Clinical Context

Urinary incontinence, particularly among women, is common and highly impactful. That was the one of the conclusions reached by the Women’s Preventive Services Initiative (WPSI). The organization cited research that found that 51% of women have experienced urinary incontinence. Three-quarters of older women have urinary incontinence, and the rate of urinary incontinence among women is approximately double that of men. Approximately one-third to one-half of women with incontinence have daily symptoms. Urinary incontinence is more common among white women compared with black and Hispanic women.

Risk factors for urinary incontinence include obesity and a history of vaginal delivery. Other risk factors include diabetes, constipation, caffeine consumption, smoking, vaginal atrophy, and a history of hysterectomy. Despite these common risk factors and high prevalence of symptoms, a survey found that more than half of women with urinary incontinence failed to discuss this issue with their healthcare providers.

Therefore, the WPSI considered whether screening for urinary incontinence among women may be warranted. Its recommendations and rationale are described in "Guideline Highlights."

Synopsis and Perspective

A new clinical guideline from the WPSI recommended annually screening all women, even adolescents, for urinary incontinence, but editorialists said this recommendation is premature and relies on insufficient evidence.

"Although minimum screening intervals are unknown, given the prevalence of urinary incontinence, that many women do not volunteer symptoms, and the multiple, frequently changing risk factors associated with incontinence, annual testing is reasonable," the authors wrote.

They added, "[A]lthough increasing parity, advancing age, and obesity are associated with an increased risk for urinary incontinence, these factors should not be used to limit screening."

Nancy O'Reilly, MHS, from the American College of Obstetricians and Gynecologists, Washington, DC, and colleagues published the clinical guideline published September 4 in the Annals of Internal Medicine on behalf of the WPSI.^[1]

Screening should address symptoms, including the type and degree of incontinence and whether those symptoms affect the woman's activities and quality of life, the authors explained.

In an accompanying editorial,^[2] Robin J. Bell, MBBS, PhD, MPH, and Susan R. Davis, MBBS, PhD, both from Monash University, Melbourne, Victoria, Australia, questioned the value of screening questionnaires currently in use.

"Although questionnaires are available to identify urinary incontinence in women, the systematic review accompanying the WPSI recommendation found limited evidence to support their diagnostic accuracy in the community," they wrote.

"The same review reports that no trials have examined the benefits and harms of urinary incontinence screening. Nonetheless, the WPSI argues that we should not wait for direct evidence and bases its recommendation on a chain of indirect evidence," they added.

In fact, the literature review to which the editorialists refer,^[3] also published in the September 4 issue of the journal, showed insufficient evidence on the overall effectiveness or harms of screening, and none of the included studies evaluated the effectiveness of screening to reduce adverse effects (AEs) or harms.

"In the absence of direct evidence of the benefits and harms of screening, the WPSI based its recommendation on the high prevalence of urinary incontinence in women; its effect on health, quality of life, and function; and indirect evidence on the accuracy of tests that may be used for screening in primary care," Ms O'Reilly and colleagues explained in the guideline.

The authors identified 17 studies that evaluated the diagnostic accuracy of 18 screening questionnaires when compared with a clinical diagnosis or diagnostic test results. The studies included between 69 and 1911 participants from primary care, gynecology, or urogynecology clinics located in the United States, United Kingdom, Denmark, Austria, Norway, Finland, and Australia.

Of the 17 studies, 14 were of poor quality and had limitations, including their origins in referral clinics and/or enrollment of symptomatic women. Twelve of these included women with incontinence and may not be pertinent to a screening population.

"Most studies enrolled participants who had incontinence symptoms, although 5 studies of 6 methods did not and are most relevant to screening," the authors noted.

One good-quality and 2 fair-quality studies evaluated 4 screening methods in women who were not symptomatic. In these studies, areas under the receiver-operating characteristic curve for stress, urge, and any type of incontinence were 0.79, 0.88, and 0.88 for the Michigan Incontinence Symptom Index; 0.85, 0.83, and 0.87 for the Bladder Control Self-Assessment Questionnaire; and 0.68, 0.82, and 0.75 for the Overactive Bladder Awareness Tool. Sensitivity and specificity for any type of incontinence were 66% and 80%, respectively, for the Incontinence Screening Questionnaire.

In the editorial, Drs Bell and Davis challenged the wisdom of trusting inadequate data. "We must learn from experience in women's health, in which faith in indirect evidence often proved naive when direct evidence became available. A randomized trial of ovarian cancer screening with ultrasonography and CA-125 levels showed that more women in the screened group were given a diagnosis of cancer and received treatment, with no reduction in mortality but with many more complications," they wrote.

Instead, researchers should conduct a randomized trial that directly evaluates the benefits and harms of screening women for urinary incontinence, they said. "This trial should be designed to assess the benefit-harm balance for screening at different life stages (from adolescence to old age) and to identify high-risk groups, such as women with comorbid pelvic floor conditions, for whom the benefits of screening might outweigh the risks."

Designing such a study would be challenging because researchers would first need to agree on a specific screening tool, and most existing questionnaires apply to symptomatic women and not the general population. For this reason, these questionnaires would likely result in many false-positive results and cause many women to undergo unnecessary diagnostic and invasive testing.

"If screening were associated with even a small amount of harm and the proportion of women who would benefit from early identification were modest, then the net benefit might be marginal or negative. Therefore, we advocate caution in implementing the WPSI recommendation until there is direct evidence for a net benefit of annual screening for urinary incontinence," Drs Bell and Davis concluded.

The guideline authors and editorialists have disclosed no relevant financial relationships.

Guideline Highlight

• The WPSI is a coalition of 21 national health organizations and patient representatives. It receives support from the US Department of Health and Human Services, and it is led by the American College of Obstetrics and Gynecology.
• The WPSI focuses on gaps in recommendations for health promotion among women. They weigh interventions based on the balance of the risk of benefits and harms to the patient, but they do not consider costs in their analysis.
• The current recommendation applies to all adolescent and adult women.
• A systematic review failed to find any clinical trials of a screening program for urinary incontinence among women.
• The evidence for a screening instrument for incontinence was poor, and the assessment of benefits and harms associated with treatment was poor to moderate.
• Most trials evaluating interview instruments enrolled women known to have urinary incontinence; however, simple tools that appeared to be accurate included the Michigan Incontinence Symptom Index, the Bladder Control Self-Assessment Questionnaire, and the Overactive Bladder Awareness Tool.
• Weight loss and pelvic floor muscle training under the supervision of a health professional have been proven to improve urinary incontinence symptoms, and no AEs were associated with these interventions.
• Intravaginal or intraurethral devices were not effective in clinical trials, although the methodology of these trials may have precluded a significant result.
• Medications have a significant but low effect on incontinence symptoms, and they are associated with well-known AEs.
• The WPSI recommends screening women annually for urinary incontinence from adolescence onward. Screening should feature validated instruments that inquire not only about symptoms but the effect of urinary incontinence on quality of life.
• Screening for urinary incontinence should be universal among women and not just according to risk factors such as obesity or multiparity.

Clinical Implications

• More than half of women have experienced urinary incontinence. Three-quarters of older women have urinary incontinence, and the rate of urinary incontinence among women overall is approximately double that of men. Approximately one-third to one-half of women with incontinence have daily symptoms.
• The WPSI recommends screening women annually for urinary incontinence from adolescence onward. Screening should feature validated instruments that inquire not only about symptoms but the effect of urinary incontinence on quality of life. Screening for urinary incontinence should be universal among women and not just according to risk factors such as obesity or multiparity.
• Implications for the Healthcare Team: The healthcare team may be activated to improve surveillance for urinary incontinence among women. Multiple team members may be best positioned to employ simple screening instruments during clinical encounters.