New Guidelines Push for Routine Incontinence Screening in All Women

All women should undergo annual screening for urinary incontinence beginning in adolescence and clinicians should refer them for further evaluation and treatment when appropriate, the Women's Preventive Services Initiative (WPSI) recommended despite a lack of direct evidence for this practice.

Given that effective screening may lead to more timely intervention, universal screening through the use of a brief questionnaire might identify symptoms of urinary incontinence before they further affect women's lives, according to Amir Qaseem, MD, PhD, MHA, and colleagues of the WPSI, in new guidelines published in Annals of Internal Medicine.

"So far, no trials have been conducted on the effectiveness and harms of urinary incontinence screening to improve symptoms, quality of life, and function," they cautioned.

"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 settings and the effectiveness and harms of treatment."

Led by the American College of Obstetricians and Gynecologists, the WPSI is a national coalition that includes the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services and several medical societies such as the American College of Physicians.

A systematic review of 17 studies formed the basis of the new recommendations. No study evaluated the overall effectiveness or harms of screening, all the studies included had been conducted to evaluate the diagnostic accuracy of screening questionnaires. Of these, just three studies were performed outside of referral clinics, with participants not recruited on the basis of symptoms.

"Using an existing tool in a low-prevalence setting might result in many false-positives. As a consequence, many women without urinary incontinence might needlessly undergo a diagnostic work-up involving invasive testing," warned Robin Bell, MBBS, PhD, MPH, and Susan Davis, MBBS, PhD, both of Australia's Monash University.

Moreover, symptoms of urinary incontinence symptoms may resolve spontaneously when given the chance, they said in an accompanying editorial.

"Conservative approaches to management, such as pelvic floor exercises and weight loss, are unlikely to be risky, but pharmacologic therapy is associated with side effects, including urine retention. Many surgical interventions are available to treat urinary incontinence in women, including midurethral slings; yet, evidence of long-term effectiveness is lacking. Procedures involving some new products have had very serious, long-term side effects, which have their own impact on quality of life," according to Bell and Davis.

"Rather than recommending annual screening for women across the lifespan, we should be advocating a randomized trial to directly assess the benefits and harms of urinary incontinence screening in women," they wrote. "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."

For now, HRSA has already adopted the recommendation for annual urinary incontinence screening in women, which will be incorporated into the summary of covered benefits for preventive services without cost sharing, as required by the Affordable Care Act, Qaseem's group noted.