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Stress urinary incontinence in women


Two systematic reviews published in recent years provide some basis on which to consider how to deal with this difficult and common problem. The overall prevalence of urinary incontinence in women is about 30%, but probably less than 5% in men. Stress urinary incontinence is the involuntary loss of urine during physical exertion, like coughing, sneezing, laughing, running, or lifting.

Surgical treatment


A systematic review of surgical interventions [1] found 11 randomised trials, 20 non-randomised studies or prospective cohort studies and 45 retrospective cohort studies. It found that the methodological quality of the 31 prospective studies was weak, and that the variability in inclusion criteria, surgical management and assessments of outcomes meant that no combining of data was possible.

The conclusion, therefore, was that evidence for the effectiveness of surgery was weak and conclusions speculative. It stressed particularly the lack of reliable information on complications after surgery and safety.

Conservative treatment


A systematic review of conservative treatments [2] found 24 randomised trials, of which 11 were of sufficient quality to allow for some analysis (though with lots of different methods and few studies for any one treatment). The main finding was that there was good evidence of benefit from pelvic floor exercises compared with no treatment, but that the amount of evidence to justify other modalities, like higher levels of exercise, or use of electrostimulation or intravaginal resistance devices, was low.

Comment


These reviews both comment on the generally poor quality of studies and lack of good quality evidence, but they are a good start for anyone trying to produce guidelines. Pelvic floor exercises which strengthen pelvic floor muscles are thought to improve the sphincteric action around the urethra and support the pelvic organs. It is suggested that strong contraction of the pelvic floor muscles will 'clamp' pressure rises in the urethra and prevent stress urinary incontinence. Pelvic floor exercises seem to work. The one message that comes through loud and clear is the need for good quality trials in which information on inclusion (diagnostic) criteria, therapy, and outcomes which include benefit and harm are clear and unambiguous.

References:


  1. NA Black, SH Downs. The effectiveness of surgery for stress incontinence in women: a systematic review. British Journal of Urology 1996 78: 497-510.
  2. LC Berghmans, HJ Hendriks, K Bø et al. Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials. British Journal of Urology 1998 82: 181-91.



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