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Reid FM, Aucott L, Glazener CMA, Elders A, Hemming C, Cooper KG, Freeman RM, Smith ARB, Hagen S, Kilonzo M, Boyers D, MacLennan G, Norrie J, Breeman S. PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse. Int Urogynecol J 2023; 34:67-78. [PMID: 36018353 PMCID: PMC9834125 DOI: 10.1007/s00192-022-05308-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/24/2022] [Indexed: 01/16/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Our aim was to compare the mid-term results of native tissue, biological xenograft and polypropylene mesh surgery for women with vaginal wall prolapse. METHODS A total of 1348 women undergoing primary transvaginal repair of an anterior and/or posterior prolapse were recruited between January 2010 and August 2013 from 35 UK centres. They were randomised by remote allocation to native tissue surgery, biological xenograft or polypropylene mesh. We performed both 4- and 6-year follow-up using validated patient-reported outcome measures. RESULTS At 4 and 6 years post-operation, there was no clinically important difference in Pelvic Organ Prolapse Symptom Score for any of the treatments. Using a strict composite outcome to assess functional cure at 6 years, we found no difference in cure among the three types of surgery. Half the women were cured at 6 years but only 10.3 to 12% of women had undergone further surgery for prolapse. However, 8.4% of women in the mesh group had undergone further surgery for mesh complications. There was no difference in the incidence of chronic pain or dyspareunia between groups. CONCLUSIONS At the mid-term outcome of 6 years, there is no benefit from augmenting primary prolapse repairs with polypropylene mesh inlays or biological xenografts. There was no evidence that polypropylene mesh inlays caused greater pain or dyspareunia than native tissue repairs.
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Affiliation(s)
- Fiona M Reid
- Warrell Unit, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road Campus, Manchester, M13 0JH, UK.
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Andrew Elders
- NMAHP Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Christine Hemming
- Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Kevin G Cooper
- Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Robert M Freeman
- Department of Obstetrics and Gynaecology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Anthony R B Smith
- Warrell Unit, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road Campus, Manchester, M13 0JH, UK
| | - Suzanne Hagen
- NMAHP Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher institute, University of Edinburgh, Edinburgh, UK
| | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Lewis AL, Young GJ, Abrams P, Blair PS, Chapple C, Glazener CMA, Horwood J, McGrath JS, Noble S, Taylor GT, Ito H, Belal M, Davies MC, Dickinson AJ, Foley CL, Foley S, Fulford S, Gammal MM, Garthwaite M, Harris MRE, Ilie PC, Jones R, Sabbagh S, Mason RG, McLarty E, Mishra V, Mom J, Morley R, Natale S, Nitkunan T, Page T, Payne D, Rashid TG, Saeb-Parsy K, Sandhu SS, Simoes A, Singh G, Sullivan M, Tempest HV, Viswanath S, Walker RMH, Lane JA, Drake MJ. Clinical and Patient-reported Outcome Measures in Men Referred for Consideration of Surgery to Treat Lower Urinary Tract Symptoms: Baseline Results and Diagnostic Findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). Eur Urol Focus 2019; 5:340-350. [PMID: 31047905 DOI: 10.1016/j.euf.2019.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/10/2019] [Accepted: 04/10/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical evaluation of male lower urinary tract symptoms (MLUTS) in secondary care uses a range of assessments. It is unknown how MLUTS evaluation influences outcome of therapy recommendations and choice, notably urodynamics (UDS; filling cystometry and pressure flow studies). OBJECTIVE To report participants' sociodemographic and clinical characteristics, and initial diagnostic findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). UPSTREAM is a randomised controlled trial evaluating whether symptoms are noninferior and surgery rates are lower if UDS is included. DESIGN, SETTING, AND PARTICIPANTS A total of 820 men (≥18 yr of age) seeking treatment for bothersome LUTS were recruited from 26 National Health Service hospital urology departments. INTERVENTION Care pathway based on routine, noninvasive tests (control) or routine care plus UDS (intervention arm). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome is International Prostate Symptom Score (IPSS) and the key secondary outcome is surgery rates 18 mo after randomisation. International Consultation on Incontinence Questionnaires were captured for MLUTS, sexual function, and UDS satisfaction. Baseline clinical and patient-reported outcome measures (PROMs), and UDS findings were informally compared between arms. Trends across age groups for urinary and sexual PROMs were evaluated with a Cuzick's test, and questionnaire items were compared using Pearson's correlation coefficient. RESULTS AND LIMITATIONS Storage LUTS, notably nocturia, and impaired sexual function are prominent in men being assessed for surgery. Sociodemographic and clinical evaluations were similar between arms. Overall mean IPSS and quality of life scores were 18.94 and 4.13, respectively. Trends were found across age groups, with older men suffering from higher rates of incontinence, nocturia, and erectile dysfunction, and younger men suffering from increased daytime frequency and voiding symptoms. Men undergoing UDS testing expressed high satisfaction with the procedure. CONCLUSIONS Men being considered for surgery have additional clinical features that may affect treatment decision making and outcomes, notably storage LUTS and impaired sexual function. PATIENT SUMMARY We describe initial assessment findings from a large clinical study of the treatment pathway for men suffering with bothersome urinary symptoms who were referred to hospital for further treatment, potentially including surgery. We report the patient characteristics and diagnostic test results, including symptom questionnaires, bladder diaries, flow rate tests, and urodynamics.
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Affiliation(s)
- Amanda L Lewis
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, Canynge Hall, University of Bristol, Bristol, UK; Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, UK
| | - Grace J Young
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, Canynge Hall, University of Bristol, Bristol, UK; Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, Level 3, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Peter S Blair
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, Canynge Hall, University of Bristol, Bristol, UK; Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, UK
| | - Christopher Chapple
- Sheffield Teaching Hospitals NHS Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Cathryn M A Glazener
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, Scotland, UK
| | - Jeremy Horwood
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, Canynge Hall, University of Bristol, Bristol, UK; Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, UK
| | - John S McGrath
- University of Exeter Medical School, St. Luke's Campus, Exeter, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Hiroki Ito
- Bristol Urological Institute, Level 3, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Mohammed Belal
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, UK
| | - Melissa C Davies
- Salisbury NHS Foundation Trust, Salisbury District Hospital, Salisbury, Wiltshire, UK
| | | | - Charlotte L Foley
- East and North Hertfordshire NHS Trust, Urology Department, Ashwell Block, Lister Hospital, Stevenage, Hertfordshire, UK
| | - Steve Foley
- Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, Reading, Berkshire, UK
| | - Simon Fulford
- South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Mohsen M Gammal
- Southport and Ormskirk Hospital NHS Trust, Southport, Merseyside, UK
| | - Mary Garthwaite
- South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Mark R E Harris
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Petre C Ilie
- The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Robert Jones
- Urology Department, Taunton and Somerset NHS Foundation Trust, Musgrove Park Hospital, Taunton, Somerset, UK
| | - Samer Sabbagh
- St George's University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Robert G Mason
- Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, UK
| | - Ester McLarty
- Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth, UK
| | - Vibhash Mishra
- Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Jaswant Mom
- North Cumbria University Hospitals NHS Trust, West Cumberland Hospital, Hensingham, Whitehaven, Cumbria, UK
| | - Roland Morley
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | | | - Tharani Nitkunan
- Epsom and St Helier University Hospitals NHS Trust, Carshalton, Surrey, UK
| | - Tobias Page
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, High Heaton, Newcastle Upon Tyne, UK
| | - David Payne
- Kettering General Hospital NHS Foundation Trust, Kettering, Northants, UK
| | - Tina G Rashid
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Kasra Saeb-Parsy
- Urology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Adrian Simoes
- East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Canterbury, Kent, UK
| | - Gurpreet Singh
- Southport and Ormskirk Hospital NHS Trust, Southport, Merseyside, UK
| | - Mark Sullivan
- Nuffield Department of Surgical Sciences, Oxford University, Headington, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford, UK
| | - Heidi V Tempest
- Nuffield Department of Surgical Sciences, Oxford University, Headington, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford, UK
| | - Srinivasa Viswanath
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Roger M H Walker
- Epsom and St Helier University Hospitals NHS Trust, Carshalton, Surrey, UK
| | - J Athene Lane
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, Canynge Hall, University of Bristol, Bristol, UK; Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, UK
| | - Marcus J Drake
- Bristol Urological Institute, Level 3, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Bristol, UK.
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Morling JR, McAllister DA, Agur W, Fischbacher CM, Glazener CMA, Guerrero K, Hopkins L, Wood R. Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997-2016: a population-based cohort study. Lancet 2017; 389:629-640. [PMID: 28010993 DOI: 10.1016/s0140-6736(16)32572-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/29/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Concerns have been raised about the safety of surgery for stress urinary incontinence and pelvic organ prolapse using transvaginal mesh. We assessed adverse outcomes after first, single mesh procedures and comparable non-mesh procedures. METHODS We did a cohort study of women in Scotland aged 20 years or older undergoing a first, single incontinence procedure or prolapse procedure during 1997-98 to 2015-16 identified from a national hospital admission database. Primary outcomes were immediate postoperative complications and subsequent (within 5 years) readmissions for later postoperative complications, further incontinence surgery, or further prolapse surgery. Poisson regression models were used to compare outcomes after procedures carried out with and without mesh. FINDINGS Between April 1, 1997, and March 31, 2016, 16 660 women underwent a first, single incontinence procedure, 13 133 (79%) of which used mesh. Compared with non-mesh open surgery (colposuspension), mesh procedures had a lower risk of immediate complications (adjusted relative risk [aRR] 0·44 [95% CI 0·36-0·55]) and subsequent prolapse surgery (adjusted incidence rate ratio [aIRR] 0·30 [0·24-0·39]), and a similar risk of further incontinence surgery (0·90 [0·73-1·11]) and later complications (1·12 [0·98-1·27]); all ratios are for retropubic mesh. During the same time period, 18 986 women underwent a first, single prolapse procedure, 1279 (7%) of which used mesh. Compared with non-mesh repair, mesh repair of anterior compartment prolapse was associated with a similar risk of immediate complications (aRR 0·93 [95% CI 0·49-1·79]); an increased risk of further incontinence (aIRR 3·20 [2·06-4·96]) and prolapse surgery (1·69 [1·29-2·20]); and a substantially increased risk of later complications (3·15 [2·46-4·04]). Compared with non-mesh repair, mesh repair of posterior compartment prolapse was associated with a similarly increased risk of repeat prolapse surgery and later complications. No difference in any outcome was observed between vaginal and, separately, abdominal mesh repair of vaginal vault prolapse compared with vaginal non-mesh repair. INTERPRETATION Our results support the use of mesh procedures for incontinence, although further research on longer term outcomes would be beneficial. Mesh procedures for anterior and posterior compartment prolapse cannot be recommended for primary prolapse repair. Both vaginal and abdominal mesh procedures for vaginal vault prolapse repair are associated with similar effectiveness and complication rates to non-mesh vaginal repair. These results therefore do not clearly favour any particular vault repair procedure. FUNDING None.
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Affiliation(s)
- Joanne R Morling
- Information Services Division, National Health Service National Services Scotland, Edinburgh, UK; Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - David A McAllister
- Information Services Division, National Health Service National Services Scotland, Edinburgh, UK; Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Wael Agur
- Obstetrics and Gynaecology Unit, Ayrshire Maternity Unit, University Hospital Crosshouse, Kilmarnock, UK
| | - Colin M Fischbacher
- Information Services Division, National Health Service National Services Scotland, Edinburgh, UK
| | | | - Karen Guerrero
- Department of Urogynaecology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Leanne Hopkins
- Information Services Division, National Health Service National Services Scotland, Edinburgh, UK
| | - Rachael Wood
- Information Services Division, National Health Service National Services Scotland, Edinburgh, UK.
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Abstract
BACKGROUND Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of these have moderate or severe symptoms. OBJECTIVES To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 12 November 2014), and the reference lists of relevant articles. SELECTION CRITERIA Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence. DATA COLLECTION AND ANALYSIS At least two authors assessed trials and extracted data independently. Two trial investigators provided additional information. MAIN RESULTS We identified 10 trials, which included 375 women having six different types of needle suspension procedures and 489 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension. There was a higher subjective failure rate after the first year (91/313 (29%) failed versus 47/297 (16%) failed after open abdominal retropubic suspension). The risk ratio (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72), although the difference in peri-operative complications was not significant (17/75 (23%) versus 12/77 (16%); RR 1.44, 95% CI 0.73 to 2.83). There were no significant differences for the other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (50/156 (32%) failed after needle suspension versus 64/181 (35%) after anterior repair; RR 0.86, 95% CI 0.64 to 1.16), but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population.No trials compared needle suspensions with conservative management, peri-urethral injections, or sham or laparoscopic surgery. AUTHORS' CONCLUSIONS Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.
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Affiliation(s)
- Cathryn M A Glazener
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen Medical School, Foresterhill, Aberdeen, AB25 2ZD, UK
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Glazener CMA, MacArthur C, Hagen S, Elders A, Lancashire R, Herbison GP, Wilson PD. Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial. BJOG 2014; 121:112-20. [PMID: 24148807 DOI: 10.1111/1471-0528.12473] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the long-term (12-year) effects of a conservative nurse-led intervention for postnatal urinary incontinence. DESIGN Follow-up of a randomised controlled trial. SETTING Community-based intervention in three centres (in the UK and New Zealand). POPULATION A cohort of 747 women with urinary incontinence at 3 months after childbirth, of whom 471 (63%) were followed up after 12 years. METHODS Women were randomly allocated to active conservative treatment after delivery (pelvic floor muscle training and bladder training), or to a control group receiving standard care. MAIN OUTCOME MEASURES Prevalence of urinary incontinence (primary outcome) and faecal incontinence, symptoms and signs of prolapse, and performance of pelvic floor muscle training at 12 years. RESULTS The significant improvements relative to controls that had been found in urinary incontinence (60 versus 69%; risk difference, RD, -9.1%; 95% confidence interval, 95% CI, -17.3 to -1.0%) and faecal incontinence (4 versus 11%; RD -6.1%; 95% CI -10.8 to -1.6%) at 1 year did not persist for urinary incontinence (83 versus 80%; RD 2.1%; 95% CI -4.9 to 9.1%) or faecal incontinence (19 versus 15%; RD 4.3%; 95% CI -2.5 to 11.0%) at the 12-year follow up, irrespective of incontinence severity at trial entry. The prevalence of prolapse symptoms or objectively measured pelvic organ prolapse also did not differ between the groups. In the short term the intervention motivated more women to perform pelvic floor muscle training (83 versus 55%), but this fell in both groups by 12 years (52 versus 49%). CONCLUSIONS The moderate short-term benefits of a brief nurse-led conservative treatment for postnatal urinary incontinence did not persist. About four-fifths of women with urinary incontinence 3 months after childbirth still had this problem 12 years later.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen School of Medicine and Dentistry, Aberdeen, UK
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Abstract
BACKGROUND Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive objective diagnosis. The aim is to help to select the treatment most likely to be successful. The investigations are invasive and time consuming. OBJECTIVES The objective of this review was to discover if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of urinary incontinence and better clinical outcomes. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings (searched 24 May 2011), and the reference lists of relevant articles. SELECTION CRITERIA Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamics against another. Trials were excluded if they did not report clinical outcomes. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS Seven small trials involving around 400 people were included but data were only available for 385 women in five trials, of whom 197 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was some evidence that the tests did change clinical decision making. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31) but not, in three trials, surgery (RR 1.75, 95% CI 0.39 to 7.75). Women in the urodynamic arms of two trials were more likely to have their management changed but this did not quite reach statistical significance (proportion with no change in management 76% versus 99%, RR 0.79, 95% CI 0.57 to 1.10).However, there was not enough evidence to demonstrate whether or not this resulted in a clinical benefit. For example there was no statistically significant difference in the number of women with urinary incontinence if they received treatment guided by urodynamics (70%) versus those whose treatment was based on history and clinical findings alone (62%) (e.g. RR for number with incontinence after first year 1.23, 95% CI 0.60 to 2.55).No trials reported whether or not there were any adverse effects. AUTHORS' CONCLUSIONS While urodynamic tests may change clinical decision making, there was not enough evidence to suggest whether this would result in better clinical outcomes. There was no evidence abut their use in men, children or people with neurological diseases. Larger definitive trials are needed, in which people are randomly allocated to management according to urodynamic findings or to standard management based on history and clinical examination.
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Affiliation(s)
- Cathryn M A Glazener
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building,Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK.
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Maher CM, Feiner B, Baessler K, Glazener CMA. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 2011; 22:1445-57. [PMID: 21927941 DOI: 10.1007/s00192-011-1542-9] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 08/10/2011] [Indexed: 01/20/2023]
Abstract
INTRODUCTION AND HYPOTHESIS A previous version of the Cochrane review for prolapse surgery in 2008 provided two conclusions: abdominal sacrocolpopexy had lower recurrent vault prolapse rates than sacrospinous colpopexy but this was balanced against a longer time to return to activities of daily life. An additional continence procedure at the time of prolapse surgery might be beneficial in reducing post-operative stress urinary incontinence; however, this was weighed against potential adverse effects. The aim of this review is to provide an updated summary version of the current Cochrane review on the surgical management of pelvic organ prolapse. METHODS We searched the Cochrane Incontinence Group Specialised Register and reference lists of randomised or quasi-randomised controlled trials on surgery for pelvic organ prolapse. Trials were assessed independently by two reviewers. RESULTS We identified 40 trials including 18 new and three updates. There were no additional studies on surgery for posterior prolapse. Native tissue anterior repair was associated with more anterior compartment failures than polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23-3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29-5.51). There were no differences in subjective outcomes, quality of life data, de novo dyspareunia, stress urinary incontinence, reoperation rates for prolapse or incontinence, although some of these data were limited. Mesh erosions were reported in 10% (30/293). Including new studies on the impact of continence surgery at the time of prolapse surgery, meta-analysis revealed that concurrent continence surgery did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53-3.70; random-effects model). CONCLUSION The inclusion of new randomised controlled trials showed that the use of mesh at the time of anterior vaginal wall repair reduced the risk of recurrent anterior vaginal wall prolapse on examination. However, this was not translated into improved functional or quality of life outcomes. The value of a continence procedure in addition to a prolapse operation in women who are continent pre-operatively remains uncertain. Adequately powered randomised controlled trials are needed and should particularly include women's perceptions of prolapse symptoms and functional outcome.
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Buckley BS, Grant AM, Glazener CMA. Case study: a patient-clinician collaboration that identified and prioritized evidence gaps and stimulated research development. J Clin Epidemiol 2011; 66:483-9. [PMID: 21816575 DOI: 10.1016/j.jclinepi.2011.03.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 02/11/2011] [Accepted: 03/24/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the effect of a research prioritization partnership that aimed to influence the research agenda relating to urinary incontinence (UI). STUDY DESIGN AND SETTING Research often neglects important gaps in existing evidence so that decisions must be made about treatments without reliable evidence of their effectiveness. In 2007-2009, a United Kingdom partnership of eight patient and 13 clinician organizations identified and prioritized gaps in the evidence that affect everyday decisions about treatment of UI. The top 10 prioritized research questions were published and reported to research funders in 2009. A year later, new research or funding applications relating to the prioritized topics were identified through reviews of research databases and consultation with funding organizations, elements of the research community, and organizations that participated in the partnership. RESULTS Since dissemination of the prioritized topics, five studies are known to have been funded, three in development; five new systematic reviews are under way, one is being updated; five questions are under consideration by a national research commissioning body. CONCLUSION The partnership successfully developed and used a methodology for identification and prioritization of research needs through patient-clinician consensus. Prioritization through consensus can be effective in informing the development of clinically useful research.
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Affiliation(s)
- Brian S Buckley
- Department of General Practice, National University of Ireland, Galway, Ireland.
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Maher C, Baessler K, Glazener CMA, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women: a short version Cochrane review. Neurourol Urodyn 2008; 27:3-12. [PMID: 18092333 DOI: 10.1002/nau.20542] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse. OBJECTIVES To determine the effects of the many different surgeries in the management of pelvic organ prolapse. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. DATA COLLECTION AND ANALYSIS Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding. MAIN RESULTS Twenty two randomised controlled trials were identified evaluating 2368 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated. AUTHORS' CONCLUSIONS Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.
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Abstract
BACKGROUND Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse. OBJECTIVES To determine the effects of the many different surgeries in the management of pelvic organ prolapse. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. DATA COLLECTION AND ANALYSIS Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding. MAIN RESULTS Twenty two randomised controlled trials were identified evaluating 2368 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated. AUTHORS' CONCLUSIONS Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.
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Affiliation(s)
- C Maher
- Sandford Jackson Building - Level 4, Suite 86, 30 Chasely Street, Auchenflower, Queensland, Australia, 4066.
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12
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Abstract
BACKGROUND Urinary incontinence is common after both radical prostatectomy (RP) and transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training (PFMT) with or without biofeedback, electrical stimulation, compression devices (penile clamps), lifestyle changes, extra-corporeal magnetic innervation or a combination of methods. OBJECTIVES To assess the effects of conservative management for urinary incontinence after prostatectomy. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Trials Register (searched 23 January 2006), MEDLINE (January 1966 to January 2006), EMBASE (January 1988 to January 2006), CINAHL (January 1982 to January 2006), PsycLIT (January 1984 to January 2006), ERIC (January 1984 to January 2006), the reference lists of relevant articles, handsearched conference proceedings and contacted investigators to locate studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence after prostatectomy. DATA COLLECTION AND ANALYSIS At least two review authors assessed the methodological quality of trials and abstracted data. MAIN RESULTS Seventeen trials met the inclusion criteria, fifteen trials amongst men after radical prostatectomy (RP), one trial after transurethral resection of the prostate (TURP) and one trial after either operation. There was considerable variation in the interventions, populations and outcome measures. The majority of trials in this area continue to be of moderate quality, although more recent studies have been of higher quality in terms of both randomization and blinding. Data were not available in all the trials for many of the pre-stated outcomes. Confidence intervals have tended to be wide except for the more recent studies, and it continues to be difficult to reliably identify or rule out a useful effect. There were several important variations in the populations being studied. Therefore the decision was made by the review authors to separate in the analysis the men having the intervention as prevention (whether administered before or after operation, to all men having surgery) or as treatment (postoperatively to those men who did have urinary incontinence), as well as separating those treated with TURP or RP. Amongst seven treatment trials of postoperative PFMT for urinary incontinence after RP, one trial suggested benefits, whereas the estimates from the others were consistent with no effect. There was clinical and statistical heterogeneity, precluding meta-analysis. There was no clear reason for this heterogeneity. Trials of preventative PFMT started pre or post-operatively also showed heterogeneity: only one large trial favoured PFMT but the data from the others were conflicting. Analysis of other conservative interventions such as transcutaneous electrical nerve stimulation and anal electrical stimulation, or combinations of these interventions were inconclusive. There were too few data to determine treatment effects on incontinence after TURP. The findings should continue to be treated with caution, as most studies were of poor to moderate quality. With respect to other management, men in one trial reported a preference for one type of external compression device compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remains undetermined as no trials involving these interventions were identified. Men's symptoms tended to improve over time, irrespective of management. AUTHORS' CONCLUSIONS The value of the various approaches to conservative management of postprostatectomy incontinence remains uncertain. Long-term incontinence may be managed by external penile clamp, but there are safety problems.
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Affiliation(s)
- K F Hunter
- University of Alberta Faculty of Nursing, Edmonton, Alberta, Canada.
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Abstract
OBJECTIVE To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery. DESIGN Longitudinal study. SETTING Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION Women (4214) who returned postal questionnaires three months and six years after the index birth. METHODS Symptom data were obtained from both questionnaires and obstetric data from case-notes for the index birth and the second questionnaire for subsequent births. Logistic regression investigated the independent effects of mode of first delivery and delivery mode history. MAIN OUTCOME MEASURES Urinary incontinence-persistent (at three months and six years after index birth) and long term (at six years after index birth). RESULTS The prevalence of persistent urinary incontinence was 24%. Delivering exclusively by caesarean section was associated with both less persistent (OR=0.46, 95% CI 0.32-0.68) and long term urinary incontinence (OR=0.50, 95% CI 0.40-0.63). Caesarean section birth in addition to vaginal delivery, however, was not associated with significantly less persistent incontinence (OR 0.93, 95% CI 0.67-1.29). There were no significant associations between persistent or long term urinary incontinence and forceps or vacuum extraction delivery. Other significantly associated factors were increasing number of births and older maternal age. CONCLUSIONS The risk of persistent and long term urinary incontinence is significantly lower following caesarean section deliveries but not if there is another vaginal birth. Even when delivering exclusively by caesarean section, the prevalence of persistent symptoms (14%) is still high.
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Glazener CMA, Herbison GP, MacArthur C, Lancashire R, McGee MA, Grant AM, Wilson PD. New postnatal urinary incontinence: obstetric and other risk factors in primiparae. BJOG 2006; 113:208-17. [PMID: 16412000 DOI: 10.1111/j.1471-0528.2005.00840.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth. DESIGN Questionnaire survey of women. SETTING Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION A total of 3405 primiparous women with singleton births delivered during 1 year. METHODS Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence. MAIN OUTCOME MEASURES Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth. RESULTS The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI>25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age. CONCLUSIONS Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen Medical School, Aberdeen, Scotland.
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16
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Abstract
BACKGROUND Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use. OBJECTIVES To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults. SEARCH STRATEGY We searched the Cochrane Incontinence Group specialised trials register (searched 9 March 2005) and the reference lists of relevant articles. SELECTION CRITERIA Randomised or quasi-randomised controlled trials in adults with urinary incontinence which included an adrenergic agonist drug in at least one arm of the trial. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook. MAIN RESULTS Twenty-two eligible randomised trials were identified, of which 11 were crossover trials. The trials included 1099 women with 673 receiving an adrenergic drug (phenylpropanolamine in 11 trials, midodrine in two, norepinephrine in three, clenbuterol in another three, terbutaline in one, eskornade in one and Ro-115-1240 in one). No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing the number of pad changes and incontinence episodes, as well as improving subjective symptoms. In two small trials, the drugs also appeared to be better than pelvic floor muscle training, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination. Over a quarter of women reported adverse effects. There were similar numbers of adverse effects with adrenergics, placebo or alternative drug treatment. However, when these were due to recognised adrenergic stimulation (insomnia, restlessness and vasomotor stimulation) they were only severe enough to stop treatment in 4% of women. AUTHORS' CONCLUSIONS There was weak evidence to suggest that use of an adrenergic agonist was better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Further larger trials are needed to identify when adrenergics may be useful. Patients using adrenergic agonists may suffer from minor side effects, which sometimes cause them to stop treatment. Rare but serious side effects, such as cardiac arrhythmias and hypertension, have been reported.
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Affiliation(s)
- A Alhasso
- Department of Urology, Western General Hospital, Edinburgh, UK, EH4 2XU.
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Ross S, Soroka D, Karahalios A, Glazener CMA, Hay-Smith EJC, Drutz HP. Incontinence-specific quality of life measures used in trials of treatments for female urinary incontinence: a systematic review. Int Urogynecol J 2005; 17:272-85. [PMID: 16025188 DOI: 10.1007/s00192-005-1357-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 06/20/2005] [Indexed: 11/25/2022]
Abstract
This systematic review examined the use of incontinence-specific quality of life (QOL) measures in clinical trials of female incontinence treatments, and systematically evaluated their quality using a standard checklist. Of 61 trials included in the review, 58 (95.1%) used an incontinence-specific QOL measure. The most commonly used were IIQ (19 papers), I-QoL (12 papers) and UDI (9 papers). Eleven papers (18.0%) used measures which were not referenced or were developed specifically for the study. The eight QOL measures identified had good clinical face validity and measurement properties. We advise researchers to evaluate carefully the needs of their specific study, and select the QOL measure that is most appropriate in terms of validity, utility and relevance, and discourage the development of new measures. Until better evidence is available on the validity and comparability of measures, we recommend that researchers consider using IIQ or I-QOL with or without UDI in trials of incontinence treatments.
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Affiliation(s)
- Sue Ross
- Department of Obstetrics, Family Medicine and Community Health Sciences, University of Calgary, Canada.
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18
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Abstract
BACKGROUND Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults. OBJECTIVES To assess the effects of complementary interventions and others such as surgery or diet on nocturnal enuresis in children, and to compare them with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Register (searched 22 November 2004), the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) (January 1984 to June 2004) and the reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised trials of complementary and other miscellaneous interventions for nocturnal enuresis in children were included except those focused solely on daytime wetting. Comparison interventions could include no treatment, placebo or sham treatment, alarms, simple behavioural treatment, desmopressin, imipramine and miscellaneous other drugs and interventions. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS In 15 randomised controlled trials, 1389 children were studied, of whom 703 received a complementary intervention. The quality of the trials was poor: four trials were quasi-randomised, five showed differences at baseline and ten lacked follow up data. The outcome was better after hypnosis than imipramine in one trial (relative risk (RR) for failure or relapse after stopping treatment 0.42, 95% confidence interval (CI) 0.23 to 0.78). Psychotherapy appeared to be better in terms of fewer children failing or relapsing than both alarm (RR 0.28, 95% CI 0.09 to 0.85) and rewards (0.29, 95% 0.09 to 0.90) but this depended on data from only one trial. Acupuncture had better results than sham control acupuncture (RR for failure or relapse after stopping treatment 0.67, 95% CI 0.48 to 0.94) in a further trial. Active chiropractic adjustment had better results than sham adjustment (RR for failure or relapse after stopping treatment 0.74, 95% CI 0.60 to 0.91). However, each of these findings came from small single trials, and need to be verified in further trials. The findings for diet and faradization were unreliable, and there were no trials including homeopathy or surgery. AUTHORS' CONCLUSIONS There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects carefully monitored.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD.
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Abstract
BACKGROUND Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults. OBJECTIVES To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94). AUTHORS' CONCLUSIONS Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD.
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Glazener CMA, Herbison GP, MacArthur C, Grant A, Wilson PD. Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: six year follow up. BMJ 2005; 330:337. [PMID: 15615766 PMCID: PMC548727 DOI: 10.1136/bmj.38320.613461.82] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the long term effects of a conservative nurse-led intervention for postnatal urinary incontinence. DESIGN Randomised controlled trial. SETTING Community based intervention in three centres in the United Kingdom and New Zealand. PARTICIPANTS 747 women with urinary incontinence at three months after childbirth, of whom 516 were followed up again at 6 years (69%). INTERVENTION Active conservative treatment (pelvic floor muscle training and bladder training) at five, seven, and nine months after delivery or standard care. MAIN OUTCOME MEASURES Urinary and faecal incontinence, performance of pelvic floor muscle training. RESULTS Of 2632 women with urinary incontinence, 747 participated in the original trial. The significant improvements relative to controls in urinary (60% v 69%) and faecal (4% v 11%) incontinence at one year were not found at six year follow up (76% v 79% (95% confidence interval for difference in means -10.2% to 4.1%) for urinary incontinence, 12% v 13% (-6.4% to 5.1%) for faecal incontinence) irrespective of subsequent obstetric events. In the short term the intervention had motivated more women to perform pelvic floor muscle training (83% v 55%) but this fell to 50% in both groups in the long term. Both urinary and faecal incontinence increased in prevalence in both groups during the study period. CONCLUSIONS The moderate short term benefits of a brief nurse-led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. About three quarters of women with urinary incontinence three months after childbirth still have this six years later.
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Affiliation(s)
- Cathryn M A Glazener
- Health Services Research Unit, University of Aberdeen Medical School, Foresterhill, Aberdeen AB25 2ZD.
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Kilonzo M, Vale L, Stearns SC, Grant A, Cody J, Glazener CMA, Wallace S, McCormack K. Cost effectiveness of tension-free vaginal tape for the surgical management of female stress incontinence. Int J Technol Assess Health Care 2005; 20:455-63. [PMID: 15609795 DOI: 10.1017/s0266462304001357] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Stress urinary incontinence affects between 10 percent and 50 percent of women. Surgery is commonly recommended for troublesome incontinence that does not respond to nonsurgical management. Tension-free vaginal tape (TVT) is a newer, minimal access surgical sling procedure, which is being increasingly adopted worldwide. The cost-effectiveness of TVT in comparison with other surgical procedures, particularly open colposuspension, is assessed. METHODS Effectiveness estimates came from a systematic review of TVT compared with other surgical procedures (open and laparoscopic colposuspension, traditional slings, and injectables). Deterministic and probabilistic analyses were used to assess the likelihood of TVT being cost-effective. Sensitivity analyses assessed the impact of changing assumptions about cure rates and costs for TVT, cure rates for retreatment open colposuspension, and proportions of women who choose retreatment. RESULTS Reliable estimates of relative effectiveness were difficult to derive because the few randomized controlled comparisons had not been optimally analyzed or fully reported. Results of the economic model suggested that TVT dominates open colposuspension (lower cost and same quality of life years [QALYs]) within 5 years after surgery. Stochastic analysis indicated that the likelihood of TVT being cost-effective was 100 percent if decision-makers are unwilling to pay for additional QALYs. TVT's dominance depended on the assumption fact that retreatment open colposuspension has lower cure rates than a first colposuspension. CONCLUSIONS Analysis based on current short-term data indicates dominance of TVT over open colposuspension from approximately 5 years. There is a need for longer-term follow-up data from methodologically rigorous randomized trials to provide a sounder basis for estimating the relative benefits and cost implications.
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Affiliation(s)
- Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, UK.
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Jarrett MED, Mowatt G, Glazener CMA, Fraser C, Nicholls RJ, Grant AM, Kamm MA. Systematic review of sacral nerve stimulation for faecal incontinence and constipation. Br J Surg 2004; 91:1559-69. [PMID: 15455360 DOI: 10.1002/bjs.4796] [Citation(s) in RCA: 206] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND METHOD This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies). RESULTS From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41-75 per cent of patients achieved complete faecal continence and 75-100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off. CONCLUSION SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation.
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Abstract
BACKGROUND Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse. OBJECTIVES To determine the effects of surgery in the management of pelvic organ prolapse. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (8 June 2004) and reference lists of relevant articles. We also contacted researchers in the field. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. DATA COLLECTION AND ANALYSIS Trials were assessed and data extracted independently by at least two reviewers. Four investigators were contacted for additional information with two responding. MAIN RESULTS Fourteen randomised controlled trials were identified evaluating 1004 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were to evaluate other clinical outcomes and adverse events. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by Vicryl mesh overlay (RR 1.39, 95% CI 1.02 to 1.90) but data on morbidity and other clinical outcomes were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh overlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new symptoms after surgery. However, more women with occult stress urinary incontinence developed postoperative stress urinary incontinence after endopelvic fascia plication alone than after endopelvic fascia plication and tension-free vaginal tape (RR 5.5, 95% CI 1.36 to 22.32). REVIEWERS' CONCLUSIONS Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of a polyglactin mesh overlay at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. Adequately powered randomised controlled clinical trials are urgently needed.
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Abstract
BACKGROUND Childhood nocturnal enuresis (bedwetting) affects many families. Although it has a high rate of spontaneous remission, bedwetting may bring social and emotional stigma, stress, and inconvenience to both the child with enuresis and his or her family. DESIGN Summary of systematic reviews of treatment for nocturnal enuresis in children, published in the Cochrane Library, using evidence only from randomized and quasi-randomized trials to compare interventions. Interventions included behavioral, alarm, and pharmacologic treatments. SETTING AND METHODS Six Cochrane Reviews contributed evidence to this review: simple behavioral interventions, alarms, complex behavioral or educational interventions, desmopressin, tricyclics and related drugs, and other drugs. SUBJECTS The participants were children (usually up to the age of 16). RESULTS Much of the available evidence was of poor quality, and there were few direct comparisons between different types of intervention. Simple behavioral Interventions, such as reward systems, are widely used as standard first-line treatment, but they require a high level of parental involvement. There is currently little evidence to show that these interventions work, but they may be worth trying because they have only a few adverse effects. The use of an alarm intervention reduced nighttime bed wetting in a majority of children both during and after treatment. Overlearning or dry-bed training may reduce the relapse rate. Before embarking on alarm treatment, families need to be made aware of both the time and the high level of parental involvement necessary to attain success. Drug therapy, such as desmopressin and tricyclics, reduced the number of wet nights per week compared with placebo but only while the drug was used. Patients and their families need to be warned about possible side effects of some of the drugs. CONCLUSIONS Alarms are the most effective treatment for nocturnal enuresis in children, but desmopressin may be considered for temporary relief.
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Affiliation(s)
- Cathryn M A Glazener
- Health Services Research Unit, University of Aberdeen, Fosterhill, Aberdeen Scotland, United Kingdom.
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Abstract
BACKGROUND Urinary incontinence is common after both radical prostatectomy and transurethral resection. Conservative management includes pelvic floor muscle training, biofeedback, electrical stimulation, compression devices (penile clamps), lifestyle changes, extra-corporeal magnetic innervation or a combination of methods. OBJECTIVES To assess the effects of conservative managements for urinary incontinence prostatectomy. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (searched 2 July 2003), MEDLINE (January 1966 to January 2004), EMBASE (January 1988 to January 2004), CINAHL (January 1982 to January 2004), PsycLIT (January 1984 to January 2004), ERIC (January 1984 to January 2004), the reference lists of relevant articles, handsearched conference proceedings and contacted investigators to locate studies. SELECTION CRITERIA Randomised controlled trials evaluating conservative interventions for urinary continence after prostatectomy. DATA COLLECTION AND ANALYSIS At least two reviewers assessed the methodological quality of trials and abstracted data. MAIN RESULTS Ten trials met the inclusion criteria, eight trials amongst men after radical prostatectomy, one trial after transurethral resection of prostate and one after either operation. There was considerable variation in the interventions, populations and outcome measures. The trials were of moderate quality and data were not available for many of the pre-stated outcomes. Confidence intervals were wide: it was not possible to reliably identify or rule out a useful effect. There was some support from five trials for pelvic floor muscle training with biofeedback being better than no treatment or sham treatment in the short term for men after radical prostatectomy: relative risk for incontinence with pelvic floor muscle training and biofeedback versus no treatment: 0.74 (95% confidence interval 0.60 to 0.93). Analysis of other conservative interventions such as pelvic floor muscle training alone, transcutaneous electrical nerve stimulation and rectal electrical stimulation, or combinations of these interventions were inconclusive. There were too few data to determine effects on incontinence after transurethral resection of the prostate. The findings should be treated with caution as there were few studies, all of moderate quality. Men in one trial reported a preference for one type of external compression device compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remains undetermined as no trials involving these interventions were identified. Men's symptoms tended to improve over time, irrespective of management. REVIEWERS' CONCLUSIONS The value of the various approaches to conservative management of postprostatectomy incontinence remains uncertain. There may be some benefit of offering pelvic floor muscle training with biofeedback early in the postoperative period immediately following removal of the catheter as it may promote an earlier return to continence. Long-term incontinence may be managed by external penile clamp, but there are safety problems.
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Affiliation(s)
- K F Hunter
- Faculty of Nursing/Geriatric Services, University of Alberta/Royal Alexandra Hospital, Edmonton, Alberta, Canada
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Abstract
BACKGROUND Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. OBJECTIVES To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002. SELECTION CRITERIA All randomised or quasi-randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclics, and miscellaneous other interventions. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS Sixteen trials involving 1081 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (eg RR for failure or relapse after stopping DBT 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (eg RR for failure or relapse after DBT alone versus DBT plus alarm 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (eg RR for failure or relapse after DBT plus alarm versus alarm alone 0.5; 95% CI 0.31 to 0.80).There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources. REVIEWER'S CONCLUSIONS Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit (Foresterhill Lea), University of Aberdeen, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD
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Abstract
BACKGROUND Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of them have moderate or severe symptoms. OBJECTIVES To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference lists of relevant articles were also searched. SELECTION CRITERIA Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence. DATA COLLECTION AND ANALYSIS Trials were assessed and data extracted independently by at least two reviewers. Two trial investigators provided additional information. MAIN RESULTS Nine trials were identified which included 347 women having six different types of needle suspension procedures and 437 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension (higher subjective failure rate after the first year (91/313, 29% failed versus 47/297, 16% failed after open abdominal retropubic suspension: the relative risk (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72) although the difference in peri-operative complications was not significant (17/75, 23% versus 12/77, 16%; RR 1.44, 95% CI 0.73 to 2.83): there were no significant differences for other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (46/128, 36% failed after needles versus 50/129, 39% after anterior repair; RR 0.93, 95% CI 0.68 to 1.26) but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population. No trials compared needle suspensions with conservative management, peri-urethral injections, sham or laparoscopic surgery. REVIEWERS' CONCLUSIONS Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD
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Abstract
BACKGROUND Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Simple behavioural methods of treating bedwetting include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction. OBJECTIVES To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference list of a previous version of this review was also searched. SELECTION CRITERIA All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials and extracted data. MAIN RESULTS Thirteen trials met the inclusion criteria, involving 702 children of whom 387 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped. Another suggested that imipramine was better than fluid deprivation and avoidance of punishment. REVIEWERS' CONCLUSIONS Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD
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29
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Abstract
The effectiveness of interventions for the treatment of nocturnal enuresis in children published in a recent issue of Effective Health Care is reviewed.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen, UK.
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Abstract
BACKGROUND Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. OBJECTIVES To assess the effects of tricyclic and related drugs on nocturnal enuresis in children, and to compare them with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles including two previously published versions of this review. Date of the most recent searches: December 2002. SELECTION CRITERIA All randomised and quasi-randomised trials of tricyclics or related drugs for nocturnal enuresis in children were included in the review. Comparison interventions included placebo, other drugs, alarms, behavioural methods or complementary/miscellaneous interventions. Trials focused solely on daytime wetting were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS Fifty four randomised trials met the inclusion criteria, involving 3379 children. The quality of many of the trials was poor. Most comparisons or outcomes were addressed only by single trials. Treatment with most tricyclic drugs (such as imipramine, amitriptyline, viloxazine, nortriptyline, clomipramine and desipramine) was associated with a reduction of about one wet night per week while on treatment (eg imipramine compared with placebo, weighted mean difference (WMD) -1.19, 95% CI -1.56 to -0.82). The exception was mianserin, where results from one small trial did not reach statistical significance. About a fifth of the children became dry while on treatment (relative risk for failure (RR) 0.77, 95% CI 0.72 to 0.83), but this effect was not sustained after treatment stopped (eg imipramine versus placebo, RR 0.98, 95% CI 0.95 to 1.03). There was not enough information to assess the relative performance of one tricyclic against another, except that imipramine was better than mianserin. The evidence comparing desmopressin with tricyclics was unreliable or conflicting, but in one small trial all the children failed or relapsed after stopping active treatment with either drug.The evidence comparing tricyclics with alarms was also unreliable or conflicting during treatment. In one small trial all the children failed or relapsed after tricyclics stopped, compared with about half after alarms. This result was compatible with the results in the Cochrane review of alarm treatment, which found that about half the children remained dry after alarm treatment was finished. There was a little evidence from single trials to suggest that imipramine might be better than a simple reward system with star charts during treatment; worse than a complex intervention involving education, counseling, waking and retention control training; better than a restricted diet; and worse than hypnosis. However, these results need to be confirmed by further research. REVIEWER'S CONCLUSIONS Although tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, most children relapse after stopping active treatment. In contrast, only half the children relapse after alarm treatment. Parents should be warned of the potentially serious adverse effects of tricyclic overdose when choosing treatment. Further research is needed into comparisons between drug and behavioural or complementary treatments, and should include relapse rates after treatment is finished.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit (Foresterhill Lea), University of Aberdeen, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD
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Abstract
BACKGROUND Faecal incontinence is a common symptom which causes significant distress and reduction in quality of life. Available treatment options for faecal incontinence include conservative treatments (biofeedback, pelvic floor muscle training, dietary manipulation or drug therapy) or surgical treatments (e.g. sphincter repair, post anal repair, neosphincter). Drug treatment is often given either alone or in combination with other treatment modalities. OBJECTIVES To assess the effects of drug therapy for the treatment of faecal incontinence. In particular, to assess the effects of individual drugs relative to placebo or other drugs, and to compare drug therapy with other treatment modalities. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (January 2003) and the reference lists of relevant articles. Date of the most recent search: January 2003. SELECTION CRITERIA All randomised or quasi-randomised controlled trials of the use of pharmacological agents for the treatment of faecal incontinence in adults. DATA COLLECTION AND ANALYSIS Working independently, reviewers selected studies from the literature, assessed the methodological quality of each trial, and extracted data. MAIN RESULTS Eleven trials were identified for inclusion in this review. Nine trials were of cross-over design. Seven trials included only people with faecal incontinence related to liquid stool (either chronic diarrhoea or following ileoanal pouch surgery). Three trials (total 58 participants) compared topical phenylephrine gel with placebo. Two trials (56 participants) compared loperamide with placebo. One trial (11 participants) compared loperamide oxide with placebo. One trial (15 participants) compared diphenoxylate plus atropine with placebo. One trial (17 participants) compared sodium valproate with placebo. One trial (30 participants) compared loperamide with codeine with diphenoxylate plus atropine. Two further trials (total 265 participants) assessed the use of lactulose in elderly people.No studies comparing drugs with other treatment modalities were identified. There was limited evidence that antidiarrhoeal drugs and drugs which enhance anal sphincter tone may reduce faecal incontinence in patients with liquid stools. However, the trials were small and of short duration. REVIEWER'S CONCLUSIONS The small number of trials identified for this review assessed several different drugs in a variety of patient populations. The focus of most of the included trials was on the treatment of diarrhoea, rather than faecal incontinence. There is little evidence to guide clinicians in the selection of drug therapies for faecal incontinence. Larger, well-designed controlled trials, which include clinically important outcome measures, are required.
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Affiliation(s)
- M Cheetham
- Department of General Surgery, Watford General Hospital, Vicarage Road, Watford, Hertfordshire, UK, WD18 0HB
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Abstract
BACKGROUND Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. OBJECTIVES To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children, and to compare them with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register. Date of the most recent search: December 2002. The reference list of a previous version of this review was also searched. SELECTION CRITERIA All randomised trials of drugs (excluding desmopressin or tricyclics) for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting. Trials focused solely on daytime wetting were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials and extracted data. MAIN RESULTS In 32 randomised controlled trials (25 new in this update), a total of 1225 out of 1613 children received an active drug other than desmopressin or a tricyclic. In all, 28 different drugs or classes of drugs were tested, but the trials were generally small or of poor methodological quality (five were quasi-randomised and the remainder failed to give adequate details about the randomisation process). Although indomethacin and diclofenac were better than placebo during treatment, desmopressin was better than both of them, with less chance of adverse effects. There were no data regarding what happened after treatment stopped. Limited data suggested that an alarm was better than drugs during treatment. REVIEWER'S CONCLUSIONS There was not enough evidence to judge whether the included drugs reduced bedwetting. There was limited evidence to suggest that desmopressin, imipramine and alarms were better than the drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit (Foresterhill Lea), University of Aberdeen, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD.
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Abstract
BACKGROUND Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use. OBJECTIVES To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (January 2002) and the reference lists of relevant articles. Date of the most recent searches: January 2002. SELECTION CRITERIA Randomised or quasi-randomised controlled trials which include an adrenergic agonist drug in at least one arm for adults with urinary incontinence. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook. MAIN RESULTS Fifteen randomised trials were identified, which included 832 women, of whom 506 received an adrenergic drug (phenylpropanolamine in 11 trials, Midodrine in two and Clenbuterol in another two). Of these, six were crossover trials. No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing number of pad changes and incontinence episodes, as well as improvement in subjective symptoms. The drugs also appeared to be better than pelvic floor muscle training in two small trials, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination. REVIEWER'S CONCLUSIONS There was weak evidence to suggest that use of an adrenergic agonist is better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Patients using adrenergic agonists may suffer from minor side effects, only occasionally leading them to stop treatment. Rare but serious side effects such as cardiac arrhythmias and hypertension have been reported, however.
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Affiliation(s)
- A Alhasso
- Department of Urology, Western General Hospital, Edinburgh, UK, EH4 2XU.
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Soroka D, Drutz HP, Glazener CMA, Hay-Smith EJC, Ross S. Perineal pad test in evaluating outcome of treatments for female incontinence: a systematic review. Int Urogynecol J 2002; 13:165-75. [PMID: 12140710 DOI: 10.1007/s192-002-8348-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Our objective was to systematically review clinical studies of incontinence treatments for women that used pad tests to assess outcome, to determine how closely the ICS guidelines had been followed. Our review (Medline 1988-2000, plus referenced studies) identified 75 relevant papers, carrying out pad tests in clinics ( n = 53) or patients' homes ( n = 28). Clinic pad tests lasted between 60 seconds and 2 hours, with inconsistent starting bladder volumes, activities carried out, other test details and presentation of results. Home pad tests lasted between 1.5 and 48 hours: the conduct and reporting of these tests were also variable. Only 25 studies used pad tests that were apparently consistent with ICS guidelines. Pad tests are important in identifying urine loss in clinical evaluations; however, we found wide variations in their conduct and reporting. We recommend that the ICS should review the guidelines, and that further research should develop clinically valid pad tests. Authors and journal editors should ensure that pad test details are fully reported.
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Affiliation(s)
- D Soroka
- University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada
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Abstract
Infertility is relative. Research into effective treatment must focus on couples with single, identifiable causes for their infertility, and must take into account the effect of chance and time on eventual success. Women with ovulatory infertility, who have no other subfertility factors, can expect normal conception rates when ovulation is restored. Unfortunately, there is no similar simple treatment for male infertility, although complicated and expensive treatment may help. Selection of the couples most likely to benefit from such help will result in the most cost-effective use of scarce resources. Knowledge of duration of infertility and the postcoital test result can help to identify those couples who have a reasonable chance of conception without treatment and those who have virtually no chance without it.
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Affiliation(s)
- Cathryn M A Glazener
- Health Services Research Unit, Foresterhill Lea, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK
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