A Straightforward Guideline for a Common Primary Care Problem: Urinary Incontinence in Women
The numbers speak for themselves. Urinary incontinence (UI)—the involuntary loss of urine—affects 44% to 57% of middle-aged and postmenopausal women, and as many as 75% of elderly women.1 This month’s Top Paper1 emphasizes that these statistics are in fact an underestimate. One study found that half of incontinent women do not even tell their physicians about the problem.
Framing the discussion in dollars and cents (an increasingly common way to do things), shows that in 2004, incontinence cost $19.5 billion.1 Furthermore, UI is responsible for 6% of nursing home placements for elderly women, which translates into another $3 billion.1 The American College of Physicians (ACP) has published a clinical practice guideline that will help primary care physicians manage this all-too-common problem with evidence-based direction.
Understanding Urinary Incontinence
There are 3 types of UI: stress, urgency, and a mixture of the two. Stress incontinence is a result of urethral sphincter failure during periods of increased intra-abdominal pressure (eg, coughing). Urgency incontinence is leakage associated with a sudden urge to void.
The ACP makes the following recommendations:
1. First line treatment for stress UI is pelvic floor muscle training. (PFMT).
2. Bladder training is the first choice for urgency incontinence.
3. Both PFMT and bladder training should be used in women with mixed UI.
4. The ACP recommended against pharmacological therapy for stress UI.
5. Pharmacological therapy can be used in women with urgency UI if bladder training is unsuccessful.
6. Weight loss and exercise can help obese women with UI.
Treatment
Pharmacological treatments have been studied as successful therapy for urgency UI. For example, vaginal estrogen tablets and ovules were more effective than placebo as treatments. High quality evidence has also demonstrated that darifenacin improved UI more than placebo. Moderate quality evidence showed that fesoterodine was superior to placebo for UI. High quality evidence also supports oxybutynin, solifenacin, tolterodine, and trospium in the same situations.
The side effects of the antimuscarinic drugs are predictable and include dry mouth, constipation, and blurred vision. Occasionally, dizziness (more often with trospium) and insomnia (predominantly with oxybutynin) occur and can be severe. Therefore, discontinuation because of these side effects is not uncommon; a higher discontinuation rate is seen with fesoterodine and oxybutynin.
WHat’s the “Take Home”?
Primary care practitioners need to be proactive and ask women about UI. If 50% of sufferers are not bringing the topic up, we need to broach the subject. And, despite the usual plethora of pharmaceutical advertisements of drugs used to treat urgency UI, there are some common caveats.
First, no prescriptions should be given for stress UIs. Second, in urgency or mixed UIs, nonpharmalogical treatment comes first. If pharmacological treatment is used, there are side effects and discontinuation is common. ■
Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.
Reference:
1.Qaseem A, Dallas P, Forciea A, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161:429-440.