Geburtshilfe Frauenheilkd
DOI: 10.1055/a-1967-1726
GebFra Science
Guideline/Leitlinie

Diagnosis and Therapy of Female Urinary Incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/091, January 2022)

Part 1 with Recommendations on Diagnostics and Conservative and Medical Treatment Article in several languages: English | deutsch
Gert Naumann
1   Klinik für Frauenheilkunde und Geburtshilfe, Helios Klinikum Erfurt, Erfurt, Germany
2   Universitätsfrauenklinik, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
,
Thomas Aigmüller
3   Abteilung für Gynäkologie und Geburtshilfe, LKH Hochsteiermark Leoben, Leoben, Austria
,
Werner Bader
4   Zentrum für Frauenheilkunde und Geburtshilfe, Universitätsklinikum OWL der Universität Bielefeld, Bielefeld, Germany
,
Ricarda Bauer
5   Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, München, Germany
,
Kathrin Beilecke
6   Klinik für Urogynäkologie, Alexianer St. Hedwig-Krankenhaus Berlin, Berlin, Germany
,
Cornelia Betschart Meier
7   Klinik für Gynäkologie, Universitätsspital Zürich, Zürich, Switzerland
,
Gunther Bruer
8   Frauenärztliche Praxis Rostock, Rostock, Germany
,
Thomas Bschleipfer
9   Klinik für Urologie und Kinderurologie, Klinikum Coburg, Coburg, Germany
,
Miriam Deniz
10   Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Germany
,
Thomas Fink
11   Frauenklinik Abteilung Gynäkologie, Sana Klinikum Lichtenberg, Berlin, Germany
,
Boris Gabriel
12   Klinik für Gynäkologie und Geburtshilfe, St. Josefs-Hospital Wiesbaden, Wiesbaden, Germany
,
Roswitha Gräble
13   Kontinenz-Selbsthilfegruppe Villingen-Schwenningen, Villingen-Schwenningen, Germany
,
Matthias Grothoff
14   Klinik für Radiologie, Alexianer St. Hedwig-Krankenhaus Berlin, Berlin, Germany
,
Axel Haverkamp
15   Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsmedizin Mainz, Mainz, Germany
,
Christian Hampel
16   Klinik für Urologie, Marienhospital Erwitte, Erwitte, Germany
,
Ulla Henscher
17   Physiotherapiepraxis Lindenphysio-Nord, Hannover, Germany
,
Markus Hübner
18   Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
,
Hansjoerg Huemer
19   Klinik für Frauenmedizin, Bethesda Spital AG Basel, Basel, Switzerland
,
Jacek Kociszewski
20   Frauenklinik, Evangelisches Krankenhaus Hagen-Haspe, Haspe, Germany
,
Heinz Kölbl
21   Klinische Abteilung für Allgemeine Gynäkologie und Gynäkologische Onkologie, Medizinische Universität Wien, AKH Wien, Wien, Austria
,
Dieter Kölle
22   Abteilung Gynäkologie Sanatorium Hera Wien, Wien, Austria
,
Stephan Kropshofer
23   Universitätsklinik für Gynäkologie und Geburtshilfe, Medizinische Universität Innsbruck, Innsbruck, Austria
,
Annette Kuhn
24   Universitätsklinik für Frauenheilkunde, Universitätsspital Bern, Bern, Switzerland
,
Monika Nothacker
25   Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Germany
,
Matthias Oelke
26   Klinik für Urologie, Kinderurologie und Urologische Onkologie, St. Antonius-Hospital Gronau GmbH, Gronau, Germany
,
Ursula Peschers
27   Beckenbodenzentrum Isarklinikum München, München, Germany
,
Oliver Preyer
28   Abteilung für Gynäkologie und Geburtshilfe Landeskrankenhaus Villach, Villach, Austria
,
Daniela Schultz-Lampel
29   Kontinenzzentrum Südwest, Schwarzwald-Baar Klinikum, Kliniken Villingen-Schwenningen, Donaueschingen, Germany
,
Karl Tamussino
30   Medizinische Universität – Landeskrankenhaus Graz, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Klin. Abteilung für Gynäkologie, Graz, Austria
,
Reina Tholen†,
Ralf Tunn
6   Klinik für Urogynäkologie, Alexianer St. Hedwig-Krankenhaus Berlin, Berlin, Germany
,
Volker Viereck
32   Blasen- und Beckenbodenzentrum, Kantonsspital Frauenfeld, Spital Thurgau AG, Frauenfeld, Switzerland
,
Christl Reisenauer
33   Universitätsfrauenklinik, Universitätsklinikum Tübingen, Tübingen, Germany
› Author Affiliations
 

Abstract

Aim This completely revised interdisciplinary S2k-guideline on the diagnosis, therapy, and follow-up care of female patients with urinary incontinence (AWMF registry number: 015-091) was published in December 2021. This guideline combines and summarizes earlier guidelines such as “Female stress urinary incontinence,” “Female urge incontinence” and “Use of Ultrasonography in Urogynecological Diagnostics” for the first time. The guideline was coordinated by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group for Urogynecology and Plastic Pelvic Floor Reconstruction (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V., AGUB).

Methods This S2k-guideline was developed using a structured consensus process involving representative members from different medical specialties and was commissioned by the Guidelines Commission of the DGGG, OEGGG and SGGG. The guideline is based on the current version of the guideline “Urinary Incontinence in Adults” published by the European Association of Urology (EAU). Country-specific items associated with the respective healthcare systems in Germany, Austria and Switzerland were also incorporated.

Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, etiology, classification, symptoms, diagnostics, and treatment of female patients with urinary incontinence. Specific solutions for the diagnostic workup and appropriate conservative and medical therapies for uncomplicated and complication urinary incontinence are discussed.


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I  Guideline Information

Guidelines program of the DGGG, OEGGG and SGGG

For information on the guidelines program, please refer to the end of the guideline.


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Citation format

Diagnosis and Therapy of Female Urinary Incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/091, January 2022). Part 1 with Recommendations on Diagnostics and Conservative and Medical Treatment. Geburtsh Frauenheilk 2023. doi:10.1055/a-1967-1726


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Guideline documents

The complete long version in German and a slide version of this guideline as well as a list of the conflicts of interest of all the authors are available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-091.html


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Guideline authors

See [Tables 1] and [2].

Table 1 Lead and/or coordinating guideline author.

Author

AWMF professional society

Prof. Dr. med. Christl Reisenauer

German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe [DGGG])

Priv. Doz. Dr. med. habil. Gert Naumann

Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG)

Table 2 Contributing guideline authors.

Author

Mandate holder

DGGG working group (AG)/AWMF/non-AWMF professional society/organization/association

PD Dr. med. Thomas Aigmüller

Austrian Urogynecology Working Group for Reconstructive Pelvic Floor Surgery (Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie [AUB])

Prof. Dr. med. Werner Bader

German Society of Ultrasound in Medicine and Biology (Deutsche Gesellschaft für Ultraschall in der Medizin [DEGUM])

Prof. Dr. med. Ricarda Bauer

German Society of Urology (Deutsche Gesellschaft für Urologie [DGU])

Dr. med. Kathrin Beilecke

Working Group for Urogynecology and Plastic Pelvic Floor Reconstruction of the DGGG (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. [AGUB] der DGGG)

PD Dr. med. Cornelia Betschart

Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG])

Swiss Working Group for Urogynecology and Pelvic Floor Pathology (Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie [AUG])

Dr. med. Gunther Bruer

Federal Association of Gynecologists (Bundesverband der Frauenärzte)

Prof. Dr. med. Dr. phil. Thomas Bschleipfer

German Society for Urology (Deutsche Gesellschaft für Urologie [DGU])

PD Dr. med. Miriam Deniz

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Dr. med. Thomas Fink

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Prof. Dr. med. Boris Gabriel

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Roswitha Gräble

Patient representative

Prof. Dr. med. Matthias Grothoff

Radiology expert

Prof. Dr. med. Axel Haferkamp

German Continence Society (Deutsche Kontinenz-Gesellschaft)

Prof. Dr. med. Christian Hampel

Deutsche Gesellschaft für Urologie (DGU)

Ulla Henscher

Gynecology, Obstetrics, Urology, Proctology Working Group of the German Association for Physiotherapy (Arbeitsgemeinschaft für Gynäkologie Geburtshilfe Urologie Proktologie [AG-GGUP] im Deutschen Verband für Physiotherapie [ZVK])

Prof. Dr. med. Markus Hübner

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Dr. med. Hansjoerg Huemer

Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie (AUG)

PD Dr. med. Jacek Kociszewski

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Prof. Dr. med. Dr. h. c. Heinz Kölbl

Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)

Dr. med. Dieter Kölle

Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)

Dr. med. Stephan Kropshofer

Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)

Prof. Dr. med. Annette Kuhn

Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie (AUG)

PD Dr. med. Gert Naumann

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Prof. Dr. med. Dr. phil. Matthias Oelke

Deutsche Gesellschaft für Urologie (DGU)

Prof. Dr. med. Ursula Peschers

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Dr. med. Oliver Preyer

Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)

Prof. Dr. med. Christl Reisenauer

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Prof. Dr. med. Daniela Schultz-Lampel

Deutsche Gesellschaft für Urologie (DGU)

Prof. Dr. med. Karl Tamussino

Austrian Society for Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe [OEGGG])

Österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie (AUB)

Reina Tholen

Arbeitsgemeinschaft für Gynäkologie Geburtshilfe Urologie Proktologie (AG-GGUP) im Deutschen Verband für Physiotherapie (ZVK)

Prof. Dr. med. Ralf Tunn

Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V. (AGUB) der DGGG

Prof. Dr. med. Volker Viereck

Schweizer Arbeitsgemeinschaft Urogynäkologie und Beckenbodenpathologie (AUG)

The following professional societies/working groups/organizations/associations stated that they wished to contribute to the guideline text and participate in the consensus conference and nominated representatives to contribute and attend the conference ([Table 2]).

The guideline was moderated by Dr. Monika Nothacker (AWMF-certified guideline consultant/moderator).


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II  Guideline Application

Purpose and objectives

The guideline “Female Urinary Incontinence” represents a summary of the current state of knowledge as well as a formal consensus of experts on the diagnostics and therapeutic options and should serve as general orientation for physicians treating these patients.


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Target areas of care

This guideline covers the whole range of diagnostics, treatment, and follow-up care of female patients with urinary incontinence and was developed for both outpatient and in-patient care. The information on diagnostics and treatment of urinary incontinence should be of interest both for chief physicians and in specialist care.


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Target user groups/target audience

This guideline covers the treatment given to adult women and is aimed at all physicians and professionals involved in outpatient and/or inpatient care or the rehabilitation of female patients with urinary incontinence.


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Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies/working groups/organizations/associations as well as by the boards of the DGGG, SGGG and OEGGG as well as by the DGGG/OEGGG/SGGG Guidelines Commission in December 2021 and was thereby approved in its entirety. This guideline is valid from 1 January 2022 through to 31 January 2024. Because of the contents of this guideline, this period of validity is only an estimate. The guideline can be reviewed and updated earlier if necessary. If the guideline still reflects the current state of knowledge, its period of validity can be extended.


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III  Methodology

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.

This guideline was classified as: S2k


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Grading of recommendations

The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k guidelines. The various individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3]):

Table 3 Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010).

Description of binding character

Expression

Strong recommendation with highly binding character

must/must not

Regular recommendation with moderately binding character

should/should not

Open recommendation with limited binding character

may/may not


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Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.


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Achieving consensus and level of consensus

At structured NIH-type consensus-based conferences (S2k/S3 level), authorized participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the extent of consensus is determined, based on the number of participants ([Table 4]).

Table 4 Level of consensus based on extent of agreement.

Symbol

Level of consensus

Extent of agreement in percent

+++

Strong consensus

> 95% of participants agree

++

Consensus

> 75 – 95% of participants agree

+

Majority agreement

> 50 – 75% of participants agree

No consensus

< 51% of participants agree


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Expert consensus

As the term already indicates, this refers to consensus decisions taken specifically relating to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).


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IV  Guideline

1  Introduction

The International Continence Society (ICS) defines urinary incontinence as any involuntary loss of urine. Urinary incontinence is one of the most common symptoms raised during visits to a general practitioner, and it constitutes a severe health problem for women of all ages. Urinary incontinence can have a severe negative impact on womenʼs quality of life with physical, psychological, social, and even economic consequences for affected women.

International studies report an incidence of 13.1%, but the rates reported in other meta-analyses range from 4.4 – 44% (mean 23.5%). Urinary incontinence can occur at any age, although the prevalence and extent of urinary incontinence in women increases with increasing age.

The rates reported for Germany also vary. According to a statistical survey carried out in 2005, the incidence of incontinence in women increased significantly with increasing age, rising from 7.8% in 18 to 40-year-old women to 11.3% in women aged between 41 and 60 and 27.1% in women aged over 60 years. This means that a total of 15% of the female population report symptoms of incontinence.

When considering female urinary incontinence, it is important to differentiate between different pathophysiological forms:

  • Stress incontinence consists of involuntary loss of urine occurring during physical exertion (e.g., coughing, sneezing, sports activities) without an urge to urinate.

  • Urge incontinence is characterized by involuntary loss of urine which is accompanied by an imperative urge to urinate or which follows a strong urge to urinate. This can be present with or without an overactive detrusor muscle.

  • The overarching syndrome known as overactive bladder (OAB) includes the symptoms of an imperative urge to urinate, which is often accompanied by pollakisuria and nocturia, as well as urge incontinence. The term should only be used if the patient has no urinary tract infection or other disease which affects the lower urinary tract.

  • Nocturnal enuresis is characterized by (imperceptible) loss of urine during sleep (usually at night).

  • Mixed urinary incontinence presents with the symptoms of both stress incontinence and urge incontinence.

  • Incontinence in combination with chronic urinary retention (previously known as overflow incontinence) is caused by an increased volume of residual urine, which can develop due to detrusor underactivity or bladder outlet obstruction.

  • Neurogenic detrusor overactivity with urinary incontinence (formerly known as reflex incontinence) is the result of neurogenic detrusor overactivity in patients with a known neurological disease or an objective neurological deficit (e.g., congenital or acquired spinal injury or neurological diseases such as Parkinsonʼs disease or multiple sclerosis).

  • Extraurethral urinary incontinence is present if there is a constant vaginal and/or rectal loss of urine without urge symptoms or physical activity. This type of urinary incontinence is caused by fistula formation or an ectopic ureter.

  • Special variants of female urinary incontinence include positional incontinence (involuntary loss of urine occurring when changing from a sitting or recumbent position), undetected urinary incontinence (affected women cannot provide any information about when or why the loss of urine occurred), giggle incontinence (loss of urine while laughing) or coital urinary incontinence (loss or urine during coital penetration and/or orgasm).

When treating stress urinary incontinence in women, it is important to differentiate between uncomplicated and complicated stress incontinence.

Uncomplicated stress incontinence is characterized as follows:

  • symptoms of stress incontinence predominate

  • no history of an operation for incontinence or extended prolapse surgery

  • no neurological bladder function disorder

  • no accompanying symptomatic genital prolapse

  • the woman does not intend to have any (further) children

Complicated stress incontinence is characterized by:

  • previous failed incontinence operations

  • previous pelvic irradiation which affected the vaginal or urethral tissue

  • neurogenic bladder function disorders

  • simultaneous genital prolapse

  • the woman wishes to have (further) children


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2  Diagnostics

2.1  Patient history and clinical examination

A careful and detailed inquiry into the patientʼs medical history is the first step that must be taken to investigate urinary incontinence, even if there is no evidence for it.

The urogynecological examination must be made with the patient in the lithotomy position, and a Sims speculum must be used both when the patient is at rest and when straining. It is important to look for any changes to the external genitals (estrogen status, vulvar atrophy, lichen sclerosus et atrophicans, etc.) and whether genital prolapse (uterus or bladder prolapse) is present. Direct observation of urinary excretion through the ureter during a clinical cough stress test carried out with the patient in a supine or standing position after being requested to cough with a full bladder is an important part of the examination. Palpation of the pelvic floor musculature which includes checking contractility is an essential examination and can be semi-quantified using the Oxford grading system.

Consensus-based recommendation E2-01

Expert consensus

Level of consensus +++

The investigation into the causes of urinary incontinence must be carried out systematically and must include the patientʼs general medical history, her urogynecological medical history, a physical examination and her expectations regarding the examination and treatment (strong recommendation).

Consensus-based recommendation E2-02

Expert consensus

Level of consensus +++

A history of the patientʼs current medications and dosages must be obtained for all female patients with urinary incontinence (strong recommendation).

Consensus-based recommendation E2-03

Expert consensus

Level of consensus +++

All new medications which are associated with the development or worsening of urinary incontinence should be reviewed (recommendation).

Consensus-based recommendation E2-04

Expert consensus

Level of consensus +++

The following aspects should be considered: urine storage, bladder voiding, symptoms after micturition, type and extent of incontinence and psychological stress for the patient (strong recommendation).

Consensus-based recommendation E2-05

Expert consensus

Level of consensus +++

The Oxford score may be used to evaluate pelvic floor contractility (open recommendation).


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2.2  Patient questionnaires

There are numerous questionnaires which include symptom scores, symptom-related questionnaires, scales, indices, patient-reported outcomes (PROMs) and questionnaires focusing on health-related quality of life. The latter two types also collect general data as well as data related to specific problems. They should be validated for every language used.

Consensus-based recommendation E2-06

Expert consensus

Level of consensus +++

If a standardized assessment is wanted, a validated and appropriate questionnaire must be used (strong recommendation).


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2.3  Bladder diary

Obtaining an objective assessment of the functional symptoms affecting the lower urinary tract (lower urinary tract symptoms, LUTS) is an important step in the management of women with disturbed bladder storage and/or voiding, including urinary incontinence. A bladder diary is a semi-objective method to quantify symptoms and the incidence of incontinence episodes.

Consensus-based recommendation E2-07

Expert consensus

Level of consensus +++

A micturition diary (bladder diary) must be kept by patients with urinary incontinence if a standardized investigation is required (strong recommendation).

Consensus-based recommendation E2-08

Expert consensus

Level of consensus ++

The micturition diary (bladder diary) should be kept for at least 3 days (recommendation).


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2.4  Pad test

Measuring urinary loss by weighing protective pads before and after use during a specific period of time with the pads being used during protocolled physical activities can demonstrate the presence and severity of urinary incontinence as well as the effect of treatment. A pad test provides an accurate diagnosis of urinary incontinence and quantifies urinary loss.

Consensus-based recommendation E2-09

Expert consensus

Level of consensus +++

A pad test during a standardized period of time using protocolled activities must be carried out (strong recommendation).

Consensus-based recommendation E2-10

Expert consensus

Level of consensus +++

A pad test should be carried out if it is necessary to quantify urinary incontinence (recommendation).


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2.5  Urine analysis and bladder infections

Urine analysis (urine strip test and, if necessary. urine microscopy [urine sediment] and urine culture) must be routinely carried out to exclude infection as well as micro-hematuria, proteinuria and glucosuria as part of the investigation into urinary incontinence.

The presence of a symptomatic urine infection worsens the symptoms of urinary incontinence and must therefore be treated.

Consensus-based recommendation E2-11

Expert consensus

Level of consensus +++

A urine analysis must be carried out during the initial investigation of a female patient with urinary incontinence (strong recommendation).

Consensus-based recommendation E2-12

Expert consensus

Level of consensus +++

A re-evaluation after treatment of the urinary infection must be carried out in incontinent female patients with symptomatic urinary tract infection (strong recommendation).

Consensus-based recommendation E2-13

Expert consensus

Level of consensus +++

Asymptomatic bacteriuria must not be routinely treated with antibiotics in geriatric female patients with urinary incontinence (strong recommendation).


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2.6  Post-void residual urine

Residual urine, i.e., the volume of urine remaining in the bladder at the end of micturition, can have varying causes. Increased bladder outlet resistance and detrusor wall weakness (detrusor hypocontractility or acontractility) – or a combination of both disorders – may be responsible for post-void residual urine. Residual urine can worsen the symptoms of incontinence and in rare cases be accompanied by urinary tract infection or a dilatation of the upper urinary tract as well as renal failure. The volume of residual urine can be determined by one-time urethral catheterization or ultrasound examination.

Consensus-based recommendation E2-14

Expert consensus

Level of consensus +++

Residual urine must be determined using ultrasound (strong recommendation).

Consensus-based recommendation E2-15

Expert consensus

Level of consensus +++

Residual urine must be determined in female patients with urinary incontinence and micturition difficulties (strong recommendation).

Consensus-based recommendation E2-16

Expert consensus

Level of consensus +++

The volume of residual urine must be determined in female patients with complicated urinary incontinence (strong recommendation).

Consensus-based recommendation E2-17

Expert consensus

Level of consensus +++

Residual urine must be determined in female patients before, during and after therapy which causes or worsens bladder voiding disorders – including incontinence surgery (strong recommendation).


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2.7  Urodynamics

Diagnosing urinary incontinence using only a urodynamic study is not possible as urodynamics must be evaluated in the context of symptoms and clinical findings. The general rule is that clinical symptoms do not necessarily correlate with urodynamic findings.

A routine urodynamic study is not indicated before starting conservative treatment of uncomplicated urinary incontinence and untreated overactive bladder and should not be carried out. But if the findings are not clear or if the urodynamic findings could affect the treatment decision, then a urodynamic study must be carried out.

Recent studies have shown that if the patient presents with uncomplicated stress urinary incontinence, a preoperative urodynamic study can neither predict the success of surgery nor predict possible complications of surgery. But many cases do not have uncomplicated stress urinary incontinence and in up to 60% of cases, the clinical assessment is incorrect.

If there is a suspicion of mixed incontinence or of a neurogenic component, if there is a discrepancy between the clinical findings and the patientʼs medical history, or if the patient has a bladder voiding disorder, a urodynamic study should be carried out prior to invasive treatment in cases with complicated stress urinary incontinence and prior to carrying repeat surgery in order to support the treatment decision and offer the patient the best possible advice.

Consensus-based recommendation E2-18

Expert consensus

Level of consensus +++

A urodynamic study should be carried out if the cause of the symptoms or the pathophysiology is not clear (recommendation).

Consensus-based recommendation E2-19

Expert consensus

Level of consensus +++

A urodynamic study must only be carried out if the results will have consequences for the subsequent therapy (strong recommendation).

Consensus-based recommendation E2-20

Expert consensus

Level of consensus +++

Urine status should be determined prior to any urodynamic study to exclude urinary tract infection, and any infection detected must be treated first (recommendation).

Consensus-based recommendation E2-21

Expert consensus

Level of consensus +++

A routine urodynamic study is not indicated prior to starting conservative treatment for uncomplicated stress urinary incontinence or untreated overactive bladder and should not be carried out (recommendation).

Consensus-based recommendation E2-22

Expert consensus

Level of consensus +++

A urodynamic study must be carried out preoperatively in female patients with complicated stress urinary incontinence (strong recommendation).

Consensus-based recommendation E2-23

Expert consensus

Level of consensus +++

A video-based urodynamic study should not be routinely carried out in cases with non-neurogenic urinary incontinence (recommendation).


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2.8  Urethrocystoscopy

Indications to carry out this further investigative procedure are:

  • questioning the patient elicits a work-related history positive for suspected urothelial bladder carcinoma

  • micro- and macro-hematuria

  • positive urine cytology results

  • recurrent urinary tract infections

  • bladder pain

  • de novo urge symptoms after surgery for urinary incontinence

  • (suspicion of) bladder empty disorder

  • patient is status post unsuccessful conservative therapy (physiotherapy, drug therapy)

Consensus-based recommendation E2-24

Expert consensus

Level of consensus +++

A urethrocystoscopy should be carried out in patients with complicated stress urinary incontinence (recommendation).

Consensus-based recommendation E2-25

Expert consensus

Level of consensus +++

A urethrocystoscopy must be carried out in female patients with treatment-resistant urge incontinence to ensure that another potential pathology has not been overlooked (strong recommendation).


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3  Diagnostic imaging for female urinary incontinence

3.1  Sonography

Ultrasound (US) is the most important imaging procedure for the diagnostic workup of female urinary incontinence as it provides the most information and can be used in all patients. There are numerous established US parameters ([Table 5]).

Table 5 Ultrasound parameters.

US scanner/frequencies

Introital ultrasound

Perineal ultrasound

Vaginal US, 2 – 10 MHz

Sector scanner, 5 – 9 MHz

Pelvic floor sonography

Curved array scanner, 3.5 – 5.0 MHz

and its combinations, evaluation of all compartments

Positioning of the probe

Introital ultrasound

Introitus (high resolution despite minimum possible contact pressure, transducer is held perpendicular to the body axis)

Vaginal introitus

Perineal ultrasound

Pelvic floor sonography

Vaginal introitus

The position of the scanner must be moved. Changing the entry angle and rotating or elevating the vaginal scanner offers the opportunity to view the organs being examined in three different planes (sagittal, frontal and axial).

Examination technique

2D or 3D technique

2D sonography is the standard approach (captures rapid changes in movement), 3D sonography is used to obtain images of the levator ani and sphincter ani muscles

Imaging

  • 2D technique

cranial – at the top of the image; caudal – at the bottom of the image

right – on the left side of the image; left – on the right side of the image

ventral – on the right side of the image; dorsal – on the left side of the image (for publications)

  • 3D technique

Computed tomography image in the transverse plane

cranial – at the top of the image; caudal – at the bottom of the image

right – on the left side of the image; left – on the right side of the image

ventral – on the right side of the image; dorsal – on the left side of the image (for publications)

urethra above, rectum below

Patient position during examination

Lithotomy position is usually sufficient.

Bladder filling

  • Diagnostic workup for incontinence must be done with a moderately filled bladder

  • affects funneling/urethral length, position of the bladder neck

  • must be recorded in scientific studies to allow results to be compared (optimal filling volume is 300 ml)

Analyzed parameters (descriptive)

  • Determination of residual urine volume

  • sonomorphological urethral length

  • Urethral mobility (rigid, hypermobile)

  • Position of the bladder neck at rest, during compression and when straining/coughing

  • Funneling: description of funnel formation

  • Evaluation of periurethral tissue (e.g., diverticula or cysts)

  • Assessment of coordination and elevation of levator ani muscle complex

  • Detrusor wall thickness

  • postoperative imaging of the tape, bulking agent depots, or hematoma

Consensus-based recommendation E3-01

Expert consensus

Level of consensus ++

Pelvic floor sonography should be used as part of conservative treatment to document improvements over the course of treatment and to obtain biofeedback (recommendation).

Consensus-based recommendation E3-02

Expert consensus

Level of consensus +++

The volume of residual urine must be determined preoperatively and postoperatively; because US is non-invasive, sonography is the preferred method used to measure residual urine (strong recommendation).

Consensus-based recommendation E3-03

Expert consensus

Level of consensus +++

Pelvic floor sonography should be used to obtain a morphological correlate to clinical information and to exclude possible clinically occult risk factors (recommendation).

Consensus-based recommendation E3-04

Expert consensus

Level of consensus +++

A control sonography to check the proper placement of vaginal tape or mesh can be carried out in cases with an unremarkable postoperative course. To manage complications, diagnostic ultrasound must be part of the primary workup in addition to the clinical examination (strong recommendation).


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3.2  Requirements for diagnostic US

Consensus-based recommendation E3-05

Expert consensus

Level of consensus +++

2D ultrasound must be the standard technique used for diagnostic US of all compartments (strong recommendation).

Consensus-based recommendation E3-06

Expert consensus

Level of consensus +++

3D sonography may be used as a supplementary procedure for the morphological assessment of the levator muscles and pelvic organs (open recommendation).

Patient position during examination

Consensus-based statement S3-01

Expert consensus

Level of consensus ++

Based on current studies, it is not possible to issue a general recommendation on how the patient must be positioned during US examinations.

Consensus-based recommendation E3-07

Expert consensus

Level of consensus +++

The position of the patient during the examination must always be recorded when carrying out a diagnostic workup in the context of a study (strong recommendation).


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Bladder filling

Consensus-based recommendation E3-08

Expert consensus

Level of consensus +++

To better compare findings and for studies carried out as part of the diagnostic workup for bladder incontinence, bladder filling should be around 300 ml because the volume of urine in the bladder affects imaging of the bladder trigone and the position of the bladder neck (recommendation).


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Using the probe

Consensus-based recommendation E3-09

Expert consensus

Level of consensus +++

The ultrasound examination should be carried out with as little pressure exerted as possible (recommendation).


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Ultrasound probes

A curved array scanner is used for perineal ultrasound with the probe placed at the introitus. The broad surface of the transducer makes orientation relatively easy. The ultrasound frequencies usually range between 3.5 and 5 MHz.

A vaginal transducer is used for introital ultrasound examinations with the probe also placed in the introital area. The ultrasound frequencies used with this type of sonography are higher, ranging from 5 – 9 MHz.


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Imaging

For studies and publications, DEGUM recommends that cranial structures are shown at the top and caudal structures at the bottom of images. Ventral structures must be shown on the right side and dorsal structures on the left side of the image. It is possible to deviate from the recommendation in clinical practice.


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3.3  Use of sonomorphology in the diagnostic workup of urinary incontinence

Bladder filling

Measurement of bladder filling volume is a prerequisite for every examination and should be done at the beginning of the examination. The residual urine volume is an important criterion to differentiate simple stress incontinence from complicated incontinence such as overflow incontinence or neurogenic incontinence.


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Urethral length

Consensus-based recommendation E3-10

Expert consensus

Level of consensus ++

Sonomorphology to determine urethral length should be done preoperatively to plan the correct placement of the tape (recommendation).


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Position of the bladder neck

Consensus-based recommendation E3-11

Expert consensus

Level of consensus +++

The position of the bladder neck should be verified under three different conditions: at rest, during Valsalva maneuver and during pelvic floor contraction (recommendation).


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Urethral mobility

Urethral mobility is evaluated based on the position of the bladder neck during different states of motion.

Consensus-based statement S3-02

Expert consensus

Level of consensus ++

Urethral mobility is evaluated to identify pathologies such as hypermobile or rigid urethra. This is important because it affects the chances of success of surgical interventions.


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Funneling

Consensus-based statement S3-03

Expert consensus

Level of consensus ++

Funneling is a typical sonomorphological correlate of stress urinary incontinence. Funneling describes funneling of the bladder neck during stress. Funneling can also occur when the urethra is unstable or in cases with overactive bladder.


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Periurethral tissue

Consensus-based recommendation E3-12

Expert consensus

Level of consensus +++

Evaluation of the anterior compartment should include periurethral tissue (recommendation).


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Evaluation of the bladder wall

Bladder wall hypertrophy due to increased detrusor activity can be confirmed by transvaginal, translabial or suprapubic positioning of the ultrasound probe.

Consensus-based recommendation E3-13

Expert consensus

Level of consensus +++

The bladder wall should be assessed using ultrasonography in female patients with urge incontinence symptoms to preclude local pathologies as the cause of incontinence. Pathological thickening of the bladder wall requires further investigation (recommendation).


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Urogenital fistula/ectopic ureter

Consensus-based recommendation E3-14

Expert consensus

Level of consensus +++

Pelvic floor sonography may be additionally used to detect urethral or bladder wall defects, particularly when investigating possible fistula formation (open recommendation).


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3.4  Use of diagnostic sonography after incontinence surgery, use of sonography after tension-free tape placement

Ultrasound is the method of choice to diagnose complications after suburethral sling procedure. The most common complications are de novo urge incontinence, bladder voiding disorder with residual urine, and unsatisfactory surgical outcome. A tape positioned in the proximal third of the urethra or at the level of the bladder neck is often associated with bladder voiding disorder, increased residual urine volume and the necessity for surgical revision.

Consensus-based recommendation E3-15

Expert consensus

Level of consensus +++

Ultrasound must be used in cases with postoperative bladder voiding disorder after tape placement to exclude incorrect positioning or retropubic/paravesical hematoma (strong recommendation).

Sonography after colposuspension

Ultrasound imaging can be used to show stabilization of the bladder neck following colposuspension. Hypermobility of the bladder neck which persists postoperatively may be correlated with recurrent urinary incontinence.

Consensus-based recommendation E3-16

Expert consensus

Level of consensus +++

An ultrasound examination should be carried out in cases with postoperative bladder voiding disorder following colposuspension to exclude overcorrection (recommendation).


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Sonography after injection of bulking agents

The use of sonography to assess the shape and localization of bulking agents has been confirmed in the literature. Ultrasound assessment of bulking agent depots can be useful to determine the mechanism of action and detect complications.

Consensus-based statement S3-04

Expert consensus

Level of consensus +++

Imaging of the morphology, size and localization of bulking agents is possible with ultrasound.


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3.5  Use of X-ray procedures and magnetic resonance imaging in the diagnostic workup of female urinary incontinence

Starting with the lumen and moving outwards, the cross-sectional anatomical continence mechanism of the urethra consists of the urothelium, the submucosa, the longitudinal smooth muscles, the circular smooth muscles, the external striated urethral sphincter, and the serosa. All these structures can be visualized with MRI, and the quality of imaging is constantly improving.

If there is a suspicion that the cause of urinary incontinence could be urogenital malformations, then a pelvic MRI which includes imaging of the upper urinary tract provides the most sensitive diagnostic imaging with the greatest soft tissue contrast.

Consensus-based statement S3-05

Expert consensus

Level of consensus ++

X-ray and MRI play only a marginal role in the routine diagnostic workup of uncomplicated urinary incontinence.

Consensus-based recommendation E3-17

Expert consensus

Level of consensus +++

Diagnostic X-ray or MRI may be indicated in selected cases with congenital or postoperative urinary incontinence and unclear clinical and sonomorphological diagnosis.

[Fig. 1] shows the algorithm used for the diagnostic workup and for the conservative and surgical treatment of different forms of urinary incontinence.

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Fig. 1 Flow chart for the diagnosis and treatment of female urinary incontinence. [rerif]

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4  Conservative therapy of urinary incontinence

4.1  Simple clinical measures

It is standard clinical practice to start treatment by trying non-surgical therapies as they are usually associated with the lowest risk of injury. Non-surgical therapies are often used combined, making it difficult to determine which components are effective. Incontinence pads play a particularly important role for those who prefer to avoid the risks of interventional procedures or for whom active treatment is not possible for some reason.

Primary disease/cognitive impairment

Consensus-based recommendation E4-01

Expert consensus

Level of consensus +++

Female patients with urinary incontinence who develop comorbidities must always receive appropriate treatment for their comorbidity in line with good medical practice (strong recommendation).


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Adaptation of other (non-incontinence) medication

It can be difficult or even impossible to differentiate between the different factors affecting urinary incontinence in patients with existing urinary incontinence, particularly if the patients are elderly. Potential factors which may additionally affect urinary incontinence can include medication, comorbidities, or ageing.


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Constipation

Consensus-based recommendation E4-02

Expert consensus

Level of consensus ++

Female patients with urinary incontinence who also suffer from constipation must receive counseling in line with good medical practice about the appropriate bowel treatment (strong recommendation).


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Aids

Aids are important for people with urinary incontinence if active treatment is unable to solve the problem or another treatment is not possible. Some people may prefer using aids rather than receiving active treatment with its associated risks. Aids can consist of incontinence pads, catheters, or external diversion.

Consensus-based recommendation E4-03

Expert consensus

Level of consensus +++

Female patients with urinary incontinence and/or their carers must be informed about the available treatment options before they decide to only use aids (strong recommendation).

Consensus-based recommendation E4-04

Expert consensus

Level of consensus ++

Patients must be offered incontinence pads and/or additional aids to treat urinary incontinence (strong recommendation).


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4.2  Lifestyle-related interventions

Examples of lifestyle factors which have been associated with incontinence include obesity, smoking, physical activity, and nutrition. Changing these factors may also improve urinary continence.

Consensus-based recommendation E4-05

Expert consensus

Level of consensus ++

Overweight or obese female patients with urinary incontinence must be motivated to reduce their weight and maintain their reduced weight (strong recommendation).

Consensus-based recommendation E4-06

Expert consensus

Level of consensus +++

Female patients with urinary incontinence must be informed that reducing their caffeine intake may reduce the symptoms of urge incontinence and their frequency of urination but will not reduce stress urinary incontinence (strong recommendation).

Consensus-based recommendation E4-07

Expert consensus

Level of consensus +++

The type and amount of the liquid intake of female patients with urinary incontinence must be verified and modified if necessary (strong recommendation).

Behavioral therapy and physiotherapy

Consensus-based recommendation E4-08

Expert consensus

Level of consensus +++

Patients with urinary incontinence and cognitive impairment must be offered prompted voiding (strong recommendation).

Consensus-based recommendation E4-09

Expert consensus

Level of consensus +++

Bladder training should be the first-choice therapy for female patients with urge incontinence or mixed incontinence (recommendation).

Consensus-based recommendation E4-10

Expert consensus

Level of consensus ++

Pelvic floor training must be offered to patients with stress urinary incontinence and mixed urinary incontinence (including elderly female patients or women who have given birth). Pelvic floor strength should be monitored and pelvic floor training should be continued for at least 3 months (strong recommendation).

Consensus-based recommendation E4-11

Expert consensus

Level of consensus ++

The pelvic floor training program must involve strength training principles (strong recommendation).

Consensus-based recommendation E4-12

Expert consensus

Level of consensus +++

Electrostimulation (skin, vaginal, anal) may be used in addition to pelvic floor training to treat urinary incontinence (open recommendation).

Consensus-based recommendation E4-13

Expert consensus

Level of consensus ++

Electromagnetic stimulation may be considered to treat urinary incontinence or overactive bladder in adult women (open recommendation).

Consensus-based recommendation E4-14

Expert consensus

Level of consensus ++

In female patients with mixed urinary incontinence, the clinically dominant symptom should be treated first (recommendation).


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4.4  Laser therapy for stress incontinence

Numerous reviews and guidelines issued by various committees have concluded that the data on the efficacy and safety of laser therapy is still insufficient, despite a huge improvement in the amount of data in the last two years about the use of laser therapy as a routine treatment for stress incontinence. Because of this new evidence, laser therapy may now be recommended to treat a selected group of women with stress incontinence.

Three laser modalities have been described for the intravaginal treatment of stress incontinence

  1. microablative fractional carbon dioxide (CO2) laser therapy (10 600 nm),

  2. biphasic erbium:YAG laser therapy (2940 nm), a combination of fractional cold ablation and thermal ablation, and

  3. non-ablative erbium:YAG laser therapy (2940 nm) with SMOOTH mode technology, the most commonly used laser therapy.

Consensus-based statement S4-01

Expert consensus

Level of consensus +++

There is no randomized controlled study yet which has directly compared the three laser modalities used to treat stress incontinence head-to-head.

Consensus-based statement S4-02

Expert consensus

Level of consensus ++

Two randomized controlled studies with a short follow-up period of up to 3 months have shown a subjective superiority of laser treatment compared to placebo/control treatment. Prospective observational studies with follow-up of up to 36 months have been published.

Consensus-based statement S3-03

Expert consensus

Level of consensus +++

Laser therapy can be topped up.

Consensus-based recommendation E4-15

Expert consensus

Level of consensus ++

* Laser therapy has not yet been approved for use by the statutory health insurance companies in Germany, Switzerland and Austria.

Intravaginal laser therapy may be a therapeutic option to treat mild or moderate stress incontinence (open recommendation).*


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4.5  Pessary therapy for urinary incontinence

Consensus-based recommendation E4-16

Expert consensus

Level of consensus ++

Pessary therapy should be offered to female patients with stress urinary incontinence as a therapeutic option (recommendation).


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4.6  Prevention of urinary incontinence

Consensus-based recommendation E4-17

Expert consensus

Level of consensus ++

Women should be informed about the association between being overweight and urinary incontinence, especially about the benefits of having a normal weight prior to conception (recommendation).

Consensus-based recommendation E4-18

Expert consensus

Level of consensus +++

Prepartum physiotherapy may reduce the risk of developing urinary incontinence and should therefore be offered to all pregnant women (recommendation).

Consensus-based recommendation E4-19

Expert consensus

Level of consensus ++/+++

Because of the risk-benefit constellation, elective caesarean section to reduce the risk of urinary incontinence must not be recommended (++). Nevertheless, pregnant women with a higher risk of postpartum pelvic floor insufficiency must be offered specific information to allow them to weigh up the benefits and risks of primary caesarean section (strong recommendation) (+++).

Consensus-based recommendation E4-20

Expert consensus

Level of consensus +++

Preventive substitution of vitamin D to reduce the risk of urinary incontinence may not be currently generally recommended during pregnancy because the data is insufficient (open recommendation).

Consensus-based recommendation E4-21

Expert consensus

Level of consensus ++

Women should be informed postpartum about the risk of pelvic floor insufficiency which increases with age (recommendation).


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5  Drug therapy for urinary incontinence

5.1  Antimuscarinic agents

The oral antimuscarinic agents currently approved for use in Germany, Austria and Switzerland and the brand names of the preparations used in Germany, their pharmacokinetic properties, and the recommended daily dosages are listed in [Table 6].

Table 6 Approved antimuscarinic drugs.

Generic name

Brand name in Germany

tmax [hours]

t½ [hours]

Recommended daily dosage

Darifencacin

Emselex

7

12

1 × 7.5 – 15 mg

Fesoterodin

Toviaz

5

7

1 × 4 – 8 mg

Oxybutynin IR

Oxybutynin

Dridase

Oxybugamma

Oxybutin

Spasyt

0.5 – 1

2 – 4

3 – 4 × 2.5 – 5 mg

Oxybutynin ER

5

16

2 – 3 × 5 mg

Propiverin

Propiverin

Mictonetten

Mictonorm

Propimedac

Propiver

2.5

13

2 – 3 × 15 mg

Propiverin ER

10

20

1 × 30 mg

Solifenacin

Vesikur

3 – 8

45 – 68

1 × 5 – 10 mg

Tolterodin IR

Tolterodon

Detrusitol

1 – 3

2 – 10

2 × 1 – 2 mg

Tolterodin ER

4

6 – 10

1 × 4 mg

Trospium IR

Trospium

Spasmolyt

Spasmex

Urivesc

Spasmo-Urgenin

Trospi

5

18

3 × 10 – 15 mg

2 × 10 – 20 mg

Trospium ER

5

36

1 × 60 mg

Consensus-based statement S5-01

Expert consensus

Level of consensus +++

Antimuscarinic agents are an effective oral treatment option for urge incontinence.

Consensus-based statement S5-02

Expert consensus

Level of consensus +++

There is no consistent evidence that any antimuscarinic agent is more effective than another.

Consensus-based statement S5-03

Expert consensus

Level of consensus +++

The side effects of immediate-release formulations are higher than those of extended-release formulations.

Consensus-based statement S5-04

Expert consensus

Level of consensus ++

If a formulation is ineffective or not sufficiently effective, changing the medication or the form of delivery may be considered.

Consensus-based statement S5-05

Expert consensus

Level of consensus ++

With the exception of oxybutynin IR, antimuscarinic agents are safe to use in older patients, but it is important to be aware of potential interactions with other medications and possible intolerances.

Consensus-based statement S5-06

Expert consensus

Level of consensus ++

(Oral) oxybutynin has a significantly negative effect on cognitive functioning.

Consensus-based recommendation E5-01

Expert consensus

Level of consensus ++

If conservative non-drug therapy fails in adults with overactive bladder or urge incontinence, then antimuscarinic agents must be additionally offered to patients (strong recommendation).

Consensus-based recommendation E5-02

Expert consensus

Level of consensus ++

ER formulations must be given priority over IR formulations (strong recommendation).

Consensus-based recommendation E5-03

Expert consensus

Level of consensus ++

Oxybutynin oral must be avoided because of its high side effects profile (strong recommendation).

Consensus-based recommendation E5-04

Expert consensus

Level of consensus ++

If treatment with an antimuscarinic agent is unsuccessful, escalating the dose, changing the medication within the same group of medications, or even a combination of antimuscarinic drugs may be considered (open recommendation).

Consensus-based recommendation E5-05

Expert consensus

Level of consensus ++

If patients (especially geriatric patients) are receiving polymedication, the (total) anticholinergic burden must be considered and interactions with other medications must be reviewed (strong recommendation).


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5.2  β3-adrenergic agonists (mirabegron) for overactive bladder, urge incontinence or mixed urinary incontinence

Consensus-based statement S5-07

Expert consensus

Level of consensus +++

β3-adrenergic agonists (mirabegron) are superior to placebo and the effect of administration is equivalent to the administration of antimuscarinic agents in terms of improving the symptoms of overactive bladder but without impairing bladder contractility (residual urine).

Consensus-based statement S5-08

Expert consensus

Level of consensus +++

It is important to be aware that one undesirable side effect of β3-adrenergic agonists (mirabegron) can be an increase in blood pressure.

Consensus-based statement S5-09

Expert consensus

Level of consensus +++

Female patients who received insufficient treatment with antimuscarinic agents may benefit more from the addition of β3-adrenergic agonists (mirabegron) than from escalating the dose of the antimuscarinic agent.

Consensus-based recommendation E5-06

Expert consensus

Level of consensus +++

β3-adrenergic agonists (mirabegron) should be offered to female patients for whom conservative non-drug therapy did not lead to any improvement and who cannot tolerate antimuscarinic drugs or in whom antimuscarinic drugs are ineffective or contraindicated (recommendation).


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5.3  Duloxetine for stress incontinence or urge urinary incontinence

Consensus-based statement S5-10

Expert consensus

Level of consensus ++

Duloxetine may improve stress urinary incontinence.

Consensus-based statement S5-11

Expert consensus

Level of consensus ++

Especially during the initial weeks, duloxetine may affect the central nervous system and have gastrointestinal side effects which lead to high rates of therapy discontinuation.

Consensus-based recommendation E5-07

Expert consensus

Level of consensus ++

* It is not approved for use in Austria and Switzerland.

Patients receiving conservative treatment who have moderately severe stress urinary incontinence must be informed about duloxetine as a treatment option (strong recommendation).*

Consensus-based recommendation E5-08

Expert consensus

Level of consensus +++

Female patients must be informed about continence rates and side effects before starting treatment with duloxetine (strong recommendation).

Consensus-based recommendation E5-09

Expert consensus

Level of consensus ++

To reduce the rate of side effects, duloxetine therapy must be started at low doses which are then gradually increased; if therapy is discontinued, the doses must be gradually reduced again (strong recommendation).

Consensus-based recommendation E5-10

Expert consensus

Level of consensus ++

A combination of duloxetine and pelvic floor training may be recommended (open recommendation).


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5.4  Estrogens for stress incontinence, urge incontinence and mixed urinary incontinence

In addition to vaginal dryness, pruritus, burning, reduced or lack of vaginal lubrication, dyspareunia and dysuria, estrogen deficiency-related changes to the female genitals may also manifest as incontinence symptoms including an imperative urge to urinate and increased urination frequency or recurrent urinary tract infections.

Consensus-based recommendation E5-13

Expert consensus

Level of consensus +++

Vaginal estriol administration must be carried out in postmenopausal women with urinary incontinence (particularly urge incontinence) and vulvovaginal atrophy. The administration of estriol must be continued for a longer period of time (strong recommendation).

Consensus-based recommendation E5-14

Expert consensus

Level of consensus +++

Ultra-low dose local estriol therapy may be used to treat female patients who are status post breast cancer after they have been informed about the lack of data regarding its oncological safety (open recommendation).

Consensus-based recommendation E5-15

Expert consensus

Level of consensus +

* Conjugated estrogens are currently no longer approved for use in Austria and Switzerland.

Alternative hormone therapies must be discussed for women receiving oral hormone replacement therapy with conjugate equine estrogens who develop urinary incontinence or experience a worsening of urinary incontinence (strong recommendation)*.

Consensus-based statement S5-12

Expert consensus

Level of consensus +++

It is unlikely that the urinary incontinence of incontinent women will improve after terminating systemic estradiol therapy.


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5.5  Desmopressin for nocturia due to nocturnal polyuria

Consensus-based recommendation E5-16

Expert consensus

Level of consensus +++

Nocturia due to nocturnal polyuria caused an arginine-vasopressin deficit must be treated with desmopressin if the patient is upset by the nocturia (strong recommendation).

Consensus-based recommendation E5-17

Expert consensus

Level of consensus +++

Female patients with overactive bladder and nocturia (but no evidence of nocturnal polyuria) must not be treated with an anti-muscarinic agent in combination with desmopressin (strong recommendation).

Consensus-based recommendation E5-18

Expert consensus

Level of consensus +++

Serum sodium concentrations must be monitored before and during desmopressin therapy with measurements carried out after at least one week and after one month (strong recommendation).


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5.6  Complementary medicine for stress, urge and mixed urinary incontinence

Complementary medicine and empirical medicine procedures are also used to treat female urinary incontinence.

Interesting treatment options include phytotherapeutic agents and homeopathic remedies. Other possible approaches are specific nutrition, orthomolecular therapy, supplements using various vitamins, especially vitamin D or the vitamin D analog elocalcitol. There are numerous studies in the literature which have investigated the efficacy of acupuncture to treat overactive bladder and stress urinary incontinence.

Consensus-based statement S5-13

Expert consensus

Level of consensus ++

There is currently insufficient evidence about complementary medicine which would allow an explicit recommendation to be made about the use of homeopathy, phytotherapy, treatment with supplements and other therapeutic complementary medicine agents.


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The references are listed in the long version of the guideline (https://register.awmf.org/de/leitlinien/detail/015-091).

Zoom Image

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Conflict of Interest

The conflicts of interest of all the authors are listed in the long version of the guideline (https://register.awmf.org/de/leitlinien/detail/015-091)./
Die Interessenkonflikte der Autoren sind in der Langfassung der Leitlinie (https://register.awmf.org/de/leitlinien/detail/015-091) aufgelistet.

Correspondence

PD Dr. med. habil. Gert Naumann
Klinik für Frauenheilkunde und Geburtshilfe
Helios Klinikum Erfurt
Nordhäuser Straße 74
99 089 Erfurt
Germany   

 

Prof. Dr. Christl Reisenauer
Universitätsklinikum Tübingen
Universitäts-Frauenklinik
Department für Frauengesundheit
Calwerstraße 7
72076 Tübingen
Germany   

Publication History

Received: 18 October 2022

Accepted: 23 October 2022

Article published online:
20 January 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

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Fig. 1 Flow chart for the diagnosis and treatment of female urinary incontinence. [rerif]
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Fig. 1 Flowchart zur Diagnostik und Therapie der Harninkontinenz der Frau. [rerif]
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