Updated Canadian guideline on management of female stress urinary incontinence

The Canadian Urological Association has updated its guideline on adult incontinence, last published in 2012. The original guideline covered male and female nonneurogenic stress and urgency incontinence. However, the updated guideline focuses on female stress urinary incontinence, because of the considerable changes in management and the distinct considerations and surgical procedures for this group.The updated guideline uses a question-and-answer format to provide brief and practical answers to common questions addressing the evaluation and management of female stress urinary incontinence. The guideline pertains to healthy female patients who present with bothersome stress urinary incontinence. These patients struggle with pure stress incontinence or stress predominant mixed urinary incontinence. They have not undergone prior stress urinary incontinence surgery, have a body mass index < 40, have not had pelvic radiotherapy, do not have significant pelvic organ prolapse, and are not in the frail elderly category where surgical options may not be appropriate.Patient evaluation requires a history and physical exam, with steps outlined in the guideline. The document also discusses when cystoscopy and/or urodynamics are indicated. Nonsurgical management options that should be considered before surgery are outlined, along with the strength of each recommendation and the quality of the evidence. Key points are summarized below:Overweight or obese women with bothersome stress incontinence should be counselled that weight loss may improve their degree of incontinence (Strong recommendation, High quality of evidence).Surgical interventions for stress incontinence should be delayed in women considering bariatric surgery (Strong recommendation, Moderate quality of evidence).Smoking cessation should be recommended for all patients as a general public health measure and may reduce chronic cough and stress incontinence (Clinical principle).Topical vaginal estrogen should not be used for the treatment of female stress urinary incontinence in isolation (Strong recommendation, Moderate quality of evidence). However, in postmenopausal patients with symptoms associated with genitourinary syndrome of menopause, topical vaginal estrogen is beneficial and may improve incontinence-related symptoms.Self-directed pelvic floor muscle training may be offered to women who want to manage their symptoms on their own after initial assessment (Weak recommendation, Weak quality of evidence).Healthcare providers should recommend a three-month individualized or group-based supervised progressive and intensive pelvic floor muscle training program, taught by a health professional, as first-line treatment for female stress urinary incontinence (Strong recommendation, High quality of evidence).Physicians should offer pessaries and other vaginal devices (e.g., incontinence tampon, intravaginal bladder support) as safe and effective treatments for female stress urinary incontinence to women who may be candidates (Weak recommendation, Moderate quality of evidence).Surgical options are discussed in the guideline, including information on obtaining informed consent for surgery, and details regarding the efficacy, recovery time, and short- and long-term complications of the primary surgical options. The role of periurethral bulking agents, midurethral slings, autologous fascial slings and retropubic colposuspension are examined.Other issues discussed in the guideline include counselling young women who wish to have children about their treatment options, the effects of stress urinary incontinence on female sexual function, investigation and management of recurrent female stress urinary incontinence after midurethral sling surgery, management of urinary retention after surgery, management of worsening or new overactive bladder after sling surgery, and the investigation and management of pain after transvaginal midurethral sling. The guideline also stresses that there is no evidence that mesh midurethral slings are associated with an increased risk of cancer or autoimmune disease.Reference:Carlson K, Andrews M, Bascom A, et al. 2024 Canadian Urological Association guideline: female stress urinary incontinence. Can Urol Assoc J 2024;18(4):83-102. (accessed June 4, 2024).

Updated Canadian guideline on management of female stress urinary incontinence

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