Urinary Incontinence in Females

Treatment of urinary incontinence is a specialty in physical therapy and the medical community.

While not everyone treats this diagnosis, most clinicians will work with women who have urinary incontinence at some point. It may be mild (occurring occasionally with intense coughing) or it may be more advanced (accidents every day). Many will ask for our advice and guidance on how to overcome this issue. It is important to have a basic understanding of how to guide the patient towards treatment.

The prevalence of urinary incontinence (UI) ranges from 25% in females 14 to 21 years of age to 75% in women 75 years and older, although it may actually be higher than reported because some evidence has shown that one-half or more of women with UI do not tell their physicians about symptoms. There is an increased risk of UI with pregnancy and with pelvic floor trauma from delivering vaginally, as well as in women who are menopausal or obese; who have a urinary tract infection, functional or cognitive impairment, chronic cough, or constipation; or who have had a hysterectomy.

There are two categories of UI: stress, which is caused when the urethral sphincter does not work because of intra-abdominal pressure, and urgency, which is associated with the urgent need to urinate. Stress UI can cause urine to leak when laughing, coughing, or sneezing. Mixed UI is stress and urgency UI combined.

The American College of Physicians (ACP) has provided recommendations for nonsurgical treatment of UI in women. Treatment of UI is aimed at achieving, or at least improving symptoms. It is deemed effective if it reduces the number of episodes by at least one-half.

American College of Physicians Guidelines Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the nonsurgical management of urinary incontinence (UI) in women. Methods: This guideline is based on published English-language literature on nonsurgical management of UI in women from 1990 through December 2013 that were identified using MEDLINE, the Cochrane Library, Scirus, and Google Scholar. The outcomes evaluated for this guideline include continence, improvement in UI, quality of life, adverse effects, and discontinuation due to adverse effects. It grades the evidence and recommendations by using ACP’s guideline grading system. The target audience is all clinicians, and the target patient population is all women with UI.

Recommendation 1: ACP recommends first-line treatment with pelvic floor muscle training in women with stress UI. (Grade: strong recommendation, high-quality evidence)

Recommendation 2: ACP recommends bladder training in women with urgency UI. (Grade: weak recommendation, low-quality evidence)

Recommendation 3: ACP recommends pelvic floor muscle training with bladder training in women with mixed UI. (Grade: strong recommendation, high-quality evidence)

Recommendation 4: ACP recommends against treatment with systemic pharmacologic therapy for stress UI. (Grade: strong recommendation, low-quality evidence)

Recommendation 5: ACP recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful. Clinicians should base the choice of pharmacologic agents on tolerability, adverse effect profile, ease of use, and cost of medication. (Grade: strong recommendation, high-quality evidence)

Recommendation 6: ACP recommends weight loss and exercise for obese women with UI. (Grade: strong recommendation, moderate-quality evidence)

Summary of Recent Research

Nonpharmacologic therapies were effective at managing UI, had a large magnitude of benefit for increasing continence rates, and were associated with a low risk for adverse effects.

Pelvic floor muscle training alone and in combination with bladder training or biofeedback and weight loss with exercise for obese women were effective at achieving continence and improving UI. Evidence was insufficient to compare nonpharmacologic therapies with one another or with pharmacologic therapies; head-to-head comparisons would be useful. Am Fam Physician. 2015 Jun 1;91(11):801-802 Pelvic floor muscle training (PFMT) is considered first-line therapy for urinary stress incontinence. In PFMT, women learn exercises to strengthen the voluntary urethral sphincter and levator ani muscles. For PFMT to be effective, it is important that the patient learn to correctly contract her muscles without straining, which increases abdominal pressure. In a systematic review of nonsurgical therapy, PFMT improved stress urinary incontinence episodes. Outcomes were even better when PFMT was combined with biofeedback and when skilled therapists directed the treatment.

Shamliyna TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148(6):459-473. PMID: 18268288

Key Points for Practice

  • PFMT and bladder training is recommended for women with stress and urgency UI, respectively.
  • Pharmacologic therapy with anticholinergics or beta3-adrenoceptor agonists is indicated upon failure of bladder training for patients with urgency UI.
  • Lifestyle modifications including weight loss and exercise are recommended, especially in women with UI who are obese.

While you may not treat this common condition, knowing where to guide patients will help them to receive the least invasive and most effective solutions.

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