New Clinical Guidelines for Stress Urinary Incontinence

The American College of Obstetricians and Gynecologists and the American Urogynecologic Society recently published recommendations for medical evaluation of women who have uncomplicated stress urinary incontinence (SUI). The following steps are recommended for evaluation: history, urinalysis, physical examination, demonstration of SUI, urethral mobility assessment, and a post void residual. For women who have complicated SUI, urodynamic testing may be appropriate, according to the article, whereas in women with uncomplicated SUI, urodynamics testing may not affect treatment outcomes.

Uncomplicated urinary incontinence is defined within this article as including the following:

• • UI with loss of urine on effort, physical exertion, sneeze or cough
• • Absence of recurrent UTI
• • No prior major pelvic surgery including surgery for SUI
• • Absence of voiding symptoms such as urinary hesitancy, straining to void, spraying of stream, dysuria, sense of incomplete emptying, postmicturition leakage
• • Absence of medical conditions affecting lower urinary tract
• • Absence of vaginal bulge beyond the hymen, absence of urethral abnormality
• • Presence of urethral mobility
• • *<150 mL postvoid residual
• • Negative urinalysis

Recommended nonsurgical approaches include pelvic muscle strengthening (with or without physical therapy), behavioral modification, pessaries, and urethral inserts. The document also includes an example list of validated urinary incontinence questionnaires. The paper makes the point clear that "…counseling should begin with conservative options." However, for those women who wish to have a sling surgery, and "in whom conservative treatment has failed…" is a phrase used in the article, leaving us to wonder: what constitutes failed conservative care? Does this mean that a patient who has failed a pessary trial is a viable candidate for surgery? Or that someone who has completed pelvic muscle strengthening (and perhaps no behavioral modification therapy) should be considered a "failed" patient? Does it mean that a patient who was given a handout about completing Kegel exercises has completed a conservative bout of care?

Further guidelines can best be made when the research describing components of pelvic rehabilitation are included. Clearly the burden of responsibility falls on the shoulders of the pelvic rehab therapists to fill in this knowledge and/or research gap. Clinical guidelines are increasingly inclusive of pelvic rehabilitation approaches, which is a terrific improvement, and yet we should not like to see (with or without physical therapy) following pelvic muscle strengthening, particularly when clinically we see such a wide variety of pelvic dysfunctions limiting appropriate strengthening techniques.

For foundational information about evaluation and treatment of urinary incontinence, a therapist can begin with the Pelvic Floor level 1 training, and then continue through the pelvic floor series continuing education courses in which urinary incontinence is continually addressed as a topic.