ACOG

PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIANGYNECOLOGISTS
NUMBER 63, JUNE 2005
This Practice Bulletin was
developed by the ACOG Com-
mittee on Practice Bulletins
Gynecology with the assistance
of Mark D. Walters, MD. The
information is designed to aid
practitioners in making deci-
sions about appropriate obstet-
ric and gynecologic care. These
guidelines should not be con-
strued as dictating an exclusive
course of treatment or proce-
dure. Variations in practice may
be warranted based on the
needs of the individual patient,
resources, and limitations
unique to the institution or type
of practice.
Reaffirmed 2013
Urinary Incontinence
in Women
Numerous techniques have been developed to evaluate the types and extent of
urinary incontinence. A number of treatment options exist, including behav-
ioral, medical, and surgical approaches. The purpose of this document is to
consider the best available evidence for evaluating and treating urinary incon-
tinence in women.
Background
Etiology
Urinary incontinence affects 1070% of women living in a community setting
and up to 50% of nursing home residents (1). Prevalence of incontinence
appears to increase gradually during young adult life, has a broad peak around
middle age, and then steadily increases in the elderly (2). Most women with
incontinence do not seek medical help (3). The estimated annual direct cost of
urinary incontinence in women in the United States is $12.43 billion (4).
Among women experiencing urinary incontinence, the differential diagnosis
includes genitourinary and nongenitourinary conditions (see box, Differential
Diagnosis of Urinary Incontinence in Women). Some conditions that cause or
contribute to urinary incontinence are potentially reversible (see box, Common
Causes of Transient Urinary Incontinence).
The relative likelihood of each condition causing incontinence varies with the
age and health of the individual. Among ambulatory women with incontinence,
the most common condition is urodynamic stress incontinence, which represents
2975% of cases. Detrusor overactivity accounts for 733% of incontinence
cases, with the remainder being mixed forms (3). Among older, noninstitutional-
ized women with incontinence evaluated in referral centers, stress incontinence is
found less often, and detrusor abnormalities and mixed disorders are more com-
mon than in younger ambulatory women. More severe and troublesome inconti-
nence probably occurs with increasing age, especially age older than 70 years (3).
2 ACOG Practice Bulletin No. 63
Diagnosis
The history and physical examination are the first and
most important steps in evaluation. A preliminary diag-
nosis can be made with simple office and laboratory tests,
with initial therapy based on these findings. If complex
conditions are present, the patient does not improve after
initial therapy, or surgery is being considered, definitive,
specialized studies may be necessary.
History and Voiding Diary
In addition to patient history, daily urinary diaries are
considered a practical and reliable method of obtaining
information on voiding behavior because patient recall
by history taking may be unreliable (5). Urinary diaries
of diurnal voiding frequency, nocturnal voiding fre-
quency, and number of incontinence episodes have been
shown to be highly reproducible and correlated well with
urodynamic diagnosis (6). Most authors recommend doc-
umentation of symptoms for a 3- to 7-day period (68).
Consistent results have been shown between the first
3-day period and the last 4-day period, suggesting that a
3-day chart may be adequate to document symptoms,
thus improving compliance (8).
After the urologic history, thorough medical, surgical,
gynecologic, neurologic, and obstetric histories should be
obtained. Certain medical and neurologic conditions, such
as diabetes, stroke, and lumbar disk disease, may cause
urinary incontinence. Furthermore, strong coughing
associated with smoking or chronic pulmonary disease
can markedly worsen symptoms of stress incontinence. A
bowel history is important because anal incontinence and
constipation are relatively more common in women with
urinary incontinence and pelvic organ prolapse. A history
of hysterectomy, vaginal repair, pelvic radiotherapy, or
retropubic surgery should alert the physician to possible
effects of prior surgery on the lower urinary tract.
A complete list of the patients medications (includ-
ing nonprescription medications) should be obtained. This
is important to determine whether individual drugs may be
influencing the function of the bladder or urethra, leading
to urinary incontinence or voiding difficulties (Table 1).
Physical Examination
General, gynecologic, and lower neurologic examina-
tions are needed on every woman with incontinence.
Palpation of the anterior vaginal wall and urethra may
elicit urethral discharge or tenderness that suggests a ure-
thral diverticulum or other inflammatory or neoplastic
conditions of the urethra. Vaginal discharge can mimic
incontinence. The pelvic examination is of primary
importance to assess vulvar and vaginal atrophy in
menopausal women.
Differential Diagnosis of Urinary
Incontinence in Women
Genitourinary etiology
Filling and storage disorders
Urodynamic stress incontinence
Detrusor overactivity (idiopathic)
Detrusor overactivity (neurogenic)
Mixed types
Fistula
Vesical
Ureteral
Urethral
Congenital
Ectopic ureter
Epispadias
Nongenitourinary etiology
Functional
Neurologic
Cognitive
Psychologic
Physical impairment
Environmental
Pharmacologic
Metabolic
Common Causes of Transient Urinary Incontinence
Urinary tract infection or urethritis
Atrophic urethritis or vaginitis
Drug side effects
Pregnancy
Increased urine production
Metabolic (hyperglycemia, hypercalcemia)
Excess fluid intake
Volume overload
Delirium
Restricted mobility
Stool impaction
Psychologic
Adapted with permission from Resnick NM, Yalla SV. Management
of urinary incontinence in the elderly. N Engl J Med 1985;313:
8005. Copyright 1985 Massachusetts Medical Society. All rights
reserved.
ACOG Practice Bulletin No. 63 3
The presence and severity of anterior vaginal relax-
ation, including cystocele and proximal urethral detach-
ment and mobility, or anterior vaginal scarring, are
important to estimate. Associated pelvic support abnor-
malities, such as posterior vaginal prolapse (rectocele or
enterocele) and uterovaginal or apical prolapse, also
should be noted. The amount or severity of prolapse in
each vaginal segment may be measured and recorded
using a method such as the Pelvic Organ Prolapse
Quantification System (9). A bimanual examination is
useful to rule out coexistent gynecologic pathology, and
the anal sphincter should be examined for evidence of
prior lacerations or weakness. A rectal examination is
useful to further evaluate pelvic and anorectal pathology
and fecal impaction, the latter of which may be associat-
ed with voiding difficulties and incontinence in older
women. Urinary incontinence has been shown to
improve or resolve after the removal of fecal impactions
in institutionalized geriatric patients (10).
Urinary incontinence may be the presenting symp-
tom of neurologic disease. The screening neurologic
examination should include mental status as well as sen-
sory and motor function of the perineum and both lower
extremities. Sacral segments 2 through 4 contain the
important neurons controlling micturition. The strength
and tone of the bulbocavernosus muscle, levators, and
external anal sphincter can be estimated digitally. Lower
extremity motor function and sensory function along the
sacral dermatomes are important to evaluate. The anal
reflex and the bulbocavernosus reflex can be used to
assess sacral reflex activity. However, these reflexes can
be difficult to evaluate clinically (11).
Measuring Urethral Mobility
Predicting the amount of urethral mobility by examination
of the anterior vaginal wall is inaccurate. It is difficult to
differentiate between cystocele and rotational descent of
the urethra with physical examination, and the two often
coexist. Placement of a cotton swab in the urethra to the
level of the vesical neck and measurement of the axis
change with straining (ie, Q-tip test) may be used to dem-
onstrate urethral mobility. Measuring urethral mobility
aids in the diagnosis of stress incontinence and in planning
treatment for this condition (eg, bladder neck suspension
versus periurethral injection of bulking agents).
Because most women with primary urodynamic
stress incontinence have urethral hypermobility, a nonmo-
bile urethra should prompt consideration of urodynamic
testing. The measurement of urethral mobility is not use-
ful in differentiating urodynamic stress incontinence from
abnormalities of voiding or detrusor function because
these diagnoses require the measurement of detrusor pres-
sure during filling and emptying. Other tests, such as per-
ineal ultrasonography and magnetic resonance imaging,
can be used for assessment of bladder neck mobility, but
these are not commonly used in clinical practice.
Laboratory Tests
Few laboratory tests are necessary for the evaluation of
incontinence. A clean midstream or catheterized urine
sample should be obtained for dipstick urinalysis. If sig-
nificant bacteriuria is found, antibiotics are appropriate,
and the patient can be reevaluated in several weeks.
Blood testing (blood urea nitrogen, creatinine, glu-
cose, and calcium) is recommended if compromised renal
function is suspected or if polyuria (in the absence of
diuretics) is present. Urine cytology is not recommended
in the routine evaluation of the patient with incontinence
(12, 13). However, patients with microscopic hematuria
(two to five red blood cells per high-power field), those
older than 50 years with persistent hematuria (14), or
those with acute onset of irritative voiding symptoms in
the absence of urinary tract infection may require cys-
toscopy and cytology to exclude bladder neoplasm.
Office Evaluation of Bladder Filling
and Voiding
During office assessment, the specific circumstances
leading to the involuntary loss of urine should be deter-
mined. If possible, such circumstances should be repro-
Table 1. Medications That Can Affect Lower Urinary Tract
Function
Type of Medication Lower Urinary Tract Effects
Diuretics Polyuria, frequency, urgency
Caffeine Frequency, urgency
Alcohol Sedation, impaired mobility, diuresis
Narcotic analgesics Urinary retention, fecal impaction,
sedation, delirium
Anticholinergic agents Urinary retention, voiding difficulty
Antihistamines Anticholinergic actions, sedation
Psychotropic agents
Antidepressants Anticholinergic actions, sedation
Antipsychotics Anticholinergic actions, sedation
Sedatives and hypnotics Sedation, muscle relaxation, confusion
Alpha-adrenergic blockers Stress incontinence
Alpha-adrenergic agonists Urinary retention, voiding difficulty
Calcium-channel blockers Urinary retention, voiding difficulty
Modified from Parsons M, Cardozo L. Female urinary incontinence in practice.
London: The Royal Society of Medicine Press; 2004. p. 36. http://www.
rsmpress.co.uk/bkparsons.htm.
4 ACOG Practice Bulletin No. 63
duced and directly observed during clinical evaluation.
The amount of urine and the time required can be evalu-
ated by normal voiding in the office setting, and the vol-
ume of residual urine can then be noted by transurethral
catheterization or ultrasound examination of the bladder.
A sterile urine sample can be obtained at this time if nec-
essary. A syringe without its piston or bulb can be used
to fill the bladder with sterile water to assess bladder
capacity. Once the catheter is removed, a cough stress
test can be performed to evaluate stress incontinence.
Urodynamic Tests
Cystometry is a test of detrusor function and can be used
to assess bladder sensation, capacity, and compliance and
to determine the presence and magnitude of both volun-
tary and involuntary detrusor contractions. Cystometry
can be simple and office based or it can be multichannel,
including measurement of intraabdominal, bladder, and
detrusor (bladder minus intraabdominal) pressures.
Urodynamic tests also are valuable for the assess-
ment of voiding function. Uroflowmetry is an electronic
measure of urine flow rate and pattern. Combined with
assessment of postvoid residual urine volume, it is a
screening test for voiding dysfunction. If the uroflowme-
try and postvoid residual urine volume are normal, void-
ing function is probably normal; however, if the
uroflowmetry or postvoid residual urine volume or both
are abnormal, further testing is necessary to determine
the cause. More sophisticated measures of voiding func-
tion include a pressure-flow voiding study with or with-
out videofluoroscopy. Electromyography of the striated
urethral sphincter may be useful to assess neurogenic
voiding dysfunction.
Normal values for postvoid residual urine volume
measurements have not been established. Volumes less
than 50 mL indicate adequate bladder emptying, and vol-
umes greater than 200 mL can be considered inadequate
emptying. Clinical judgment must be exercised in inter-
preting the significance of postvoid residual urine vol-
umes, especially in the intermediate range of 50200 mL.
Because isolated instances of elevated residual urine vol-
ume may not be significant, the test should be repeated
when abnormally high values are obtained.
Cystourethroscopy
Cystourethroscopy may help to identify bladder lesions
and foreign bodies, as well as urethral diverticula, fistu-
las, urethral strictures, and intrinsic sphincter deficiency.
It frequently is used as part of the surgical procedures
to treat incontinence and is an important component of
the evaluation of postoperative incontinence and other
intraoperative and postoperative lower urinary tract
complications.
Management Options
Absorbent products are the most common method used
to actively manage urinary incontinence among commu-
nity residents (3). Many individuals with mild symptoms
or with incontinence that cannot be cured depend on bar-
rier management.
Behavioral Approaches
For women who desire treatment, several behavior mod-
ifications can be incorporated, including lifestyle inter-
ventions, scheduled or prompted voiding, bladder
training, and pelvic muscle rehabilitation. Lifestyle inter-
ventions that may help modify incontinence include weight
loss, caffeine reduction and fluid management, reduction
of physical forces (eg, work, exercise), cessation of smok-
ing, and relief of constipation (1). Other lifestyle alter-
ations are not well supported by published literature.
Bladder training is widely used with no reported side
effects and does not limit future treatment options. Also
known as bladder drills or timed voiding, it generally is
used for the treatment of urge incontinence, but it also
may improve symptoms of mixed and stress inconti-
nence. This method aims to increase the time interval
between voiding, by either a mandatory or self-adjusted
schedule. It is most effective for patients who are physi-
cally and cognitively able and who are motivated.
Bladder training generally is improved with patient edu-
cation, the use of scheduled voiding, and positive rein-
forcement by trained health care professionals (15).
Pelvic muscle exercises, also called Kegel and pelvic
floor exercises, are performed to strengthen the voluntary
periurethral and perivaginal muscles (voluntary urethral
sphincter and levator ani). Pelvic muscle exercises may
be used alone or augmented with bladder training, bio-
feedback, or electrical stimulation. Health care providers
can teach patients the correct method of distinguishing
and contracting the pelvic muscles.
Medical Management
The urethra and bladder contain a rich supply of estrogen
receptors; therefore, it is biologically feasible that estro-
gen therapy affects postmenopausal urogenital symptoms.
However, trials have demonstrated an increase in urinary
incontinence with estrogen therapy.
A number of other pharmacologic agents appear to
be effective for frequency, urgency, and urge inconti-
nence. However, the response to treatment often is unpre-
dictable, and side effects are common with effective
doses. Generally, drugs improve detrusor overactivity by
inhibiting the contractile activity of the bladder. These
agents can be broadly classified into anticholinergic
agents, tricyclic antidepressants, musculotropic drugs,
and a variety of less commonly used drugs.
ACOG Practice Bulletin No. 63 5
Surgical Treatments
Many surgical treatments have been developed for stress
urinary incontinence, but only a fewretropubic colpo-
suspension and sling procedureshave survived and
evolved with enough supporting evidence to make
recommendations. Contemporary, less invasive modifica-
tions of these operations are being performed, and stud-
ies assessing their efficacy are ongoing.
Procedures. The basic goal of retropubic colposuspen-
sion is to suspend and stabilize the anterior vaginal wall,
and, thus, the bladder neck and proximal urethra, in a
retropubic position. This prevents their descent and
allows for urethral compression against a stable sub-
urethral layer.
Most recent studies are performed with colposus-
pension techniques using two or three nonabsorbable
sutures on each side of the mid urethra and bladder neck.
One randomized trial of patients undergoing laparo-
scopic Burch procedures for stress incontinence showed
that two sutures on each side of the urethra resulted in a
significantly higher cure rate than one suture (16).
The tension-free vaginal tape procedure is based on
a theory that the pathophysiology of stress urinary incon-
tinence is the impairment of the pubourethral ligaments
(17). A narrow strip of polypropylene mesh is placed at
the mid urethra to compensate for this inefficiency. The
success of tension-free vaginal tape has led to the intro-
duction of similar products with modified methods of
mid-urethral sling placement (retropubic top-down and
transobturator). The use of these other materials and
modified methods compared with tension-free vaginal
tape has yet to be fully evaluated.
A number of bulking agents have been used for the
treatment of urodynamic stress incontinence with
intrinsic sphincter deficiency in women. The bulking
agents (collagen, carbon-coated beads, and fat) are
injected transurethrally or periurethrally in the peri-
urethral tissue around the bladder neck and proximal
urethra. They provide a washer effect around the
proximal urethra and the bladder neck. These agents
usually are used as second-line therapy after surgery has
failed, when stress incontinence persists with a nonmo-
bile bladder neck, or among older, debilitated women
for whom any form of operative treatment may be espe-
cially hazardous.
Complications. Intraoperative or immediate postopera-
tive complications of surgery for stress incontinence
include direct surgical injury to the lower urinary tract,
hemorrhage, bowel injury, wound complications, reten-
tion, and urinary tract infection. Gynecologic surgeons
may perform cystoscopy during or after retropubic and
sling procedures to verify ureteral patency and the
absence of sutures or sling material in the bladder. Most
of the chronic complications after Burch colposuspen-
sion and sling procedures relate to voiding dysfunction
and urge symptoms (Table 2).
Incontinence With Pelvic Organ Prolapse. Urinary
incontinence frequently coexists with uterine prolapse
and descent of the anterior vaginal wall. Symptoms of
stress incontinence can be overt, or the patient can be
asymptomatic but will develop stress incontinence if the
vaginal prolapse is reduced or repaired (potential stress
incontinence).
Table 2. Complication Rates Following Surgical Treatment
for Stress Urinary Incontinence
Complication Rate Procedure
Bladder perforation 39% Tension-free tape
1, 2
2% Colposuspension
1
Detrusor overactivity/ 527% Burch colposuspension
3
urge incontinence
030% Sling
4, 5
6% Tension-free tape
6
Erosion of surgical 5% Sling
5
materials
Sling revision or removal 535% Sling
7
Voiding disorders 237% Sling
8
411% Tension-free tape
1, 2, 9
1
Ward K, Hilton P. Prospective multicentre randomised trial of tension-free vagi-
nal tape and colposuspension as primary treatment for stress incontinence.
United Kingdom and Ireland Tension-free Vaginal Tape Trial Group. BMJ
2002;325:6770.
2
Tamussino KF, Hanzal E, Kolle D, Ralph G, Riss PA. Tension-free vaginal tape
operation: results of the Austrian registry. Austrian Urogynecology Working
Group. Obstet Gynecol 2001;98:7326.
3
Dainer M, Hall CD, Choe J, Bhatia NN. The Burch procedure: a comprehensive
review. Obstet Gynecol Surv 1999;54:4960.
4
Bezerra CA, Bruschini H, Cody DJ. Suburethral sling operations for urinary incon-
tinence in women. The Cochrane Database of Systematic Reviews 2001, Issue 3.
Art. No.: CD001754. DOI: 10.1002/14651858.CD001754.
5
Bidmead J, Cardozo L. Sling techniques in the treatment of genuine stress incon-
tinence. BJOG 2000;107:14756.
6
Nilsson CG, Falconer C, Rezapour M. Seven-year follow-up of the tension-free
vaginal tape procedure for treatment of urinary incontinence. Obstet Gynecol
2004;104:125962.
7
Persson J, Iosif C, Wolner-Hanssen P. Risk factors for rejection of synthetic sub-
urethral slings for stress urinary incontinence: a case-control study. Obstet
Gynecol 2002;99:62934.
8
Jarvis GJ. Surgery for genuine stress incontinence. Br J Obstet Gynaecol 1994;
101:3714.
9
Klutke C, Siegel S, Carlin B, Paszkiewicz E, Kirkemo A, Klutke J. Urinary retention
after tension-free vaginal tape procedure: incidence and treatment. Urology
2001;58:697701.
6 ACOG Practice Bulletin No. 63
Clinical Considerations and
Recommendations
When is office evaluation of bladder filling,
voiding, or cystometry useful for evaluation
of incontinence?
The findings of a careful history and physical examina-
tion predict the actual incontinence diagnosis with rea-
sonable accuracy. Whenever objective clinical findings
do not correlate with or reproduce the patients symp-
toms, simple bladder filling and cough stress tests are
useful. When trials of therapy are used, patients must be
monitored periodically to evaluate response. If the patient
fails to improve to her satisfaction, appropriate further
testing is indicated. Of women who have the symptom
of stress incontinence as their only symptom, 1030%
are found to have bladder overactivity (alone or coexist-
ent with urodynamic stress incontinence) or other rare
conditions.
Retrograde bladder filling provides an assessment of
bladder sensation and an estimate of bladder capacity.
Patients without urgency and frequency who note a sen-
sation of bladder fullness and have an estimated bladder
capacity that is within normal range probably have normal
bladder filling function. The definition of normal bladder
capacity lacks consensus, with values that range from 300
mL to 750 mL. In addition, large bladder capacities are
not always pathologic. Researchers showed that 33% of
women with bladder capacities greater than 800 mL were
urodynamically normal, and only 13% had true bladder
atony (18).
Loss of small amounts of urine in spurts, simultane-
ous with coughing and in the absence of urge, strongly
suggests a diagnosis of urodynamic stress incontinence
(19, 20). Prolonged loss of urine, leaking 510 seconds
after coughing, or no urine loss with provocation
indicates that other causes of incontinence, especially
detrusor overactivity, may be present. The inability to
demonstrate the sign of stress incontinence during simple
bladder filling and cough stress test correlates highly
with the absence of urodynamic stress incontinence (20,
21). Interpretation of these office tests can be difficult
because of artifact introduced by increases in intra-
abdominal pressure caused by straining or patient move-
ment. Borderline or negative test results should be
repeated to maximize their diagnostic accuracy.
Limited data support the need for cystometric testing
in the routine or basic evaluation of urinary incontinence.
It is indicated as part of the evaluation of more complex
disorders of bladder filling and voiding, such as the pres-
ence of neurologic disease and other comorbid conditions.
Multichannel or subtracted cystometry allows more
precise measurements of detrusor pressures with filling
and voiding, although both false-positive and false-nega-
tive test results generally are found with cystometry. No
studies have determined whether the addition of multi-
channel cystometry or video assessment over simple
filling cystometry improves diagnostic accuracy or out-
comes after treatment. Other complex urodynamic tests,
such as a pressure-flow voiding study, uroflowmetry, and
electromyography of the urethral sphincter, are available
for the assessment of complex and neurogenic causes of
urinary incontinence and voiding disorders.
Even under the most typical clinical situations, the
diagnosis of incontinence based only on clinical evalua-
tion may be uncertain. This diagnostic uncertainty may
be acceptable if medical or behavioral treatment (as
opposed to surgery) is planned because of the low mor-
bidity and cost of these treatments and because the rami-
fications of continued incontinence are not severe. When
surgical treatment of stress incontinence is planned, uro-
dynamic testing often is recommended to confirm the
diagnosis, unless the patient has an uncomplicated his-
tory and compatible physical findings of stress inconti-
nence and has not had previous surgery for incontinence.
When are urethral pressure profilometry and
leak point pressure measurements useful for
evaluation of incontinence?
Based on extensive review of the evidence, researchers
found that urethral pressure profilometry is not standard-
ized, reproducible, or able to contribute to the differential
diagnosis in women with stress incontinence symptoms
(22). Therefore, it does not meet the criteria for a use-
ful diagnostic test (22). Leak point pressure measures
the amount of increase in intraabdominal pressure that
causes stress incontinence, although its usefulness also
has not been proved (23).
When is cystoscopy useful for evaluation of
incontinence?
Cystoscopy is indicated for the evaluation of patients
with incontinence who have sterile hematuria or pyuria;
irritative voiding symptoms, such as frequency, urgency,
and urge incontinence, in the absence of any reversible
causes; bladder pain; recurrent cystitis; suburethral
mass; and when urodynamic testing fails to duplicate
symptoms of urinary incontinence (24). Bladder lesions
are found in less than 2% of patients with incontinence
(25, 26); therefore, cystoscopy should not be performed
routinely in patients with incontinence to exclude
neoplasm.

ACOG Practice Bulletin No. 63 7

Are pessaries and medical devices effective
for the treatment of urinary incontinence?
Pessaries and other mechanical devices modified to
selectively support the bladder neck may be effective for
treating some cases of urinary incontinence, but objective
evidence regarding their effectiveness has not been
reported (1). Replacement of the prolapsed anterior vagi-
nal wall with a pessary may unmask incontinence by
straightening out the urethrovesical kinking that may
have been responsible for either continence or some
degree of urinary retention.
Are behavior modifications (eg, bladder
retraining, biofeedback, weight loss) effective
for the treatment of urinary incontinence?
In one study, behavioral therapy that included group and
individual instruction, individualized scheduled voiding,
diary keeping, and instructions on pelvic muscle exer-
cises resulted in a 50% reduction in the mean number of
incontinence episodes (compared with a 15% reduction
in controls; P = .001), and this was maintained for
6 months (27). Thirty-one percent of women were 100%
improved (dry), 41% were at least 75% improved, and
52% were at least 50% improved. There were no differ-
ences in treatment efficacy by type of incontinence
(stress, urge, mixed) (27). Data show that behavioral
training with biofeedback resulted in a 63% mean reduc-
tion in incontinence episodes, compared with a 69%
mean reduction following verbal feedback and a 59%
mean reduction after receiving a self-help booklet (dif-
ferences not significant) (28). Patient satisfaction was
highest in the verbal feedback group and lowest in the
self-help booklet group. For stress incontinence, behav-
ioral training reduced the mean number of incontinence
episodes by 69%; the addition of pelvic floor electrical
stimulation did not result in significantly greater
improvement than behavioral training alone (29).
Therefore, behavioral therapy improves symptoms of
urge and mixed incontinence and can be recommended
as a noninvasive treatment in many women.
Researchers showed that combining drug and behav-
ioral therapy in a stepped program can produce added
benefit for patients with urge incontinence (30).
However, there is not enough evidence to show whether
drug therapy is better than bladder training or useful as a
supplement (31).
Obesity appears to be an independent risk factor for
the development of incontinence, with obese women
having a 4.2-fold greater risk of stress urinary inconti-
nence than those with a normal body mass index
(3235). Few published intervention studies have inves-
tigated incontinence after weight loss, and these
addressed only the effects of massive weight loss in mor-
bidly obese women (36, 37).
Are pelvic muscle exercises effective for the
treatment of urinary incontinence?
Pelvic floor training appears to be an effective treatment
for adult women with stress and mixed incontinence
(38), and pelvic muscle exercises appear better than no
treatment or placebo. Pelvic muscle exercise reduces
incontinence and increases vaginal pressure measure-
ments, but direct correlations between these alterations
are weak (39). Pelvic muscle exercise appears to be
superior to electrical stimulation and vaginal cones in the
treatment of stress incontinence (40). Bladder training,
pelvic muscle exercise, or their combination appeared
equal in symptom improvement and urodynamic param-
eters in one randomized trial (41). Generally, the effect
of adding pelvic muscle training to other treatments
for stress urinary incontinence and the effects of pelvic
muscle exercise on urge incontinence alone remain
unclear (38).
Is pharmacotherapy (eg, estrogen, tolterodine,
oxybutynin, imipramine) effective for the
treatment of urinary incontinence?
The effect of postmenopausal hormone therapy (HT) on
urinary incontinence has been evaluated in several
randomized controlled trials. One trial studied post-
menopausal women with at least one episode of inconti-
nence weekly at baseline, randomized to receive either
HT or placebo (42). Exacerbation of incontinence
occurred in 39% of the HT group and 27% of the place-
bo group (P = .001). In a subset analysis of the Womens
Health Initiative study, postmenopausal women both
with and without symptoms of incontinence were ran-
domized to receive a) combined HT or placebo or b)
unopposed estrogen therapy or placebo (43). Both com-
bined therapy and unopposed estrogen were found to
increase the incidence of urinary incontinence among
women without symptoms at baseline. For those women
with symptoms at baseline, frequency increased in both
the combined therapy and unopposed estrogen groups.
Other smaller studies have examined the use of oral
estrogen preparations in the treatment of stress or urge
incontinence and found that the use of estrogen did not
reduce incontinence (4447). Therefore, oral estrogen
regimens cannot be recommended as treatment or pre-
vention for any type of urinary incontinence.
Several meta-analyses addressing drug therapy for
bladder overactivity have been published (48, 49). The

anticholinergic drugs oxybutynin chloride and toltero-

dine have five or more randomized controlled trials each;
these trials report a small beneficial effect of anticholin-
ergic drug treatment as therapy for urge incontinence
(48). However, for many of the outcomes studied, the
observed differences between treatment with anticholin-
ergic medications and placebo may be of questionable
clinical significance (49). No significant difference
among these agents was reported. The most typical side
effect of anticholinergic therapy is dry mouth; other side
effects most frequently reported were blurred vision,
constipation, nausea, dizziness, and headache (48).
Alternative drugs, new drugs, and new formulations of
existing drugs are all available, but limited data exist on
which to base recommendations.
Is there a role for bulking agents in the
treatment of urinary incontinence?
Most of the reported studies have used glutaraldehyde
cross-linked collagen as the bulking agent. Reviewers
summarized the literature on cross-linked bovine colla-
gen for the treatment of stress incontinence and intrinsic
sphincter deficiency (50). Most patients in the studies
had failed incontinence surgeries and had a supported
nonmobile bladder neck. Seventeen studies were cited
with cure rates ranging from 7% to 83% over a 10-year
period. The cure rate, defined in 15 articles as complete-
ly dry, averaged 48%. An overall average of 76% of sub-
jects (range, 6890%) were listed as dry or
improved (50). The limitations of existing bulking
agents are their durability and long-term results.
For women with extensive comorbidity precluding
surgery or anesthesia or both, injection of bulking agents
may provide a useful option for relief of symptoms for a
12-month period. Two or three injections are likely to be
required to achieve a satisfactory result (51).
When is surgery indicated for urinary
incontinence?
Surgery is indicated for the treatment of stress urinary
incontinence when conservative treatments have failed to
satisfactorily relieve the symptoms and the patient wish-
es further treatment in an effort to achieve continence. It
is desirable if the patient does not wish to have more
children, although retaining fertility potential is not a
contraindication of surgery. However, there is no evi-
dence on the effect of subsequent pregnancy.
Not all patients with urinary incontinence need uro-
dynamic testing before surgery. These patients include
women who lose urine only with physical exertion; have
normal voiding habits (<8 voiding episodes per day, <2
per night); have no associated findings on neurologic or
physical examination; have no history of antiinconti-
nence or radical pelvic surgery; possess a hypermobile
urethra, pliable vaginal wall, and adequate vaginal capac-
ity on physical examination; have a normal postvoid
residual volume; and are not pregnant.
Patients who are thought to have detrusor overactiv-
ity on clinical evaluation can be given appropriate behav-
ioral or medical therapy, and a substantial percentage of
patients can be expected to respond (52). Even patients
with mixed disorders (coexistent stress and urge inconti-
nence) respond to various forms of conservative therapy
(53, 54).
Which type of surgery is indicated in the
treatment of urinary incontinence?
Retropubic colposuspension procedures are indicated for
women with the diagnosis of urodynamic stress inconti-
nence and a hypermobile proximal urethra and bladder
neck. Selection of a retropubic approach (versus a sling)
depends on many factors, such as the need for laparot-
omy for other pelvic disease, the amount of pelvic organ
prolapse and whether a vaginal or abdominal procedure
will be used to suspend the vagina, the age and health
status of the patient, and the preferences of the patient
and surgeon. Although retropubic procedures can be
used for intrinsic sphincter deficiency with urethral
hypermobility, sling operations may yield better long-
term results. Hysterectomy adds little to the efficacy of
Burch colposuspension in curing stress incontinence
(55), and it should be performed only for specific uterine
pathology or for the treatment of uterine prolapse.
One consensus panel review indicated that after 48
months, retropubic suspensions and sling procedures
seem to be more efficacious than transvaginal needle sus-
pension procedures or anterior colporrhaphy (56). The
authors also noted that retropubic suspensions and sling
procedures are associated with slightly higher compli-
cation rates, including longer convalescence and post-
operative voiding dysfunction. Clinical outcomes of
the tension-free vaginal tape procedure and other
mid-urethral slings were not available at the time of the
consensus panel review.
Several review articles have been published summa-
rizing the cure rates of retropubic procedures compared
with other procedures for the treatment of urodynamic
stress incontinence. Open abdominal retropubic suspen-
sion appears to be better than anterior vaginal repair,
even in women with prolapse, judged on subjective cure
rates in six trials (57).
A multicenter randomized trial found no difference
between Burch colposuspension and tension-free vaginal
tape procedures, with objective cure rates for urodynamic
8 ACOG Practice Bulletin No. 63

ACOG Practice Bulletin No. 63 9

stress incontinence of 57% and 66%, respectively (58).
Bladder injury was more common during the tension-
free vaginal tape procedure (P = .013); delayed voiding,
operation time (P <.001), and return to normal activity
(P <.001) were all longer after colposuspension (58).
In a cohort of women who underwent Burch colpo-
suspension, the cure rate of stress incontinence gradually
decreased over 1012 years, reaching a plateau at 69%
(59). Cure rates were significantly lower in women who
had previous bladder neck surgery (P = .02). Approxi-
mately 10% of patients required at least one additional
surgery to cure their stress incontinence (59).
Only a few studies have assessed the paravaginal
defect repair for stress incontinence. A prospective ran-
domized trial found that only 61% of women were con-
tinent 3 years after a paravaginal defect repair, compared
with 100% of women who were continent 3 years after a
Burch colposuspension (P = .004) (60). The paravaginal
defect repair should not be used as primary treatment of
urodynamic stress incontinence.
Laparoscopic access can be used to perform a Burch
colposuspension, and this technique has become popular
with some physicians and patients. However, it remains
to be proved whether laparoscopic colposuspension
yields cure rates equal to open Burch colposuspension
for stress incontinence in women. One recent random-
ized trial comparing open Burch colposuspension with
laparoscopic colposuspension showed significantly
higher objective and subjective stress incontinence cure
rates in the open Burch group (P <.001) (61); however,
the results of most other studies comparing the two tech-
niques are inconclusive (62, 63).
Long-term objective results of the tension-free vagi-
nal tape procedure for primary stress incontinence were
shown in a multicenter trial; at a median follow-up of 56
months, 85% of patients were objectively and subjec-
tively cured, 10.6% were improved, and 4.7% were
regarded as failures (64). There were no cases of mesh
erosion or permanent retention. Two randomized trials
comparing the results of tension-free vaginal tape with
Burch colposuspension showed similar objective and
subjective cure rates from both procedures (58, 65).
However, a recent randomized trial of laparoscopic
Burch colposuspension and tension-free tape procedures
showed higher objective cure rates for urodynamic stress
incontinence for tension-free tape procedures, although
quality of life and satisfaction scores were similar
between procedures (66).
Two large cohort studies have assessed the results of
pubovaginal fascial bladder neck sling for stress inconti-
nence. At a mean follow-up of 51 months (range 2268),
continence rates were 88% overall (67). Preoperative
urge incontinence resolved in 81 of 109 women (74%),
whereas de novo urgency developed in 7% of women.
In patient questionnaires, 92% reported a high degree
of satisfaction with low symptom distress scores. In
another study of 251 women, permanent urinary reten-
tion developed in 2% of patients (68).
The intermediate and long-term results for sub-
urethral slings suggest that the 10-year continence rate is
similar to the 1-year continence rate (69). In fact, it
appears that sling procedures that are effective after 6
months are likely to remain effective for many years
(69).
For patients with both prolapse and urinary
incontinence, what surgical procedures are
appropriate?
Patients with vaginal prolapse with coexistent sympto-
matic stress incontinence have a number of treatment
options. Treatment choice often depends on patient char-
acteristics and the surgeons experience. If the prolapse
is to be repaired abdominally, as with a sacral colpopexy,
a retropubic colposuspension may be appropriate.
Transvaginal prolapse repair may include a sling placed
at the time of repair to treat stress incontinence.
Women who have severe pelvic organ prolapse but
potential stress incontinence present a unique challenge.
Data supporting specific recommendations in these
patients are scarce and several opposing opinions are
common. In fact, even the correct method for making the
diagnosis of potential stress incontinence is controver-
sial. For women who have significant anterior vaginal
wall prolapse after their vaginal apex is suspended,
appropriate repair generally is indicated. Suburethral
plication of the bladder neck to stabilize a hypermobile
urethra is probably appropriate in many cases. One
recent randomized controlled trial of women with
prolapse and potential stress incontinence showed that a
tension-free vaginal tape procedure resulted in less
incontinence postoperatively than a suburethral plication
(P = .01) with similar rates of urinary retention and urge
incontinence (70).
Summary of Conclusions
and Recommendations
The following recommendations are based on
good and consistent scientific evidence (Level A):
Behavioral therapy, including bladder training and
prompted voiding, improves symptoms of urge and
mixed incontinence and can be recommended as a
noninvasive treatment in many women.

10 ACOG Practice Bulletin No. 63

Pelvic floor training appears to be an effective treat-
ment for adult women with stress and mixed incon-
tinence and can be recommended as a noninvasive
treatment for many women.
Pharmacologic agents, especially oxybutynin and
tolterodine, may have a small beneficial effect on
improving symptoms of detrusor overactivity in
women.
The following recommendations are based on lim-
ited or inconsistent scientific evidence (Level B):
Cystometric testing is not required in the routine or
basic evaluation of urinary incontinence.
Bulking agents are a relatively noninvasive method
of treatment for stress incontinence and can be used
in women for whom any form of operative treatment
is contraindicated.
Long-term data suggest that Burch colposuspension
and sling procedures have similar objective cure
rates; therefore, selection of treatment should be
based on patient characteristics and the surgeons
experience.
The combination of a hysterectomy and a Burch col-
posuspension does not result in higher continence
rates than a Burch procedure alone.
Tension-free vaginal tape and open Burch colposus-
pension have similar success rates.
Anterior colporrhaphy, needle urethropexy, and par-
avaginal defect repair have lower cure rates for
stress incontinence than Burch colposuspension.
The following recommendations are based primar-
ily on consensus and expert opinion (Level C):
After the basic evaluation of urinary incontinence,
simple cystometry is appropriate for detecting
abnormalities of detrusor compliance and con-
tractibility, measuring postvoid residual volume,
and determining capacity.
Patients with urinary incontinence should undergo a
basic evaluation that includes a history, physical
examination, measurement of postvoid residual vol-
ume, and urinalysis.
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13 ACOG Practice Bulletin No. 63
The MEDLINE database, the Cochrane Library, and
ACOGs own internal resources and documents were used
to conduct a literature search to locate relevant articles pub-
lished between January 1985 and February 2005. The
search was restricted to articles published in the English
language. Priority was given to articles reporting results of
original research, although review articles and commentar-
ies also were consulted. Abstracts of research presented at
symposia and scientific conferences were not considered
adequate for inclusion in this document. Guidelines pub-
lished by organizations or institutions such as the National
Institutes of Health and the American College of Obstetri-
cians and Gynecologists were reviewed, and additional
studies were located by reviewing bibliographies of identi-
fied articles. When reliable research was not available,
expert opinions from obstetriciangynecologists were used.
Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services Task
Force:
I Evidence obtained from at least one properly de-
signed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncon-
trolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level ARecommendations are based on good and consis-
tent scientific evidence.
Level BRecommendations are based on limited or incon-
sistent scientific evidence.
Level CRecommendations are based primarily on con-
sensus and expert opinion.
Copyright June 2005 by the American College of Obstetri-
cians and Gynecologists. All rights reserved. No part of this
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Urinary incontinence in women. ACOG Practice Bulletin No. 63.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;105:153345.