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Nonsurgical Treatments for Urinary Incontinence in Adult Women: A Systematic Review Update

Systematic Review Draft

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Related Activities include: PCORI Virtual Multi-Stakeholder Workshop on Nonsurgical Treatments for Urinary Incontinence in Adult Women

Purpose of Review

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

Key Messages

  • Available nonpharmacological and pharmacological interventions generally result in better urinary incontinence outcomes than no treatment.
  • Behavioral therapy and neuromodulation, each alone or combined, and onabotulinum toxin A (BTX)  result in the highest rates of cure, improvement, and satisfaction. Other treatments were also effective.
  • Dry mouth is the most common side effect with several drugs, particularly anticholinergics.
  • Serious adverse events most commonly occurred with periurethral bulking agents, but were rare for other interventions. BTX was associated with risk of urinary tract infections and urinary retention. Duloxetine was associated with numerous constitutional adverse effects such as nausea, insomnia, and fatigue.
  • Nonpharmacological interventions generally have few adverse events.

Structured Abstract

Introduction. About 17% of nonpregnant, adult women have had urinary incontinence (UI). Nonpharmacological therapies mostly strengthen the pelvic floor and change behaviors affecting bladder function; pharmacological therapies mostly affect bladder nerves and sphincter function.

Methods. We updated AHRQ’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 May 17, 2017. We included UI outcomes (cure, improvement, satisfaction), quality of life, and adverse events. For UI outcomes, we conducted network meta-analyses. Quality of life and adverse event outcomes are narratively described.

Results. We identified 251 eligible studies. UI outcomes were reported in 117 studies, quality of life in 89 studies, and adverse events in 138 studies. Trials evaluated 16 categories of interventions with 53 specific interventions. All evaluated interventions were generally more effective to achieve favorable UI outcomes than no treatment (moderate strength of evidence [SoE]). For nonpharmacological interventions, combined neuromodulation and behavioral therapy had better UI outcomes than neuromodulation alone (moderate SoE). For pharmacological interventions, onabotulinum toxin A (BTX) had better UI outcomes than other pharmacological interventions (low to moderate SoE for specific comparisons). Among comparisons of nonpharmacological and pharmacological interventions, behavioral therapy and neuromodulation (alone or combined) had better UI outcomes than various pharmacological interventions (low to moderate SoE for specific comparisons). For combination nonpharmacological and pharmacological interventions, addition of behavioral therapy to anticholinergics resulted in better satisfaction (but not cure or improvement) than anticholinergics alone (moderate SoE). Behavioral interventions, neuromodulation, and anticholinergics resulted in better quality of life than sham or no treatment (low SoE). Nonpharmacological interventions generally had few adverse events (low SoE). But in three studies urinary tract infections occurred in 11% of women receiving TENS. The highest rate of serious adverse events was reported with periurethral bulking agents (4.7%) (moderate SoE). The most commonly reported adverse event was dry mouth, which occurred in 0% to 35% of women on various pharmacological, nonpharmacological, and placebo interventions (low SoE). BTX was associated with urinary tract infections (35%) and urinary retention and voiding dysfunction (4-25%) (moderate SoE). Alpha agonists resulted in high rates of constitutional adverse events (e.g., nausea 23%, insomnia 12%, fatigue 10%) (moderate SoE).

Conclusions. Both nonpharmacological and pharmacological interventions are more likely than no treatment to improve UI outcomes and quality of life. Neuromodulation, behavioral therapy, and BTX are most likely to improve UI outcomes. For most interventions, adverse events are generally uncommon and nonserious (except for periurethral bulking agents). Large gaps remain in the literature regarding the comparison of individual interventions. Standardized quality of life and adverse event reporting would allow stronger conclusions in future systematic reviews.