urinary incontinence

Idiopathic Normal Pressure Hydrocephalus A Review

Nathan Hinkle — Wed, 16 Sep 2026 05:00:00 +0000

Date Added:

September 16, 2026

Journal/Publication:

JAMA

Publisher:

The American Medical Association

Publication Date:

September 14, 2026

URL:

E1-E14

Type:

Meta-analyses, Reviews, and Guidelines

CME Credits:

Format:

Article

DOI (1):

doi: 10.1001/jama.2026.15519

Keywords

Idiopathic Normal Pressure Hydrocephalus

neurology

cognitive assessment

MeSH

Hydrocephalus, Normal Pressure*

Cognitive Dysfunction* / therapy

urinary incontinence

RPR Commentary: A review of what we know about normal pressure hydrocephalus, and condition affecting up to 4% of older adults. James W. Mold, MPH.

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Abstract
Importance Idiopathic normal pressure hydrocephalus (iNPH) is a progressive neurological disorder characterized by cerebral ventricular enlargement that is typically associated with gait impairment and often urinary dysfunction and cognitive decline in older adults. iNPH prevalence is approximately 1% to 4% among individuals 65 years and older and 6% to 8% among those 80 years and older.

Observations iNPH is a multifactorial disorder involving interactions among cerebrospinal fluid (CSF) circulation, vascular dysfunction, and white matter injury. Unlike secondary NPH, iNPH occurs without a known antecedent event such as subarachnoid hemorrhage. Gait disturbance, including a broad-based, slow, shuffling gait and impaired turning, occurs in 85% to 95% of patients with iNPH and is often the earliest symptom. Urinary dysfunction occurs in approximately 75% to 90% of patients with iNPH and commonly includes urgency, nocturia, urge incontinence, or leakage. Cognitive impairment is reported in 60% to 80% of patients with iNPH, predominantly involving impaired attention, processing speed, working memory, verbal fluency, and cognitive flexibility. iNPH is diagnosed primarily based on characteristic clinical findings and neuroimaging (typically brain magnetic resonance imaging) demonstrating cerebral ventricular and subarachnoid space enlargement. Although necessary for diagnosis, these neuroimaging findings are not reliably associated with response to treatment. Early diagnosis of NPH is important because shorter symptom duration and less advanced disease are associated with more favorable outcomes. Patients being evaluated for iNPH should undergo large-volume lumbar puncture with removal of 30 to 50 mL of CSF to confirm the diagnosis and predict shunt responsiveness, measured as improvement in objective gait measures starting within hours after drainage. Extended lumbar drainage with removal of 200 to 300 mL of CSF over several days in an inpatient setting provides higher prognostic accuracy, and may be performed in patients with high clinical suspicion and a negative or equivocal clinical response to lumbar puncture. Treatment for iNPH is CSF diversion with shunt placement, most commonly performed with ventriculoperitoneal shunts, although ventriculoatrial and lumboperitoneal shunts may have similar efficacy. After shunting, approximately 75% to 80% of patients have gait velocity improvement; cognitive and urinary improvements occur in approximately 50% to 70%. Complications of shunts include overdrainage and underdrainage (10%-30%), presenting as postural headaches and subdural collections, and recurrence or worsening of iNPH symptoms, shunt malfunction (10%-20%), and shunt infections (<1%-2%).

Conclusions and Relevance iNPH affects approximately 1% to 4% of adults 65 years and older and is associated with gait impairment, cognitive decline, and urinary dysfunction. Symptoms improve in approximately 70% to 90% of patients with iNPH who undergo shunt surgery.

Author/s:

S. Farzad Maroufi, Sevil Yasar, Abhay Moghekar, Mark G. Luciano

Non-Surgical Management of Urinary Incontinence

Alex Haga — Tue, 25 Feb 2025 17:42:11 +0000

Date Added:

February 25, 2025

Journal/Publication:

The Journal of the American Board of Family Medicine

Publication Date:

September 1, 2024

Issue:

Volume:

Pages:

909-918

URL:

Non-Surgical Management of Urinary Incontinence

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.3122/jabfm.2023.230471R1

Keywords

urinary incontinence

incontinence

stress urinary incontinence

MeSH

urinary tract infections

A review of the non-surgical management of urinary incontinence. James W. Mold, MD, MPH

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Urinary incontinence management varies depending on the type of incontinence and severity of symptoms. Types of incontinence include stress (SUI), urge or overactive bladder (OAB), mixed, neurogenic, and overflow incontinence. First-line treatment for OAB and SUI is nonpharmacologic management. Behavioral therapy is first-line treatment for urge incontinence. Vaginal mechanical devices (cones, pessaries, and urethral plugs), pelvic floor muscle training, and electroacupuncture are recommended as first-line treatment for women with SUI. Biofeedback and electric muscle stimulation can be adjunctive therapy for SUI. Antimuscarinics and β-3 agonists can be used as adjective therapy for those with OAB who do not improve with behavioral therapy. β-3 agonists have less anticholinergic side effects compared with antimuscarinics for OAB. Adverse medication effects can often lead to discontinuation due to poor tolerability. Third-line therapies are for those who fail conservative and pharmacologic therapies and lack high-grade evidence. Neuromodulation, neurotoxin injections, vaginal laser therapy, and acupuncture are third-line in OAB management. Pharmacologic management with α-1-blockers is recommended as first-line treatment for moderate to severe overflow incontinence from BPH. 5-α reductase inhibitors can be used as an adjunct medication in those with refractory overflow incontinence symptoms and a PSA ≥ 1.5 mg/dL. Clean intermittent catheterization is first-line therapy for neurogenic bladder but can increase risk of catheter-associated urinary tract infection. Clinicians should assess type of incontinence, patient goals, side effect profile, and tolerability to determine an individualized treatment plan for each patient.

Author/s:

Ranna Al-Dossari, Monica Kalra, Julie Adkison, Bich-May Nguyen

Stress urinary incontinence and synthetic mesh midurethral slings in women

Rowan Hutchins — Wed, 27 Sep 2023 05:00:00 +0000

Date Added:

September 27, 2023

Journal/Publication:

CMAJ

Publisher:

CMA

Publication Date:

August 21, 2023

Issue:

Volume:

195

URL:

Stress urinary incontinence and synthetic mesh midurethral slings in women

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.221592

Keywords

female

Surgical treatment

suburethral slings

PMID (1):

37604526

MeSH

urinary incontinence

Stress* / surgery

Surgical Mesh / adverse effects

Suburethral Slings* / adverse effects

A concise review of the management of stress urinary incontinence in women including the use of synthetic mesh. James W. Mold, MD, MPH

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Stress urinary incontinence has a prevalence of 10%–40% and is considered severe in 3%–17% of women worldwide.1 Diagnosis involves demonstrating involuntary urine leakage with increases in intra-abdominal pressure (e.g., exercising, coughing). On history, it is important to differentiate this leakage from symptoms like urgency, frequency and nocturia, as these may indicate mixed urinary incontinence or overactive bladder.

Author/s:

Kanji, Sarah, Clancy, Aisling A.

Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes

Jeffrey Wilson — Tue, 19 Mar 2019 19:29:38 +0000

Date Added:

March 19, 2019

Journal/Publication:

Annals of Internal Medicine

Publisher:

American College of Physicians

Publication Date:

March 19, 2019

URL:

Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M18-3227

Keywords

behavioral interventions

incontinence

PMID (1):

30884526

MeSH

urinary incontinence

behavior therapy

cholinergic antagonists

Another large systematic review showing that behavioral interventions are more effective than drugs for both stress and urge incontinence in women. Primary care clinicians can learn to prescribe behavioral interventions if incontinence therapists are unavailable. I only used drugs while patients were mastering the behavioral techniques. James Mold, MD, MPH

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BACKGROUND:

Urinary incontinence (UI), a common malady in women, most often is classified as stress, urgency, or mixed.

PURPOSE:

To compare the effectiveness of pharmacologic and nonpharmacologic interventions to improve or cure stress, urgency, or mixed UI in nonpregnant women.

DATA SOURCES:

MEDLINE, Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), EMBASE (Elsevier), CINAHL (EBSCO), and PsycINFO (American Psychological Association) from inception through 10 August 2018.

STUDY SELECTION:

84 randomized trials that evaluated 14 categories of interventions and reported categorical cure or improvement outcomes.

DATA EXTRACTION:

1 researcher extracted study characteristics, results, and study-level risk of bias, with verification by another independent researcher. The research team collaborated to assess strength of evidence (SoE) across studies.

DATA SYNTHESIS:

84 studies reported cure or improvement outcomes (32 in stress UI, 16 in urgency UI, 4 in mixed UI, and 32 in any or unspecified UI type). The most commonly evaluated active intervention types included behavioral therapies, anticholinergics, and neuromodulation. Network meta-analysis showed that all interventions, except hormones and periurethral bulking agents (variable SoE), were more effective than no treatment in achieving at least 1 favorable UI outcome. Among treatments used specifically for stress UI, behavioral therapy was more effective than either α-agonists or hormones in achieving cure or improvement (moderate SoE); α-agonists were more effective than hormones in achieving improvement (moderate SoE); and neuromodulation was more effective than no treatment for cure, improvement, and satisfaction (high SoE). Among treatments used specifically for urgency UI, behavioral therapy was statistically significantly more effective than anticholinergics in achieving cure or improvement (high SoE), both neuromodulation and onabotulinum toxin A (BTX) were more effective than no treatment (high SoE), and BTX may have been more effective than neuromodulation in achieving cure (low SoE).

LIMITATION:

Scarce direct (head-to-head trial) evidence and population heterogeneity based on UI type, UI severity, and history of prior treatment.

CONCLUSION:

Most nonpharmacologic and pharmacologic interventions are more likely than no treatment to improve UI outcomes. Behavioral therapy, alone or in combination with other interventions, is generally more effective than pharmacologic therapies alone in treating both stress and urgency UI.

Author/s:

Balk, E.M., Rofebero, V.N., Adam, G.P., Kimmel, H.J., Trikalinos, T.A., Jeppson, P.C.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

Tracy Ashby — Tue, 23 Oct 2018 05:00:00 +0000

Date Added:

October 23, 2018

Journal/Publication:

Cochrane Database Of Systematic Reviews

Publisher:

John Wiley & Sons, Ltd

Publication Date:

October 4, 2018

Volume:

Pages:

CD005654

URL:

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1002/14651858.CD005654.pub4

Keywords

pelvic floor

women

urinary incontinence

PMID (1):

30288727

MeSH

pelvic floor

female humans

urinary incontinence

This updated systematic review concluded that pelvic floor muscle training (Kegel exercises) improve symptoms and quality of life in patients with both stress and urge incontinence.

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Background

Pelvic floor muscle training (PFMT) is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed urinary incontinence (MUI) and, less commonly, urgency urinary incontinence (UUI).

This is an update of a Cochrane Review first published in 2001 and last updated in 2014.

Objectives

To assess the effects of PFMT for women with urinary incontinence (UI) in comparison to no treatment, placebo or sham treatments, or other inactive control treatments; and summarise the findings of relevant economic evaluations.

Search methods

We searched the Cochrane Incontinence Specialised Register (searched 12 February 2018), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings, and the reference lists of relevant articles.

Selection criteria

Randomised or quasi‐randomised controlled trials in women with SUI, UUI or MUI (based on symptoms, signs or urodynamics). One arm of the trial included PFMT. Another arm was a no treatment, placebo, sham or other inactive control treatment arm.

Data collection and analysis

At least two review authors independently assessed trials for eligibility and risk of bias. We extracted and cross‐checked data. A third review author resolved disagreements. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We subgrouped trials by diagnosis of UI. We undertook formal meta‐analysis when appropriate.

Main results

The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. Overall, trials were of small‐to‐moderate size, with follow‐ups generally less than 12 months and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration, study populations and outcome measures. There was only one study of women with MUI and only one study with UUI alone, with no data on cure, cure or improvement, or number of episodes of UI for these subgroups.

Symptomatic cure of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were eight times more likely to report cure (56% versus 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68 to 19.07; 4 trials, 165 women; high‐quality evidence). For women with any type of UI, PFMT groups were five times more likely to report cure (35% versus 6%; RR 5.34, 95% CI 2.78 to 10.26; 3 trials, 290 women; moderate‐quality evidence).

Symptomatic cure or improvement of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were six times more likely to report cure or improvement (74% versus 11%; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women; moderate‐quality evidence). For women with any type of UI, PFMT groups were two times more likely to report cure or improvement than women in the control groups (67% versus 29%; RR 2.39, 95% CI 1.64 to 3.47; 2 trials, 166 women; moderate‐quality evidence).

UI‐specific symptoms and quality of life (QoL) at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT group were more likely to report significant improvement in UI symptoms (7 trials, 376 women; moderate‐quality evidence), and to report significant improvement in UI QoL (6 trials, 348 women; low‐quality evidence). For any type of UI, women in the PFMT group were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate‐quality evidence) and to report significant improvement in UI QoL (4 trials, 258 women; moderate‐quality evidence). Finally, for women with mixed UI treated with PFMT, there was one small trial (12 women) reporting better QoL.

Leakage episodes in 24 hours at the end of treatment: PFMT reduced leakage episodes by one in women with SUI (mean difference (MD) 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women; moderate‐quality evidence) and in women with all types of UI (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women; moderate‐quality evidence).

Leakage on short clinic‐based pad tests at the end of treatment: women with SUI in the PFMT groups lost significantly less urine in short (up to one hour) pad tests. The comparison showed considerable heterogeneity but the findings still favoured PFMT when using a random‐effects model (MD 9.71 g lower, 95% CI 18.92 lower to 0.50 lower; 4 trials, 185 women; moderate‐quality evidence). For women with all types of UI, PFMT groups also reported less urine loss on short pad tests than controls (MD 3.72 g lower, 95% CI 5.46 lower to 1.98 lower; 2 trials, 146 women; moderate‐quality evidence).

Women in the PFMT group were also more satisfied with treatment and their sexual outcomes were better. Adverse events were rare and, in the two trials that did report any, they were minor. The findings of the review were largely supported by the 'Summary of findings' tables, but most of the evidence was downgraded to moderate on methodological grounds. The exception was 'participant‐perceived cure' in women with SUI, which was rated as high quality.

Authors' conclusions

Based on the data available, we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI‐specific symptom questionnaires. The authors of the one economic evaluation identified for the Brief Economic Commentary reported that the cost‐effectiveness of PFMT looks promising. The findings of the review suggest that PFMT could be included in first‐line conservative management programmes for women with UI. The long‐term effectiveness and cost‐effectiveness of PFMT needs to be further researched.

Author/s:

Dumoulin, Chantale E., Hay-Smith, Jean C., Mac Habee-Seguin, Gabrielle

Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update

Jeffrey Wilson — Mon, 22 Oct 2018 16:08:25 +0000

Date Added:

October 22, 2018

Journal/Publication:

Comparative Effectiveness Review

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

August 8, 2018

Issue:

212

URL:

Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.23970/AHRQEPCCER212

Keywords

urinary tract infections

MeSH

botulinum toxins, type A

urinary tract infections

This is a concise summary of the evidence regarding management of stress and urge-type urinary incontinence in women.

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Introduction. About 17 percent of adult women have had urinary incontinence (UI), classified as stress, urgency, or mixed. Stress UI is associated with an inability to retain urine with activities that increase intraabdominal pressure. Urgency UI is associated with the sudden, compelling urge to void. Mixed UI occurs when both are present.

Methods. We updated the Agency for Healthcare Research and Quality's 2012 systematic review with new literature searches in MEDLINE®, the Cochrane Central Trials Registry, the Cochrane Database of Systematic Reviews, and Embase® from 2011 through December 4, 2017. We included UI outcomes (cure, improvement, satisfaction), quality of life, and adverse events. For UI outcomes, we conducted network meta-analyses, combining direct and indirect comparisons across studies. Quality of life and adverse event outcomes are narratively described.

Results. We identified 233 eligible studies, of which 140 reported on UI outcomes, 96 on quality of life, and 127 on adverse events. Studies evaluated 16 categories of interventions with 53 specific interventions. Fourteen intervention categories have been evaluated for UI outcomes; all except hormones and periurethral bulking agents were more effective to achieve at least one favorable UI outcome than no treatment (variable strength of evidence [SoE]). Among 1st or 2nd line interventions for stress UI, behavioral therapy (BT, alone and in combination with hormones) was more effective than either alpha agonists or hormones to achieve cure or improvement (moderate SoE); alpha agonists were more effective than hormones to achieve improvement (moderate SoE). Among treatments used as 1st or 2nd line interventions for urgency UI, BT was significantly more effective than anticholinergics to achieve cure or improvement (high SoE). Among 3rd line interventions for stress UI, intravesical pressure release, but not periurethral bulking agents, was more effective than no treatment (variable SoE). Neuromodulation, which is commonly used for treatment of urgency UI, is more effective than no treatment of stress UI for cure, improvement, and satisfaction (high SoE). Among studies of women with only stress UI, indirect evidence suggests that intravesical pressure release is more effective to achieve improvement than combination BT and neuromodulation, and triple combination neuromodulation, hormones, and BT may be more effective than either periurethral bulking or combination neuromodulation and BT (all low SoE). Among treatments used as 3rd line interventions for urgency UI, both neuromodulation and onabotulinum toxin A (BTX) are more effective than no treatment (high SoE), and BTX may be more effective than neuromodulation to achieve cure (low SoE). BT, neuromodulation, and anticholinergics resulted in better quality of life than no treatment (low SoE). Urinary tract infections (UTIs) were reported in 11 percent of women receiving transcutaneous electrical nerve stimulation and erosion in 1.6 percent of women with the periurethral bulking agent macroplastique (low SoE). Dry mouth was the most commonly reported adverse event for the anticholinergic oxybutynin (36%) and the alpha agonist duloxetine (13%) (high SoE). BTX was associated with UTIs (36%) and urinary retention (10% to 20%) (moderate SoE). Constitutional adverse events (e.g., nausea, insomnia, fatigue) were common with duloxetine (moderate SoE).

Conclusions. Network meta-analyses demonstrated that most nonpharmacological and pharmacological interventions are more likely than no treatment to improve UI outcomes and quality of life. BT, alone or in combination with other interventions, is generally more effective than 2nd line (pharmacological) therapies alone for both stress and urgency UI. Common adverse events with pharmacological treatments include dry mouth, nausea, and fatigue. BTX is associated with urinary infections and retention. Periurethral bulking agents are associated with erosion and need for surgical removal. Large gaps remain in the literature regarding head-to-head comparisons of individual interventions.

Author/s:

Balk, Ethan, Adam, Gaelen P., Kimmel, Hannah, Rofeberg, Valerie, Saeed, Iman, Jeppson, Peter, Trikalinos, Thomas