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    ACOG Guidelines: Urinary Incontinence in Women

     

    Behavior and lifestyle modifications 

    The ACOG guideline emphasizes the importance of behavioral and lifestyle modifications including bladder training, weight loss, and dietary management. SUI is highly associated with obesity, and weight loss not only has been shown to reduce and resolve incontinence but also has many other obvious benefits.

    Voiding diary information and institution of appropriate fluid management, especially for the many women who drink excessive amounts of fluid, may resolve complaints in some cases. For example, a woman who takes her Lasix and then gets into her car for an hour-long commute to work only to leak trying to get to the bathroom can be told to take her diuretic at a different time.

    The time-honored practice of pelvic muscle exercises is also discussed, and giving appropriate instructions, particularly about when to use muscle contraction to prevent urine leakage, can make a substantial difference for many women. However, just suggesting that a patient contract the muscles a few times a day is not adequate treatment and use of the regimens in the published literature that have been demonstrated to work is needed.

    Medications

    A wide variety of medications is available to treat urgency urinary incontinence and is nicely summarized. Antimuscarinics are the primary class of medications used with the long-acting forms being best. The new β-3 adrenoreceptor agonist, mirabegron, leads to detrusor muscle relaxation and, because it works on a different pathway, may be useful in women for whom anticholinergic medications have not worked or are inappropriate.

    The guideline recommends considering combining these treatments with behavioral therapy because of high discontinuation rates for the medications over the long term. The guideline also discusses the demonstrated effectiveness in women with refractory urge incontinence of onabotulinum toxin A (Botox) and sacral neuromodulation, which practitioners should be aware of as an avenue of treatment for overactive bladder when primary and secondary measures have failed.

    Surgical management

    Surgical management for SUI centers on the role of synthetic midurethral mesh slings for treatment of SUI associated with urethral hypermobility. The important point made is that these slings do not have the same problems as vaginal mesh for pelvic organ  prolapse repair. Midurethral tapes work by interacting with a mobile urethra, so they are only appropriate for women whose urethra moves enough to activate the tape. If, as sometimes occurs, there is little or no urethral hypermobility, the treating physician should carefully assess whether other modes of treatment, such as an autologous pubovaginal sling or injection of the urethral bulking agent, are appropriate.

    Sling placement

    Retropubic and transobturator slings both show good efficacy with rates of subjective cure of about 80%. Careful counseling about the fact that concomitant urge incontinence may not resolve is a key to patients understanding what the operations can and cannot do. Single-incision mini-slings have not had the same consistent good results as full-length slings and their role remains uncertain. Autologous pubovaginal slings remain an important treatment for women who are not candidates for synthetic mesh, those with an immobile urethra, or who have had complications from mesh placed around the urethra.

    The guideline has an appropriate discussion of anti-incontinence operations at the time of prolapse repair. Adding a midurethral tape at the time of prolapse surgery shows a reduction in occurrence of SUI on physical examination from 44% to 24%. That can guide a discussion about an initial placement of a sling at the time of repair or staged approach, in which one waits to see if incontinence develops and then places a tape at that time. 

    Overall, this concise and well-written guide provides a balanced approach to urinary incontinence that should be useful in guiding treatment of the types of patients seen by most gynecologists.

     

    Reference

    1. Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015;126:e66–81.

     

    John O.L. DeLancey, MD
    DR. DELANCEY is Professor of Gynecology, director of Pelvic Floor Research, University of Michigan Medical School, Ann Arbor, MI.

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