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

Referral and Prescription Patterns for Female Patients With Urinary Incontinence

IMPORTANCE

Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them.

OBJECTIVES

To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system.

STUDY DESIGN

Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates.

RESULTS

In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48).

CONCLUSION

Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.

Multicomponent Intervention for Overactive Bladder in Women: A Randomized Clinical Trial

Importance

Although the cognitive components of behavioral therapy for overactive bladder (OAB) are widely recognized, there is a lack of studies evaluating the effectiveness of multicomponent interventions that include cognitive components as a treatment for OAB.

Objective

To examine the efficacy of a multicomponent intervention in improving health-related quality of life (HRQOL) for women with moderate to severe OAB.

Design, Setting, and Participants

This multicenter, open-label, randomized clinical trial was conducted in Japan among women aged 20 to 80 years who had moderate to severe OAB. Participants were recruited from 4 institutions between January 16, 2020, and December 31, 2022, through self-referral via advertisement or referral from the participating institutions.

Interventions

Participants were randomized 1:1 by minimization algorithm using an internet-based central cloud system to four 30-minute weekly sessions of a multicomponent intervention or waiting list. Both groups continued to receive baseline treatment throughout the study period.

Main Outcomes and Measures

The primary outcome was the least-squares mean changes from baseline through week 13 in HRQOL total scores of the OAB questionnaire between 2 groups. Secondary outcomes included OAB symptom score and frequency volume chart.

Results

A total of 79 women were randomized to either the intervention group (39 participants; mean [SD] age, 63.5 [14.6] years) or the waiting list control group (40 participants; mean [SD] age, 63.5 [12.9] years). One participant from each group dropped out from the allocated intervention, while 5 participants in the intervention group and 2 in the control group dropped out from the primary outcome assessment at week 13. Thirty-six participants (92.3%) in the intervention group and 35 (87.5%) in the control group had moderate OAB. The change in HRQOL total score from baseline to week 13 was 23.9 points (95% CI, 18.4-29.5 points) in the intervention group and 11.3 points (95% CI, 6.2-16.4 points) in the waiting list group, a significant difference of 12.6 points (95% CI, 6.6-18.6 points; P < .001). Similar superiority of the intervention was confirmed for frequency of micturition and urgency but not for OAB symptom score.

Conclusions and Relevance

These findings demonstrate that a multicomponent intervention improves HRQOL for women with moderate to severe OAB and suggest that the cognitive component may be an effective treatment option for women with OAB.

Trial Registration

UMIN Clinical Trials Registry Identifier: UMIN000038513.

Management of mixed urinary incontinence: IUGA committee opinion

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is defined by the International Urogynecology Association (IUGA) and International Continence Society as the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing. It therefore implies the coexistence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). MUI is a heterogeneous diagnosis that requires an assessment of its individual components of SUI and UUI. Management requires an individualised approach to the symptom components. The aim of this review is to identify the assessment/investigations and management options for MUI.

METHODS

A working subcommittee from the IUGA Research & Development (R&D) Committee was created and volunteers invited from the IUGA membership. A literature review was performed to provide guidance focused on the recommended assessment and management of MUI. The document was then evaluated by the entire IUGA R&D Committee and IUGA Board of Directors and revisions made. The final document represents the IUGA R&D Committee Opinion.

RESULTS

The R&D Committee MUI opinion paper provides guidance on the assessment and management of women with MUI and summarises the evidence-based recommendations.

CONCLUSIONS

Mixed urinary incontinence is a complex problem and successful management requires alleviation of both the stress and urge components. Care should be individualised based on patient preferences. Further research is needed to guide patients in setting goals and to determine which component of MUI to treat first. The evidence for many of the surgical/procedural treatment options for MUI are limited and needs to be explored in more detail.

A Multisite Study on the Effect of a Urinary Incontinence Self-Management Program on Community-Dwelling Older Women in Korea

PURPOSE

The purpose of this study was to evaluate the effects of a urinary incontinence (UI) self-management program on UI symptoms, knowledge, and self-efficacy in community-dwelling older women.

DESIGN

A 1-group pretest-posttest design.

SUBJECTS AND SETTING

Participants were recruited from 14 primary healthcare posts (PHCPs) in South Chungcheong Province, rural South Korea. A total of 163 women participated in a 5-session UI self-management program.

METHODS

The UI self-management program was sequentially conducted across 14 PHCPs between May and November 2016. In each PHCP, 6 to 22 women participated in the program. The program consisted of weekly 90-minute sessions that were conducted across 5 weeks. Each session included a lecture on UI, reflective discussion, pelvic floor muscle training, and the assignment of homework (exercises and a daily bladder diary). Main outcome variables were measured using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Urinary Incontinence Knowledge Scale (UIKS), and Geriatric Self-Efficacy Index for Urinary Incontinence (GSE-UI), which were administered before and after the intervention. Descriptive statistics were computed, and Wilcoxon signed-rank tests analyzed the data.

RESULTS

The intervention resulted in a significant decrease in the ICIQ-SF scores, which was indicative of improvement in UI severity (pretest: 6.64 [SD 6.15], posttest: 4.76 [SD 5.08], P = .001), significant increases in the UIKS (pretest: 15.69 [SD 6.36], posttest: 23.14 [SD 5.54], P = .001] and GSE-UI (pretest: 75.34 [SD 31.80], [posttest: 86.20 [SD 27.06], P = .001) scores.

CONCLUSIONS

The UI self-management program improved UI symptoms, knowledge, and self-efficacy among community-dwelling older women.

Comparative effectiveness of nonsurgical interventions for urinary incontinence in older women: A systematic review and network meta-analysis

PURPOSE

To compare the effectiveness of existing nonsurgical interventions to improve or cure urinary incontinence in older women.

METHODS

Five English databases (Medline, EMBASE, Web of Science, PsychINFO and the Cochrane Library) were searched from January 1, 2018, until August 27, 2023. Studies published before 2018 were directly extracted from a review published in 2019 on a similar research question. Three Chinese databases (China National Knowledge Infrastructure (CNKI), Wanfang and SinoMed) were searched from January 1, 2000, until August 27, 2023. Randomized controlled trials of nonsurgical interventions for women aged ≥ 60 years with urinary incontinence were considered eligible. The primary outcome was the rate of improvement and cure. Pairwise meta-analysis and network meta-analysis were performed, with the pooled risk ratio (RR) and 95 % confidence interval (CI) being reported.

RESULTS

There were 15 intervention categories among the included 32 randomized controlled trials for older women with urinary incontinence. The combination of behavioral therapy with other interventions, including Chinese herbal medicine, electrical stimulation, and acupuncture were effective for both improvement and cure rates. Behavioral therapy plus Chinese herbal medicine was the most effective intervention category for both improvement and cure rates.

CONCLUSION

Behavioral therapy plus Chinese herbal medicine was currently the optimal selection for the management of older women with urinary incontinence. However, the clinicians should carefully consider the effectiveness and quality of evidence because of the limited quality and quantity of the randomized controlled trials included.

Comparative Efficacy of Neuromodulation Technologies for Overactive Bladder in Adults: A Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to investigate the comparative efficacy of neuromodulation technologies for overactive bladder (OAB) syndrome in adults.

DATA SOURCES

A computerized search was conducted of Cochrane Library, EMBASE, MEDLINE (via PubMed), Web of Science, CNKI, Wan Fang Data, and ClinicalTrials.gov up to April 21, 2022.

STUDY SELECTION

The search selected clinical trials with random allocation to percutaneous tibial nerve stimulation (PTNS), transcutaneous tibial nerve stimulation (TTNS), vaginal electrical stimulation (VES), sacral neuromodulation (SNM), parasacral stimulation (PS), pudendal neuromodulation, or placebo.

DATA EXTRACTION

The main outcomes were the voiding diary, OAB-related quality of life, and positive response rate. The Cochrane Risk of Bias tool (RoB 2.0) was used to assess the risk of bias of each included study, and the Grading of Recommendations Assessment, Development, and Evaluation tool was used to evaluate the overall evidence quality of key outcomes.

DATA SYNTHESIS

The study included 21 randomized controlled trials involving 1433 participants, and all trials were used for the meta-analysis. In the network meta-analyses, five of six neuromodulation technologies, including PTNS, TTNS, VES, SNM, and PS, were related to higher efficacy than the placebo. Ranking probability showed that SNM was the most efficacious therapy for improving OAB-related quality of life, urinary episodes, and urinary frequency. For urgency incontinence episodes and the number of pads, PTNS and TTNS were the most efficacious modalities, respectively.

CONCLUSION

Neuromodulation technologies, including PTNS, TTNS, VES, SNM, and PS, may be effective and safe solutions for OAB syndrome in adults. Moreover, SNM is the most efficacious regimen for OAB-related quality of life, urinary episodes, and urinary frequency. PTNS and TTNS are the most efficacious modalities for reducing urgency incontinence episodes and the number of pads, respectively. Future studies should pay more attention to the quality of study design and report, patients who may benefit the most from neuromodulation, and the long-term effect, cost-effectiveness, and satisfaction of neuromodulation.

Screening and Treating Urinary Incontinence in Primary Care: A Missed Opportunity

More than 60% of adult women in the United States have urinary incontinence (UI), with the prevalence increasing to over 80% in women over age 65. Despite its high prevalence, most patients do not seek care and few clinicians screen for UI. The Medicare Health Outcomes Survey queries patients about satisfaction with their provider's discussion and management of UI, but formal recommendations about screening, diagnosis, and treatment are lacking. This review presents a practical algorithm for primary care providers to incorporate management of UI into routine preventive care for women, and outlines UI prevalence, risk factors, screening, and non-surgical treatment options.

Prognostic factors of urinary incontinence in women: A cohort study in a third-level hospital

INTRODUCTION

Urinary incontinence (UI) is the involuntary loss of urine. It is highly prevalent in women and has a great biopsychosocial impact. Rehabilitation is established as the first-line treatment, although its use has not been protocolized.

OBJECTIVE

To identify which personal risk factors and type of treatment applied are statistically related to patient improvement.

STUDY DESIGN

Retrospective cohort study.

METHODS

Retrospective cohort study of female patients diagnosed with urinary incontinence who attended the Pelvic Floor Rehabilitation Clinic of the Río Hortega University Hospital, receiving rehabilitation treatment during the year 2021. The minimum follow-up period was 12 weeks. The presence or absence of improvement was evaluated according to seven objective and subjective variables, and improvement was established as positive evolution in at least five of the seven variables.

RESULTS

A total of 114 women with urinary incontinence were analyzed. The most frequent types of incontinence were stress (53%) and mixed (36%). The most important risk factors and associated pathology were episiotomy (68%), repeated urinary tract infections (61%), and constipation (40.9%). None of these factors showed a statistically significant relationship with patient improvement. The most used rehabilitative treatment was kinesitherapy + biofeedback (51%) which showed a statistically significant relationship with the improvement of these patients (P = .037) together with biofeedback + posterior tibial nerve electrostimulation (PTNS) (P = .044).

CONCLUSION

Biofeedback combined with kinesitherapy or PTNS are established as the most effective rehabilitative procedures.

Mixed urinary incontinence: Are there effective treatments?

The aim of this debate article is to discuss whether effective treatments are available for mixed urinary incontinence (MUI). Because patients with MUI have both stress and urgency urinary incontinence (SUI and UUI) episodes and current treatment guidelines currently recommend treating the predominant symptom first, this article presents standard and emerging treatments for both SUI and UUI before discussing how well these treatments meet the medical needs of patients with MUI. Standard treatments presented include noninvasive options such as lifestyle changes and pelvic floor exercises, pharmacological agents, and surgery. Treatment of all three types of urinary incontinence (UI) is usually initiated with noninvasive options, after which treatment options diverge based on UI subtype. Multiple pharmacological agents have been developed for the treatment of UUI and overactive bladder, whereas surgery remains the standard option for SUI and stress-predominant MUI. The divide between UUI and SUI options seems to be propagated in emerging treatments, with most novel pharmacological agents still targeting UUI and even having SUI and stress-predominant MUI as exclusion criteria for participation in clinical trials. Considering that current treatment options focus almost exclusively on treating the predominant symptom of MUI and that emerging pharmacological treatments exclude patients with stress-predominant MUI during the development phase, effective treatments for MUI are lacking both in standard and emerging practice. Ideally, agents with dual mechanisms of action could provide symptom benefit for both the stress and urgency components of MUI.

Impact of Female Stress Urinary Incontinence on Quality of Life, Mental Health, Work Limitation, and Healthcare Seeking in China, Taiwan, and South Korea (LUTS Asia): Results from a Cross-Sectional, Population-Based Study

Background

Stress urinary incontinence (SUI) is common among adult women with negative effects on psychosocial well-being, mental health, and health-related quality of life. The purpose of the research is to determine if SUI in women is a factor implicated in changes in health-related quality of life (HRQoL) in both physical and mental health domains and in work difficulties.

Methods

Data of women 40 years or older from a cross-sectional, population-based, internet survey were examined post-hoc. The effect of SUI frequency on HRQoL (SF12 score), in physical and mental health domains, was assessed. In addition, multivariate and univariate analyses were used to show the influence of SUI on HADS (Hospital Anxiety and Depression Scale) depression score and HADS anxiety score. The effects of demographic factors and physical ailments and SUI on work difficulties were similarly analyzed using multivariate logistic regression.

Results

A total of 4208 women with mean age of 60 were included in the analysis. The more frequent SUI episodes were associated with a greater reduction of HRQoL in both physical and mental health domains. In addition, both multivariate and univariate analyses showed that SUI could be correlated with a negative effect on HADS anxiety score (OR 1.617, CI 1.335-1.958, p=0.000) and HADS depression score (OR 1.263, CI 1.044-1.527, p=0.016). Univariate analyses suggested that work difficulties were correlated with SUI. Available data revealed that many sufferers, including up to 40% of individuals with SUI frequency rating 1 (less than once a month) to 3 (a few times a week), failed to seek treatment.

Conclusion

SUI, common in women ≥40 years of age, impairs quality of life in both physical and mental health domains. SUI is an independent risk factor for anxiety and depression and has been linked to significant work dysfunctions.

Trial Registration

This study is registered at ClinicalTrials.gov: NCT02618421 (Date of registration: December 1, 2015).

Efficacy of frankincense‐based herbal product in urinary incontinence: A randomized, double‐blind, placebo‐ and active‐controlled clinical trial

Urinary incontinence is a silent epidemic that has a serious impact on a person's quality of life (QOL). This study aimed to evaluate the efficacy of frankincense-based herbal product (FHP) in urinary incontinence compared with placebo and solifenacin. In this randomized, double-blind clinical trial, 120 postmenopausal women with mixed urinary incontinence were randomized to one of the three groups of FHP, placebo, and standard treatment (solifenacin). Frequency, amount of leakage, and score of urinary incontinence as well as the QOL were measured at the end of the second and fourth weeks and 2 weeks after the interruption of the treatment. The ICIQ-UI SF and I-QOL questionnaires were used for the measurements. Mean frequency of urinary incontinence and amount of leakage significantly decreased in the FHP and solifenacin groups in the fourth week compared to the placebo group. In addition, 2 weeks after treatment completion, the effects of the FHP were significant compared to the solifenacin group. Due to the effect of FHP on improving the QOL and also the prolonged effect of this drug, the use of FHP in urinary incontinence, as a complementary treatment could be suggested.

Attitudes and barriers to pelvic floor muscle exercises of women with stress urinary incontinence

Background

Pelvic floor muscle exercise (PFME) is a first-line treatment for stress urinary incontinence (SUI), but adherence to PFME is often problematic. The aim of this study was to better understand the attitudes and barriers to practicing pelvic floor muscle exercise among women with SUI.

Methods

We conducted a qualitative study using semi-structured interviews. Purposive sampling was used to approach eligible participants. The interview included questions focused on women’s perceptions regarding SUI and PFME, sources of information, support, and barriers and motivators of PFME. In-depth interviews were conducted until data saturation occurred. After several readings of written interview transcripts, codes were retrieved, and thematic analysis was conducted.

Results

Seven women participated in the study (average age 53.2 years), and most (4/7) were retired. Three salient themes emerged from the data: (1) perception of SUI, (2) barriers to PFME, and (3) motivators to exercise. Participants highlighted various barriers to PFME: (1) lack of self-discipline owing to both intrinsic and extrinsic factors, (2) lack of confidence in how to perform the exercises properly, and (3) skepticism regarding the efficacy of treatment according to women’s direct and indirect experiences. Achievement of desired outcomes, symptom severity, women’s expectations, and fear of surgery were motivators to regularly perform PFME.

Conclusions

The main barriers to regular PFME were inadequate self-discipline, knowledge, and confidence in performing the exercises, and a poor perception about the effectiveness of PFME.

Urinary Incontinence and Sleep Quality in Older Women with Type 2 Diabetes: A Cross-Sectional Study

BACKGROUND

Urinary incontinence (UI) and poor sleep negatively affect health-related quality of life (HRQoL). This study explored the UI-related factors and the relationships between UI, sleep quality, and HRQoL.

METHODS

This cross-sectional study collected data from 237 women with type 2 diabetes. Multivariate logistic regression was conducted to identify the factors associated with UI. One-way analysis of variance was used to compare the mean sleep quality and HRQoL scores of women without UI and those who experienced UI of varying severities. Correlation coefficients were estimated, and multivariate linear regression was conducted to examine the relationships between UI severity, sleep quality, and HRQoL.

RESULTS

Of the 237 women, 115 (48.52%) experienced UI and 139 (58.65%) were poor sleepers. The three factors associated with UI were advanced age, a higher body mass index, and a history of vaginal delivery. Significant associations between UI severity and sleep quality and between sleep quality and HRQoL were revealed. UI severity and night-time voiding frequency were both associated with sleep quality.

CONCLUSIONS

One factor associated with UI (body mass index) is modifiable. UI severity is associated with sleep quality as the possible influence of night-time voiding frequency on sleep quality has been considered.

Treatment of refractory overactive bladder with OnabotulinumtoxinA vs PTNS: TROOP trial

INTRODUCTION AND HYPOTHESIS

We hypothesized that patients with refractory overactive bladder (rOAB) have similar improvement with percutaneous tibial nerve stimulation (PTNS) and OnabotulinumtoxinA (BTX).

METHODS

This multicenter cohort study compared BTX and PTNS in women with rOAB. Baseline information included Overactive Bladder Questionnaire (OABq) short form, Urinary Distress Inventory-6 (UDI-6), and voiding diary. Primary outcome was cure, defined as "very much better" or "much better" on the Patient Global Impression of Improvement (PGII) AND a reduction in OABq symptom severity scale (SSS) ≥10 at 3 months after treatment. Assuming 80% power to detect a ten-point difference in OABq-SSS, 80 participants were required per group.

RESULTS

A total of 150 patients were enrolled; 97 completed 3 months of therapy and were included. At baseline, BTX patients had more detrusor overactivity (70% vs 40%, p = 0.025), urgency incontinence (UUI; OABq-SSS#6 4 vs 3, p = 0.02, SSS 65 vs 56, p = 0.04), but similar health-related quality of life (HRQL 49 vs 54, p = 0.28), voids (7 vs 8, p = 0.13), and UUI episodes (2 vs 2, p = 1.0). At 3 months, cure rates were similar: BTX 50% vs PTNS 44.2% (p = 0.56). Both groups had improved SSS (-37 vs -29, p = 0.08) and HRQL (31 vs 24, p = 0.14). Patients receiving BTX had a greater improvement in urgency (ΔOABq-SSS#2-3 vs -2; p = 0.02) and UUI (ΔOABq-SSS#6-2 vs -1; p = 0.02). No characteristics were predictive of cure.

CONCLUSIONS

BTX resulted in significantly greater improvement in urgency and UUI than PTNS, but no difference in success based on PGII and OABq-SSS, which may be due to a lack of power.

Cognitive-behavioral therapy and urge urinary incontinence in women. A systematic review

INTRODUCTION AND HYPOTHESIS

UUI co-exists with numerous health conditions, having a substantial negative impact on health-related quality of life and mental health. Cognitive-behavioral therapy (CBT) could help patients manage these problems by changing the way they think and behave.

METHODS

We carried out a systematic review of the literature assessing the modalities and effects of CBT as a stand-alone strategy, without adding PFMT, on symptoms and clinical signs, in women with UUI. Our secondary objective was to report modalities and effects of CBT on health-related quality of life, psychological symptoms and patient-reported satisfaction. The PRISMA methodology was used to carry out this systematic review. A literature search was conducted in PubMed, PEDro, Web of Science and Cochrane Library databases from inception to December 2020. The PICO approach was used to determine the eligibility criteria.

RESULTS

Twelve papers were included in the present review which showed beneficial effects on both symptom severity (p < 0.05) and more subjective areas such as quality of life, psychological symptoms or patient satisfaction level (p < 0.05), respectively). However, results on the effectiveness of CBT on clinical signs remains conflicting.

CONCLUSION

Based on the available literature, this review suggested a high level of evidence for the effectiveness of CBT on symptom severity and a moderate level of evidence for the effectiveness of CBT on quality of life, psychological symptoms and patient satisfaction. However, we highlighted no evidence for the effects of CBT on clinical signs.

Relationship Between Blood Glucose and Hemoglobin A1c Levels and Urinary Incontinence in Women

Objective

The purpose of this study was to evaluate the associations between blood glucose and hemoglobin A1c (HbA1c) levels with the degree of stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) in women.

Methods

We conducted a cross-sectional study of female participants in the National Health and Nutrition Examination Survey (NHANES) database between 2007 and 2012. Univariate and multivariate logistic regressions were used to assess the relationship between blood glucose and HbA1c levels and the degree of SUI and UUI.

Results

A total of 3821 participants were enrolled in the study, of whom 2421 (63.4%) had no SUI, 1133 (29.7%) had monthly SUI, 267 (7.0%) had weekly SUI; 2883 (75.5%) had no UUI, 735 (19.2%) had monthly UUI, 203 (5.3%) had weekly UUI. The levels of blood glucose and HbA1c were positively correlated with SUI and UUI, and increased with increasing degree of UUI. Multivariate logistic regression showed that there was a positive association between blood HbA1c level and degree of SUI.

Conclusion

Our study found that blood glucose and HbA1c levels can be used as indicators of SUI and UUI severity in women.

Regenerated Cell Therapy for Stress Urinary Incontinence: A Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of regenerated cell therapy for stress urinary incontinence (UI) in humans.

METHODS

We searched articles from PubMed, Embase, and the Cochrane Library database published before February 24, 2020. Of 396 records identified, 23 articles on human clinical research met our criteria, including a total of 890 patients. Stata/SE12.0 software was used to analyze cure, efficiency (cure rate plus improvement rate), and complication rates.

RESULTS

No significant differences in cure rates and effective rates were observed for any cell type in males. However, in females, the myocytes with fibroblasts subgroup (82%) and nucleated cells with platelets subgroup (89%) exhibited significantly higher cure rates compared with the other two subgroups (25% and 36%). Pooled effective rates of myocytes and fibroblasts (92%) and nucleated cells with platelets (97%) were also higher compared with the other two subgroups (72% and 60%). Pooled complication rates were 23% and 26% in males and females, respectively, and there were some differences among subgroups. Although some studies reported postoperative complications, no serious complications were reported and most recovered within 1-2 weeks.

CONCLUSIONS

Limited studies have indicated the safety and effectiveness of regenerated cells for treating stress UI in the follow-up period, which may be an ideal method to treat stress UI in the future. Moreover, nucleated cells with platelets and myocytes with fibroblasts were markedly effective, but whether cell injection therapies elicit superior effects need further confirmation.

Research progress of single nucleotide polymorphism in stress urinary incontinence

Stress urinary incontinence (SUI), as one of the manifestations of pelvic floor dysfunction diseases with high incidence, seriously affects women's physical and mental health and quality of life. The etiology and pathogenesis of SUI are complex and not yet completely clear, now believed to be involved with environmental factors, genetic factors and cross-cutting factors between the two. SUI genetic susceptibility may be related to single nucleotide polymorphism. This article reviews the current studies on SUI-related single nucleotide polymorphisms.

Rapid and precise delivery of cells in the urethral sphincter complex by a novel needle-free waterjet technology

OBJECTIVES

To investigate the therapy of stress urinary incontinence in a preclinical setting cells were injected into the urethrae of minipigs; however, cells injected by William's needle were frequently misplaced or lost; thus, we investigated if needle-free cell injections using a novel waterjet technology facilitates precise injections in the urethral sphincter complex.

MATERIALS AND METHODS

Porcine adipose tissue-derived stromal cells (pADSCs) were isolated from boars, expanded, labelled, and injected in the sphincter of female pigs by waterjet employing two different protocols. After incubation for 15 min or 3 days, the urethrae of the pigs were examined. Injected cells were visualised by imaging and fluorescence microscopy of tissue sections. DNA of injected male cells was verified by polymerase chain reaction (PCR) of the sex-determining region (SRY) gene. Cell injections by William's needle served as controls.

RESULTS

The new waterjet technology delivered pADSCs faster and with better on-site precision than the needle injections. Bleeding during or after waterjet injection or other adverse effects, such as swelling or urinary retention, were not observed. Morphologically intact pADSCs were detected in the urethrae of all pigs treated by waterjet. SRY-PCR of chromosomal DNA and detection of recombinant green fluorescent protein verified the injection of viable cells. In contrast, three of four pigs injected by William's needle displayed no or misplaced cells.

CONCLUSION

Transurethral injection of viable pADSCs by waterjet is a simple, fast, precise, and yet gentle new technology. This is the first proof-of-principle concept study providing evidence that a waterjet injects intact cells exactly in the tissue targeted in a preclinical in vivo situation. To further explore the clinical potential of the waterjet technology longer follow-up, as well as incontinence models have to be studied.

Cognitive behavioral therapy for overactive bladder in women: study protocol for a randomized controlled trial

Background

Overactive bladder (OAB) symptoms affect daily life by decreasing health-related quality of life (HRQol). However, there remain no very effective treatment for OAB. Pharmacotherapy is one of the best treatments, but it is not always efficient and may incur adverse events. Although behavioral therapy is another effective treatment, there are very few structured treatment manuals on how to prescribe behavioral therapy to treat OAB for whom.

Cognitive behavioral therapy (CBT) is a psychotherapy consisting of structured sessions to solve problems with the collaborative empiricism between therapists and patients. OAB symptoms are supposed to worsen with cognitive distortion, and CBT is expected to be effective in treating OAB by modifying such cognitive processes. In this trial, we will evaluate the efficacy of CBT for OAB.

Methods

A randomized, controlled, open-label, multicenter parallel-group superiority trial will be conducted. Participants with moderate to severe OAB symptoms with or without pharmacotherapy will be recruited and will be randomly allocated 1:1 to two different groups by minimization (age, baseline OAB severity, treatment status, types of intervention, and treating institutions). The intervention group will be prescribed an individual CBT program covering six techniques in 4 sessions (30 min each), with or without pharmacotherapy. The primary outcome is the change scores in an OAB-questionnaire (OAB-q) from baseline to the end of the trial (week 13). Secondary outcomes will include other patient reported outcome measures and the frequency volume chart. All analyses will be conducted on an intention-to-treat principle.

Discussion

This trial will determine the efficacy of CBT to treat OAB using a rigorous methodology. The effectiveness of CBT with a structured manual may not only lead to a new treatment option for patients suffering from OAB symptoms, but may also reduce the social burden by OAB.

Trial registration

UMIN-CTR Clinical Trial, CTR-UMIN000038513. Registered on November 7, 2019.

Clinical feasibility and acceptability of adding cognitive behavioral therapy to pharmacotherapy for drug-resistant overactive bladder in women: A single-arm pilot study

OBJECTIVES

Drug-resistant overactive bladder (OAB) represents an unmet medical need in that treatment options are limited. We developed a treatment model based on cognitive behavioral therapy and evaluated its feasibility and acceptability for drug-resistant OAB in women.

METHODS

This was an open-label, single-arm, multicenter pilot study. We defined drug-resistant OAB as OAB with moderate to severe symptoms despite pharmacotherapy for more than 12 weeks. A face-to-face intervention was prescribed as six sessions (30 minutes each) over 6 to 12 weeks according to a treatment manual. The effects were assessed by self-reported questionnaires and frequency voiding charts (FVC) at baseline, during intervention, immediately after intervention, and at follow-up.

RESULTS

Ten patients participated in this study. Median age was 72 years, median OAB Symptom Score was nine points, and median duration of prior treatment for OAB was 5.5 years at baseline. Two participants dropped out of the study. Among the remaining patients, the scores of the OAB Questionnaire subscales improved (effect size: 0.75-1.73), and the mean urinary frequency in the FVC also improved from baseline (9.0 times, SD: 2.1) to follow-up (6.2 times, SD: 1.2). All participants were satisfied with the intervention. There were no adverse events during this study.

CONCLUSIONS

The new treatment based on cognitive behavioral therapy was well tolerated and feasible in women with drug-resistant OAB. Further randomized research is needed to rigorously evaluate the efficacy of the treatment.

[How did COVID-19 pandemic change the way we attend the patients in an urogynaecological unit]

La actual pandemia ocasionada por el SARS-coronavirus tipo 2 ha generado, en pocas semanas, cambios importantes en el funcionamiento del sistema sanitario y la forma en cómo se realiza la atención a las pacientes. La patología uroginecológica afecta a la calidad de vida, pero sin riesgo vital en la mayoría de casos, por lo que suele ser demorable. Además, afecta a un alto porcentaje de mujeres > 65 años (población de riesgo ante la infección por COVID-19). En este manuscrito se resume la evidencia que existe sobre la efectividad de la telemedicina aplicada en las disfunciones de suelo pélvico, así como recomendaciones de las sociedades científicas uroginecológicas durante el estado de alarma. Describimos el abordaje de las disfunciones de suelo pélvico durante la pandemia por COVID-19 y una propuesta de cómo organizar las agendas para el diagnóstico (visitas y pruebas diagnósticas) y tratamiento (conservador, farmacológico y la cirugía) en el período interpandemia y en el futuro.

Comparative efficacy and acceptability of pharmacological interventions for the treatment and prevention of delirium: A systematic review and network meta-analysis

We performed a network meta-analysis to build clear hierarchies of efficacy and tolerability of pharmacological interventions for the treatment and prevention of delirium. Electronic databases including PubMed, Google Scholar, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and MEDLINE were searched published up to February 22, 2019. A total of 108 randomized controlled trials (RCTs) investigating pharmacotherapy on delirium were included for analysis, and the strength of evidence (SoE) was evaluated for critical outcomes. In terms of treatment, quetiapine (low SoE), morphine (low SoE), and dexmedetomidine (moderate SoE) were effective in the intensive care unit (ICU) patients. In terms of prevention, dexmedetomidine (high SoE) and risperidone (high SoE) significantly reduced the incidence of delirium in ICU surgical patients, while ramelteon (high SoE) reduced the incidence of delirium in ICU medical patients. Despite the efficacy, dexmedetomidine and risperidone demonstrated higher drop-out rate (moderate to high SoE). Haloperidol and other antipsychotics, except for quetiapine and risperidone, showed no benefit. None of the agents showed benefit in non-ICU patients. In conclusion, dexmedetomidine may be a drug of choice for both treating and preventing delirium of the ICU and postsurgical patients. However, it may be less tolerable, and side-effects should be adequately managed. Current evidence does not support the routine use of antipsychotics. For medical patients, oral ramelteon might be useful for prevention.

Continence: Bowel and Bladder and Physical Function Decline in Women

Purpose of review

The purpose of this article is to review the various forms of incontinence, highlight their impact on older women, and to explore current literature regarding the link between physical activity, physical function, and incontinence.

Recent findings

Both urinary and fecal incontinence become more prevalent with age, and are associated with significant morbidity. In parallel, there is a well-established decline in physical function that occurs with age. Furthermore, incontinence has a bidirectional relationship with physical function decline. Given the known link between increasing physical activity and preserved physical function, there is an emerging body of literature seeking to determine whether increases in physical activity may also improve incontinence outcomes. We review some recent data on this topic.

Summary

Continence and physical function are two closely linked entities. Further research is needed to determine whether interventions that increase physical activity might result in improved continence outcomes.

A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence

Introduction and hypothesis

The COVID-19 pandemic and the desire to “flatten the curve” of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic.

Methods

We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19.

Results

Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission.

Conclusions

We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.

An evidence-based self-management package for urinary incontinence in older women: a mixed methods feasibility study

Background

Urinary incontinence (UI) is a distressing condition that limits women’s quality of life and places a heavy burden on health care services. Behavioural treatments are recommended as a first-line treatment. An evidence-based self-management package was developed following the Medical Research Council (MRC) framework for complex interventions. This study aimed to evaluate the feasibility and acceptability of the intervention.

Methods

A mixed-methods approach was undertaken, namely a randomised controlled feasibility study with nested qualitative study. Fifty women aged 55 or over living with UI, recruited from community centres were randomly assigned to either a 3-month course with the package with a support session or a control group to receive the same package only 3 months later. Principal outcome measures were: self-reported quality of life, UI severity, self-efficacy and psychological status. Analysis of covariance was undertaken to estimate within- and between- group changes for all outcomes. Acceptability was explored using individual interviews at follow-up.

Results

Fifty women were randomised (24 to intervention, 26 to control); mean age of 69.7 (±9.1) years and mean UI frequency 2.2 (±2.2) episodes/day at baseline. Overall, 49 women (98%) completed 3-month follow-up (24 in the intervention, 25 in the control). A positive trend was detected in the impact of UI on their personal relationships (− 3.89, p = 0.088), symptom severity (− 1.77, p = 0.025), UI symptoms scale (− 1.87, p = 0.031) and anxiety status (− 2.31, p = 0.001), respectively. Changes in quality of life and self-efficacy did not differ significantly between groups. Majority of women (71%) in the intervention group reported subjective improvement after 3 months. Spearman correlation coefficient was 0.43 (p < 0.05) between their subjective perception of change and self-efficacy. Women perceived the package being acceptable and described that the package had the potential to increase their knowledge and confidence to manage symptoms and improve quality of life.

Conclusions

The study demonstrated that the self-management package is feasible and acceptable for older women with UI. Further studies are needed with a large sample size in clinical settings to evaluate the effectiveness of this package.

Trial registration

ISRCTN17194896. Registered on 11th September 2019 (retrospectively registered).

Current Resources for Evidence-Based Practice, May 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of a new National Academy of Medicine report on planned place of birth and implications during the SARS-CoV-2 pandemic and commentaries on reviews focused on anorectal sexually transmitted infections and feeding methods following cleft lip repair in infants.

Adverse Events Associated with Nonsurgical Treatments for Urinary Incontinence in Women: a Systematic Review

BACKGROUND

Urinary incontinence (UI) is a common malady in women. Numerous nonsurgical treatments are available, each associated with risk of adverse events (AEs).

METHODS

We systematically reviewed nonsurgical interventions for urgency, stress, or mixed UI in women, focusing on AEs. We searched MEDLINE®, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and Embase® through December 4, 2017. We included comparative studies and single-group studies with at least 50 women. Abstracts were screened independently in duplicate. One researcher extracted study characteristics and results with verification by another independent researcher. When at least four studies of a given intervention reported the same AE, we conducted random effects model meta-analyses of proportions. We also assessed the strength of evidence.

RESULTS

There is low strength of evidence that AEs are rare with behavioral therapies and neuromodulation, and that periurethral bulking agents may result in erosion and increase the risk of voiding dysfunction. High strength of evidence finds that anticholinergics and alpha agonists are associated with high rates of dry mouth and constitutional effects such as fatigue and gastrointestinal complaints. Onabotulinum toxin A (BTX) is also associated with increased risk of urinary tract infections (UTIs) and voiding dysfunction (moderate strength of evidence).

DISCUSSION

Behavioral therapies and neuromodulation have low risk of AEs. Anticholinergics and alpha agonists have high rates of dry mouth and constitutional effects. BTX is associated with UTIs and voiding dysfunction. Periurethral bulking agents are associated with erosion and voiding dysfunction. These AEs should be considered when selecting appropriate UI treatment options. AE reporting is inconsistent and AE rates across studies tended to vary widely. Trials should report AEs more consistently.