Primary Care Corner with Geoffrey Modest MD: Guidelines for incontinence

By: Dr. Geoffrey Modest 

The Am College of Physicians released practice guidelines for the nonsurgical management of urinary incontinence in women (see doi:10.7326/M13-2410​).

Baseline issues:

–urinary incontinence is really common: 25% in women aged 14-21; 44-57% in middle-aged and postmenopausal women aged 40-60; 75% in those >75 yo (though likely that these numbers reflect under-reporting)

–risk factors: pregnancy, pelvic floor trauma after vaginal delivery, menopause, hysterectomy, obesity, UTI, functional and/or cognitive impairment, chronic cough, constipation

–2 main types: stress incontinence from urethral sphincter failure with increased intra-abdominal pressure (e.g. from laughing, coughing, sneezing) and urge incontinence from involuntary loss of urine from compelling urge to void. There are also mixed incontinence and overactive bladder (with urinary urgency with or without incontinence, typically with frequency and nocturia). No comment in guidelines on overflow incontinence.

Most women do not volunteer that they are incontinent — clinicians need to ask!!

 Recommendations:

  1. Stress incontinence: first-line treatment is pelvic floor muscle training — e.g. Kegel exercises (strong recommendation, high-quality evidence).

–these exercises work well (5 times more effective than no active treatment) and NNT (number needed to treat) in pooled data is 2. Added use of biofeedback using a vaginal electromyography probe also works with NNT of 3 (low-quality evidence, but high quality evidence for urge incontinence). Insufficient data for other treatments (pessaries, other devices).

  1. Urge incontinence: bladder training – e.g. progressively lengthening the time between voiding(strong rec, moderate-quality evidence).

–low-quality evidence that bladder training improves urge incontinence (NNT=2), data on complete continence was insufficient

  1. mixed incontinence: both pelvic floor muscle and bladder training (strong rec, moderate-quality evidence)

–using both trainings, NNT=6 to achieve continence, NNT=3 to improve continence

  1. NOT use systemic meds for stress incontinence

–as opposed to systemic drugs, vaginal estrogen preparations do help (NNT=5). One low-quality study found additional efficacy of vaginal estrogens plus Kegel’s. (They did not comment that vaginal estrogens are only for postmenopausal women, though I’m sure that’s what they meant, and their 2 references are for postmenopausal women).

  1. Use meds for urge incontinence if bladder training unsuccessful. Choose med by tolerability, adverse effect profile, ease of use, and cost (strong rec, high-quality evidence)

— There was moderate-to-high quality evidence that the following antimuscarinic agents achieved continence with NNT=8-9: darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin, solifenacin (Vesicare), tolterodine, and trospium.

–of these, I tend to use trospium first (prior review a few years ago found higher likelihood of success, see Ann Intern Med. 2012;156:861-874), then the other 2 generics: tolterodine and oxybutynin (tolterodine is my second choice, since it seems to be better tolerated). The present guidelines do not find much difference between these 3 (though I also find that sometimes when one does not work, another does). There is moderate-quality evidence that fesoterodine achieved continence more than tolterodine.

–if these fail, consider using the b3-adrenoreptor agonist mirabegron (Myrbetriq), which has moderate-quality evidence that it works with NNT=12 (I have never used this, so cannot personally comment)

​–most common adverse events from antimuscarinics were dry mouth, constipation, blurred vision. Also insomnia (esp. with oxybutynin). Dizziness (esp. with trospium). Drug discontinuation rates from adverse effects were higher for fesoterodine and oxybutynin than tolterodine.

  1. Weight loss and exercise help for obese women with urge incontinence

So, I think this is a reasonable approach. Begin with non-pharmacologic therapies (which seem to work really well for about 1/2 of the women I’ve seen), then progress to meds if needed. Topical estrogens also decrease UTI recurrences in women with atrophic vaginitis and frequent UTIs, which commonly goes along with incontinence (i.e., both are common in postmenopausal women). And I have almost always found significant improvement with one of the generic antimuscarinics: trospium, tolterodine, oxybutynin.

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