Summary Clinical Practice Guidelines: Rehabilitation Interventions f... : The Journal of Women's & Pelvic Health Physical Therapy journals.lww.com
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The guideline provides evidence-based recommendations for rehabilitating urinary urgency, frequency, and UUI in adult women.
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Key Points
- Clinical Practice Guideline (CPG) provides evidence-based recommendations for rehabilitation interventions of urgency urinary incontinence (UUI), urinary urgency, or urinary frequency in adult women
- Lower urinary tract consists of the bladder and urethra, with UI more common in women than men
- Recommended interventions include behavioral interventions, pelvic floor muscle training, neuromodulation, medication combined with rehabilitation, weight loss, and mindfulness-based stress reduction
- Addressing constipation and fall risk management is important for patients with UUI
- Anticholinergic medications for UUI treatment may increase fall risk
- Future research should focus on differentiating behavioral interventions, relationship between constipation and UUI, and assessment of overactive pelvic floor muscles
- CPG intended to guide healthcare providers and patients in treatment of urinary urge incontinence, urinary urgency, and urinary frequency
Summaries
18 word summary
This guideline focuses on evidence-based rehab for UUI, urinary urgency, and frequency in adult women, with 7 recommendations.
63 word summary
This Clinical Practice Guideline (CPG) focuses on evidence-based rehabilitation interventions for urgency urinary incontinence (UUI), urinary urgency, and urinary frequency in adult women. The search strategy resulted in 545 articles, informing 7 recommendations for intervention, including behavioral interventions, pelvic floor muscle training, neuromodulation, medication combined with rehabilitation, and mindfulness-based stress reduction. The CPG recommends future research on differentiation between behavioral interventions for UUI.
132 word summary
This Clinical Practice Guideline (CPG) focuses on evidence-based rehabilitation interventions for urgency urinary incontinence (UUI), urinary urgency, and urinary frequency in adult women. It does not cover examination and evaluation of women with urinary incontinence. The worldwide prevalence of urge and mixed UI is over 20%, with increasing prevalence with age. The estimated per capita cost of OAB with UUI in the United States was $82.6 billion in 2020. The search strategy resulted in 545 articles, informing 7 recommendations for intervention. These include behavioral interventions, pelvic floor muscle training, neuromodulation, medication combined with rehabilitation, weight loss, mindfulness-based stress reduction, constipation management, and fall risk management. The CPG recommends future research on differentiation between behavioral interventions for UUI, the relationship between constipation and UUI, and the causal relationship between UUI and fall risk.
458 word summary
This Clinical Practice Guideline (CPG) offers evidence-based recommendations for rehabilitation interventions of urgency urinary incontinence (UUI), urinary urgency, or urinary frequency in adult women. The patient population of interest are women with UUI, urinary urgency, and/or urinary frequency. The guideline does not provide information regarding the examination and evaluation of women with urinary incontinence.
The lower urinary tract consists of the bladder and urethra, with UI being more common among women than men. The estimated worldwide prevalence of urge and mixed UI is more than 20%, with prevalence increasing with age. The per capita cost of OAB with UUI in the United States was estimated at $82.6 billion in 2020.
The search strategy included OVID Medline, EMBASE, Cochrane Library, CINAHL, and ProQuest, resulting in 545 articles that qualified for full-text appraisal. Thirty-one articles informed the development of 7 recommendations for intervention of UUI, urinary urgency, and/or urinary frequency.
The recommendations include behavioral interventions, pelvic floor muscle training, transcutaneous tibial nerve neuromodulation, transvaginal neuromodulation, medication combined with rehabilitation, weight loss, mindfulness-based stress reduction, constipation management, and fall risk management. Each recommendation is supported by evidence quality and grade of recommendation.
Behavioral interventions must include bladder retraining, dietary and fluid modification, and urge suppression techniques for symptoms of UUI, urinary urgency, and/or urinary frequency. Pelvic floor muscle training programs should be prescribed when contraction quality has been confirmed for these symptoms. Low-frequency transcutaneous tibial nerve electrical stimulation should be used for symptoms of urgency urinary incontinence in the absence of contraindications for electrical stimulation.
Rehabilitation interventions for urinary incontinence have been studied extensively. Behavioral training, biofeedback, and bladder training have been shown to be effective in reducing urinary symptoms. Pelvic floor muscle training (PFMT) programs are recommended when contraction quality has been confirmed, with or without surface electromyography (sEMG) biofeedback, for symptoms of UUI, urinary urgency, and/or urinary frequency. Neuromodulation has also been effective in treating pelvic floor disorders. Medication combined with rehabilitation has shown improved outcomes for UUI. Weight loss has been found to reduce symptoms of UUI in women with a BMI of more than 25 kg/m. Mindfulness-based stress reduction (MBSR) may also be considered to reduce symptoms of UUI.
The Clinical Practice Guidelines (CPG) provide recommendations for the treatment of urinary urge incontinence, urinary urgency, and urinary frequency in women based on a critical review and appraisal of thousands of articles published from 1997 to 2017. The recommendations include behavioral interventions and pelvic floor muscle training (PFMT) as the most effective treatments, followed by electrical stimulation (ES) and lifestyle modifications.
The CPG authors recommend future research focus on differentiation between various forms of behavioral interventions commonly used to treat UUI, the relationship between constipation and UUI, as well as the causal relationship between UUI and fall risk.
663 word summary
This Clinical Practice Guideline (CPG) offers evidence-based recommendations for rehabilitation interventions of urgency urinary incontinence (UUI), urinary urgency, or urinary frequency in adult women. The guideline aims to inform readers of the current evidence for physical therapy intervention of UUI, urinary urgency, and/or urinary frequency, and identify areas in which further research is needed. The patient population of interest are women with UUI, urinary urgency, and/or urinary frequency. The guideline does not provide information regarding the examination and evaluation of women with urinary incontinence.
The lower urinary tract consists of the bladder and urethra, with bladder filling and urine storage mediated by sympathetic input from the spinal cord, and voiding controlled primarily by parasympathetic input. UI is more common among women than men, with SUI being the most prevalent type followed by mixed UI (MUI) and then UUI. The estimated worldwide prevalence of urge and MUI is more than 20%, with prevalence increasing with age. The per capita cost of OAB with UUI in the United States was estimated at $82.6 billion in 2020.
The search strategy included OVID Medline, EMBASE, Cochrane Library, CINAHL, and ProQuest, resulting in 545 articles that qualified for full-text appraisal. Thirty-one articles informed the development of 7 recommendations for intervention of UUI, urinary urgency, and/or urinary frequency.
The recommendations include behavioral interventions, pelvic floor muscle training, transcutaneous tibial nerve neuromodulation, transvaginal neuromodulation, medication combined with rehabilitation, weight loss, mindfulness-based stress reduction, constipation management, and fall risk management. Each recommendation is supported by evidence quality and grade of recommendation.
Behavioral interventions must include bladder retraining, dietary and fluid modification, and urge suppression techniques for symptoms of UUI, urinary urgency, and/or urinary frequency. Pelvic floor muscle training programs should be prescribed when contraction quality has been confirmed for these symptoms. Low-frequency transcutaneous tibial nerve electrical stimulation should be used for symptoms of urgency urinary incontinence in the absence of contraindications for electrical stimulation.
The guideline will be updated and revised within 5 years of its publication as new evidence emerges. The procedures utilized for updating the guideline will follow those utilized in the writing of this guideline, based on the recommended standards of the APTA and APHPT.
Rehabilitation interventions for urinary incontinence have been studied extensively. Behavioral training, biofeedback, and bladder training have been shown to be effective in reducing urinary symptoms. Pelvic floor muscle training (PFMT) programs are recommended when contraction quality has been confirmed, with or without surface electromyography (sEMG) biofeedback, for symptoms of urgency urinary incontinence (UUI), urinary urgency, and/or urinary frequency. Neuromodulation has also been effective in treating pelvic floor disorders. Medication combined with rehabilitation has shown improved outcomes for UUI. Weight loss has been found to reduce symptoms of UUI in women with a BMI of more than 25 kg/m. Mindfulness-based stress reduction (MBSR) may also be considered to reduce symptoms of UUI.
The Clinical Practice Guidelines (CPG) provide recommendations for the treatment of urinary urge incontinence, urinary urgency, and urinary frequency in women based on a critical review and appraisal of thousands of articles published from 1997 to 2017. The recommendations include behavioral interventions and pelvic floor muscle training (PFMT) as the most effective treatments, followed by electrical stimulation (ES) and lifestyle modifications.
Patients and health care providers should address constipation to reduce symptoms of UUI, urinary urgency, and/or urinary frequency. Health care providers should address fall risk management for patients with UUI, urinary urgency, and/or urinary frequency. Providers considering an anticholinergic medication prescription for a patient should complete a fall risk assessment prior to starting pharmaceutical treatment.
The CPG authors recommend future research focus on differentiation between various forms of behavioral interventions commonly used to treat UUI, the relationship between constipation and UUI, as well as the causal relationship between UUI and fall risk. The CPG is intended to provide guidance to health care providers and patients for the treatment of urinary urge incontinence, urinary urgency, and urinary frequency. It is anticipated that future research will address constipation and fall management more explicitly.
1353 word summary
This Clinical Practice Guideline (CPG) provides evidence-based recommendations for rehabilitation interventions of urgency urinary incontinence (UUI), urinary urgency, or urinary frequency in adult women. The guideline aims to inform readers of the current evidence for physical therapy intervention of UUI, urinary urgency, and/or urinary frequency, and identify areas in which further research is needed. The patient population of interest are women with UUI, urinary urgency, and/or urinary frequency. The guideline does not provide information regarding the examination and evaluation of women with urinary incontinence.
The lower urinary tract is comprised of the bladder and urethra. Bladder filling and urine storage are mediated by sympathetic input from the spinal cord, while voiding is controlled primarily by parasympathetic input. The type of UI one experiences is directly related to underlying mechanical or neurological impairments. UI is more common among women than among men, with SUI being the most prevalent type followed by mixed UI (MUI), characterized by symptoms of SUI and UUI, and then UUI. The estimated worldwide prevalence of urge and MUI is more than 20%, with prevalence increasing with age. The per capita cost of OAB with UUI in the United States was estimated at $82.6 billion in 2020.
The search strategy and databases used to search for scientific literature published from January 1, 1995, to June 30, 2017, included OVID Medline, EMBASE, Cochrane Library, CINAHL, and ProQuest. Abstract screening resulted in 545 articles that qualified for full-text appraisal. Thirty-one articles informed the development of 7 recommendations for intervention of UUI, urinary urgency, and/or urinary frequency.
The recommendations include behavioral interventions, pelvic floor muscle training, transcutaneous tibial nerve neuromodulation, transvaginal neuromodulation, medication combined with rehabilitation, weight loss, mindfulness-based stress reduction, constipation management, and fall risk management. Each recommendation is supported by evidence quality and grade of recommendation.
Behavioral interventions must include bladder retraining, dietary and fluid modification, and urge suppression techniques for symptoms of UUI, urinary urgency, and/or urinary frequency. Pelvic floor muscle training programs should be prescribed when contraction quality has been confirmed for these symptoms. Low-frequency transcutaneous tibial nerve electrical stimulation should be used for symptoms of urgency urinary incontinence in the absence of contraindications for electrical stimulation.
The guideline will be updated and revised within 5 years of its publication as new evidence emerges. The procedures utilized for updating the guideline will follow those utilized in the writing of this guideline, based on the recommended standards of the APTA and APHPT.
In conclusion, this CPG offers guidance to health care providers and patients for the treatment of urinary urge incontinence, urinary urgency, and urinary frequency. The evidence-based recommendations are intended to inform clinician and patient decisions about appropriate health care for UUI, urinary urgency, and/or urinary frequency in adult women. The guideline does not serve as a standard of clinical care for all patients and clinical judgment regarding use of a particular clinical procedure or treatment plan must be made considering the clinical data presented by a given patient.
Rehabilitation interventions for urinary incontinence have been studied extensively. Behavioral training, biofeedback, and bladder training have been shown to be effective in reducing urinary symptoms. Pelvic floor muscle training (PFMT) programs are recommended when contraction quality has been confirmed, with or without surface electromyography (sEMG) biofeedback, for symptoms of urgency urinary incontinence (UUI), urinary urgency, and/or urinary frequency. The methods of confirmation varied and included exercises such as PFMT of 8 weeks or longer consisting of 20 to 60, 10-second contractions per day combined with behavioral therapy. Higher doses of PFMT may be more appropriate for women with stress UI, but not for urge UI. Studies have shown that PFMT in combination with behavioral intervention provides the greatest outcomes for women with symptoms of UUI. Neuromodulation, including transcutaneous tibial nerve neuromodulation and transvaginal neuromodulation, has also been effective in treating pelvic floor disorders. Low-frequency transcutaneous tibial nerve ES has been recommended for symptoms of UUI. Transvaginal neuromodulation has been shown to be effective in reducing symptoms of UUI. Medication combined with rehabilitation has also shown improved outcomes for UUI. Weight loss has been found to reduce symptoms of UUI in women with a BMI of more than 25 kg/m. Mindfulness-based stress reduction (MBSR) may also be considered to reduce symptoms of UUI. MBSR has been shown to improve health-related quality of life and reduce episodes of incontinence. These interventions have the potential to significantly improve the quality of life for women experiencing symptoms of UUI, urinary urgency, and/or urinary frequency.
The Clinical Practice Guidelines (CPG) provide recommendations for the treatment of urinary urge incontinence, urinary urgency, and urinary frequency in women. The CPG is based on a critical review and appraisal of thousands of articles published from 1997 to 2017. The recommendations include behavioral interventions and pelvic floor muscle training (PFMT) as the most effective treatments, followed by electrical stimulation (ES) and lifestyle modifications. Health care practitioners who can prescribe medication for the treatment of urgency urinary incontinence (UUI) should inform patients of the improved outcome when combined with pelvic health rehabilitation.
Patients and health care providers should address constipation to reduce symptoms of UUI, urinary urgency, and/or urinary frequency. Physical therapists treating women with UUI are accustomed to patients having concomitant constipation, and resolution of constipation symptoms can improve UUI symptoms. There is a significant association between constipation and the risk of urinary incontinence, and symptoms of overactive bladder (OAB) are more likely to be moderate to severe and present with urinary incontinence when constipation is present. Although the relationship between constipation and bladder function is not clearly understood, animal models show that colorectal distention can cause spontaneous bladder contractions.
Health care providers should address fall risk management for patients with UUI, urinary urgency, and/or urinary frequency. Several authors have identified UI as a risk factor for falls, and research has found a correlation between nocturia and UI with an increased incidence of falls among adults older than 65 years. Urgency, particularly UUI, poses a significantly higher risk of falls among individuals 40 years and older. All patients referred for management of UUI should also be screened for fall risks. For those individuals with a high fall risk, evaluation and treatment of balance, strength, and gait should be included in the rehabilitation plan of care.
Providers considering an anticholinergic medication prescription for a patient should complete a fall risk assessment prior to starting pharmaceutical treatment. Anticholinergic medications for the treatment of UUI act by blocking receptors in the detrusor muscle, but they also affect cholinergic receptors in muscles and the central nervous system. Side effects common to anticholinergic medications such as muscle weakness, blurred vision, and cognitive impairments contribute to falls among older adults. The fall risk of patients with UUI may therefore be increased by employing anticholinergic medications.
The CPG authors recommend future research focus on differentiation between various forms of behavioral interventions commonly used to treat UUI, the relationship between constipation and UUI, as well as the causal relationship between UUI and fall risk, and assessment and treatment of overactive pelvic floor muscles (PFMs) as it relates to UUI. The initial literature search was conducted in 2016 with a revised more accurate search in 2017 to include treatment of UUI and urinary urgency and/or urinary frequency only, excluding studies looking at stress urinary incontinence (SUI). Due to the nature of the project and available time and resources coupled with the volume of results, the CPG is being presented 5 years after the initial search. Criteria of writing the CPG do not allow inclusion of more recent studies outside the initial end point of 2017.
The CPG authors recognize a limitation of this CPG is the focus on rehabilitation interventions only. Due to the scope of literature search, the intervention recommendations were the highest priority. There is a need for recommendations of the most effective examination tools and outcome measures in the treatment of UUI, urinary urgency, and/or urinary frequency.
The CPG is intended to provide guidance to health care providers and patients for the treatment of urinary urge incontinence, urinary urgency, and urinary frequency. It is anticipated that future research will address constipation and fall management more explicitly.