The treatment of female urinary
incontinence has always been a bit of a shambles. The
number of specialists is so overwhelmed by the number
of patients that, in practice, incontinence is the family
physician's problem.
But family physicians are often
unsure of their own knowledge. A 2002 survey by Canadian
Family Physician of 1500 family doctors found only
35% felt very comfortable dealing with incontinence
and a mere 46% felt they really understood the condition.
A 2005 survey of Ontario women
over 45 in the same journal found that only 40% of those
who reported incontinence had discussed it with their
physician, and of these only 70% were satisfied with
the results. Combine these findings and the picture
that emerges is far from optimum.
Just keeping up with the newest
treatment options can be a struggle in this field. Fortunately
the US National Institutes of Health (NIH) have come
to the rescue, publishing in the March 18 Annals
of Internal Medicine recommendations and a meta-analysis
that encompass most available treatments. Their findings
will be reassuring to most Canadian physicians —
it seems we were already on the right track.
TREATMENT
OPTIONS
Anticholinergic drugs, which have become the first-line
treatment of choice in both Canada and the US, get the
NIH's nod of approval. A moderate level of evidence
suggests that they can resolve incontinence in most
women. There was insufficient data to allow conclusions
about which anticholinergic is superior between the
two commonest choices, oxybutynin or tolterodine.
Canada's one and only set of urinary
incontinence guidelines, put together by the Canadian
Continence Foundation in 2000, is basically in agreement
on the vital question of anticholinergics, but lists
oxybutynin as a first choice, recommending tolterodine
if that is poorly tolerated. Oxybutynin can cause a
very dry mouth in a minority of patients.
Hormone therapy fared a lot worse
in the analysis. In fact, the NIH team's only finding
backed by "strong" evidence was that oral hormone therapy
increases the risk of incontinence. Transdermal and
vaginal hormone applications, conversely, seemed to
show benefit, but the evidence was weak.
Adrenergics look like a dead end.
Duloxetine, a fairly common alternative to anticholinergics,
tended to bring improvement but not resolution of incontinence.
One clear finding with this drug was that if 20mg won't
help your patient, 80mg won't either. There is no dose-response
association. Duloxetine combined quite well with pelvic
floor training.
Pelvic floor training on its own
outperformed bladder training, but results varied wildly
across studies, suggesting that only well-run programs
with skilled trainers will do much good.
Electrical stimulation and injectable
bulking agents showed some utility, but the evidence
quality was deemed low.
One treatment not looked at by
the NIH which has been used off-label in several hundred
Canadians is the bladder botox injection. Used only
for urge incontinence, it may be one to watch in the
future, though anecdote suggests it can lead to incomplete
voiding and sometimes a need for catheterization.
NOT
JUST IN OLD AGE
The NIH also held a conference to look at the prevalence
and prevention of incontinence. Two findings stand out
from this. First, incontinence is not nearly so much
a geriatric problem as we tend to think. Many young
women suffer, and prevalence among middle-aged women
is not much lower than among the over-60s. Second, treating
comorbid conditions is probably more effective than
overall lifestyle changes. Treating depression, surprisingly,
can often relieve incontinence, and controlling diabetes
is also important.
One major weakness of all the studies
the NIH relied on is the near total absence of long-term
follow-up in incontinence studies. This leaves us in
the dark as to whether anticholinergics must be taken
indefinitely. It also leaves us wondering whether the
effect of pelvic floor exercises will fade over time.
For a condition that affects nearly a third of adult
women, these are still pretty serious knowledge gaps.
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