualized basis only since there is currently no clear added benefit (conditional, moderate).
      • 9
        Management – behavioural; bladder training (mixed urinary incontinence, urge urinary incontinence):
        • We recommend scheduled toilet regimens to be offered to all women with urge urinary incontinence and mixed urinary incontinence (strong, high).
      • 10
        Management – intravaginal mechanical devices (stress urinary incontinence):
        • We recommend mechanical devices be used on an individualized basis. We recommend particular consideration of mechanical devices when women have urinary incontinence with high-impact exercises or when there are barriers in accessing supervised pelvic floor muscle training (strong, high).

      Key Words

      DEFINITIONS:

      Stress urinary incontinence (SUI) (The complaint of involuntary leakage on effort or exertion or on sneezing or coughing), Urge urinary incontinence (UUI) (The complaint of involuntary leakage accompanied by or immediately preceded by urgency), Mixed urinary incontinence (MUI) (The complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing, and coughing), Pelvic floor muscle training (PFMT) (A structured and individualized program of exercises that aims to improve pelvic floor muscle strength, endurance, power, relaxation, or a combination of these parameters), Cough stress test (CST) (A test that involves visualization of synchronous urinary loss while the patient coughs with a comfortably full bladder (usually at 200–300 mL). CST is used to document the presence of SUI), Q-tip test (Q-tip test is a test for urethral hypermobility where a cotton-tip applicator is inserted into the bladder neck, and vesicourethral angle mobility is observed on coughing. The urethra is considered hypermobile when the straining angle is 30 degrees or greater)
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      REFERENCES

        • Bo K
        • Frawley H
        • Haylen B
        • et al.
        An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction.
        Neurourol Urodyn. 2016; 36: 221-244
        • Farrell SA
        • Epp A
        • Flood C
        • et al.
        The evaluation of stress incontinence prior to primary surgery.
        J Obstet Gynaecol Can. 2003; 25: 313-324
        • Syan R
        • Brucker B.
        Guideline of guidelines: urinary incontinence.
        BJU Int. 2016; 117: 20-33
        • Robert M
        • Ross S.
        Conservative management of urinary incontinence.
        J Obstet Gynaecol Can. 2018; 40: e119-e125
        • GRADE Working Group
        The GRADE Handbook.
        (editors)in: Schünemann H Brożek J The GRADE Handbook. GRADE Working Group, 2013 (Available at:)
      1. Committee opinion no. 603: evaluation of uncomplicated stress urinary incontinence in women before surgical treatment.
        Obstet Gynecol. 2014; 123: 1403-1407
        • Jensen JK
        • Nielsen Jr, FR
        • Ostergard DR
        The role of patient history in the diagnosis of urinary incontinence.
        Obstet Gynecol. 1994; 83: 904-910
        • Haddad JM
        • Monaco H
        • Kwon C
        • et al.
        Predictive value of clinical history compared with urodynamic study in 1,179 women.
        Rev Assoc Med Bras (1992). 2016; 62: 54-58
        • Harvey MA
        • Versi E.
        Predictive value of clinical evaluation of stress urinary incontinence: a summary of the published literature.
        Int Urogynecol J Pelvic Floor Dysfunc. 2001; 12: 31-37
        • Khandelwal C
        • Kistler C.
        Diagnosis of urinary incontinence.
        Am Fam Physician. 2013; 87: 543-550
        • Guralnick ML
        • Fritel X
        • Tarcan T
        • et al.
        ICS educational module: cough stress test in the evaluation of female urinary incontinence: introducing the ICS-uniform cough stress test.
        Neurourol Urodyn. 2018; 37: 1849-1855
        • Najjari L
        • Janetzki N
        • Kennes L
        • et al.
        Comparison of perineal sonographically measured and functional urodynamic urethral length in female urinary incontinence.
        Biomed Res Int. 2016; 20164953091
        • Culligan PJ
        • Heit M.
        Urinary incontinence in women: evaluation and management.
        Am Fam Physician. 2000; 62 (2447, 2452): 2433-2444
        • Price DM
        • Noblett K.
        Comparison of the cough stress test and 24-h pad test in the assessment of stress urinary incontinence.
        Int Urogynecol J. 2012; 23: 429-433
        • Berild GH
        • Kulseng-Hanssen S.
        Reproducibility of a cough and jump stress test for the evaluation of urinary incontinence.
        Int Urogynecol J. 2012; 23: 1449-1453
        • de Tayrac R
        • Letouzey V
        • Triopon G
        • et al.
        [Clinical diagnosis and evaluation of female urinary incontinence].
        J Gynecol Obstet Biol Reprod (Paris). 2009; 38 ([in French]): S153-S165
        • Patnam R
        • Edenfield AL
        • Swift SE
        Standing vs supine; does it matter in cough stress testing?.
        Female Pelvic Med Reconstr Surg. 2017; 23: 315-317
        • Swift S
        • Bent A
        Basic evaluation of the incontinent female patient.
        in: Bent A Cundiff G Swift S Ostergard's urogynecology and pelvic floor dysfunction. 6th ed. Wolters Kluwer Lippincott Williams & Wilkins, Philadelphia, PA2007: 120-141
        • Chen Y
        • Wen JG
        • Shen H
        • et al.
        Valsalva leak point pressure-associated Q-tip angle and simple female stress urinary incontinence symptoms.
        Int Urol Nephrol. 2014; 46: 2103-2108
        • Swift S
        • Barnes D
        • Herron A
        • et al.
        Test-retest reliability of the cotton swab (Q-tip) test in the evaluation of the incontinent female.
        Int Urogynecol J. 2010; 21: 963-967
        • Noblett K
        • Lane FL
        • Driskill CS
        Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and I prolapse?.
        Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16: 268-271
        • Cogan SL
        • Weber AM
        • Hammel JP
        Is urethral mobility really being assessed by the pelvic organ prolapse quantification (POP-Q) system?.
        Obstet Gynecol. 2002; 99: 473-476
        • Mattison ME
        • Simsiman AJ
        • Menefee SA
        Can urethral mobility be assessed using the pelvic organ prolapse quantification system? An analysis of the correlation between point Aa and Q-tip angle in varying stages of prolapse.
        Urology. 2006; 68: 1005-1008
        • Meyer I
        • Szychowski JM
        • Illston JD
        • et al.
        Vaginal swab test compared with the urethral Q-tip test for urethral mobility measurement: a randomized controlled trial.
        Obstet Gynecol. 2016; 127: 348-352
        • Pearce MM
        • Zilliox MJ
        • Rosenfeld AB
        • et al.
        Pelvic Floor Disorders Network. The female urinary microbiome in urgency urinary incontinence.
        Am J Obstet Gynecol. 2015; 213 (e1–11): 347
        • Ward RM
        • Hampton BS
        • Blume JD
        • et al.
        The impact of multichannel urodynamics upon treatment recommendations for female urinary incontinence.
        Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19: 1235-1241
        • Gemer O
        • Bergman M
        • Segal S
        Prevalence of hydronephrosis in patients with genital prolapse.
        Eur J Obstet Gynecol Reprod Biol. 1999; 86: 11-13
        • Cho KJ
        • Kim HS
        • Koh JS
        • et al.
        Evaluation of female overactive bladder using urodynamics: relationship with female voiding dysfunction.
        Int Braz J Urol. 2015; 41: 722-728
        • Nowakowski L
        • Futyma K
        • Zietek A
        • et al.
        Use of free uroflowmetry vs pressure-flow studies in the diagnosis of overactive bladder syndrome in females.
        Eur J Obstet Gynecol Reprod Biol. 2016; 207: 137-140
        • Coskun B
        • Lavelle RS
        • Alhalabi F
        • et al.
        Urodynamics for incontinence after midurethral sling removal.
        Neurourol Urodyn. 2016; 35: 939-943
        • Huang L
        • He L
        • Wu SL
        • et al.
        Impact of preoperative urodynamic testing for urinary incontinence and pelvic organ prolapse on clinical management in Chinese women.
        J Obstet Gynaecol Res. 2016; 42: 72-76
        • Holtedahl K
        • Verelst M
        • Schiefloe A
        • et al.
        Usefulness of urodynamic examination in female urinary incontinence–lessons from a population-based, randomized, controlled study of conservative treatment.
        Scand J Urol Nephrol. 2000; 34: 169-174
        • Vereecken RL.
        A critical view on the value of urodynamics in non-neurogenic incontinence in women.
        Int Urogynecol J Pelvic Floor Dysfunct. 2000; 11: 188-195
        • Nager CW
        • Brubaker L
        • Litman HJ
        • et al.
        A randomized trial of urodynamic testing before stress-incontinence surgery.
        N Engl J Med. 2012; 366: 1987-1997
        • Rachaneni S
        • Latthe P.
        Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis.
        BJOG. 2015; 122: 8-16
        • van Leijsen SA
        • Kluivers KB
        • Mol BW
        • et al.
        Value of urodynamics before stress urinary incontinence surgery: a randomized controlled trial.
        Obstet Gynecol. 2013; 121: 999-1008
        • Royal College of Physicians and Surgeons of Canada
        Objectives of training in the specialty of obstetrics and gynecology, version 2.1, section 5.2.2.41.
        Royal College of Physicians and Surgeons of Canada, Ottawa2016
        • ACOG committee opinion. number 372. July 2007
        The role of cystourethroscopy in the generalist obstetrician-gynecologist practice.
        Obstet Gynecol. 2007; 110: 221-224
        • Han MO
        • Lee NY
        • Park HS
        Abdominal obesity is associated with stress urinary incontinence in Korean women.
        Int Urogynecol J. 2006; 17: 35-39
        • Agur W
        • Rizk DE.
        Obesity and urinary incontinence in women: is the black box becoming grayer?.
        Int Urogynecol J. 2010; 22: 257-258
        • Subak LL
        • Whitcomb E
        • Shen H
        • et al.
        Weight loss: a novel and effective treatment for urinary incontinence.
        J Urol. 2005; 174: 190-195
        • Vissers D
        • Neels H
        • Vermandel A
        • et al.
        The effect of non surgical weight loss interventions on urinary incontinence in overweight women: a systematic review and meta analysis.
        Obes Rev. 2014; 15: 610-617
        • Auwad W
        • Steggles P
        • Bombieri L
        • et al.
        Moderate weight loss in obese women with urinary incontinence: a prospective longitudinal study.
        Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19: 1251-1259
        • Pinto AM
        • Subak LL
        • Nakagawa S
        • et al.
        The effect of weight loss on changes in health-related quality of life among overweight and obese women with urinary incontinence.
        Qual Life Res. 2012; 21: 1685-1694
        • Davis NJ
        • Vaughan CP
        • Johnson TM
        • et al.
        Caffeine intake and its association with urinary incontinence in united states men: results from National and Nutrition Examination Surveys 2005-2006 and 2007-2008.
        J Urol. 2013; 189: 2170-2174
        • Wells MJ
        • Jamieson K
        • Markham TC
        • et al.
        The effect of caffeinated versus decaffeinated drinks on overactive bladder: a double-blind, randomized, crossover study.
        J Wound Ostomy Continence Nurs. 2014; 41: 371-378
        • Friedlander JI
        • Shorter B
        • Moldwin RM
        Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions.
        BJU Int. 2012; 109: 1584-1591
        • Dumoulin C
        • Glazener C
        • Jenkinson D
        Determining the optimal pelvic floor muscle training regimen for women with stress urinary incontinence.
        Neurourol Urodyn. 2011; 30: 746-753
        • Dumoulin C
        • Hay‐Smith J
        Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.
        Cochrane Database Syst Rev. 2010; 1CD005654
        • Polden M
        • Mantle J.
        Physiotherapy in obstetrics and gynaecology.
        Butterworth‐Heinemann, Oxford, United Kingdom1990
        • Cacciari L
        • Dumoulin C
        • Hay-Smith EJ
        • et al.
        Pelvic floor muscle training versus no treatment or inactive control treatments for urinary incontinence in women: a Cochrane review update.
        Neurourol Urodyn. 2017; 36: S270-S271
        • Dumoulin C
        • Hay-Smith EJC
        • Habée-Séguin GM
        Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.
        Cochrane Database Syst Rev. 2014; 5CD005654
        • National Institute for Health and Care Excellence
        Urinary incontinence in women: the management of urinary incontinence in women. National Collaborating Centre for Women's and Children's Health, commissioned by the National Institute for Health and Care Excellence.
        Royal College of Obstetricians and Gynaecologists, London2013 (Available at:)
        • Delneri C
        • Iona L
        • Giorgini T
        • et al.
        Effect of pelvic floor muscle training on sexual function in women with urinary incontinence.
        Neurourol Urodyn. 2016; 35: S12-S13
        • Dumoulin C
        • Adewuyi T
        • Booth J
        • et al.
        Adult conservative management. Committee 12.
        in: Abrams PH Cardoza L Khoury AE International consultation on urinary incontinence, 6th ed. vol 2. Health Publication, Ltd., Plymbridge, United Kingdom2017, pp.: 1443-1462
        • Stewart F
        • Berghmans B
        • Bø K
        • et al.
        Electrical stimulation with non-implanted devices for stress urinary incontinence in women.
        Cochrane Database Syst Rev. 2017; 12CD012390
        • Bertotto A
        • Schvartzman R
        • Uchos A
        • et al.
        Effect of electromyographic biofeedback as an add-on to pelvic floor muscle exercises on neuromuscular outcomes and quality of life in postmenopausal women with stress urinary incontinence: a randomized controlled trial.
        Neurourol Urodyn. 2017; 36: 2142-2147
        • Lukacz ES
        • Santiago-Lastra Y
        • Albo ME
        • et al.
        Urinary incontinence in women: a review.
        JAMA. 2017; 218: 1592-1604
        • Gephart L
        • High R
        • Lewis A
        • et al.
        Comparison of anti-incontinence devices during crossfit exercise.
        Neurourol Urodyn. 2018; 37: S582
        • Best C
        • Diamond P
        • Lovatis D
        A randomized controlled trial of the Uresta continence device: short term Uresta efficacy study (“SURE” study).
        Neurourol Urodyn. 2014; 33: 930-931
        • Lovatsis D
        • Best C
        • Diamond P
        Short-term Uresta efficacy (SURE) study: a randomized controlled trial of the Uresta continence device.
        Int Urogynecol J. 2017; 28: 147-150
        • Richter HE
        • Burgio KL
        • Brubaker L
        • et al.
        Continence pessary compared with behavioural therapy or combined therapy for stress urinary incontinence: a randomized controlled trial.
        Obstet Gynecol. 2010; 115: 609-617