View Systematic Review Update Report

Urinary incontinence (UI) is the involuntary loss of urine. UI can affect a woman's physical, psychological, and social well-being and can impose substantial lifestyle restrictions. The effects of UI range from slightly bothersome to debilitating. This review focuses specifically on women with stress, urgency, or mixed UI. Stress UI is associated with impaired urethral sphincter function and results in an inability to retain urine during coughing, sneezing, or other activities that increase intraabdominal pressure. Urgency UI is defined as the involuntary loss of urine associated with the sensation of a sudden, compelling urge to void that is difficult to defer. Mixed UI occurs when both stress and urgency UI are present. Stress UI is more common in younger women and in association with pelvic floor trauma and uterine prolapse, both of which are often related to vaginal childbirth and may require surgical interventions (which are not addressed by this review). Urgency and mixed UI are more common in older women and in association with overactive bladder, with or without sphincter dysfunction. Nonsurgical treatments include pharmacological and nonpharmacological options. Nonpharmacological therapies aim to strengthen the pelvic floor and change behaviors that influence bladder function, whereas pharmacological therapies address bladder innervation and sphincter function.

This systematic review is an update, in part, of an earlier report published by the Agency for Healthcare Research and Quality’s Effective Healthcare Program in 2012. The key questions for this systematic review update derive from the original review and have been updated based on stakeholder feedback obtained by PCORI.

Key Questions

1. What are the benefits and harms of nonpharmacological treatments of UI in women, and how do they compare with each other?

• How do nonpharmacological treatments affect UI, UI severity and frequency, and quality of life when compared with no active treatment?
• What are the harms from nonpharmacological treatments when compared with no active treatment?
• What is the comparative effectiveness of nonpharmacological treatments when compared with each other?
• What are the comparative harms from nonpharmacological treatments when compared with each other?
• Which patient characteristics, including age, type of UI, severity of UI, baseline diseases that affect UI, adherence to treatment recommendations, and comorbidities, modify the effects of nonpharmacological treatments on patient outcomes, including continence, quality of life, and harms?

2. What are the benefits and harms of pharmacological treatments of UI in women, and how do they compare with each other?

• How do pharmacological treatments affect UI, UI severity and frequency, and quality of life when compared with no active treatment?
• What are the harms from pharmacological treatments when compared with no active treatment?
• What is the comparative effectiveness of pharmacological treatments when compared with each other?
• What are the comparative harms from pharmacological treatments when compared with each other?
• Which patient characteristics, including age, type of UI, severity of UI, baseline diseases that affect UI, adherence to treatment recommendations, and comorbidities, modify the effects of the pharmacological treatments on patient outcomes, including continence, quality of life, and harms?

3. What are the comparative benefits and harms of nonpharmacological versus pharmacological treatments of UI in women?

• What is the comparative effectiveness of nonpharmacological treatments when compared with pharmacological treatments?
• What are the comparative harms of nonpharmacological treatments when compared with pharmacological treatments?
• Which patient characteristics, including age, type of UI, severity of UI, baseline diseases that affect UI, adherence to treatment recommendations, and comorbidities, modify the relative effectiveness of nonpharmacological and pharmacological treatments on patient outcomes, including continence, quality of life, and harms?

4. What are the benefits and harms of combined nonpharmacological and pharmacological treatment of UI in women?

• How do combined nonpharmacological and pharmacological treatments affect UI, UI severity and frequency, and quality of life when compared with no active treatment?
• What are the harms from combined nonpharmacological and pharmacological treatments when compared with no active treatment?
• What is the comparative effectiveness of combined nonpharmacological and pharmacological treatments when compared with nonpharmacological treatment alone?
• What is the comparative effectiveness of combined nonpharmacological and pharmacological treatments when compared with pharmacological treatment alone?
• What is the comparative effectiveness of combined nonpharmacological and pharmacological treatments when compared with other combined nonpharmacological and pharmacological treatments?
• What are the comparative harms from combined nonpharmacological and pharmacological treatments when compared with nonpharmacological treatment alone, pharmacological treatment alone, or other combined treatments?
• Which patient characteristics, including age, type of UI, severity of UI, baseline diseases that affect UI, adherence to treatment recommendations, and comorbidities, modify the effects of combined nonpharmacological and pharmacological treatments on patient outcomes, including continence, quality of life, and harms?

The review also asks a contextual question, which is not systematically reviewed but uses a "best evidence" approach: What is the available evidence concerning adult women's conceptions of what defines a successful outcome in the treatment of UI (i.e., how do patients measure treatment success)?

More on This Project

• Final Protocol for This Review
• Stakeholder Meeting (December 2016)
• Stakeholder Meeting [Summary] (June 2019)
• AHRQ Project Page
• View Systematic Review Update Report (Published August 2018)