Urinary Incontinence

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

2018

Changed evidence summaries and recommendations can be found in sections:

4.3.1.1.3 Summary of evidence for mid-urethral slings

Summary of evidence LE
Mid-urethral synthetic sling inserted by either the transobturator or retropubic route provides equivalent patient-reported outcome at five years. 1a
Mid-urethral synthetic sling inserted by the retropublic routes has higher objective patient-reported cure rates at 8 years. 1b
Long term analysis of TVT cohorts showed a sustained response up to 17 years. 2b
The transobturator route of insertion is associated with a higher risk of groin pain than the retropubic route. 1a
Long term analysis showed no difference in terms of efficacy for the skin-to vagina compared to vagina-to-skin directions up to nine years. 2a
The top-to-bottom direction in the retropubic approach is associated with a higher risk of post-operative voiding dysfunction. 1b
Incontinence surgery has similar outcomes in older patients (≥ 65 years). 2a
Incontinence surgery may be safely performed in obese women; however, outcomes may be inferior. 2b
Improvement in sexual life is higher with single incision slings than with standard MUS. 1a

SUI = stress urinary incontinence; MUS = mid-urethral sling; TVT = tension-free vaginal tape.

NB: Most evidence on single-incision slings is from studies using the tension-free vaginal tape secure (TVT-S) device and although this device is no longer available, many women still have the device in place.

 

4.3.1.4.3 Summary of evidence for open and laparoscopic surgery for stress urinary incontinence

Summary of evidence LE
Laparoscopic colposuspension has a shorter hospital stay and may be more cost-effective than open colposuspension. 1a

 

4.3.1.5.3 Summary of evidence for bulking agents

Summary of evidence LE
Peri-urethral injection of bulking agent may provide short-term improvement and cure (twelve months), in women with SUI. 1b
Autologous fat and hyaluronic acid as bulking agents have a higher risk of adverse events. 1a
Intra-urethral route of injection of bulking agaents may be associated with a higher risk of urinary retention compared to the transurethral route. 2b

SUI = stress urinary incontinence.

 

4.2.6.3 Additional recommendations for the use of antimuscarinic drugs in the elderly

Recommendation Strength rating
Long-term antimuscarinic treatment should be used with caution in elderly patients especially those who are at risk of, or have, cognitive dysfunction. Strong

 

4.3.1.6 Recommendations for women with uncomplicated stress urinary incontinence

 

Recommendation Strength rating
Offer a MUS, colpsuspension or autologous fascial sling to women with uncomplicated SUI. Strong
Inform women of the unique complications associated with each individual procedure. Strong
Inform women who are being offered a single-incision sling that long-term efficacy remains
uncertain
Strong
Inform older women with SUI about the increased risks associated with surgery, including the lower probability of success. Weak
Inform women that any vaginal surgery may have an impact on sexual function, which is generally positive. Weak
Only offer new devices, for which there is no level 1 evidence base, as part of a structured research programme. Strong
Only offer adjustable MUS as a primary surgical treatment for SUI as part of a structured research programme. Strong
Offer bulking agents to women with SUI who request a low-risk procedure with the understanding that repeat injections are likely and long-term durability is not established. Strong

 

 

4.3.2.1.3 Summary of evidence for colposuspension or sling following failed surgery

Summary of evidence LE
TVT and TOT have similar outcomes in patients with recurrent SUI. 1a
Burch Colposuspension have similar patient reported or objective cure rates when compared to TVT. 1b

TOT = trans-obturator tape; TVT = tension-free vaginal tape.

 

4.3.3.4    Recommendations for women with both stress urinary incontinence and pelvic organ prolapse

Recommendations for women requiring surgery for bothersome pelvic organ prolapse who have symptomatic or unmasked stress urinary incontinence Strength rating
Inform women of the increased risk of adverse events with combined surgery compared to prolapse surgery alone, as well as the risk of UI progression if UI is untreated at the time of POP repair. Strong

POP = pelvic organ prolapse; UI = urinary incontinence.

 

4.3.5.1.1 Summary of evidence for drug therapy in men with stress urinary incontinence

Summary of evidence LE
Duloxetine, either alone or combined with conservative treatment, can hasten recovery but does not improve continence rates following prostate surgery. However, it can be associated with significant, albeit often transient, side effects. 1b

 

4.3.5.3.3 Summary of evidence for fixed male sling

Summary of evidence LE
There is no evidence that intraoperative placement of an autologous sling during RARP improves return of continence at 6 months. 1b

RARP = robotic assisted radical prostatectomy.

 

4.3.5.6    Recommendations for men with stress urinary incontinence

Recommendations Strength rating
Offer duloxetine only to hasten recovery of continence after prostate surgery but inform the patient about the possible adverse events and that its use is off label for this indication in most European countries. Weak

 

4.3.6.2.3                Summary of evidence for sacral nerve stimulation

Summary of evidence LE
Sacral nerve neuromodulation is not more effective than OnabotulinumA toxin 200U injection at 6 months. 1b

 

4.3.6.3.4 Recommendations for cystoplasty/urinary diversion

Recommendations Strength rating
Offer augmentation cystoplasty to patients with UI who have failed all other treatment options. Weak
Inform patients undergoing augmentation cystoplasty of the high risk of having to perform clean intermittent self-catheterisation (ensure they are willing and able to do so) and that they need lifelong surveillance. Weak

UI = urinary incontinence.

2017

Summary of changes.

Section 4.2 Pharmacological management has been revised for this 2017 print, including the addition of a new section 4.3.5.1 on Drug therapy.

Changed evidence summaries and recommendations can be found in sections:

4.2.1        Antimuscarinic drugs

Summary of evidence LE
There is limited evidence that one antimuscarinic drug is superior to an alternative antimuscarinic drug for cure or improvement of urgency urinary incontinence. 1b
Higher doses of antimuscarinic drugs are more effective to cure or improve urgency urinary incontinence, but with a higher risk of side effects. 1b
Once daily (extended release) formulations are associated with lower rates of adverse events compared to immediate release ones, although similar discontinuation rates are reported in clinical trials. 1b
Dose escalation of antimuscarinic drugs may be appropriate in selected patients to improve treatment effect although higher rates of adverse events can be expected. 1b
Transdermal oxybutynin (patch) is associated with lower rates of dry mouth than oral antimuscarinic drugs, but has a high rate of withdrawal due to skin reaction. 1b

 

4.2.3.3     Recommendations for antimuscarinic drugs

Recommendations GR
Offer antimuscarinic drugs for adults with urgency urinary incontinence who failed conservative treatment. A
Consider extended release formulations in patients who do not tolerate immediate release antimuscarinics. A
If antimuscarinic treatment proves ineffective, consider dose escalation or offering an alternative treatment. B
Consider using transdermal oxybutynin if oral antimuscarinic agents cannot be tolerated due to dry mouth. B
Offer and encourage early review (of efficacy and side effects) of patients on antimuscarinic medication for urgency urinary incontinence. C

 

4.2.4        Antimuscarinic agents: adherence and persistence

Summary of evidence LE
Adherence to antimuscarinic treatment is low and decreases over time because of lack of efficacy, adverse events and/or cost. 2
Most patients will stop antimuscarinic agents within the first three months. 2

 

4.2.5      Antimuscarinic and beta3 agonist agents, the elderly and cognition 

Summary of evidence LE
Antimuscarinic drugs are effective in elderly patients. 1B
Mirabegron has been shown to efficacious and safe in elderly patients. 1B
In older people, the cognitive impact of drugs which have anticholinergic effects is cumulative and increases with length of exposure. 2
Oxybutynin may worsen cognitive function in elderly patients. 2
Solifenacin, darifenacin, fesoterodine and trospium have been shown not to cause cognitive dysfunction in elderly people in short-term studies. 1B

 

4.2.5.2.13 Additional recommendations for antimuscarinic drugs in the elderly

Recommendations GR
In older people being treated for urinary incontinence, every effort should be made to employ nonpharmacological treatments first. C
Long-term antimuscarinic treatment should be used with caution in elderly patients especially those who are at risk of, or have, cognitive dysfunction. B*
When prescribing antimuscarinic for urgency urinary incontinence, consider the total antimuscarinic load in older people on multiple drugs. C
Consider the use of Mirabegron in elderly patients if additional antimuscarinic load is to be avoided. C

*Recommendation based on expert opinion.

 

4.2.6        Mirabegron

Summary of evidence LE
Mirabegron is better than placebo and as efficacious as antimuscarinics for improvement of urgency urinary incontinence symptoms. 1a
Adverse event rates with mirabegron are similar to placebo. 1a
Patients inadequately treated with solifenacin 5 mg may benefit more from the addition of mirabegron than dose escalation of solifenacin. 1b

 

Recommendation GR
In patients with urgency urinary incontinence and an inadequate response to conservative treatments, offer mirabegron unless they have uncontrolled hypertension. A

 

4.2.7        Drugs for stress urinary incontinence 

Summary of evidence LE
Duloxetine, 40 mg twice daily improves stress urinary incontinence in women. 1a
Duloxetine causes significant gastrointestinal and central nervous system (CNS) side effects leading to a high rate of treatment discontinuation, although these symptoms are limited to the first weeks of treatment. 1a

 

Recommendations GR
Duloxetine can be used with caution to treat women with symptoms of stress urinary incontinence. A
Duloxetine should be initiated using dose titration because of high adverse event rates. A

 

4.2.8        Oestrogen 

Recommendation GR
Vaginal oestrogen therapy for vulvovaginal atrophy should be prescribed long-term. In women with a history of breast cancer, the treating oncologist needs to be consulted. C

 

4.2.9.2.2 Monitoring for hyponatraemia

Recommendations GR
Consider offering desmopressin to patients requiring occasional short-term relief from daytime urinary incontinence and inform them that this drug is not licensed for this indication. A
Monitor plasma sodium levels in patients on desmopressin. A*

*Recommendation based on expert opinion.

 

4.2.10      Drug treatment in mixed urinary incontinence 

Recommendation GR
Offer antimuscarinic drugs or beta3 agonists to patients with urgency-predominant mixed urinary incontinence. A*

*Recommendation based on expert opinion.

 

4.3.5.1     Drug therapy 

Summary of evidence LE
Duloxetine, either alone or combined with conservative treatment, can hasten recovery of continence but does not improve continence rate following prostate surgery. 1b

 

4.3.5.5     Compression devices in males

Recommendation GR
Consider offering duloxetine to hasten recovery of continence after prostate surgery but inform the patient about the possible adverse events. B

2016

All chapters of the 2016 Urinary Incontinence Guidelines have been updated, based on the 2015 version of the guideline. Conclusions and recommendations have been rephrased and added to, throughout the current document.

 Key changes in the 2016 print:

  • Section 4.1 Conservative Management;
  • Section 4.2.8 Oestrogen;
  • Section 4.3.6.1 Bladder wall injection of botulinum toxin A.

2015

For the 2015 Guidelines, the text has been significantly reduced so that only key information is included and re-formatted according to the EAU non-oncology template so that all Guidelines follow a similar format.

  • Complete literature update Chapter Assessment & diagnosis
  • Literature update on mirabegron

2014

Changes to Urinary Incontinence guidelines edition 2014
New topics/additional searches:
  • 1 Urethral diverticulum
  • 2    Fistula (ICS summary)
  • 3    PROMS
  • 4    Pessary (RING test)
  • 5    Bladder wall thickness
  • 6    Anticholinergic load
  • 7    Oestrogen
  • 8    Mirabegron

2013

Updated chapters using a structured literature search:
•    Chapter 2 “Assessment and diagnosis”
•    Chapter 3 “Conservative treatment”
•    Chapter 4 “Drug therapy”
•    Chapter 5 “Surgical treatment”

2012

– Complete update