Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD; Mary Ann Forciea, MD, MS; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD; Paul Shekelle, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians (*)
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians’ judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the U.S. Department of Veterans Affairs.
Acknowledgment: The authors thank Timothy Wilt, MD, MPH, and Tatyana Shamliyan, MD, for updating the literature from the original evidence review for this guideline.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Dr. Dallas reports support for travel to meetings for the study or other purposes from the American College of Physicians and stock/stock options from Pfizer, Ortho-McNeil, Sanofi-Aventis, GlaxoSmithKline, and Merck. Dr. Shekelle reports personal fees from ECRI Institute and the U.S. Department of Veterans Affairs; grants from the Agency for Healthcare Research and Quality, U.S. Department of Veterans Affairs, Centers for Medicare & Medicaid Services, and Office of the National Coordinator for Health and Information Technology; and a patent with royalties paid to UpToDate. Dr. Shekelle is the coauthor of a draft paper with Dr. Jennifer Anger on “The Quality of Care Provided to Women With Urinary Incontinence” and a published 2013 paper on the “Development of Quality Indicators for Women With Urinary Incontinence” in Neurology and Urodynamics that was funded by the Patient-Oriented Research
Career Development Award (1 K23 DK080227, JTA) and an American Recovery and Reinvestment Act (ARRA) Supplement Award (5RC1EB010649) from the National Institute of Diabetes and Digestive and Kidney Diseases; his role was a mentor to the K23 award, and he received no financial compensation for this role. Dr. Barry reports grants and other support from Informed Medical Decisions Foundation (a nonprofit organization) and other support from Healthwise (a nonprofit organization) outside the submitted work. Dr. Cooke reports support for travel to meetings for the study or other purposes from the American College of Physicians; board membership on the National Board of Medical Examiners; consultancy for the University of Texas; employment at the University of California, San Francisco; and travel/accommodations/meeting expenses unrelated to activities listed from the American Board of Internal Medicine (ABIM) and the Accreditation Council for Graduate Medical Education.
Dr. Fitterman is a member of the ABIM Examination Committee. To protect the integrity of Board Certification, the ABIM enforces the confidentiality and its ownership of ABIM exam content, and Dr. Fitterman has agreed to keep ABIM exam content confidential. No ABIM exam content is shared or otherwise disclosed in this article. Dr. Schwartz reports other support from the National Heart, Lung, and Blood Institute, National Institutes of Health, during the conduct of the study; personal fees from Allergan, Bayer, the Blue Cross and Blue Shield Association, General Electric, UBC, and Genentech; and grants from Pfizer. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2410. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Dallas: Virginia Tech Carilion School of Medicine, 1906 Bellview Avenue, Roanoke, VA 24014.
Dr. Forciea: University of Pennsylvania Health System, 3615 Chestnut Street, Philadelphia, PA 19104.
Dr. Denberg: Carilion Clinic, PO Box 13727, Roanoke, VA 24036.
Dr. Shekelle: West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073.
Author Contributions: Conception and design: A. Qaseem, T.D. Denberg, P. Shekelle.
Analysis and interpretation of the data: A. Qaseem, P. Dallas, M.A. Forciea, M. Starkey, T.D. Denberg.
Drafting of the article: A. Qaseem, P. Dallas, M.A. Forciea, M. Starkey, T.D. Denberg.
Critical revision of the article for important intellectual content: P. Dallas, M.A. Forciea, M. Starkey, T.D. Denberg, P. Shekelle.
Final approval of the article: A. Qaseem, P. Dallas, M.A. Forciea, M. Starkey, T.D. Denberg, P. Shekelle.
Statistical expertise: A. Qaseem.
Obtaining of funding: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, M. Starkey, T.D. Denberg.
Collection and assembly of data: A. Qaseem, M. Starkey.
Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P, et al. Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161:429-440. doi: 10.7326/M13-2410
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Published: Ann Intern Med. 2014;161(6):429-440.
This article has been corrected. The original version (PDF) is appended to this article as a Supplement.
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the nonsurgical management of urinary incontinence (UI) in women.
This guideline is based on published English-language literature on nonsurgical management of UI in women from 1990 through December 2013 that was identified using MEDLINE, the Cochrane Library, Scirus, and Google Scholar. The outcomes evaluated for this guideline include continence, improvement in UI, quality of life, adverse effects, and discontinuation due to adverse effects. It grades the evidence and recommendations by using ACP's guideline grading system. The target audience is all clinicians, and the target patient population is all women with UI.
ACP recommends first-line treatment with pelvic floor muscle training in women with stress UI. (Grade: strong recommendation, high-quality evidence)
ACP recommends bladder training in women with urgency UI. (Grade: weak recommendation, low-quality evidence)
ACP recommends pelvic floor muscle training with bladder training in women with mixed UI. (Grade: strong recommendation, high-quality evidence)
ACP recommends against treatment with systemic pharmacologic therapy for stress UI. (Grade: strong recommendation, low-quality evidence)
ACP recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful. Clinicians should base the choice of pharmacologic agents on tolerability, adverse effect profile, ease of use, and cost of medication. (Grade: strong recommendation, high-quality evidence)
ACP recommends weight loss and exercise for obese women with UI. (Grade: strong recommendation, moderate-quality evidence)
Table 1. Nonpharmacologic Treatments for UI
Table 2. The American College of Physicians’ Guideline Grading System
Appendix Table 1. Nonpharmacologic Treatments for UI, Pooled With Random-Effects Model
Appendix Table 2. Pharmacologic Treatments for UI
Summary of the American College of Physicians guideline on nonsurgical management of urinary incontinence in women.
PFMT = pelvic floor muscle training; UI = urinary incontinence.
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