Urinary Incontinence New Hope
Research Activities, July 2012, No. 383
"Urinary incontinence is an age-old problem. We want women to know that they don't have to have their grandmother's experience," says Beth Collins Sharp, Ph.D., R.N., senior advisor for women's health and gender research at AHRQ.
Especially since it's not only grandmothers who experience urinary incontinence. The AHRQ review found that about 25 percent of young women, 44 to 57 percent of middle-aged and postmenopausal women, and 75 percent of older women in nursing homes experience some involuntary urine loss. Being older is certainly a risk factor, but so are pregnancy, childbirth, menopause, hysterectomy, and obesity.
Not only is urinary incontinence common, it's costly. "About 19.5 billion dollars are spent on incontinence care each year," says Tatyana Shamliyan, M.D., M.S. "The issue is important to women and to society." Shamliyan and Jean F. Wyman, Ph.D., A.P.R.N., were part of an independent team of investigators at the Minnesota Evidence-based Practice Center who analyzed 889 studies to prepare the comparative effectiveness review, Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness.
Wyman has worked in the field of incontinence since the early 1980s. She says, "Back then, there wasn't a lot of evidence around diagnostic approaches. There also weren't as many treatments."
The AHRQ review compared pelvic floor muscle training (Kegel exercises); bladder training; medical devices, including vaginal cones and inserts; weight loss; electrical stimulation; percutaneous tibial nerve stimulation; medications; and more. "We looked at interventions that perhaps could be used in the primary care setting," explains Wyman. "This report was unique in that we tried to compare the benefits of drugs as well as non-pharmacological treatments, and we looked at the harms of treatments."
Comparing drugs was especially important, since television advertisements promote medications. "People are much more aware that urinary incontinence is a problem, and they're more willing to go for help," says Wyman, who stresses that when women do get help: "It can change their whole life."
"Our report provides insights for women and clinicians who want to know which methods are the best," says Shamliyan. "We found that pelvic floor muscle training combined with bladder training is effective for treating women with urinary incontinence without risk of side effects. The drugs for urgency incontinence showed similar effectiveness. However, with some drugs, more women discontinued treatment due to bothersome side effects."
There's still much more to study. "We need more research for women who are obese," says Shamliyan. "Only one of the six drugs used to treat urinary incontinence was tested on an obese population."
In addition to suggestions for future research, Shamliyan shared her personal view with Research Activities on the importance of pelvic floor exercises for young women and even girls to prevent future urinary incontinence. She says, "That could have a large impact on society."
Chronic Pelvic Pain—Challenges
"Chronic pelvic pain is a good example of a health issue that is a huge challenge to clinicians, researchers, and women. It's high prevalence, high burden. But it's also difficult to box into a workable definition and diagnosis, so the treatment decisions are not always obvious," says Collins Sharp.
"The problem is very common. About 1 in 10 outpatient gynecologist appointments, up to 40 percent of laparoscopies, and up to 12 percent of hysterectomies are for chronic pelvic pain," says Jeff Andrews, M.D., of the Vanderbilt Evidence-based Practice Center, which prepared the review, Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness for AHRQ. "We spend over a billion dollars just on outpatient management of chronic pelvic pain."
Not only is chronic pelvic pain common and costly, it's also confusing. "As a patient if you have chronic pelvic pain, you're not always sure who to see—a gastroenterologist, urologist, gynecologist, or someone else. If you only see one provider, you may not get a complete assessment," says Andrews. "And a general gynecologist who has hysterectomy in his toolbox may recommend a hysterectomy and miss the real cause of the pain."
Given women's suffering and sometimes radical treatments like hysterectomy for chronic pelvic pain, it's not surprising that a nomination from the public on comparing the effectiveness of nonsurgical treatments versus surgery for chronic pelvic pain prompted the AHRQ review focused on noncyclical chronic pelvic pain lasting 3 or more months.
"The review was complicated by the fact that chronic pelvic pain is a symptom. It's hard to isolate an etiology," says Nila Sathe, M.A., M.L.I.S., program manager at the Vanderbilt Center. "The causes can be many—irritable bowel syndrome, painful bladder syndrome, endometriosis, adhesions. Some research identified 60 potential diseases associated with chronic pelvic pain."
The research team at Vanderbilt University tackled questions about the comparative effectiveness of treatments for noncyclic chronic pelvic pain. From an initial literature search of 1,868 nonduplicate citations, the team winnowed down the list of relevant articles to 601. Most were eliminated primarily due to research that was not original, had an ineligible study size, or was lacking in quality. "There was surprisingly little literature devoted to noncyclic chronic pelvic pain," says Sathe.
"The review provides an analytic approach for evaluating symptoms in consideration of potential etiologies and provides insights on current medical and surgical strategies," says Shilpa Amin, M.D., AHRQ medical officer who managed the review process: "But it also highlights evidence gaps at present and provides considerations for researchers to think about to answer the most pertinent questions about noncyclic chronic pelvic pain evaluation and management."
Just as the report raised questions for future research, it also honed in on the importance of patients and providers asking poignant questions. As Amin explains, "Ultimately, it is an individualized process. The patient and the provider have a course of navigation to find out which clinical pathway to pursue."
To help clinicians and patients find that pathway, AHRQ posts and prints research summaries of all its comparative effective reviews. Summaries for clinicians include strength of evidence tables while summaries for consumers in English and Spanish include specific questions for patients to ask their providers.
Amanda Cofer Yuker, D.O., estimates that 80 percent of her patients come in with chronic pelvic pain. The gynecology specialist and team member on the review says, "Number one, it's important for women to get a proper diagnosis, but we need more validating tools."
"Both urinary incontinence and chronic pelvic pain are highly personal issues that can be difficult to discuss with anyone," says Collins Sharp. "By sharing the latest research with patients and clinicians, we can help women become more comfortable and explore what options are best for them."
Editor's Note: AHRQ's comparative effectiveness research helps clinicians and patients find the best available treatments for individual patients. To learn more about this research through comparative effectiveness reviews, including the two discussed in this article, webinars, and continuing education opportunities, visit the Effective Health Care Program at http://www.effectivehealthcare.ahrq.gov.