Clinical Evidence Handbook

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Stress Incontinence



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Am Fam Physician. 2010 Mar 15;81(6):773-774.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 709.

Stress incontinence, which involves involuntary leaking of urine on effort, exertion, sneezing, or coughing, affects 17 to 45 percent of adult women.

  • Risk factors include pregnancy (especially with vaginal delivery), smoking, and obesity.

Pelvic floor muscle exercises improve incontinence symptoms compared with no treatment. Pelvic floor electrical stimulation and vaginal cones are also effective compared with no treatment.

  • Pelvic floor electrical stimulation can cause tenderness and vaginal bleeding, whereas vaginal cones can cause vaginitis and abdominal pain. Pelvic floor muscle exercises can cause discomfort.

Estrogen supplements increase cure rates compared with placebo, but there are risks associated with their long-term use. They can be less effective at reducing incontinence compared with pelvic floor muscle exercises.

Selective serotonin reuptake inhibitors (duloxetine at 80 mg per day) reduce the frequency of incontinence at four to 12 weeks compared with placebo or pelvic floor muscle exercises, but increase adverse effects, such as headache and gastric problems.

We do not know whether adrenoceptor agonists improve incontinence compared with placebo or with other treatments, but they can cause insomnia, restlessness, and vasomotor stimulation. Phenylpropanolamine has been withdrawn from the U.S. market because of an increased risk of hemorrhagic stroke.

Open retropubic colposuspension may be more likely to cure stress incontinence than nonsurgical treatments, anterior vaginal repair, or needle suspension at up to five years. Complication rates are similar to those with other surgical procedures.

Suburethral slings and open retropubic colposuspension are equally effective in curing stress incontinence at up to five years.

Tension-free vaginal tape may be as effective as open retropubic colposuspension in curing stress incontinence. Complications of tension-free vaginal tape include bladder perforation.

Transobturator foramen procedures may be as effective as open retropubic colposuspension and tension-free vaginal tape.

Laparoscopic colposuspension and open retropubic colposuspension seem equally effective.

Clinical Questions

What are the effects of nonsurgical treatments for women with stress incontinence?

Likely to be beneficial

Pelvic floor electrical stimulation

Pelvic floor muscle exercises

Selective serotonin reuptake inhibitors (duloxetine)

Vaginal cones

Trade-off between benefits and harms

Estrogen supplements

Unknown effectiveness

Adrenoceptor agonists

What are the effects of surgical treatments for women with stress incontinence?

Beneficial

Laparoscopic colposuspension (similar cure rates to open retropubic colposuspension and TVT)

Open retropubic colposuspension (higher cure rates than nonsurgical treatment, anterior vaginal repair, or needle suspension, and similar cure rates to laparoscopic colposuspension, traditional suburethral slings, transobturator foramen procedures, and TVT)

Suburethral slings other than TVT (similar cure rates to open retropubic colposuspension, TVT, and needle suspension, but more perioperative complications than needle suspension)

Likely to be beneficial

Transobturator foramen procedures (similar cure rates to TVT and open retropubic colposuspension)

Trade-off between benefits and harms

TVT (similar cure rates to laparoscopic colposuspension, non-TVT suburethral slings, transobturator foramen procedures, and open retropubic colposuspension, but associated with more bladder and vaginal perforations)

Unlikely to be beneficial

Anterior vaginal repair (lower cure rates than open retropubic colposuspension, but similar cure rates to needle suspension)

Needle suspension (lower cure rates and more surgical complications than open retropubic colposuspension)


TVT = tension-free vaginal tape.

Clinical Questions

View Table

Clinical Questions

What are the effects of nonsurgical treatments for women with stress incontinence?

Likely to be beneficial

Pelvic floor electrical stimulation

Pelvic floor muscle exercises

Selective serotonin reuptake inhibitors (duloxetine)

Vaginal cones

Trade-off between benefits and harms

Estrogen supplements

Unknown effectiveness

Adrenoceptor agonists

What are the effects of surgical treatments for women with stress incontinence?

Beneficial

Laparoscopic colposuspension (similar cure rates to open retropubic colposuspension and TVT)

Open retropubic colposuspension (higher cure rates than nonsurgical treatment, anterior vaginal repair, or needle suspension, and similar cure rates to laparoscopic colposuspension, traditional suburethral slings, transobturator foramen procedures, and TVT)

Suburethral slings other than TVT (similar cure rates to open retropubic colposuspension, TVT, and needle suspension, but more perioperative complications than needle suspension)

Likely to be beneficial

Transobturator foramen procedures (similar cure rates to TVT and open retropubic colposuspension)

Trade-off between benefits and harms

TVT (similar cure rates to laparoscopic colposuspension, non-TVT suburethral slings, transobturator foramen procedures, and open retropubic colposuspension, but associated with more bladder and vaginal perforations)

Unlikely to be beneficial

Anterior vaginal repair (lower cure rates than open retropubic colposuspension, but similar cure rates to needle suspension)

Needle suspension (lower cure rates and more surgical complications than open retropubic colposuspension)


TVT = tension-free vaginal tape.

Definition

Stress incontinence is involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Stress incontinence predominantly affects women, and can cause social and hygiene problems. Typically, there is no anticipatory feeling of needing to urinate. Under urodynamic testing, urodynamic stress incontinence is confirmed by demonstrating loss of urine when intravesical pressure exceeds maximum urethral pressure, in the absence of a detrusor contraction. A confirmed diagnosis of urodynamic stress incontinence is particularly important before surgical treatment, because symptoms can occur in persons with detrusor overactivity, which is confirmed by the demonstration of uninhibited bladder contractions. This review deals with stress incontinence in general.

Incidence and Prevalence

Stress incontinence is a common problem. Prevalence has been estimated at 17 to 45 percent of adult women in resource-rich countries. One cross-sectional study (15,308 women in Norway, younger than 65 years) found that the prevalence of stress incontinence was 4.7 percent in women who had not given birth, 6.9 percent in women who had cesarean deliveries only, and 12.2 percent in women who had vaginal deliveries only.

Etiology and Risk Factors

Etiological factors include pregnancy, vaginal or cesarean delivery, cigarette smoking, and obesity. The cross-sectional study found that, when compared with women who had not given birth, the risk of stress incontinence was increased in women who had a cesarean delivery (age-adjusted odds ratio [OR] = 1.4; 95% confidence interval [CI], 1.0 to 2.0) or a vaginal delivery (age-adjusted OR = 3.0; 95% CI, 2.5 to 3.5). The risk of stress incontinence was also increased in women who had a vaginal delivery compared with women who had a caesarean delivery (adjusted OR = 2.4; 95% CI, 1.7 to 3.2). One case-control study (606 women) found that the risk of genuine (now called urodynamic) stress incontinence was increased in former smokers (adjusted OR = 2.20; 95% CI, 1.18 to 4.11) and in current smokers (adjusted OR = 2.48; 95% CI, 1.60 to 3.84). The risks associated with obesity are unclear.

Prognosis

The natural history of stress incontinence is unclear. Untreated stress incontinence is believed to be a persistent, lifelong condition.

Author disclosure: Nothing to disclose.


search date: June 2008.

Adapted with permission from Onwude JL. Stress incontinence. Clin Evid Handbook. December 2009:649–651. Please visit http://www.clinicalevidence.bmj.com for full text and references.

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.

A collection of Clinical Evidence Handbook published in AFP is available at http://www.aafp.org/afp/bmj.


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