Clinicians should screen all women for urinary incontinence annually, according to a new recommendation from a national coalition of women's health organizations.
The Women's Preventive Services Initiative (WPSI) also said that screening ideally should assess whether urinary incontinence affects activities and quality of life, and then refer women for further evaluation and treatment if needed.
The recommendation is intended for all clinicians providing preventive health care for women of all ages, particularly in primary care. They also guide clinical practice and coverage of services for the U.S. Health Resources and Services Administration. The recommendation, a systematic review, and an accompanying editorial were published on Aug. 14 by Annals of Internal Medicine.
Although childbearing, advanced age, and obesity are associated with an increased risk for urinary incontinence, these factors should not be used to limit screening, the recommendation said. Given the prevalence of urinary incontinence, the fact that many women do not volunteer symptoms, and the multiple and frequently changing risk factors associated with incontinence, annual testing is reasonable, according to the recommendation.
“Standardized screening in routine clinical practice, particularly as part of a preventive health care visit, has the potential to identify affected women and initiate diagnostic evaluations and treatment,” the recommendation said. “No clinical recommendations addressing routine screening for urinary incontinence have been issued from guideline groups, although recommendations for diagnostic evaluations and treatment are available and have generally been accepted as standards of care. The implementation of universal screening through the use of a brief questionnaire might identify symptoms of urinary incontinence before they further affect women's lives.”
The accompanying editorial pointed out that the recommendation is based on a chain of indirect evidence. “We must learn from experience in women's health, in which faith in indirect evidence often proved naive when direct evidence became available,” stated the editorial, which cited how ovarian cancer screening with ultrasonography and CA-125 levels lead to increased rates of a cancer diagnosis, treatment, and complications, with no reduction in mortality.
“Applying a screening test to a large population is a very serious responsibility,” the editorial concluded. “If screening were associated with even a small amount of harm and the proportion of women who would benefit from early identification were modest, then the net benefit might be marginal or negative. Therefore, we advocate caution in implementing the WPSI recommendation until there is direct evidence for a net benefit of annual screening for urinary incontinence.”
The accompanying systematic review found insufficient evidence on the overall effectiveness and harms of screening for urinary incontinence in women. No studies evaluated the overall effectiveness or harms of screening. Seventeen studies evaluated the diagnostic accuracy of 18 screening questionnaires against a clinical diagnosis or results of diagnostic tests. Of these, 14 poor-quality studies were based in referral clinics, enrolled only symptomatic women, or had other limitations. One good-quality and two fair-quality studies (evaluating four methods) enrolled women who were not recruited on the basis of symptoms. Limited evidence in general populations suggests fairly high accuracy for some screening methods, the review concluded.