menu-iconMore mobile-close-icon
Skip Navigation
Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Recommendations for the management of urge urinary incontinence in women.
Bibliographic Source(s)
University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations for the management of urge urinary incontinence in women. Austin (TX): University of Texas at Austin, School of Nursing; 2010 May. 9 p. [24 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations for the management of stress and urge urinary incontinence in women. Austin (TX): University of Texas at Austin, School of Nursing; 2002 May. 13 p. [19 references]

Scope

Disease/Condition(s)

Urge urinary incontinence

Guideline Category
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Nursing
Obstetrics and Gynecology
Surgery
Urology
Intended Users
Advanced Practice Nurses
Nurses
Pharmacists
Physician Assistants
Physicians
Guideline Objective(s)
  • To aid practitioners in making decisions about appropriate care for women with urinary urge incontinence
  • To consider the best available evidence for evaluating and treating urinary urge incontinence in women
Target Population

Women with urge urinary incontinence

Interventions and Practices Considered

Management/Treatment

  1. Absorbent products
  2. Lifestyle changes:
    • Weight loss
    • Dietary changes
    • Smoking cessation
  3. Behavioral modification:
    • Bladder training
    • Pelvic floor muscle rehabilitation (PFMR)
    • Biofeedback
    • Weighted vaginal cones
  4. Medical management
    • Anticholinergic agents (oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, and darifenacin)
    • Tricyclic antidepressants (not recommended in older patients)
    • Botulinum toxin (considered but no recommendation made for or against)
  5. Neurologic stimulation therapy
    • Noninvasive electrical stimulation (considered but no recommendation made for or against)
    • Sacral nerve stimulation (SNS) (considered but no recommendation made for or against)
    • Percutaneous tibial nerve stimulation (PTNS)
  6. Surgical treatments
    • Cystoplasty (for severe cases only)
Major Outcomes Considered
  • Number of voids per day
  • Leakage episodes
  • Cure rate
  • Relapse rate
  • Treatment adherence
  • Duration of improvement
  • Quality of life
  • Patient satisfaction
  • Adverse effects of medications

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The MEDLINE database, the Cochrane Library, UpToDate, CINAHL, American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin were used to conduct a literature search to locate relevant articles published between 2005 and present. The search was restricted to articles published in the English language. The reference tool by the International Continence Society was also reviewed.

Number of Source Documents

Seventeen articles and/or guidelines were reviewed.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor).

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. The USPSTF found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.

B. The USPSTF recommends that clinicians provide the service to eligible patients. The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or against routine provision of the service. The USPSTF found at least fair evidence that the service can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing the service to asymptomatic patients. The USPSTF found at least fair evidence that the service is ineffective or that harms outweigh benefits.

I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. Evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

A draft guideline was developed by a team of family nurse practitioner students based on current research. The guideline was then submitted for review to the Family Nurse Practitioner Program faculty and community physician experts. Revisions were made after recommendations were received.

Recommendations

Major Recommendations

Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of the "Major Recommendations" field.

Absorbent Products: the most common method used to manage urinary incontinence. Useful in managing mild symptoms. Not a curative treatment method. (Grade A, Evidence Fair) (DuBeau, "Treatment," 2009)

Lifestyle Changes

  • Weight loss: recommended as noninvasive therapy. Outcomes were better when looking at stress versus urge incontinence, and obese versus overweight, but still effective. Formerly obese patients were shown to have improved outcomes after weight loss. (Grade A, Evidence Fair) (DuBeau, "Treatment," 2009; Holroyd-Leduc & Straus, 2004; American College of Obstetricians and Gynecologists [ACOG], 2005)
  • Dietary changes: recommended as noninvasive therapy. The elimination of bladder irritants from the diet has not been rigorously evaluated. (Grade A, Evidence Fair) (DuBeau,"Treatment," 2009; DuBeau, "Clinical," 2009; ACOG, 2005)
  • Smoking cessation: recommended as noninvasive therapy. Risk for urge incontinence is greatest for current smokers and less but still present for former smokers. (Grade A, Evidence Fair) (DuBeau, "Treatment," 2009; DuBeau, "Clinical," 2009; Holroyd-Leduc & Straus, 2004; ACOG, 2005)

Behavioral Modification

  • Bladder training: recommended as noninvasive therapy. It is beneficial in treating urge incontinence though it is suggested that it should be supplemented with other therapies. (Grade A, Evidence Good) (DuBeau, "Treatment," 2009; DuBeau, "Clinical," 2009; Dumoulin & Hay-Smith, 2010; Holroyd-Leduc & Straus, 2004; ACOG, 2005; Tran, Levin, & Mousa, 2009)
  • Pelvic floor muscle rehabilitation (PFMR): recommended as a noninvasive therapy. It appears to be an effective treatment for women with urge incontinence. Services can be provided by primary care provider, obstetrician/gynecologist (OB/GYN), urologist, or physical therapist. (Grade A, Evidence Good) (DuBeau, "Treatment," 2009; Dumoulin & Hay-Smith, 2010; Holroyd-Leduc & Straus, 2004; Surwit, Campbell, & Karaszewski, 2009; ACOG, 2005; Tran, Levin, & Mousa, 2009)
  • Biofeedback: recommended as noninvasive therapy. Although it is helpful in improving urge incontinence, it is best when supplemented with bladder training and/or pelvic floor muscle rehabilitation. Biofeedback can be provided by an OB/GYN, urologist or physical therapist. (Grade A, Evidence Fair) (DuBeau, "Treatment," 2009; DuBeau, "Clinical," 2009; Holroyd-Leduc & Straus, 2004; ACOG, 2005)
  • Weighted vaginal cones: recommended as noninvasive therapy. Small trials show some efficacy compared to no treatment. (Grade B, Evidence Fair) (DuBeau, "Treatment," 2009; Holroyd-Leduc & Straus, 2004)

Medical Management

  • Anticholinergic agents (oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, and darifenacin): Anticholinergic medications, especially oxybutynin and tolterodine, may have a beneficial effect on improving symptoms of detrusor overactivity in women. Anticholinergic side effects decrease compliance. (Grade A, Evidence Good) (Abrams & Andersson, 2007; Chapple et al., 2008; DuBeau, "Treatment," 2009; Herschorn et al., 2010; Holroyd-Leduc & Straus, 2004; Kelleher et al., 2008; Lam & Hilas, 2007; Van Kerrebroeck et al., 2009; Weiss, 2005)
  • Tricyclic antidepressants (imipramine): anticholinergic activity may be effective in treatment of urge incontinence. Not recommended in use in older patients in whom anticholinergic adverse effects and orthostatic hypotension may be significant. (Grade B, Evidence Good) (Abrams & Andersson, 2007; DuBeau, "Treatment," 2009)
  • Botulinum toxin: considered an investigative treatment for urge incontinence. Data is limited on optimal technique and appropriate dosing. (Grade C, Evidence Fair) (Campbell et al., 2009; DuBeau, "Treatment," 2009; Flynn et al., 2009; Lazzeri & Spinelli, 2006; McKertich, 2008)
  • Noninvasive electrical stimulation: reported to have some efficacy for urge incontinence. (Grade C, Evidence Fair) (DuBeau, "Treatment," 2009)
  • Sacral Nerve Stimulation (SNS): utilized in cases of refractory urge incontinence. Case series have reported long-term positive results. Surgical treatment of urge incontinence is recommended only in severe cases of intractable urge incontinence. (Grade C, Evidence Good) (Chen, 2009; DuBeau, "Treatment," 2009; Leng & Morrisroe, 2006; Weiss, 2005)
  • Percutaneous Tibial Nerve Stimulation (PTNS): found to be moderately effective in the treatment of urge incontinence. PTNS in combination with pelvic floor muscle rehabilitation is found to be very effective in the treatment of urge incontinence. (Grade B, Evidence Fair) (DuBeau, "Treatment," 2009; Surwit, Campbell, & Karaszewski, 2009)

Surgical Treatments

Cystoplasty: utilized in cases of refractory urge incontinence. Surgical treatment of urge incontinence is recommended only in severe cases of intractable urge incontinence. (Grade C, Evidence Good) (Campbell et al., 2009; DuBeau, "Treatment," 2009; Holroyd-Leduc & Straus, 2004; McKertich, 2008)

Expert Recommendation

Patients with urinary incontinence should undergo a basic evaluation that includes a history, physical examination, measurement of postvoid residual volume, and urinalysis. (Grade A, Evidence Good)

Definitions:

Strength of Recommendation (Based on U.S. Preventive Services Task Force [USPSTF] Ratings)

A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. The USPSTF found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.

B. The USPSTF recommends that clinicians provide the service to eligible patients. The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or against routine provision of the service. The USPSTF found at least fair evidence that the service can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing the service to asymptomatic patients. The USPSTF found at least fair evidence that the service is ineffective or that harms outweigh benefits.

I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. Evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Quality of Evidence (Based on USPSTF Ratings)

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor).

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is specifically stated for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate and effective management of urge urinary incontinence in women
  • Improved quality of life in women with a diagnosis of urge urinary incontinence
Potential Harms

Medical Intervention

  • There are no significant risks associated with the use of noninvasive treatments of urge incontinence. These interventions consist of patient commitment to lifestyle and behavioral changes. Though there are no risks associated, financial cost to the patient may be a limitation.
  • The response to pharmacologic treatment often is variable, and side effects are common. The most common side effects of anticholinergic therapy are dry mouth, blurred vision, constipation, drowsiness, and tachycardia. These side effects are the main factors that lead to a high rate of patient discontinuation of medication within six months of treatment.
  • Botulinum toxin is an investigative treatment. At this time there has not been enough research to develop a standard technique for administration and an appropriate dosage. Patients will require reinjections every 6-12 months. Botulinum toxin can result in urinary retention and increased risk for urinary tract infection (UTI). Botulinum toxin is not yet U.S. Food and Drug Administration (FDA) approved for the treatment of urinary incontinence.

Surgical Intervention

  • The mechanism of action of sacral nerve stimulation (SNS) is unknown. Adverse events related to SNS have included lead migration, pain at lead site, infection and transient electrical shock.
  • Cystoplasty is a surgical procedure associated with high morbidity and is reserved for those patients with severe incontinence.

Contraindications

Contraindications
  • Oxybutynin. Hypersensitivity to drug/class, urinary retention, gastric retention, and narrow angle glaucoma
  • Tolterodine. Hypersensitivity to drug/class, urinary retention, gastric retention, and narrow angle glaucoma
  • Fesoterodine. Hypersensitivity to drug/class, urinary retention, gastric retention, narrow angle glaucoma, and severe hepatic impairment
  • Trospium. Hypersensitivity to drug/class, urinary retention, gastric retention, and narrow angle glaucoma
  • Solifenacin. Hypersensitivity to drug/class, urinary retention, gastric retention, and narrow angle glaucoma
  • Darifenacin. Hypersensitivity to drug/class, urinary retention, gastric retention, and narrow angle glaucoma

Qualifying Statements

Qualifying Statements

These guidelines are provided for educational purposes and should not be viewed as an exclusive course of treatment. Treatment plans should be developed based on individual patient needs.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations for the management of urge urinary incontinence in women. Austin (TX): University of Texas at Austin, School of Nursing; 2010 May. 9 p. [24 references]
Adaptation

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

Date Released
2002 May (revised 2010 May)
Guideline Developer(s)
University of Texas at Austin School of Nursing, Family Nurse Practitioner Program - Academic Institution
Source(s) of Funding

University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program

Guideline Committee

University of Texas at Austin Family Nurse Practitioner Student Practice Guidelines Committee

Composition of Group That Authored the Guideline

Authors: Shannon O'Neill, RN, MSN; Sara Strother, RN, BSN, MSN; Kitty Woo Ham, RN, MSN

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations for the management of stress and urge urinary incontinence in women. Austin (TX): University of Texas at Austin, School of Nursing; 2002 May. 13 p. [19 references]

Guideline Availability

Electronic copies: None available.

Print copies: Available from the University of Texas at Austin, School of Nursing. 1700 Red River, Austin, Texas, 78701-1499, Attn: Nurse Practitioner Program

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on October 3, 2002. The information was verified by the guideline developer on October 16, 2002. This summary was updated by ECRI Institute on November 2, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This NGC summary was updated by ECRI Institute on October 21, 2010. This NGC summary was updated by ECRI Institute on October 21, 2010.

Copyright Statement

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

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...