ACP Guidelines for Urinary Incontinence: Nonsurgical Management in Women

The Clinical Guidelines Committee of the American College of Physicians (ACP) makes strong recommendations for pelvic floor muscle training (PFMT) and pharmacologic therapy for urgency UIs if these prove unsuccessful, but they caution that older women are at risk for adverse cognitive effects from certain agents (JAMA. 2016;317[1]:79-80).

The guidelines developed by the committee were developed through a multistep process including a systematic review of the evidence; review by a committee composed of internists, geriatricians, and health service researchers; and summary recommendations with evidence and recommendation grading.
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The review established 3 primary outcomes: complete continence; improvement in UI, defined by decrease in UI frequency by 50%; and effects on quality of life, assessed for each of urgency UI, mixed UI, and stress UI.

The committee made the following strong recommendations based on high-quality evidence:

• Pelvic floor muscle training (PFMT) as first-line therapy in women with stress UI
• Combined PFMT with bladder training in women with mixed UI
• If bladder training is unsuccessful in treatment of women with urgency UI, pharmacologic therapy should be used (choice of agent a multifactorial decision)

And they made the following recommendations based on what they considered low- to moderate-quality evidence:

• Bladder training in women with urgency UI
• Do not treat stress UI with systemic pharmacologic therapy
• Weight loss and exercise for obese women with UI                                          

According to the article authors, Sandra Culbertson, MD, and Andrew M Davis, MD, MPH, (University of Chicago, Chicago, IL) among pharmacologic treatments, “common early adverse effects included dry mouth (20%-50%), constipation (5%-10%), and blurred vision, especially for antimuscarinic anticholinergics, with somewhat lower rates of adverse effects for topical and extended-release agents.”

“Potent anticholinergic agents may also have longer-term effects on cognition, especially in older adults. Moreover, in this population, it may be advisable to use anticholinergics that have lower penetration through the blood-brain barrier (darifenacin, trospium, and 5-hydroxymethyl tolterodine) or mirabegron.”

In conclusion, the authors believe many questions still remain concerning the treatment of UI, including sustainability and the role of surgical interventions. In addition, as other studies have pointed out, there is a need for research additional long-term adherence, effectiveness, and safety data for all treatment modes.—Amanda Del Signore