What is urinary incontinence?
Bladder problems are common in women. Having to go to the toilet frequently, urgently and sometimes not making it in time is called urgency urinary incontinence. Urgency urinary incontinence occurs when, for some reason, the signals telling women to empty their bladder are much stronger and occur more often than necessary. Leaking when sneezing or exercising is called stress urinary incontinence, and can happen if the muscles controlling the outlet from the bladder are weaker than they should be. Women can also have a mixture of these two conditions, which is called mixed urinary incontinence.
Symptoms of bladder problems can cause a lot of distress. For example, women can often be reluctant to go out and may fear going for walks or taking part in exercise classes. Often these women can feel isolated and their quality of life is significantly poorer compared to women without bladder symptoms.
How is urinary incontinence treated?
Treatment options for urinary incontinence mainly include 'conservative treatment' (avoiding invasive methods), medication and surgery. Conservative treatments should be offered first and these include training of the pelvic floor muscle (muscle between the tail bone (coccyx) and pubic bone that support the bladder, bowel, vagina, and womb) (with and without add-on treatments such as electrical stimulation), bladder training and devices. These are usually provided by physiotherapists or nurses who have had specialist training.
What did we aim to do?
There are a growing number of Cochrane Reviews relating to conservative management for different types of urinary incontinence, and our aim was to bring together these research findings into one accessible overview document, with input from clinicians and women affected by incontinence.
How up-to-date is this overview?
This overview is up-to-date to 18 January 2021.
What did we do?
We searched for Cochrane Reviews relating to the conservative management of urinary incontinence in women and found 29 relevant reviews. From these, we collated data regarding the type of intervention (treatment) and what it was compared to in tables. The comparison treatment could have been a control (such as a sham (pretend) treatment or usual care), another conservative intervention or a non-conservative intervention. We identified two key outcomes that were important to women: if they were cured or improved and if their quality of life had improved. We assessed the quality of the included reviews and the certainty of the data within these reviews (the extent of our confidence that review results are correct in supporting or rejecting a finding).
Key results
There is high certainty evidence that undertaking pelvic floor muscle training can cure symptoms and improve quality of life for all types of urinary incontinence. There is moderate or high certainty evidence that these pelvic floor muscle exercises work better if they are more intense, have more support from a health professional, and are combined with strategies to support continued use. Lifestyle modifications, such as losing weight and trying to control how often you empty your bladder, may also be beneficial for some types of urinary incontinence. The use of adjuncts, such as electrical stimulation, may also be of benefit, especially for those with mixed or urgency urinary incontinence.
Quality of evidence
Approximately half of our findings provided moderate or high certainty evidence. However, 81% of our findings from analyses within the reviews included data only from one trial. These reviews had not been able to pull together the results of several trials. We could not identify any Cochrane Reviews for some commonly used treatments, such as psychological therapies. Generally, long-term follow-up was lacking and the use of multiple and diverse outcomes limited the possibility of combining results to give meaningful evidence.
Authors' conclusions
There is a lot of evidence for conservative management of urinary incontinence in women and the use of pelvic floor muscle exercises is strongly supported for most patients, regardless of the type of incontinence. However, there are many limitations with the current evidence for conservative treatment of urinary incontinence and often the evidence does not support clear clinical decisions. More research is urgently required to establish high-quality evidence addressing questions which matter to women affected by urinary incontinence.
There is high certainty that PFMT is more beneficial than control for all types of UI for outcomes of cure or improvement and quality of life. We are moderately certain that, if PFMT is more intense, more frequent, with individual supervision, with/without combined with behavioural interventions with/without an adherence strategy, effectiveness is improved. We are highly certain that, for cure or improvement, cones are more beneficial than control (but not PFMT) for women with SUI, electrical stimulation is beneficial for women with UUI, and weight loss results in more cure and improvement than control for women with AUI.
Most evidence within the included Cochrane Reviews is of low certainty. It is important that future new and updated Cochrane Reviews develop questions that are more clinically useful, avoid multiple overlapping reviews and consult women with UI to further identify outcomes of importance.
Urinary incontinence (UI) is the involuntary loss of urine and can be caused by several different conditions. The common types of UI are stress (SUI), urgency (UUI) and mixed (MUI). A wide range of interventions can be delivered to reduce the symptoms of UI in women. Conservative interventions are generally recommended as the first line of treatment.
To summarise Cochrane Reviews that assessed the effects of conservative interventions for treating UI in women.
We searched the Cochrane Library to January 2021 (CDSR; 2021, Issue 1) and included any Cochrane Review that included studies with women aged 18 years or older with a clinical diagnosis of SUI, UUI or MUI, and investigating a conservative intervention aimed at improving or curing UI. We included reviews that compared a conservative intervention with 'control' (which included placebo, no treatment or usual care), another conservative intervention or another active, but non-conservative, intervention. A stakeholder group informed the selection and synthesis of evidence.
Two overview authors independently applied the inclusion criteria, extracted data and judged review quality, resolving disagreements through discussion. Primary outcomes of interest were patient-reported cure or improvement and condition-specific quality of life. We judged the risk of bias in included reviews using the ROBIS tool. We judged the certainty of evidence within the reviews based on the GRADE approach. Evidence relating to SUI, UUI or all types of UI combined (AUI) were synthesised separately. The AUI group included evidence relating to participants with MUI, as well as from studies that combined women with different diagnoses (i.e. SUI, UUI and MUI) and studies in which the type of UI was unclear.
We included 29 relevant Cochrane Reviews. Seven focused on physical therapies; five on education, behavioural and lifestyle advice; one on mechanical devices; one on acupuncture and one on yoga. Fourteen focused on non-conservative interventions but had a comparison with a conservative intervention. No reviews synthesised evidence relating to psychological therapies. There were 112 unique trials (including 8975 women) that had primary outcome data included in at least one analysis.
Stress urinary incontinence (14 reviews)
Conservative intervention versus control: there was moderate or high certainty evidence that pelvic floor muscle training (PFMT), PFMT plus biofeedback and cones were more beneficial than control for curing or improving UI. PFMT and intravaginal devices improved quality of life compared to control.
One conservative intervention versus another conservative intervention: for cure and improvement of UI, there was moderate or high certainty evidence that: continence pessary plus PFMT was more beneficial than continence pessary alone; PFMT plus educational intervention was more beneficial than cones; more-intensive PFMT was more beneficial than less-intensive PFMT; and PFMT plus an adherence strategy was more beneficial than PFMT alone. There was no moderate or high certainty evidence for quality of life.
Urgency urinary incontinence (five reviews)
Conservative intervention versus control: there was moderate to high-certainty evidence demonstrating that PFMT plus feedback, PFMT plus biofeedback, electrical stimulation and bladder training were more beneficial than control for curing or improving UI. Women using electrical stimulation plus PFMT had higher quality of life than women in the control group.
One conservative intervention versus another conservative intervention: for cure or improvement, there was moderate certainty evidence that electrical stimulation was more effective than laseropuncture. There was high or moderate certainty evidence that PFMT resulted in higher quality of life than electrical stimulation and electrical stimulation plus PFMT resulted in better cure or improvement and higher quality of life than PFMT alone.
All types of urinary incontinence (13 reviews)
Conservative intervention versus control: there was moderate to high certainty evidence of better cure or improvement with PFMT, electrical stimulation, weight loss and cones compared to control. There was moderate certainty evidence of improved quality of life with PFMT compared to control.
One conservative intervention versus another conservative intervention: there was moderate or high certainty evidence of better cure or improvement for PFMT with bladder training than bladder training alone. Likewise, PFMT with more individual health professional supervision was more effective than less contact/supervision and more-intensive PFMT was more beneficial than less-intensive PFMT. There was moderate certainty evidence that PFMT plus bladder training resulted in higher quality of life than bladder training alone.