Purpose of Review

Compare nonpharmacological and pharmacological interventions in adult women with urinary incontinence.

Key Messages

• The nonpharmacological and pharmacological interventions studied, except hormones and periurethral bulking agents, result in better urinary incontinence (UI) outcomes than no treatment.
• For stress UI, among treatments commonly used as first- or second-line interventions, behavioral therapy is more effective than either alpha agonists or hormones. Combination behavioral therapy and hormones are more effective than alpha agonists. Alpha agonists, in turn, are more effective than hormones.
• There is insufficient evidence comparing periurethral bulking agents and intravesical pressure release, treatments used as third-line interventions for women with stress UI.
• For urgency UI, among treatments commonly used as first- or second-line interventions, behavioral therapy is more effective than anticholinergics.
• Onabotulinum toxin A may be more effective than neuromodulation as third-line therapy for women with urgency UI.
• Dry mouth is the most common side effect of pharmacological interventions, particularly with anticholinergics. Duloxetine is associated with numerous constitutional adverse effects such as nausea, insomnia, and fatigue.
• Serious adverse events are rare for all interventions. Onabotulinum toxin A is associated with risk of urinary tract infections and urinary retention.  Periurethral bulking agents are associated with erosion in a small percentage of women.

Structured 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.

Journal Citations

Balk EM, Rofeberg VN, Adam GP, et al. Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes. Ann Intern Med. 2019 Apr 2;170(7):465-79. doi:10.7326/M18-3227.

Balk EM, Adam GP, Corsi K, et al. Adverse Events Associated with Nonsurgical Treatments for Urinary Incontinence in Women: a Systematic Review. J Gen Intern Med. 2019 May 6;34(8):1615-25. doi:10.1007/s11606-019-05028-0.

Citation

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. (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. DOI: https://doi.org/10.23970/AHRQEPCCER212.