DiagnostiCriteria: Incontinence in women

Major Recommendations

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of the publication date. However, because EAU updates their guidelines frequently, users may wish to consult the EAU Web site for the most current version available.
Note from the National Guideline Clearinghouse (NGC) and the European Association of Urology (EAU): Following the complete updating for print in 2009 of the EAU Guidelines on Urinary Incontinence, the Incontinence Guidelines Writing Panel considered it helpful to provide an addendum to the Guidelines on the role of weight loss in urinary incontinence. Recent high-quality scientific publications underpin the statements made here. The new recommendation is labeled 2010 Addendum.
Levels of evidence (1a-4) and the grades of recommendations (A-C) are provided at the end of the "Major Recommendations" field.

Initial Assessment
Initial assessment should triage patients into those with a 'complicated' incontinence, who require referral for specialised management and those suitable for general assessment. The 'complicated' incontinence group comprises patients with:

Pain
Haematuria
Recurrent infections
Voiding dysfunction
Significant pelvic organ prolapse
Failed previous incontinence surgery
Previous pelvic radiotherapy
Previous pelvic surgery
Suspected fistula

The remaining patients, with a history of urinary incontinence (UI) identified by initial assessment, can be stratified into three main symptomatic groups of women suitable for initial primary care management:

Stress incontinence
Overactive bladder (OAB) symptoms: urgency with or without urgency incontinence, frequency and nocturia
Mixed urgency and stress incontinence

Routine physical examination includes abdominal, pelvic and perineal examinations. Women should perform a 'stress test' (cough and strain) to detect leakage secondary to sphincter incompetence. Any pelvic organ prolapse (POP) or urogenital atrophy must be assessed. It is also important to assess voluntary pelvic floor muscle function by vaginal or rectal examination before teaching pelvic floor muscle training (PFMT).
Initial Treatment of UI in Women
For women with stress, urgency or mixed urinary incontinence, initial treatment includes appropriate lifestyle advice, physical therapy, a scheduled voiding regime, behavioral therapy and medication. Some recommendations are based on good and consistent evidence of effect. However, many other recommendations are based on insufficient level 1 or 2 evidence and are essentially hypotheses requiring better evidence of their benefit.
Table: Initial Treatment for UI in Women

Treatment	GR
Lifestyle interventions
For morbidly and moderately obese women, weight loss helps to reduce UI prevalence.	A
Caffeine intake reduction may benefit UI symptoms.	B
A decrease in fluid intake should only be tried in patients with abnormally high fluid intakes, as a decrease in fluids may lead to UTIs, constipation, or dehydration.	C
Crossing the legs and bending forward can help to reduce leakage during coughing or other provocations.	C
Pelvic floor muscle training: general considerations
PFMT should be offered as first-line conservative therapy to women with stress, urgency, or mixed UI.	A
Provide the most intensive PFMT programme possible (i.e., amount of exercise and of health professional supervision) within service constraints, as health-professional or supervised programmes are more effective than self-directed programmes. In addition, greater health professional contact is better than less.	A
The addition of biofeedback to the PFMT programme does not appear to be of benefit:
Clinic biofeedback	A
Home-based biofeedback	B
Vaginal cones
VC may be offered to women with SUI or MUI.
VC can be offered as first-line conservative therapy to those who can, and are prepared to use them.	B
VC may not be helpful because of side-effects and discomfort.
VC and EStim seem equally effective in SUI and MUI, but the usefulness of VC and Estim is limited because of side-effects and discomfort.	B
Electrical stimulation
EStim may be offered to women with SUI, UUI or MUI.
For treating SUI, 6 months of EStim, 50 Hz twice daily at home, may be better than no treatment.	C
Low-intensity home-based EStim daily for 6 months may be better than 16 sessions of maximal clinic-based Estim.	C
For treating UUI secondary to DO, 9 weeks of EStim, 4-10 Hz twice daily at home, might be better than no treatment.	C
Addition of EStim to a biofeedback-assisted PFMT programme does not appear to add benefit.	C
EStim may have limited usefulness, because some women cannot use it (due to contraindications), have difficulty using it, or dislike it.
Magnetic stimulation
MStim should only be used as part of a clinical trial as its benefit has not been established.	NR
Bladder training
BT is an appropriate first-line treatment for UUI in women.	A
Either BT or antimuscarinic drugs may be effective for treating UUI.	B
Some patients may prefer BT because it does not produce the adverse events associated with drug therapy.
Addition of a brief written instruction for BT, in addition to drug therapy, has no benefit.	B
For women with symptoms of SUI or MUI, a combination of PFMT/BT may be better than pelvic floor muscle training (PFMT) alone in the short-term.	B
Clinicians and researchers should refer to the operant conditioning and educational literature to explain their choice of training parameters or approach.	NR
Clinicians should provide the most intensive BT supervision possible within service constraints.	B
Timed voiding
Timed voiding with a 2-hour voiding interval may be beneficial as a sole intervention for women with mild UI and infrequent voiding patterns.	C

GR = grade of recommendation; UI = urinary incontinence; UTI = urinary tract infection; PFMT = pelvic floor muscle training; VC = vaginal cone; SUI = stress urinary incontinence; MUI = mixed urinary incontinence; EStim = electrical stimulation; MStim = magnetic stimulation; UUI = urgency urinary incontinence; DO = detrusor overactivity; NR = no recommendation possible; BT = bladder training.

Pelvic Floor Muscle Training (PFMT) Under Special Circumstances
The following recommendations may help with decision-making for specific groups. However, most of these are essentially hypotheses that need further testing. Since empirical evidence is lacking the recommendations presented below are supported by expert opinion.

Recommendations	GR
Pregnant women expecting their first baby
Offer an intensive strengthening ante-partum PFMT.
Provide regular health professional contact to supervise PFMT training to prevent postpartum UI:
Women continent at 18 weeks	A
Population approaches, i.e., intervention offered whether or not women are continent at 20 weeks' gestation	B
Post-partum women, immediately after delivery
After vaginal delivery of a large baby (>4000 g) or a forceps delivery an individually taught PFMT programme, which includes advice on how to keep to the programme, will be beneficial.	C
Post-partum women with persistent symptoms of UI at 3 months after delivery
PFMT is offered as first-line conservative therapy.	A
'Intensive' programmes, i.e., highly supervised and high amount of exercise	B
Women with SUI
PFMT is more effective than EStim as first-line conservative therapy, particularly if PFMT is intensively supervised.	B
PFMT is more effective than BT as first-line conservative therapy.	B
PFMT and duloxetine are both effective. Clinicians and women may choose to try PFMT first because of the side-effects associated with drug therapy.	C
PFMT and surgery are both effective, but many clinicians and women may prefer PFMT as a first-line therapy because it is less invasive.	C
PFMT and VC are both effective. PFMT is the preferred first choice because there is less leakage and some women cannot or do not like to use VCs.	B
PFMT is better than clenbuterol or phenylpropanolamine hydrochloride as first-line therapy because of the side-effects experienced with the medications.	B
A combination of PFMT + BT may be better than PFMT alone in short-term.	C
Women with UUI or MUI
PFMT and BT are both effective as first-line conservative therapies.	B
PFMT is better than oxybutynin as first-line therapy.	B

GR = grade of recommendation; PFMT = pelvic floor muscle training; UI = urinary incontinence; SUI = stress urinary incontinence; EStim = electrical stimulation; BT = bladder training; VC = vaginal cone; UUI = urgency urinary incontinence; MUI = mixed urinary incontinence.

Specialized Management of UI in Women
Assessment
Women with 'complicated' incontinence requiring specialist management will probably need additional testing to rule out any underlying pathology, i.e., cytology, cysto-urethroscopy or urinary tract imaging. If these tests reveal no further pathology, the patient should be treated for UI by initial or specialized management options, as appropriate (see Figure 4 in the original guideline document).
Women who have failed initial management and with an impaired quality of life (QoL) are likely to request further treatment. If initial management has been given an adequate trial, then interventional therapy may be helpful. Urodynamic testing to diagnose the type of UI is highly recommended prior to intervention if the results are likely to influence the choice of management. It may also be helpful to test urethral function by urethral pressure profile or leak point pressure during urodynamic testing.
A systematic assessment for Pelvic Organ Prolapse (POP) is highly recommended. The Pelvic Organ Prolapse Quantification (POPQ) method should be used in research studies. Co-existing POP should be treated.
Treatment
If urodynamic stress urinary incontinence (SUI) is confirmed, the following treatment options may be recommended for patients with some bladder-neck and urethral mobility:

Full range of non-surgical treatments
Retropubic suspension procedures
Bladder neck/sub-urethral sling operations

It may be helpful to correct symptomatic POP at the same time. For patients with limited bladder-neck mobility, consider using bladder neck sling procedures, injectable bulking agents and the artificial urinary sphincter.
Urgency incontinence (overactive bladder) secondary to idiopathic detrusor overactivity (DO) may be treated by neuromodulation or bladder augmentation. Botulinum toxin injection can be used to treat symptomatic do unresponsive to other therapies (grade of recommendation: C). Botulinum toxin is currently being used for detrusor injection 'off-label' for this indication.
Surgery for UI in Women

Surgical Approach	LE	GR
Anterior colporrhaphy
Outcome of anterior colporrhaphy is comparable to needle suspension, but less effective than open colposuspension. The effectiveness deteriorates substantially with time.	2
Anterior colporrhaphy is not recommended as treatment of SUI alone.		A
Open colposuspension
Similar success compared to mid-urethral retropubic slings.	1
Similar success compared to bladder neck slings.	1-2
Similar success compared to transobturator slings.	2
Risk of voiding dysfunction is higher than with TVT.	1
Risk of voiding dysfunction is less than with slings.	1
Prolapse after colposuspension is more likely than after TVT.	1
The risk of de-novo DO is the same as after TVT.	1
Mitrofanoff urethroplasty, BNS, and paravaginal repair are not recommended for treatment of SUI alone.		B
Open colposuspension is an effective, long-lasting treatment for primary SUI.		A
Laparoscopic colposuspension
Laparoscopic colposuspension is comparable to open colposuspension when performed by experienced laparoscopic surgeons.	1-2
Equal or higher cure rates compared to TVT.	1-2
Shorter operating time and faster recovery compared to TVT.	1-2
Laparoscopic colposuspension is an option for treating SUI.		B
Laparoscopic colposuspension should only be performed by experienced Laparoscopic surgeons.		NR
Traditional sling procedures
Autologous fascial sling is effective.	1
Autologous fascial sling may be more effective than biological and synthetic slings.	2
Adverse events may be more common than with non-autologous materials.	3
Autologous fascial sling is recommended as an effective, long-lasting treatment for SUI.		A
Urethral bulking agents
Urethral bulking agents show similar symptomatic improvement with both placebo and autologous fat.	1
Less effective than conventional surgery.	2
No evidence to show that any bulking agent is more effective than another.	2
No data to compare urethral bulking agents with non-surgical treatments or with other minimal-access surgical techniques.	2
Women should be aware that efficacy of ureteral bulking agents decreases with time, repeat injections may be necessary, and efficacy is less than that of other surgical techniques.		B
Mid-urethral tapes
TVT® is more effective than SpArc® tape.	2
IVS® has similar efficacy as TVT®, but a higher complication rate.	2
Mid-urethral tapes vs other procedures
TVT® is equally effective as colposuspension and traditional sling operations.	1-2
Operation time, hospital stay and return to normal activity are shorter with TVT® than with colposuspension.	1-2
Post-operative voiding problems and need for prolapse surgery are more common with colposuspension.	1-2
Retropubic tapes vs transobturator tapes
Similar efficacy up to 12 months.
Similar complication rates in Finnish study.	1
Relative risk of bladder injury increased by 6-fold for retropubic sling.
Relative risk of urethral injury increased by 4-fold for transobturator sling.
Contraindications for mid-urethral slings
Absolute contraindications are urethrovaginal fistula, urethral diverticulum, intra-operative urethral injury and untreated urinary malignancy.	4
Increased risk of complications including failure with radiotherapy, UTI, steroids, COPD, anticoagulant therapy, vaginal atrophy, congenital anomalies (exstrophy, ureteral ectopy, etc.) and planned pregnancy
'Mini-slings'
Data immature, no recommendation possible.		NR
Surgery for detrusor overactivity
Sacral neuromodulation appears to have benefit for patients with urgency incontinence, as well as urgency and frequency.	1-3	A
Posterior tibial nerve stimulation is effective, but durability is a concern.	3-4
Urethral diverticulae
No grade A recommendations regarding optimal diagnostic algorithm or adjuvant therapy of concomitant SUI.
One long-term study showing recurrence of diverticulum in 17%, de-novo SUI in 38%, and dyspareunia in 22%.	3
Non-obstetric urinary fistulae
No grade A recommendation for fistula evaluation, timing of corrective intervention, methods and adjuncts of correction, and associated management strategies. All evidence is based on clinical series and/or case studies and lacks randomised and/or controlled studies.	2-4

LE = level of evidence; GR = grade of recommendation; SUI = stress urinary incontinence; TVT = tension-free vaginal tape; NR = no recommendation possible; BNS = bladder-neck suspension; DO = detrusor overactivity; IVS = intravaginal slingplasty; UTI = urinary tract infection; COPD = chronic obstructive pulmonary disease.

Table: Confounding Variables for Use of Surgery for UI in Women

Confounding Variables for Use of Surgery
Age
Physical activity
Medical illness
Psychiatric illness
Obesity
Parity
Previous incontinence surgery
Hysterectomy during anti-incontinence procedure
Race
Severity and duration of symptoms
Overactive bladder
Urethral occlusive forces
Surgical factors

Outcome Measures
Until a universal outcome tool has been established, multiple outcome measures must be used. They include:

Symptoms and separate bother questionnaire
Clinically important outcomes (pad use, re-operation rates, anticholinergics, clean intermittent self-catheterisation [CIC] and recurrent urinary tract infections [UTIs])
Complications
Quality of life tool with 'minimal clinically important difference' (MCID) Global Impression Index
Health-economic outcome

Table: Recommendations for Surgical Treatment of Stress Urinary Incontinence (SUI)

Surgical Procedure	GR
Anterior colporrhaphy	NR
Transvaginal BNS (needle)	NR
Burch procedure: open	A
Burch procedure: laparoscopic (by experienced laparoscopic surgeon only)	B
Paravaginal	NR
MMK urethroplasty	NR
BN sling: autologous fascia	A
Sub-urethral slings (TVT)	A
Urethral bulking agents	B

NR = no recommendation possible; BNS = bladder-neck suspension; GR = grade of recommendation; MMK = Marshall-Marchetti-Krantz; BN = bladder neck; TVT = tension-free vaginal tape.

2010 Addendum
Table: Weight Loss