Tatyana A. Shamliyan, MD, MS; Robert L. Kane, MD; Jean Wyman, PhD; Timothy J. Wilt, MD, MPH
Acknowledgment: The authors thank the librarians, Jim Beattie, MLIS, Judy Stanke, MA, and Delbert Reed, PhD, for their contributions to the literature search; Sue Duval, PhD, for her contribution to the statistical analysis; Marilyn Eells for editing and formatting the report; and Charmaine Bird and Kristina Mucha for assistance with data entry and formatting tables. They also thank Linda Brubaker, MD, Tomas Griebling, MD, Robert Madoff, MD, Richard Nelson, MD, Joseph Ouslander, MD, Neil Resnick, MD, Carolyn Sampselle, PhD, David Thom, MD, PhD, and Joann Townsend, RN, for serving on the Technical Expert Panel; Chadwick Huckabay, MD, for advice and counsel on urinary incontinence management, and Ingrid Nygaard, Mary H. Palmer, PhD, and Debra Saliba, MD, for reviewing the draft of this report and providing helpful recommendations for revisions and clarifications.
Disclaimer: The authors of this report are responsible for its content. Statements in the paper should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Grant Support: This project was funded under contract no. 290-02-0009 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Additional support for Dr. Wilt was provided by RO1-NIDDK-DK 063300-01A2.
Potential Financial Conflicts of Interest:Consultancies: J. Wyman (Eli Lilly, Pfizer).
Requests for Single Reprints: Robert L. Kane, MD, Division of Health Policy and Management, University of Minnesota School of Public Health, D351 Mayo (MMC 197), 420 Delaware Street SE, Minneapolis, MN 55455; e-mail, email@example.com.
Current Author Addresses: Drs. Shamliyan and Kane: Division of Health Policy and Management, University of Minnesota School of Public Health, D351 Mayo (MMC 197), 420 Delaware Street SE, Minneapolis, MN 55455.
Dr. Wyman: University of Minnesota School of Nursing, Room 6-161 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455.
Dr. Wilt: Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center (111-0), 1 Veterans Drive, Minneapolis, MN 55417.
Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic Review: Randomized, Controlled Trials of Nonsurgical Treatments for Urinary Incontinence in Women. Ann Intern Med. 2008;148:459-473. doi: 10.7326/0003-4819-148-6-200803180-00211
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Published: Ann Intern Med. 2008;148(6):459-473.
This article has been corrected. The original version (PDF) is appended to this article as a supplement.
Urinary incontinence in women is a common problem that adversely affects quality of life.
To synthesize evidence of management of urinary incontinence in women.
MEDLINE, CINAHL, and the Cochrane Library.
96 randomized, controlled trials (RCTs) and 3 systematic reviews published in English from 1990 through May 2007.
Using standardized protocols, reviewers abstracted cases of continence, improvement of urinary incontinence, and prevalence of urinary incontinence to calculate risk difference.
Compared with regular care, pelvic floor muscle training plus bladder training resolved urinary incontinence (pooled risk difference, 0.13 [95% CI, 0.07 to 0.20]). Pelvic floor muscle training alone resolved or improved urinary incontinence compared with regular care, although the effect size was inconsistent across studies. Different injectable bulking agents and medical devices were associated with similar continence and improvement rates. Electrical stimulation failed to resolve urinary incontinence. Oral hormone administration increased rates of urinary incontinence compared with placebo in most RCTs (1243 women). Transdermal or vaginal estrogen resulted in inconsistent improvement of urinary incontinence. Adrenergic drugs did not resolve or improve urinary incontinence. Oxybutynin or tolterodine resolved urinary incontinence compared with placebo (pooled risk difference, 0.18 [CI, 0.13 to 0.22]). Duloxetine compared with placebo improved (pooled risk difference, 0.11 [CI, 0.07 to 0.14]) but did not resolve urinary incontinence, with no significant dose–response association.
Inconsistent measurements of outcomes limited the findings. Predictors of better effect have not been identified in RCTs.
Moderate levels of evidence suggest that pelvic floor muscle training and bladder training resolved urinary incontinence in women. Anticholinergic drugs resolved urinary incontinence, with similar effects from oxybutynin or tolterodine. Duloxetine improved but did not resolve urinary incontinence. The effects of electrostimulation, medical devices, injectable bulking agents, and local estrogen therapy were inconsistent.
Study flow diagram.
PFMT = pelvic floor muscle training; UI = urinary incontinence. *Literature search was conducted to examine diagnosis of, prevalence of, incidence of, risk factors for, and clinical interventions for UI and fecal incontinence. †Some randomized, controlled trials examined several interventions.
Table. Evidence of the Comparative Effectiveness of Clinical Interventions on Urinary Incontinence in Community-Dwelling Women
Effects of pelvic floor muscle training compared with regular care on resolving or improving urinary incontinence in community-dwelling women (risk difference from individual randomized, controlled trials).
*Improved urinary incontinence. †Resolved urinary incontinence.
Effects of duloxetine compared with placebo on resolving or improving urinary incontinence in community-dwelling women (risk difference from individual randomized, controlled trials).
CST = cough stress test; PFMT = pelvic floor muscle training; PGI-I = Patient Global Impression of Improvement; SPT = stress pad test.
Effects of different doses of duloxetine on resolving or improving urinary incontinence in community-dwelling women (risk difference from individual randomized, controlled trials).
Effects of anticholinergic drugs on resolving or improving urinary incontinence in community-dwelling women (risk difference from individual randomized, controlled trials).
CR = controlled release; ER = extended release; IR = immediate release.
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