Portal de Periódicos da CAPES

No. 397 – Conservative Care of Urinary Incontinence in Women

2020; Elsevier BV; Volume: 42; Issue: 4 Linguagem: Inglês

10.1016/j.jogc.2019.04.009

2665-9867

Sinéad Dufour, Maria Wu,

Urinary Tract Infections Management

Abstract Objective To outline the evidence for conservative care, including both assessment and management options, for urinary incontinence in women. Intended Users Relevant primary care providers and medical specialists including but not limited to physicians, nurses, midwives, and pelvic health physiotherapists. Target Population Women (>18 years of age) with urinary incontinence. Options Assessment options include gathering of a detailed history, physical examination, laboratory analysis, urodynamic evaluation, and cystoscopy. Conservative management options include lifestyle management, pelvic floor muscle training, behavioural management, and mechanical devices. Outcomes To provide an evaluation-based summary of current available evidence concerning efficacy of conservative care (assessment and management) strategies for urinary incontinence in women. Evidence The Cochrane Library and Medline (2013-2018) were searched to find articles related to conservative care of urinary incontinence in women (>18 years). Articles were appraised, and the collective evidence was graded. Validation Methods The evidence obtained was reviewed and evaluated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Urogynecology Committee under the leadership of the principal authors. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. Benefits, Harms, and Costs Evidence for the efficacy of conservative care (assessment and management) options for women with urinary incontinence is strong. Furthermore, these options carry minimal or no harm and confer an established cost benefit. Guideline Update This SOGC Clinical Practice Guideline will be automatically reviewed 5 years after publication. SUMMARY STATEMENTS 1Assessment – history (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •History alone is not sufficient to diagnose the full spectrum of urinary incontinence. However, a clear history of urinary leakage with physical activity, in the absence of complicated urinary incontinence features, may be sufficient for stress urinary incontinence diagnosis in conjunction with physical examination. 2Assessment – physical examination (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •The cough stress test, if positive, is a reliable test to diagnose uncomplicated stress urinary incontinence when complemented by a history consistent with stress urinary incontinence. •Measurement of urethral hypermobility alone has poor reliability and remains controversial in the conservative management of urinary incontinence. However, the presence of an immobile, fixed urethra suggests complex urinary incontinence and may warrant further investigation. 3Assessment – urinalysis (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •Urine dipstick testing, microscopic urinalysis and urine culture and sensitivity along with measurement of post-void residual volume when indicated should be performed in all women with urinary incontinence to rule out infections, hematuria, and proteinuria. Further evaluations are indicated when the post-void residual volume is persistently greater than 150 mL. 4Assessment – urodynamic studies (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •Urodynamic studies are not indicated in otherwise healthy women with uncomplicated stress urinary incontinence on history and physical examination, as urodynamic study results do not assist with diagnosis or improve treatment outcomes in this group of women. Urodynamic study testing may be warranted in women with complicated urinary incontinence symptoms, urinary incontinence refractory to treatment, or conflicting history and physical examination results. 5Assessment – cystoscopy (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •Cystoscopic evaluation of the lower urinary tract may be indicated in women with urge urinary incontinence refractory to treatment, continuous urine leakage suspicious for iatrogenic genitourinary injuries or fistulas, persistent post-void dribbling, and hematuria. 6Management – lifestyle (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •Evidence from one randomized controlled trial and one meta-analysis supports lifestyle modification interventions promoting weight loss as a management strategy to reduce urinary incontinence in women who are overweight or obese. A 5% reduction in weight loss has an impact on the reduction of urinary incontinence symptoms. Caffeine reduction demonstrates reduction in symptoms of urgency and frequency. 7Management – pelvic floor muscle training (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •Pelvic floor muscle training is an effective therapy for urinary incontinence and can be used alone or as part of a multicomponent therapy that includes lifestyle and behavioural approaches. Progressive programs that are supervised by health care providers are more effective. 8Management – adjuncts (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •Although current published studies have limitations, currently there does not appear to be any clear added benefit of using adjunctive therapies (biofeedback, electrical stimulation, or vaginal cones). 9Management – behavioural; bladder training (mixed urinary incontinence, urge urinary incontinence): •Scheduled voiding regimens represent an important and effective management strategy as a stand-alone therapy or part of a multicomponent therapy that includes lifestyle and pelvic floor muscle training. Women have been more satisfied with voiding regimens compared with no treatment. 10Management – intravaginal mechanical devices (stress urinary incontinence, mixed urinary incontinence): •There is evidence that intravaginal mechanical devices (incontinence pessaries) are effective and may be preferred for women who have incontinence in specific situations such as exercise. Intravaginal mechanical devices may not be as effective as pelvic floor muscle training. RECOMMENDATIONS 1Assessment – history (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We recommend eliciting a comprehensive voiding, medical, and surgical history in women with urinary incontinence to distinguish those with uncomplicated stress urinary incontinence from other types of urinary incontinence, in order to better assess the need for further physical examinations and investigations prior to treatment planning (strong, low). 2Assessment – physical examination (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We recommend that cough stress test be performed on physical examination to diagnose stress urinary incontinence in conjunction with history taking (strong, low). This cough stress test may have to be done also with reduction of prolapse, if present. While urethral hypermobility may contribute to stress urinary incontinence diagnosis, we recommend against the routine use of Q-tip testing in women with urinary incontinence. The vaginal Q-tip test may be used as an alternative to urethral Q-tip testing in select patients (conditional, moderate). 3Assessment – urinalysis (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We recommend that initial investigations include a urinalysis and, if indicated, urine culture and sensitivity and post-void residual assessment for all women with urinary incontinence. Further evaluations such as a hemoglobin A1c, serum creatinine, and imaging may be considered on a case-by-case basis depending on the results of these initial investigations (strong, moderate). 4Assessment – urodynamic studies (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We recommend that in women with uncomplicated urinary incontinence on history and physical examination, routine urodynamic studies not be undertaken prior to treatment planning (strong, high). •We suggest that urodynamic studies be considered in women with refractory or complicated urinary incontinence symptoms, who have undergone prior incontinence procedures, or with urinary incontinence in the setting of stage 3–4 pelvic organ prolapse (conditional, low). 5Assessment – cystoscopy (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We suggest that cystoscopic evaluation be considered in women with hematuria, or refractory and/or complicated urinary incontinence symptoms (conditional, low). 6Management – lifestyle (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We recommend counselling to support weight loss as a first-line strategy for all women with urinary incontinence who are overweight or obese (strong, high). •We recommend counselling related to reducing caffeine to address symptoms of frequency and urgency (conditional, moderate). 7Management – pelvic floor muscle training (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We recommend pelvic floor muscle training (individually tailored, inclusive of digital pelvic floor muscle examination) to be offered to all women with urinary incontinence (strong, high). 8Management – adjuncts (stress urinary incontinence, mixed urinary incontinence, urge urinary incontinence): •We suggest adjunctive pelvic floor muscle therapies be used on an individualized basis only since there is currently no clear added benefit (conditional, moderate). 9Management – behavioural; bladder training (mixed urinary incontinence, urge urinary incontinence): •We recommend scheduled toilet regimens to be offered to all women with urge urinary incontinence and mixed urinary incontinence (strong, high). 10Management – intravaginal mechanical devices (stress urinary incontinence): •We recommend mechanical devices be used on an individualized basis. We recommend particular consideration of mechanical devices when women have urinary incontinence with high-impact exercises or when there are barriers in accessing supervised pelvic floor muscle training (strong, high).