Urinary Incontinence in Women: Screening Guidelines and Recommendations

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During screening, clinicians should assess whether women experience urinary incontinence and whether it affects their activities or quality of life.
During screening, clinicians should assess whether women experience urinary incontinence and whether it affects their activities or quality of life.

The Women's Preventative Services Initiative (WPSI) recommends screening all women for urinary incontinence annually, according to guidelines published in the Annals of Internal Medicine.1

During screening, clinicians should assess whether women experience urinary incontinence and whether it affects their activities or quality of life. If indicated, the WPSI recommends that clinicians refer women for further treatment.

The WPSI is a national coalition of 21 women's health professional organizations and patient representatives.

To develop these guidelines, the WPSI reviewed evidence regarding the benefits and harms of screening for urinary incontinence in women. Researchers conducted a systematic review of the accuracy of screening instruments and the benefits and harms of treatment. Where there was an absence of direct evidence, they included indirect evidence to link screening and health outcomes that might support screening.

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The WPSI found 17 studies that evaluated the accuracy of 18 screening methods against a clinical diagnosis of incontinence or diagnostic test results. In these studies, the instruments showed high levels of accuracy for stress, urge, and mixed incontinence.

Overall, the WPSI found that the Actionable Bladder Symptom Screening Tool, the Michigan Incontinence Symptom Index, and the Overactive Bladder Awareness Tool are most applicable and effective for primary care settings.

In terms of treatment efficacy, the WPSI reviewed systematic reviews of both surgical and nonsurgical interventions. Effective nonsurgical interventions include weight loss for women who are obese, pelvic floor muscle training, and medication (solifenacin and fesoterodine). Surgical options include synthetic midurethral mesh slings, urethral bulking agents, retropubic suspension, and fascial slings. They noted that surgical options are generally reserved for patients whose symptoms do not improve with nonsurgical interventions.

There were no adverse effects reported for behavioral interventions such as weight loss and pelvic floor muscle training. Patients who received pharmacologic treatment had higher rates of adverse effects compared with placebo, with the most common adverse effects being dry mouth, constipation, heartburn, and urinary retention. Complications of surgical interventions included direct injury to the lower urinary tract, hemorrhage, infection, bowel injury, and wound complications.

There is a lack of direct evidence that assess the benefits and harms of screening. However, the WPSI determined that the benefits would likely outweigh the harms for many women, noting that more definite studies are needed to strengthen current evidence.

Future research should include trials that assess the effectiveness and harms of urinary incontinence screening on improving symptoms, quality of life, and function. Additionally, studies on the incidence and prevalence of urinary incontinence are needed to better identify risk factors, factors related to progression, and differences among women based on sociodemographic and other characteristics.

In a related editorial,2 Robin J. Bell, MBBS, PhD, MPH, and Susan R. Davis, MBBS, PhD, advised caution about the recommendations. “We must learn from experience in women's health, in which faith in indirect evidence often proved naive when direct evidence became available,” they wrote.

Instead of routine screening, Drs Bell and Davis recommend a randomized trial that directly assess the benefits and harms of urinary incontinence screening in women. Until direct evidence is found to support the benefits of screening, they argue, clinicians should exercise caution.

References

  1. O'Reilly N, Nelson HD, Conry JM, et al. Screening for urinary incontinence in women: a recommendation from the Women's Preventative Services Initiative. [published online August 13, 2018]. Ann Intern Med. doi:10.7326/M18-0595
  2. Bell RJ, Davis SR. Routine screening for urinary incontinence in women: caution advised. [published online August 13, 2018]. Ann Intern Med. doi:10.7326/M18-1768

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