Consensus statement on bladder training and bowel training

Can we increase the value of data from bladder diaries? International Consultation on Incontinence-Research Society 2023

BACKGROUND

Bladder diaries represent a fundamental component in the assessment of patients presenting with lower urinary tract symptoms. Nevertheless, their importance often remains underappreciated and undervalued within clinical practice. This paper aims to conduct a comprehensive review of the existing literature concerning the utility of bladder diaries, underscore the criticality of their precision, elucidate the factors contributing to noncompliance with bladder diary completion, and investigate potential strategies for enhancing patient compliance.

MATERIALS AND METHODS

A review of the English-language scientific literature available in the domains of Medline, Embase, Emcare, Midirs, and Cinahl was conducted. This was supplemented by discussion at the International Consultation on Incontinence Research Society Proposal session to define knowledge and identify gaps in knowledge surrounding the utility of bladder diaries. The existing evidence and outcome of the relevant discussion held in the meeting are presented.

RESULTS

Bladder diaries (BD) serve to characterize the nature and severity of storage lower urinary tract symptoms (LUTS) and provide an objective record of an individual's urination patterns. They aid in the refinement and customization of treatment strategies based on the clinical responses documented in the diary, optimizing treatment outcomes. Notably, both BD and urodynamic studies (UDS) play complementary yet distinct roles in LUTS evaluation. BD offers a more comprehensive and accessible approach to assessing specific storage LUTS, particularly due to their affordability and widespread availability, especially in resource-limited settings. Nevertheless, the absence of a standardized BD format across global healthcare systems presents a significant challenge. Despite being recognized as reliable, noninvasive, validated, and cost-effective tools for evaluating patients with LUTS, the implementation and completion of BD have proven to be complex. The introduction of automated bladder diaries heralds an era of precise, real-time data collection, potentially enhancing the patient-clinician relationship. Completion of bladder diaries depends on an array of individual, social, and healthcare-specific factors. Compliance with bladder diary completion could be enhanced with clear instructions, patient education, regular follow-ups and positive re-enforcement. This study has identified four critical areas for future research: Addressing healthcare disparities between affluent and developing nations, enhancing the current functionality and effectiveness of bladder diaries, exploring the feasibility of incorporating bladder diaries into the treatment and education process and improving the quality and functionality of existing bladder diaries.

CONCLUSION

Bladder diaries play a pivotal role in the evaluation and management of patients with LUTS, providing a holistic perspective. When their complete potential is harnessed, they have the capacity to revolutionize the paradigm of LUTS management, ushering in a patient-centered era of care.

Methodologies Used in Studies of Self-Management Interventions for Urinary Incontinence in Adult Women: An Integrative Review

BACKGROUND

Urinary incontinence (UI) affects approximately 60% of women in the United States and negatively impacts self-esteem, sexual function, participation in social activities, and quality of life (QOL). Self-management interventions show promise for improving UI symptoms and QOL. Previous reviews of UI self-management studies have focused on outcomes for older women. However, the literature lacks a synthesis of methodologies of these studies.

PURPOSE

The purpose of this integrative review was to synthesize and evaluate methodologies used in studies of self-management interventions for UI in adult women.

METHODS

Using an integrative review approach, a search of PubMed, CINAHL, and Embase was conducted yielding 1404 results, 23 of which met inclusion criteria. Data abstracted from each article included author(s), year of publication, study design and purpose, sample, country and setting, measures of UI symptoms, and intervention description.

RESULTS

Findings showed methodological differences, particularly in design, assessment of UI subtypes, measures of UI symptoms, and intervention components. Multicomponent self-management interventions were used in 18 studies and 1 component used in 5 studies. Education, pelvic floor muscle exercises, and bladder training were the intervention components most frequently used, either alone or in combination; however, intervention components were not consistently aligned with the UI subtypes. Analysis of ethical matters revealed areas for improvement, specifically in reporting privacy and confidentiality and in methods to obtain informed consent.

CONCLUSIONS

Results highlight opportunities to improve the rigor of methodologies used in studies of self-management interventions for UI in adult women.

Systematic voiding programme in adults with urinary incontinence following acute stroke: the ICONS-II RCT

BACKGROUND

Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively.

OBJECTIVE

The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital.

DESIGN

This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot.

SETTING

Eighteen NHS stroke services with stroke units took part.

PARTICIPANTS

Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment.

INTERVENTION

Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit.

MAIN OUTCOME MEASURES

The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained blinded until clinical effectiveness analysis was complete.

RESULTS

The planned sample size was 1024 participants, with 512 allocated to each of the intervention and the usual-care groups. The internal pilot did not meet the target for recruitment and was extended to March 2020, with changes made to address low recruitment. The trial was paused in March 2020 because of COVID-19, and was later stopped, at which point 157 participants had been randomised (intervention, n = 79; usual care, n = 78). There were major issues with attrition, with 45% of the primary outcome data missing: 56% of the intervention group data and 35% of the usual-care group data. In terms of the primary outcome, patients allocated to the intervention group had a lower score for severity of urinary incontinence (higher scores indicate greater severity in urinary incontinence) than those allocated to the usual-care group, with means (standard deviations) of 8.1 (7.4) and 9.1 (7.8), respectively.

LIMITATIONS

The trial was unable to recruit sufficient participants and had very high attrition, which resulted in seriously underpowered results.

CONCLUSIONS

The internal pilot did not meet its target for recruitment and, despite recruitment subsequently being more promising, it was concluded that the trial was not feasible owing to the combined problems of poor recruitment, poor retention and COVID-19. The intervention group had a slightly lower score for severity of urinary incontinence at 3 months post randomisation, but this result should be interpreted with caution.

FUTURE WORK

Further studies to assess the effectiveness of an intervention starting in or continuing into the community are required.

TRIAL REGISTRATION

This trial is registered as ISRCTN14005026.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 31. See the NIHR Journals Library website for further project information.

App-based self-management of urgency and mixed urinary incontinence in women: One-year follow-up

Aims

To evaluate the long‐term effect of the Tät®II app for treatment of urgency (UUI) and mixed urinary incontinence (MUI).

Methods

Long‐term follow‐up of a randomized controlled trial, including 123 women ≥18 years old with UUI or MUI, without red‐flag symptoms, and ≥2 leakages per week. All participants, regardless of group, had received the intervention, a treatment app, at the long‐term follow‐up. Long‐term data were collected through web‐based questionnaires 15 months after participants received the intervention. The app included pelvic floor muscle training, bladder training, psychoeducation, lifestyle advice, an exercise log, reminders, reinforcement messages, and tailored advice. The primary outcome was a change in incontinence symptoms (International Consultation on Incontinence Questionnaire [ICIQ]—Urinary Incontinence Short Form [ICIQ‐UI SF]), from baseline to follow‐up. Other outcomes were urgency symptoms (ICIQ—Overactive Bladder Module (ICIQ‐OAB)), quality of life (ICIQ—Lower Urinary Tract Symptoms Quality of Life Module [ICIQ‐LUTSqol]), and improvement (Patient's Global Impression of Improvement [PGI‐I]).

Results

Of the 123 women, 102 (83%) completed the long‐term follow‐up. The ICIQ‐UI SF mean score improved from 11.5 to 7.6 (mean difference 4.0, 95% CI 3.2–4.7). The ICIQ‐OAB improved from 6.7 to 5.5 (mean difference 1.3, 95% CI 0.9–1.6) and the ICIQ‐LUTSqol improved from 38.0 to 30.9 (mean difference 7.1, 95% CI 5.7–8.5). Of the 102 women, 74 (73%) reported improvement.

Conclusions

Self‐management with the Tät®II app for UUI and MUI had a significant effect across all outcome measures also long‐term and might serve as an alternative first‐line treatment for these conditions.

Anorectal dysfunction in multiple sclerosis patients: A pilot study on the effect of an individualized rehabilitation approach

BACKGROUND:

Anorectal dysfunction (ARD), especially bowel incontinence, frequently compromises the quality of life in multiple sclerosis (MS) patients. The effect of rehabilitation procedures has not been clearly established.

OBJECTIVE:

To determine the effect of an individualized rehabilitation approach on bowel incontinence and anorectal pressures.

METHODS:

MS patients with ARD underwent 6-months of individually targeted biofeedback rehabilitation. High resolution anorectal manometry (HRAM) and St. Mark’s Fecal Incontinence Scores (SMIS) were completed prior to rehabilitation, after 10 weeks of supervised physiotherapy, and after 3 months of self-treatment.

RESULTS:

Ten patients (50%) completed the study. Repeated measures analysis of variance (ANOVA) demonstrated significant improvement in the SMIS questionnaire over time [14.00 baseline vs. 9.70 after supervised physiotherapy vs. 9.30 after self-treatment (p = 0.005)]. No significant improvements over time were noted in any HRAM readings: maximal pressure [49.85 mmHg baseline vs. 57.60 after supervised physiotherapy vs. 60.88 after self-treatment (p = 0.58)], pressure endurance [36.41 vs. 46.89 vs. 49.95 (p = 0.53)], resting pressure [55.83, vs 52.69 vs. 51.84 (p = 0.704)], or area under the curve [230.0 vs. 520.8 vs. 501.9 (p = 0.16)].

CONCLUSIONS:

The proposed individualized rehabilitation program supports a positive overall effect on anorectal dysfunction in MS patients.

Cognitive components of behavioral therapy for overactive bladder: a systematic review

INTRODUCTION AND HYPOTHESIS

Behavioral therapy is the first-line treatment for overactive bladder (OAB); however, the cognitive components of behavioral therapy for OAB have not been evaluated. The purposes of this systematic review were to describe the cognitive components of behavioral therapy for OAB and evaluate their effectiveness as well as to describe their rationale and origins.

METHODS

Searches were conducted on the PubMed, CINAHL, Web of Science, Cochrane and PEDro databases. Inclusion criteria were single-arm or randomized controlled trials on OAB treatment that utilized behavioral therapy, with a description of a cognitive component of the behavioral therapy. Study participants were neurologically intact adults (n = 1169). Study methodological quality was assessed with the PEDro and Newcastle-Ottawa scales.

RESULTS

Five studies were included, published between 2009 and 2020. Methodological quality was variable. All studies reported a reduction of symptoms in participants receiving behavioral therapy. Cognitive components of behavioral therapy were not extensively described. Distraction was the most common cognitive strategy for managing urgency. The relative impact of the cognitive aspect of behavioral therapy could not be evaluated, and the cognitive aspects of behavioral therapy appear to be accepted wisdom, traceable to several key authors, that has not been subjected to scientific investigation.

CONCLUSIONS

Behavioral therapy for OAB appears useful, but its cognitive components are not well described, their relative importance has not been evaluated or ascertained, nor have they been rigorously studied.