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Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update
Comparative Effectiveness Review, No. 212
Investigators: Ethan Balk, M.D., M.P.H., Gaelen P. Adam, M.L.I.S., Hannah Kimmel, M.P.H., Valerie Rofeberg, Sc.M., Iman Saeed, Sc.M., Peter Jeppson, M.D., and Thomas Trikalinos, M.D.
Author Information and AffiliationsStructured Abstract
Introduction:
About 17 percent of adult women have had urinary incontinence (UI), classified as stress, urgency, or mixed. Stress UI is associated with an inability to retain urine with activities that increase intraabdominal pressure. Urgency UI is associated with the sudden, compelling urge to void. Mixed UI occurs when both are present.
Methods:
We updated the Agency for Healthcare Research and Quality’s 2012 systematic review with new literature searches in MEDLINE®, the Cochrane Central Trials Registry, the Cochrane Database of Systematic Reviews, and Embase® from 2011 through December 4, 2017. We included UI outcomes (cure, improvement, satisfaction), quality of life, and adverse events. For UI outcomes, we conducted network meta-analyses, combining direct and indirect comparisons across studies. Quality of life and adverse event outcomes are narratively described.
Results:
We identified 233 eligible studies, of which 140 reported on UI outcomes, 96 on quality of life, and 127 on adverse events. Studies evaluated 16 categories of interventions with 53 specific interventions. Fourteen intervention categories have been evaluated for UI outcomes; all except hormones and periurethral bulking agents were more effective to achieve at least one favorable UI outcome than no treatment (variable strength of evidence [SoE]). Among 1st or 2nd line interventions for stress UI, behavioral therapy (BT, alone and in combination with hormones) was more effective than either alpha agonists or hormones to achieve cure or improvement (moderate SoE); alpha agonists were more effective than hormones to achieve improvement (moderate SoE). Among treatments used as 1st or 2nd line interventions for urgency UI, BT was significantly more effective than anticholinergics to achieve cure or improvement (high SoE). Among 3rd line interventions for stress UI, intravesical pressure release, but not periurethral bulking agents, was more effective than no treatment (variable SoE). Neuromodulation, which is commonly used for treatment of urgency UI, is more effective than no treatment of stress UI for cure, improvement, and satisfaction (high SoE). Among studies of women with only stress UI, indirect evidence suggests that intravesical pressure release is more effective to achieve improvement than combination BT and neuromodulation, and triple combination neuromodulation, hormones, and BT may be more effective than either periurethral bulking or combination neuromodulation and BT (all low SoE). Among treatments used as 3rd line interventions for urgency UI, both neuromodulation and onabotulinum toxin A (BTX) are more effective than no treatment (high SoE), and BTX may be more effective than neuromodulation to achieve cure (low SoE). BT, neuromodulation, and anticholinergics resulted in better quality of life than no treatment (low SoE). Urinary tract infections (UTIs) were reported in 11 percent of women receiving transcutaneous electrical nerve stimulation and erosion in 1.6 percent of women with the periurethral bulking agent macroplastique (low SoE). Dry mouth was the most commonly reported adverse event for the anticholinergic oxybutynin (36%) and the alpha agonist duloxetine (13%) (high SoE). BTX was associated with UTIs (36%) and urinary retention (10% to 20%) (moderate SoE). Constitutional adverse events (e.g., nausea, insomnia, fatigue) were common with duloxetine (moderate SoE).
Conclusions:
Network meta-analyses demonstrated that most nonpharmacological and pharmacological interventions are more likely than no treatment to improve UI outcomes and quality of life. BT, alone or in combination with other interventions, is generally more effective than 2nd line (pharmacological) therapies alone for both stress and urgency UI. Common adverse events with pharmacological treatments include dry mouth, nausea, and fatigue. BTX is associated with urinary infections and retention. Periurethral bulking agents are associated with erosion and need for surgical removal. Large gaps remain in the literature regarding head-to-head comparisons of individual interventions.
Contents
- Preface
- Acknowledgments
- Evidence Summary
- Introduction
- Methods
- Contextual Question
- Results
- Overview of the Evidence Base Addressing All Key Questions
- Key Questions 1 to 4. Network Meta-Analyses for Urinary Incontinence Outcomes Across All Interventions
- Key Question 1. What are the benefits and harms of nonpharmacological treatments of UI in women, and how do they compare with each other?
- Key Question 2. What are the benefits and harms of pharmacological treatments of UI in women, and how do they compare with each other?
- Key Question 3. What are the comparative benefits and harms of nonpharmacological versus pharmacological treatments of UI in women
- Key Question 4. What are the benefits and harms of combined nonpharmacological and pharmacological treatment of UI in women?
- Discussion
- Appendixes
- Appendix A. Literature Search Strategy
- Appendix B. Excluded Studies
- Appendix C. Design, Arm Details, and Baselines
- Appendix D. Risk of Bias
- Appendix E. Quality of Life
- Appendix F. Adverse Events
- Appendix G. Urinary Incontinence Results for Individual Interventions
- Appendix H. Results of Subgroup Analyses by Type of UI
- Appendix I. Expert Guidance and Review
- Appendix J. Network Meta-Analysis Model and Inconsistency Analysis Results
- Appendix K. PCORI Methodology Standards Checklist
- Report References
Suggested citation:
Balk E, Adam GP, Kimmel H, Rofeberg V, Saeed I, Jeppson P, Trikalinos T. Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update. Comparative Effectiveness Review No. 212. (Prepared by the Brown Evidence-based Practice Center under Contract No. 290-2015-00002-I for AHRQ and PCORI.) AHRQ Publication No. 18-EHC016-EF. PCORI Publication No. 2018-SR-03. Rockville, MD: Agency for Healthcare Research and Quality; August 2018. Posted final reports are located on the Effective Health Care Program search page. https://doi.org/10.23970/AHRQEPCCER212.
This report is based on research conducted by the Brown Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00002-I). The Patient Centered Outcomes Research Institute (PCORI) funded the report (PCORI Publication No. 2018-SR-03). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ or PCORI. Therefore, no statement in this report should be construed as an official position of PCORI, AHRQ, or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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 the application of 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 is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.
PCORI, AHRQ, or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at: www.effectivehealthcare.ahrq.gov.
Persons using assistive technology may not be able to fully access information in this report. For assistance contact vog.shh.qrha@cpe.
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