New recommendations for treating urinary incontinence in women

"Urinary incontinence is a common problem for women that is often underreported and underdiagnosed," said Dr. David Fleming, president, ACP. "Physicians should take an active approach and ask specific questions such as onset, symptoms, and frequency of urinary incontinence; it is estimated that about half of the women with incontinence do not report it to their doctor."

For women with stress UI (the inability to retain urine when laughing, coughing, or sneezing), ACP recommends Kegel exercises and recommends against systemic drug therapy. For women with urgency UI (the loss of urine for no apparent reason after suddenly feeling the need or urge to urinate), ACP recommends bladder training. If bladder training is unsuccessful, ACP recommends medication. Physicians should choose a medication based on adverse effects and tolerability, ease of use, and cost.

For mixed UI, a combination of stress and urgency incontinence, ACP recommends Kegel exercises with bladder training. For obese women with UI, ACP recommends weight loss and exercise.

ACP's guideline, "Nonsurgical Management of Urinary Incontinence in Women," includes High Value Care advice to help doctors and patients understand the benefits, harms, and costs of tests and treatment options so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices.

UI contributes to high medical spending in the United States. Approximately $19.5 billion was spent on UI care in 2004, and UI accounts for 6 percent of nursing home admissions for elderly women, costing around $3 billion.

"Physicians should utilize non-drug treatments as much as possible for urinary incontinence," said Dr. Fleming. "Kegel exercises for stress UI, bladder training for urgency UI, and Kegel exercises with bladder training for mixed UI are effective, have few side effects, and are less expensive than medications. Although various drugs can improve UI and provide complete continence, adverse effects often lead many patients to stop taking their medication."

Kegel exercises are a form of pelvic floor muscle training that comprise relaxing and tightening the muscles that control urine flow. Bladder training is a form of behavioral therapy that involves urinating on a set schedule and gradually increasing the time between urination.

UI affects about 25 percent of women ages 14 to 21, 44 to 57 percent of women ages 40 to 60, and 75 percent of women ages 75 and older. These estimates may be low as one study showed that at least half of incontinent women do not report the issue to their physician.

Risk factors for UI include pregnancy, pelvic floor trauma after vaginal delivery, menopause, hysterectomy, obesity, urinary tract infections, functional and/or cognitive impairment, chronic cough, and constipation.

ACP's recommendations are based on published literature in the English language on nonsurgical management of UI in women from 1990 through December 2013. ACP did not evaluate surgical treatment options and some nonsurgical treatments, such as botulinum toxin, percutaneous nerve stimulation, magnetic stimulation, or electrical stimulation, because these treatments are not typically utilized by or available to primary care physicians.