Low-quality evidence showed that tolterodine improved quality of life Low-quality evidence did not show a statistically significant improvement in UI compared with placebo 94, Individual studies showed that trospium improved quality of life Evidence was insufficient to determine the effect of solabegron on continence or improving UI, but low-quality evidence showed that it decreased the frequency of UI episodes in a dose-dependent manner Evidence was insufficient to determine the clinical effectiveness of resiniferatoxin or nimodipine compared with placebo for treatment of UI Moderate-quality evidence showed that fesoterodine achieved continence more often than tolterodine NNT B , 18 [CI, 11 to 52] 55, 56, Low-quality evidence showed no difference between oxybutynin and tolterodine for achieving continence Moderate-quality evidence showed no difference for improving UI 66, 68, , Low-quality evidence from 1 study showed that tolterodine and trospium were similarly effective at treating urgency UI Evidence was insufficient to compare solifenacin with tolterodine for effects on continence or improvement of UI Low-quality evidence showed no differences between trospium and oxybutynin for effects on continence or improvement of UI Evidence was insufficient to determine the comparative effectiveness on continence or improvement of UI for darifenacin, propiverine, solifenacin, or flavoxate versus oxybutynin; solifenacin versus darifenacin; or tolterodine or solifenacin versus propiverine Moderate-quality evidence showed that age did not modify clinical outcomes associated with pharmacologic treatment High-quality evidence showed that trospium, oxybutynin, and darifenacin effectively improved UI and quality of life in older women 52, 71, High-quality evidence also showed that solifenacin achieved continence more often than placebo, regardless of age Evidence was inconclusive about differences among various racial groups.
Low-quality evidence showed that the baseline frequency of UI was not associated with statistically significantly different clinical outcomes for any drugs examined However, women with more frequent UI episodes had slightly greater benefits with active pharmacologic treatment than placebo , High-quality evidence showed that solifenacin achieved continence more than placebo regardless of the response to previous treatments; a larger dose did not improve an initially poor response Moderate-quality evidence indicated that trospium reduced the number of urgency UI episodes regardless of whether the patient was receiving other drugs.
Patients receiving 7 or more concomitant medications had more adverse effects than those receiving fewer than 7 Evidence did not show any difference in effectiveness of trospium in achieving continence in obese or nonobese patients The risk for adverse effects associated with nonpharmacologic treatments was low.
Appendix Table 2 summarizes the adverse effects associated with pharmacologic treatments, which were similar within drug classes. The most commonly reported adverse effects associated with antimuscarinics included dry mouth, constipation, and blurred vision. Moderate-quality evidence showed that adverse effects, including dry mouth and headache, were more common with fesoterodine than with tolterodine NNT H , 11 [CI, 8 to 17] Dry mouth and insomnia were more frequently reported for oxybutynin than for tolterodine Dizziness was more frequently reported for trospium, and dry mouth and insomnia were more frequently reported for oxybutynin Tolterodine has also been associated with increased risk for hallucinations Nasopharyngitis and gastrointestinal disorders were more frequent with mirabegron than placebo 96, Discontinuation of treatment due to adverse effects was common.
High-quality evidence showed no statistically significant difference in treatment discontinuation rate due to adverse effects between darifenacin 52—54, — or tolterodine and placebo 55, 56, 59, 66, 87, , , , , , , , Discontinuation due to adverse effects was higher with fesoterodine than tolterodine moderate-quality; NNT H , 58 [CI, 33 to ] 55, 56, 59, and with oxybutynin than tolterodine high-quality; NNT H , 14 [CI, 7 to ] 67, 68, , , — Discontinuation of treatment due to adverse effects did not differ between solifenacin and tolterodine moderate-quality , — or between trospium and oxybutynin low-quality , , Nonpharmacologic therapies were effective at managing UI, had a large magnitude of benefit for increasing continence rates, and were associated with a low risk for adverse effects.
Pelvic floor muscle training alone and in combination with bladder training or biofeedback and weight loss with exercise for obese women were effective at achieving continence and improving UI. Evidence was insufficient to compare nonpharmacologic therapies with one another or with pharmacologic therapies; head-to-head comparisons would be useful. Pharmacologic therapies were effective and equally efficacious at managing urgency UI and had a moderate magnitude of benefit in achieving continence rates but were associated with adverse effects. In addition, evidence showed that some patients were likely to discontinue pharmacologic treatment because of adverse effects.
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Solifenacin was associated with the lowest risk for discontinuation due to adverse effects, whereas oxybutynin was associated with the highest risk. Only darifenacin and tolterodine had risks for discontinuation due to adverse effects similar to placebo. Evidence was insufficient to compare most drugs with one another for safety and efficacy.
Tolterodine and oxybutynin resulted in the same benefits, but tolterodine caused fewer harms. Of note, many studies did not fully specify details of the patient populations studied, including whether they received prior treatment for UI, which could potentially influence treatment response. In addition, because these statistics are derived from the risk difference, they are ultimately an expression of a specific treatment versus a specific control active or placebo and should not be used to indirectly compare NNT B and NNT H across various treatments.
See the Figure for a summary of the recommendations and clinical considerations. Pelvic floor muscle training increased continence rates and improved UI and quality of life in women with stress UI. Bladder training improved UI for women with urgency UI. The addition of PFMT to bladder training did not improve continence compared with bladder training alone for urgency UI. Pelvic floor muscle training combined with bladder training improved continence and UI in women with mixed UI. Recommendation 4: ACP recommends against treatment with systemic pharmacologic therapy for stress UI.
Treatment of stress UI with standard pharmacologic therapies used for urgency UI has not been shown to be effective. Vaginal estrogen formulations improved continence and stress UI, but transdermal estrogen patches worsened UI. Recommendation 5: ACP recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful. Pharmacologic therapies were effective and equally efficacious at managing urgency UI and had a moderate magnitude of benefit in achieving continence rates. However, they were associated with adverse effects and evidence showed that some patients were likely to discontinue pharmacologic treatment because of these effects.
For urgency UI, oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium increased continence rates and improved UI. Evidence was insufficient to evaluate the comparative effectiveness of different drugs and to determine the long-term safety of pharmacologic treatments for UI.
Patient characteristics, such as age, race, comorbid conditions, or baseline UI, did not affect the outcomes of the various pharmacologic medications. However, adherence to pharmacologic treatments for UI was poor. Adverse effects were a major reason for treatment discontinuation. Clinicians and their patients should compare the risk for pharmacologic adverse effects with the severity and bothersomeness of the patient's symptoms.
Appendix Table 2 shows the quality of evidence for outcomes of continence and improvement of UI as well as the adverse effects for the various drugs. Evidence was insufficient to evaluate the comparative effectiveness of nonpharmacologic versus pharmacologic treatments for UI, and nonpharmacologic treatment should be considered first-line therapy. Evidence showed that nonpharmacologic treatments were better than no treatment in achieving continence and improving UI with a large magnitude of effect and are associated with a low risk for adverse effects.
Pharmacologic treatments are associated with adverse effects that may be intolerable and lead to discontinuation of treatment. Clinicians and patients should keep in mind the costs of treatment, especially long-term costs, when choosing treatment. Weight loss and exercise improved UI in obese women with no evident harms.
In addition, the benefits of weight loss in obese women extend beyond improvement of UI. Urinary incontinence is a common and important health care problem in women that is underreported and underdiagnosed. Clinicians should take a detailed history and ask specific questions, such as the time of onset, symptoms, and frequency. Although pharmacologic therapy can improve UI and provide complete continence, many patients discontinue medication because of adverse effects. The prevalence of stress urinary incontinence in high school and college-age female athletes in the midwest: implications for education and prevention.
The prevalence, burden, and treatment of urinary incontinence among women in a managed care plan. Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Should we actively screen for urinary and anal incontinence in the general gynaecology outpatients setting?
Fraction of nursing home admissions attributable to urinary incontinence. Hay Smith.
Urology Clinical Practice Guidelines Summaries
Department of Health and Human Services; U. Reductions in stress urinary incontinence episodes: what is clinically important for women? Comparative Effectiveness Review no. AHRQ publication no. Accessed at www. Agency for Healthcare Research and Quality. Benefits and harms of pharmacologic treatment for urinary incontinence in women: a systematic review. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods.
A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia. Biofeedback and pelvic floor exercises for the rehabilitation of urinary stress incontinence. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. Exercise treatment to reduce the urine leakage in elderly community-dwelling Japanese women with stress, urge, and mixed urinary incontinence [Abstract]. Abstract no. Treatment of stress incontinence with pelvic floor exercises and biofeedback.
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A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women. Single-blind, randomized, controlled trial of pelvic floor muscle training, electrical stimulation, vaginal cones, and no active treatment in the management of stress urinary incontinence. An alternative intervention for urinary incontinence: retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function.
Controlled trial of pelvic floor exercises in the treatment of urinary stress incontinence in general practice. Urodynamic changes associated with behavioral and drug treatment of urge incontinence in older women. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence. Prevention of urinary incontinence by behavioral modification program: a randomized, controlled trial among older women in the community.
Outcomes of a small group educational intervention for urinary incontinence: episodes of incontinence and other urinary symptoms. Urinary incontinence: prevalence, need for treatment, and effectiveness of intervention by nurse. Continence efficacy intervention program for community residing women with stress urinary incontinence in Japan. Randomised controlled trial of nurse continence advisor therapy compared with standard urogynaecology regimen for conservative incontinence treatment: efficacy, costs and two year follow up.
Clinical and cost-effectiveness of a new nurse-led continence service: a randomised controlled trial. A population based, randomized, controlled trial of conservative treatment for urinary incontinence in women. Efficacy of low-dose intravaginal estriol on urogenital aging in postmenopausal women. A double-blind placebo-controlled trial on the effects of 25 mg estradiol implants on the urge syndrome in postmenopausal women.
The effect of ultralow-dose transdermal estradiol on urinary incontinence in postmenopausal women. Effects of intravaginal estriol and pelvic floor rehabilitation on urogenital aging in postmenopausal women. Duloxetine vs placebo in the treatment of stress urinary incontinence: a four-continent randomized clinical trial. Duloxetine versus placebo in the treatment of stress urinary incontinence. Pharmacological treatment of women awaiting surgery for stress urinary incontinence. Short- and long-term efficacy and safety of duloxetine in women with predominant stress urinary incontinence.
Duloxetine versus placebo for the treatment of women with stress predominant urinary incontinence in Taiwan: a double-blind, randomized, placebo-controlled trial. Minimal clinically important differences in incontinence quality-of-life scores in stress urinary incontinence. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence.
Duloxetine compared with placebo for treating women with symptoms of overactive bladder. Dose response with darifenacin, a novel once-daily M3 selective receptor antagonist for the treatment of overactive bladder: results of a fixed dose study. An investigation of dose titration with darifenacin, an M3-selective receptor antagonist. Superior efficacy of fesoterodine over tolterodine with rapid onset: a prospective, head-to-head, placebo-controlled trial [Abstract]. Pharmacologic treatment for urgency-predominant urinary incontinence in women diagnosed using a simplified algorithm: a randomized trial.
Randomized, double-blind, placebo-controlled trial of flexible-dose fesoterodine in subjects with overactive bladder. Comparison of fesoterodine and tolterodine extended release for the treatment of overactive bladder: a head-to-head placebo-controlled trial. Fesoterodine Flexible Dose Study. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial.
Pharmacokinetics, efficacy, and safety of intravesical formulation of oxybutynin in patients with detrusor overactivity. Oxybutynin hydrochloride 3 mg in the treatment of women with idiopathic detrusor instability. Efficacy and safety of oxybutynin chloride topical gel for overactive bladder: a randomized, double-blind, placebo controlled, multicenter study. Tolterodine, a new antimuscarinic agent: as effective but better tolerated than oxybutynin in patients with an overactive bladder. Combine keywords with OR to retrieve guidelines containing any of the keywords e.
Use quotation marks " " to search a phrase e. Include full text in search. Search tips. Browse by letter: A-Z. Searched for: Number of CPGs:. Enterococcus species also have been isolated in women with structural abnormalities. Gram-positive isolates, including group B streptococci, are increasingly isolated along with fungal infections in women with indwelling catheters 6. Anaerobic organisms and mycoplasmas are uncommonly isolated from UTIs and probably have a minor role in urinary tract pathogenesis. Although ascending infection is the predominant route of infection in the urinary tract, occasionally infection may arise from hematogenous or lymphatic spread.
Bloodborne pathogens may seed the renal parenchyma during episodes of bacteremia. Renal abscesses may arise from bacterial endocarditis bacteremia from Staphylococcus aureus. Rare cases of pyelonephritis, caused by fungemia from Candida species in hospitalized patients, have been reported.
Although lymphatic connections are present along the ureters and kidneys and reverse lymphatic flow into the kidneys has been reported, lymphatic spread of microorganisms leading to UTI is rare 8. Risk factors for UTI in women vary among the different age groups. In school-aged girls, common risk factors include congenital abnormalities and new onset of sexual activity.
Risk factors for premenopausal and postmenopausal women are listed in the box. With advancing age, the rate of UTI increases, likely because of the hypoestrogenic state and vaginal epithelium atrophy, impaired voiding, and changes in hygiene 7, 9. Acute bacterial cystitis usually presents clinically as dysuria, with symptoms of frequent and urgent urination, secondary to irritation of the urethral and bladder mucosa.
Women also may experience suprapubic pain or pressure and rarely have hematuria. Fever is uncommon in women with uncomplicated lower UTI. Acute urethritis secondary to infection from Neisseria gonorrhoeae and Chlamydia trachomatis or pain secondary to genital herpes simplex virus type 1 and herpes simplex virus type 2 may occur with similar clinical symptoms and should be ruled out. In contrast, upper UTI or acute pyelonephritis frequently occurs with a combination of fever and chills, flank pain, and varying degrees of dysuria, urgency, and frequency.
Severe flank pain radiating to the groin is more indicative of renal calculi.
Occasionally, renal pain may radiate to other abdominal areas, necessitating evaluation for cholelithiasis, cholecystitis, pelvic inflammatory disease, gastric ulcers, and appendicitis. Older women with UTI may be asymptomatic, present moribund from septic shock urosepsis , have symptoms only of urinary incontinence, or have any combination of these symptoms.
Bacteriuria is diagnosed using a clean-voided midstream urine sample. To diagnose bacteriuria, decreasing the colony count to 1,—10, bacteria per milliliter in symptomatic patients will improve the sensitivity without significantly compromising specificity. It is a good screening test, but women with negative test results and symptoms should still have a urine culture or urinalysis or both performed because false-negative results are common. A standard urinalysis will detect pyuria, defined as 10 leukocytes per milliliter, but pyuria alone is not a reliable predictor of infection.
However, pyuria and bacteriuria together on microscopic examination results markedly increases the probability of UTI. The use of a postvoid residual volume measure, urodynamic testing, cystourethroscopy, or radiologic imaging is not cost-effective in women unless they have evidence of a complicated infection or renal calculi.
These are rarely necessary to diagnose acute uncomplicated cystitis and pyelonephritis. A major consequence of indiscriminate prescribing practices of common antibiotics is the emergence of antimicrobial resistance. Particularly for acute pyelonephritis, urine culture and susceptibility testing can help tailor antimicrobial choices. If available, local community or hospital surveillance data should be reviewed to guide empirical therapy for UTIs.
These data should be periodically updated as susceptibility patterns change over time. In the past, uncomplicated acute cystitis has been treated with 7—10 days of antimicrobial therapy. Recommended agents for the 3-day therapy are detailed in the next section and in Table 1. This is because of increasing resistance among the common uropathogens, rapid excretion from the urinary tract, and the inability to completely clear gram-negative rods from the vagina, increasing the risk for recurrence 5, Acute pyelonephritis traditionally has been treated with hospitalization and parenteral antibiotics.
However, there has been a recent shift to outpatient management, when possible, with an emphasis on cost-savings, although this management scheme is based on results from few large treatment trials In otherwise healthy women who are clinically stable and able to tolerate oral antimicrobial agents and fluids, outpatient management is acceptable and has similar efficacy The reliability of the patient and the social situation also should be taken into account when determining inpatient versus outpatient management.
A urine culture is performed and empiric antibiotic therapy initiated as detailed in the next section. The exception to this is if a gram-positive organism is the causative agent. Amoxicillin or amoxicillin combined with clavulanic acid may then be used. Outcomes after a 2-week course are equivalent to the traditional 6-week parenteral course, with no differences in recurrence rates. A substantial clinical response should be evident by 48—72 hours after initiating therapy. A urine culture test of cure usually is performed when the 2-week course of antibiotics is completed.
Management of recurrent UTIs should start with a search for known risk factors associated with recurrence. These include frequent intercourse, long-term spermicide use, diaphragm use, a new sexual partner, young age at first UTI, and a maternal history of UTI 15, Behavioral changes, such as using a different form of contraception instead of spermicide, should be advised.
Antimicrobial treatment of recurrent UTIs is based on patient desire and frequency of recurrences. A 3-day course of one of the antimicrobial regimens listed in Table 1 is started to clear the infection. A urine culture test of cure 1—2 weeks later to confirm clearance is suggested. This can be continued for 6—12 months and then reassessed. Women with recurrences associated with sexual activity may benefit from postcoital prophylaxis—a single dose of one of the agents listed in Table 1, taken after sexual intercourse, is effective in decreasing recurrences 1, 17, Antimicrobial therapy for UTIs in postmenopausal women is influenced by a number of factors.
The organisms causing UTIs in this population differ from the causative agents in younger women. Pharmacokinetic and pharmacodynamic changes also influence medication choices to limit drug toxicity and interactions 19, Despite these differences, few studies have adequately evaluated treatment options in these women. In a meta-analysis that evaluated 13 trials, including a total of 1, older women with UTIs, it was concluded that 3—6 days of antibiotic treatment was equivalent to longer courses of treatment 7—14 days , with fewer adverse events Single-dose therapy was not as effective as longer treatment regimens and should not be used.
Another randomized, controlled trial assessing the optimal duration of antibiotic therapy for uncomplicated UTIs in women aged 65 years or older concluded that the 3-day regimen was equally effective but better tolerated than a 7-day course Many women with recurrent UTIs are aware of symptom onset. As the cost of office and hospital emergency room visits continues to increase, patient-initiated therapy has become a viable option for treatment. Women are given a prescription for one of the 3-day dosage regimens listed in Table 1 and should be instructed to start therapy when symptoms develop.
Some clinicians also will give the women urine dipsticks and use pyuria as well as symptoms as an indication to initiate treatment. If symptoms do not improve in 48 hours, clinical evaluation should be performed. Patient-initiated therapy has been found to be safe, effective, and economical 22— It is a common practice among primary care physicians to empirically treat women with symptoms of a lower UTI without performing laboratory analyses.
It has been considered a cost-effective strategy, decreasing the number of diagnostic tests and office visits 25, However, many women, especially postmenopausal women, without a laboratory-proven UTI have symptoms of intermittent dysuria or urgent or frequent urination.
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Empiric treatment of these women leads to unnecessary antibiotic use and the development of antimicrobial resistance. Thus, in women without a history of a laboratory-confirmed UTI, an office visit for urinalysis or dipstick testing is appropriate. Women with frequent recurrences and prior confirmation by diagnostic tests who are aware of their symptoms may be empirically treated without recurrent testing for pyuria. The initial treatment of a symptomatic lower UTI with pyuria or bacteriuria does not require a urine culture. However, if clinical improvement does not occur within 48 hours or in the case of recurrence, a urine culture is useful to help tailor treatment.
A urine culture should be performed in all cases of upper UTIs. Imaging of the urinary tract rarely is required in women—it is not cost-effective nor does it provide useful information in the setting of uncomplicated lower or upper UTIs. Women with infections that do not respond to appropriate antimicrobial therapy or in whom the clinical status worsens require further evaluation.
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Renal ultrasonography is the best noninvasive method to evaluate renal collecting system obstruction. An intravenous pyelography also may be useful in this situation. Contrast-enhanced computed tomography or magnetic resonance imaging is useful to obtain an image of the renal parenchyma in order to rule out a perinephric abscess or phlegmon. Table 1 lists the current recommended regimens for treatment, both 3-day and 7-day courses. The other medications that have shown equivalency include trimethoprim alone, ciprofloxacin, levofloxacin, norfloxacin, and gatifloxacin.
The fluoroquinolones, although highly effective, should not be used as a first-line agent in areas where resistance prevalence to trimethoprim—sulfamethoxazole is low—currently resistance to the fluoroquinolones is uncommon, and overuse will likely hinder the ability to effectively use this class of antimicrobials in patients with complicated UTIs and those patients with respiratory and other non—urinary tract infections.
Most experts now agree that use of sulfonamides, ampicillin, and amoxicillin is less effective than use of trimethoprim—sulfamethoxazole and the fluoroquinolones see previous section and should not be used as first-line therapy. Use of nitrofurantoin, a drug frequently used in the pregnant population, is not well studied in nonpregnant women with acute cystitis.
It is not recommended for use in a 3-day regimen but has been found to be effective in a 7-day antimicrobial regimen and is listed in Table 1. The low prevalence of resistance and its ability to concentrate in urine continue to make nitrofurantoin a useful medication in the treatment of uncomplicated cystitis, particularly in areas where resistance rates to the first-line medications are high.
It is ineffective against Proteus mirabilis. Of note, nitrofurantoin can rarely induce hemolytic anemia in patients with glucosephosphate dehydrogenase deficiency, and use should be avoided in these patients Compared with the nitrofurantoin macrocrystal formulation, which requires frequent dosing four times per day and has a high likelihood of gastrointestinal side effects, monohydrate macrocrystal formulation is given twice daily, so side effects occur less frequently.
Women who present with acute pyelonephritis should have an initial urine culture and susceptibility testing before the initiation of antimicrobial therapy.
Intravenous hydration should be started while the clinical assessment is being performed. Women who are severely ill, have complications, are unable to tolerate oral medications or fluids, or who the clinician suspects will be noncompliant with outpatient therapy should be hospitalized and receive empiric broad-spectrum parenteral antibiotics.
Knowledge of specific antimicrobial resistance in the community should influence the choice of initial antimicrobial agent. Once the urine and susceptibility culture results are available, therapy is altered as needed. Most women can be treated on an outpatient basis initially or given intravenous fluids and one parenteral dose of an antibiotic before being discharged and given a regimen of oral therapy. The initial antimicrobial regimen is empiric. If a gram-positive organism is identified on a Gram stain, amoxicillin or ampicillin are acceptable treatment choices.
Gram-positive organisms in clusters probable Staphylococci maybe treated initially with cephalosporin. First-line therapy now is use of a fluoroquinolone for 14 days. In areas where resistance rates are low, trimethoprim—sulfamethoxazole use is an acceptable alternative For women with severe illness or urosepsis who require hospitalization, the broad-spectrum parenteral antibiotics available include aminoglycosides plus ampicillin, piperacillin or first-generation cephalosporins, aztreonam, third-generation cephalosporins, piperacillin-tazobactam, or parenteral fluoroquinolones used alone or in combination, depending on the individual case.
In all cases of acute pyelonephritis, whether the patient is treated on an inpatient or outpatient basis, 14 days of total antimicrobial therapy should be completed. Treatment of severe complications associated with pyelonephritis, such as septic shock, acute respiratory distress syndrome, and multiorgan failure, is beyond the scope of this bulletin. A notable clinical response should be evident by 48—72 hours.