Behavioral and drug therapy for urinary incontinence

Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006.

OBJECTIVES

To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.

Mixed urinary incontinence: international urogynecological association research and development committee opinion

BACKGROUND AND AIM

The definition as well as the treatment of women with mixed urinary incontinence (MUI) is controversial. Since women with MUI are a heterogeneous group, the treatment of MUI requires an individual assessment of the symptom components: stress urinary incontinence, urinary urgency, urgency urinary incontinence, urinary frequency, and nocturia. The purpose of this paper is to summarize the current literature and give an evidence-based review of the assessment and treatment of MUI.

METHODS

A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the diagnosis and management of MUI was drafted based on a literature review. After evaluation by the entire IUGA R&D Committee, revisions were made, and the final document represents the IUGA R&D Committee Opinion on MUI.

RESULTS

This R&D Committee Opinion reviews the literature on MUI and summarizes the assessment and treatment with evidence-based recommendations.

CONCLUSIONS

The diagnosis of MUI encompasses a very heterogeneous group of women. The evaluation and treatment requires an individualized approach. The use of validated questionnaires is recommended to assess urinary incontinence symptoms and effect on quality of life. Conservative therapy is suggested as a first-line approach; if surgery is contemplated, urodynamic investigation is recommended. Women undergoing surgical treatment for MUI need to be counselled about the possibility of persistence of urinary urgency, frequency and urge incontinence even if stress urinary incontinence is cured.

Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis

Biofeedback (BF) has been widely used in the treatment of pelvic floor dysfunctions, mainly by promoting patient learning about muscle contraction with no side effects. However, its effectiveness remains poorly understood with some studies suggesting that BF offers no advantage over the isolated pelvic floor muscle training (PFMT). The main objective of this study was to systematically review available randomized controlled trials assessing the effectiveness of BF in female pelvic floor dysfunction treatment. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). Randomized controlled trials assessing the training of pelvic floor muscle (PFM) using BF in women with PFM dysfunction were selected. Outcomes were converted to a scale ranging from 0 to 100. Trials were pooled with software used to prepare and update Cochrane reviews. Results are presented as weighted mean differences with 95 % confidence intervals (CI). Twenty-two trials with 1,469 patients that analyzed BF in the treatment of urinary, anorectal, and/or sexual dysfunctions were included. PFMT alone led to a superior but not significant difference in the function of PFM when compared to PFMT with BF, by using vaginal measurement in the short and intermediate term: 9.89 (95 % CI -5.05 to 24.83) and 15.03 (95 % CI -9.71 to 39.78), respectively. We found a few and nonhomogeneous studies addressing anorectal and sexual function, which do not provide the cure rate calculations. Limitations of this review are the low quality and heterogeneity of the studies, involving the usage of distinct protocols of interventions, and various and different outcome measures. The results of this systematic review suggest that PFMT with BF is not more effective than other conservative treatments for female PFM dysfunction.

A comparison of the efficacy of darifenacin alone vs. darifenacin plus a Behavioural Modification Programme upon the symptoms of overactive bladder

PURPOSE

This study assessed the benefit of adding behavioural modification to darifenacin treatment for overactive bladder (OAB).

MATERIALS AND METHODS

The ABLE trial was a randomised, open-label, parallel-group, multicentre study of 12 weeks of darifenacin treatment [with voluntary up-titration from 7.5 mg once daily (qd) to 15 mg qd at week 2] alone or in combination with a Behavioural Modification Programme (BMP) for men and women with dry or wet OAB. Efficacy was assessed as the change in the number (per day) of micturitions (primary variable), urge urinary incontinence (UUI) episodes, urgency episodes, pads used and nocturnal voids. Health-related quality of life (HRQoL) was also evaluated. Tolerability and safety assessments included adverse events and the number of discontinuations.

RESULTS

Of 592 patients screened, 395 were randomised, 190 to darifenacin alone and 205 to darifenacin + BMP. At baseline, the majority of subjects were dry (mean 2.8 and three UUI episodes per day in the darifenacin and darifenacin + BMP groups respectively). At study end, darifenacin alone and darifenacin + BMP both produced significant reductions from baseline in median numbers of micturitions, UUI episodes, urgency episodes and nocturnal voids (all p < 0.05), but not in the number of pads used. HRQoL also improved. There were no significant differences between treatment groups in efficacy or HRQoL variables.

CONCLUSIONS

Darifenacin treatment provides a degree of normalisation of micturition variables and improvement in HRQoL that cannot be further enhanced by behavioural therapy of the type used in this study. Whether behavioural modification would add benefit over darifenacin treatment in patients with more pronounced incontinence problems remains to be determined.

Palliative Care for the Older Adult

The majority of deaths in the United States occur in the geriatric population. These older adults often develop multiple chronic medical problems and endure complicated medical courses with a variety of disease trajectories. Palliative care physicians need to be skilled in addressing the needs of these frail elders with life-limiting illness as they approach the end of life. Although geriatrics and palliative medicine share much in common, including an emphasis on optimizing quality of life and function, geriatric palliative care is distinct in its focus on the geriatric syndromes and on the provision of care in a variety of long-term care settings. Expertise in the diagnosis and management of the geriatric syndromes and in the complexities of long-term care settings is essential to providing high-quality palliative care to the elderly patient. This paper is a practical review of common geriatric syndromes, including dementia, delirium, urinary incontinence, and falls, with an emphasis on how they may be encountered in the palliative care setting. It also highlights important issues regarding the provision of palliative care in different long-term care settings.

Anticholinergic drugs versus placebo for overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (urgency with frequency and/or urge incontinence). The prevalence increases with age. Anticholinergic drugs are commonly used to treat this condition.

OBJECTIVES

To determine the effects of anticholinergic drugs for the treatment of overactive bladder syndrome.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 14 June 2005) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug with placebo treatment or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewer authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2005).

MAIN RESULTS

Sixty -one trials, 42 with parallel-group designs and 19 crossover trials were included (11,956 adults). Most trials were described as double-blind but were variable in other aspects of quality. The crossover trials did not present data in a way that allowed inclusion in the meta-analysis. Nine medications were tested: darifenacin; emepronium bromide or carrageenate; oxybutynin; propiverine; propantheline; tolterodine; trospium chloride; and solifenacin. One trial included the newer, slow release formulation of tolterodine. At the end of the treatment period, cure or improvement (relative risk (RR) 1.39, 95% CI 1.28 to 1.51), difference in leakage episodes in 24 hours (weighted mean difference (WMD) -0.54; 95% CI -0.67 to -0.41) and difference in number of voids in 24 hours (WMD -0.69; 95% CI -0.84 to -0.54) were statistically significant favouring medication. Statistically significant but modest sized improvements in quality of life scores were reported in recently completed trials. There was three times the rate of dry mouth in the medication group (RR 3.00 95% CI 2.70 to 3.34) but no statistically significant difference in withdrawal (RR 1.11, 95% CI 0.91 to 1.36). Sensitivity analysis, while limited by small numbers of trials, showed little likelihood that the effects were modified by age, sex, diagnosis, or choice of drug.

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in statistically significant improvements in symptoms. Recent trials suggest that this is associated with modest improvement in quality of life. Dry mouth is a common side effect of therapy but did not seem to have an effect on the numbers of withdrawals. It is not clear whether any benefits are sustained during long-term treatment or after treatment stops.

Pelvic Floor Muscle Biofeedback in the Treatment of Urinary Incontinence: A Literature Review

Biofeedback is efficacious in the training of the pelvic floor musculature in order to enhance continence. This article reviews the anatomy and physiology of micturition as the underlying rationale for pelvic floor muscle biofeedback in the treatment of urinary incontinence. It critically reviews 28 studies published in peer reviewed journals from 1975 to 2005 that were prospective, randomized studies with parametric statistical analyses, operationally defined patient selection criteria, treatment protocols and outcome measures. The overall mean treatment improvement for patients undergoing biofeedback for urinary incontinence was 72.61%. In 21 of 35 (60%) paired comparisons, biofeedback demonstrated superior symptomatic outcome to control or alternate treatment groups. Larger studies and a standardization of technology and methodology are required for more conclusive determinations.

Urinary incontinence: selected current concepts

UI is highly prevalent in older adults and associated with excess comorbidity and increased mortality. Intensive screening and comprehensive clinical examination of all elders enables prompt detection, accurate classification, and appropriate treatment. OAB is the most common cause of persistent incontinence in the older adult. As with other types of UI, behavior modification is first-line treatment of OAB. Although antimuscarinic agents have been shown to be highly effective in the treatment of OAB, limited data are available regarding the safety and tolerability of these agents in older adults. Patients who fail to respond to noninvasive treatment or those in whom surgery may be appropriate should be referred to the urologist for evaluation and further management.

Urinary incontinence in women

Urinary incontinence is common in women, but is under-reported and under-treated. Urine storage and emptying is a complex coordination between the bladder and urethra, and disturbances in the system due to childbirth, aging, or other medical conditions can lead to urinary incontinence. The two main types of incontinence in women, stress urinary incontinence and urge urinary incontinence, can be evaluated by history and simple clinical assessment available to most primary care physicians. There is a wide range of therapeutic options, but the recent proliferation of new drug treatments and surgical devices for urinary incontinence have had mixed results; direct-to-consumer advertising has increased public awareness of the problem of urinary incontinence, but many new products are being introduced without long-term assessment of their safety and efficacy.

Bladder training for urinary incontinence in adults

BACKGROUND

Urinary incontinence is a common and distressing problem. Bladder training aims to increase the interval between voids and is widely used for the treatment of urinary incontinence.

OBJECTIVES

To assess the effects of bladder training for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (January 2003). The reference lists of relevant articles were searched, and trialists contacted for details of other trials. Date of the most recent search: January 2003.

SELECTION CRITERIA

Randomised or quasi-randomised trials of bladder training for the treatment of any type of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and independently extracted data. Five primary outcomes were prespecified: participant's perception of cure of urinary incontinence; participant's perception of improvement of urinary incontinence; number of incontinent episodes; number of micturitions; and quality of life. Adverse events were also noted. Three hypotheses were tested: bladder training is better than no bladder training; bladder training is better than other treatments; and combining bladder training with another treatment is better than that other treatment alone.

MAIN RESULTS

We assessed 73 reports of 36 potentially relevant trials; 28 reports of ten trials were eligible for inclusion with a total of 1366, predominantly female, participants. Not all participants' with overactive bladder, in five trials had urinary incontinence. Data from five trials with 467 participants, all female, are therefore included in the review. The quality of trials was variable. Few data describing long term follow up are available.Is bladder training better than no bladder training? Data were available for 149 women from two trials comparing bladder training with no bladder training. These described only a limited number of prespecified outcomes, which varied across the two trials. Point estimates of effect favoured bladder training however confidence intervals were wide and no statistically significant differences were found for primary outcome variables.Is bladder training better than other treatments? Only two trials including 125 women compared bladder training with drugs: one with oxybutynin and one with imipramine plus flavoxate. In the former trial the only outcomes demonstrating a statistically significant difference were participant's perception of cure at six months (RR 1.69; 95% CI 1.21 to 2.34) and adverse events (RR 0.03; 95% CI 0.00 to 0.44), both favouring bladder training. In the latter trial participant's perception of cure immediately after treatment just achieved statistical significance (RR 1.50; 95% CI 1.02 to 2.21) favouring bladder training, and this difference was maintained at approximately two months post treatment. One comparison of bladder training with pelvic floor muscle training plus biofeedback included 132 women: none of the differences in the primary outcomes achieved statistical significance.Is combining bladder training with another treatment better than that other treatment alone? One trial compared pelvic floor muscle training plus biofeedback supplemented with bladder training versus pelvic floor muscle training plus biofeedback alone and included 125 women. Of the primary outcomes both participants' perception of improvement and quality of life, both immediately after treatment, achieved statistical significance, favouring the bladder training combined with pelvic floor muscle training and biofeedback group (perception of improvement: RR 1.18; 95% CI 1.01 to 1.39; quality of life: MD -47.20; 95% CI -87.03 to -7.37), this was not sustained at three months.

REVIEWER'S CONCLUSIONS

The limited evidence available suggests that bladder training may be helpful for the treatment of urinary incontinence, but this conclusion can only be tentative as the trials were of variable quality and of small size with wide confidence intervals around the point estimates of effect. There was also not enough evidence to determine w evidence to determine whether bladder training was useful as a supplement to another therapy. Definitive research has yet to be conducted: more research is required.