Research Questions
- 1.
What is the clinical effectiveness of behavioural modification for the treatment of adults with urinary incontinence resulting from neurogenic bladder?
- 2.
What are the evidence-based guidelines associated with the use of behavioural modification for the treatment of adults with urinary incontinence resulting from neurogenic bladder?
Key Findings
There was no evidence found that directly compared behavioural modification to pharmacologic treatment such as anticholinergics for the treatment of adults with urinary continence from neurogenic bladder.
Data from a 2014 systematic review on the effects of pelvic floor muscle training (PFMT) suggested that it lead to better control of stress urinary incontinence (SUI) in women as compared to no treatment or inactive control treatments, as determined by patient-reported or clinician-reported measures, with few adverse effects. When the type of urinary incontinence was unspecified, the effect size was reduced. There were no data on urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI) alone. Women with either SUI or any type of urinary incontinence were also more satisfied with PFMT treatment than controls, while women in the control groups were more likely to seek further treatment.
The American College of Physicians (ACP) recommends PFMT as first-line therapy for SUI, and recommends against treatment with systemic pharmacologic therapy. For UUI, ACP recommends bladder training as first-line therapy, and pharmacologic treatment if bladder training was unsuccessful. ACP recommends PFMT plus bladder training for MUI (no algorithm relative to pharmacologic therapy stated).
Methods
A limited literature search was conducted on key resources including PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No methodological filters were applied to limit retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2012 and August 18, 2017.
Rapid Response reports are organized so that the evidence for each research question is presented separately.
Selection Criteria and Methods
One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in .
Exclusion Criteria
Articles were excluded if they did not meet the selection criteria outlined in , they were duplicate publications were already reported in the included SRs, or were published prior to 2012. Guidelines were excluded if they were not evidence-based (i.e., based on a formal search for relevant literature with assessments of evidence quality).
Critical Appraisal of Individual Studies
The included systematic review (SR) and guidelines were assessed using the AMSTAR11 and AGREE12 checklists, respectively. Summary scores were not calculated for the included studies; rather, a review of the strengths and limitations of each included study were described narratively.
Summary of Evidence
Quantity of Research Available
A total of 656 citations were identified in the
literature search. Following screening of titles
and abstracts, 648citations were excluded and eight potentially relevant reports from the electronic search were retrieved for full-text review. One potentially relevant publication was retrieved from the grey literature search. Of these potentially relevant articles, seven publications were excluded for various reasons, while two publications met the inclusion criteria and were included in this report. Appendix 1 describes the PRISMA flowchart of the study selection.
Summary of Study Characteristics
The included review13 is a SR with meta-analysis that aims to evaluate the efficacy of PFMT in women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments (such as advice on use of pads). The SR included 20 randomized controlled trials (RCTs) and 1 quasi-RCT. Primary outcomes reported were efficacy of PFMT determined by patient-reported measures and urinary incontinence-related quality of life; clinician-reported measures such dry pads, and adverse events were also reported. The review was done in Canada and New Zealand.
The included guideline is a Clinical Practice Guideline developed by the American College of Physicians (ACP) on non-surgical management of urinary incontinence in women.14 The guideline was based on a comprehensive systematic evidence search from 1990 to 2013. The guideline rates the evidence by using the ACP’s guideline grading system adopted from the GRADE (Grading of Recommendations, Assessments, Development, and Evaluation) workgroup.
Characteristics of the included studies are
detailed in Appendix 2.
Summary of Critical Appraisal
The included SR13 had a priori design provided, independent studies selection and data extraction procedure in place, comprehensive literature search performed, list of included and excluded studies, studies characteristics provided, quality assessment of included studies provided and used in formulating conclusions, assessment of publication bias performed, and conflict of interest stated. Heterogeneity across trials in interventions, comparators, and length of follow-up was present in a number of pooled analyses, so a random-effects model was used.
The guideline had clear scope and purpose, the recommendations are specific and unambiguous, the method for searching for and selecting the evidence are clear, methods used for formulating the recommendations are clearly described, health benefits, side effects and risks were stated in the recommendations, and the procedures for updating the guidelines provided and target users of the guideline are clearly defined. Potential cost implications of applying the recommendation were included. It was unclear whether the guideline was piloted among target users, or whether patients’ views and preferences were sought.
Details of the critical appraisal of the included studies are presented in Appendix 3.
Summary of Findings
What is the clinical effectiveness of behavioural modification for the treatment of adults with urinary incontinence resulting from neurogenic bladder?
There was no evidence found that compared behavioural modification to pharmacologic treatment such as anticholinergics for the treatment of adults with urinary incontinence resulting from neurogenic bladder.
The 2014 Cochrane systematic review determined the effects of PFMT for women with urinary incontinence in comparison to no treatment, placebo, sham treatments, or other inactive control treatments.13 The SR included 15 trials on SUI and six trials on unspecified urinary incontinence; there was no trial on patients with UUI or MUI alone.
Women with SUI who were in the PFMT groups were eight times more likely than the controls to report that they were “cured”, by several definitions (e.g., “dry”, “no leakage”, “unproblematic”, >75% improvement) and 17 times more likely to report cure or improvement at the end of treatment. Women with any incontinence in the PFMT group were also more likely to report that they were cured, or more likely to report cure and improvement than the control group at the end of treatment. Six months to one year after the end of treatment, women with SUI who were in the PFMT groups were 28 times more likely than the control group to report cure or improvement, and 24 times more likely than the control to report cure or improvement in women with any incontinence. Women were more satisfied with PMFT, while women in the control groups were more likely to seek further treatment. Women with PFMT leaked urine less often, lost smaller amounts on short office-based pad tests, emptied their bladders less often during the day, and their sexual outcomes were better than women in the control group. Adverse events were rare (one trial reported adverse events with PMFT) and minor (pain, uncomfortable feeling after exercise, or “bothered”). The authors concluded that based on the available evidence, PFMT is better than no treatment, placebo drug, or inactive control treatments for women with SUI or urinary incontinence (all types), but there was no information about women with UUI alone or MUI.
What are the evidence-based guidelines associated with the use of behavioural modification for the treatment of adults with urinary incontinence resulting from neurogenic bladder?
The 2014 Clinical Practice Guideline from the American College of Physicians (ACP) issued recommendations for nonsurgical management of urinary incontinence in women.14
Recommendation 1: ACP recommends first-line treatment with PFMT in women with stress UI. (Grade: strong recommendation, high-quality evidence). (p 434)
Recommendation 2: ACP recommends bladder training in women with urgency UI. (Grade: strong recommendation, moderate-quality evidence).(p 434)
Recommendation 3: ACP recommends PFMT with bladder training in women with mixed UI. (Grade: strong recommendation, moderate-quality evidence)(p 434)
Recommendation 4: ACP recommends against treatment with systemic pharmacologic therapy for stress UI. (Grade: strong recommendation, low-quality evidence)(p 434)
Recommendation 5: ACP recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful. Clinicians should base the choice of pharmacologic agents on tolerability, adverse effect profile, ease of use, and cost of medication. (Grade: strong recommendation, high quality evidence)(p 434)
Recommendation 6: ACP recommends weight loss and exercise for obese women with UI. (Grade: strong recommendation, moderate-quality evidence)(p 434)
The main findings of the included studies are presented in Appendix 4.
Limitations
There was no evidence found that directly compared behavioural modification to pharmacologic treatment such as anticholinergics. No trials evaluated efficacy of behavioural modification one year or more after the end of treatment. The major limitation in reporting of the included trials was the lack of a clear description of the PFMT programs.
Heterogeneity across trials in PFMT programs, comparators, length of follow-up, was present in a number of pooled analyses.
Conclusions and Implications for Decision or Policy Making
There was no evidence found that directly compared behavioural modification to pharmacologic treatment such as anticholinergics for the treatment of adults with urinary incontinence resulting from neurogenic bladder.
Data from a 2014 systematic review on the effects of PFMT lead to better control of SUI in women as determined by patient-reported (such as likeliness to report continence) or clinician-reported measures (such as pad testing for urine loss), with few adverse effects. When the type of urinary incontinence was unspecified, the effect size was reduced. There were no data on UUI or MUI alone. Women with either SUI or any type of urinary incontinence were also more satisfied with PFMT treatment, while women in the control groups were more likely to seek further treatment.
The efficacy of behavioural modification such as PFMT, bladder training and biofeedback may also be enhanced with the addition of other conservative strategies such as lifestyle changes (e.g., weight loss, dietary changes, physical activity), physical therapy (e.g., vaginal cones) and electrical stimulation.7,15,16
Despite the evidence that behavioural modification helps to control urinary incontinence, there are factors that influence its uptake and delivery. A qualitative review on patients and staff perception on behavioural modification found that from clients perspective, increase fear of accidents and convenience of treatments are barriers to participation in the program, and from a staff perspective, barriers to adopting behavioural interventions included staff education and perceptions of treatment effectiveness.17
The American College of Physicians (ACP) recommends PFMT as first-line therapy for SUI, and recommends against treatment with systemic pharmacologic therapy. For UUI, ACP recommends bladder training as first-line therapy, and pharmacologic treatment if bladder training was unsuccessful. ACP recommends PFMT plus bladder training for MUI (no algorithm relative to pharmacologic therapy stated).
References
- 1.
Tudor KI, Sakakibara R, Panicker JN. Neurogenic lower urinary tract dysfunction: evaluation and management.
J Neurol. 2016;263(12):2555–2564. [
PubMed: 27401178]
- 2.
- 3.
- 4.
- 5.
- 6.
- 7.
- 8.
Newman DK, Wein AJ. Office-based behavioral therapy for management of incontinence and other pelvic disorders.
Urol Clin North Am. 2013;40(4):613–635. [
PubMed: 24182980]
- 9.
Burgio KL. Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training.
Curr Urol Rep. 2013;14(5):457–464. [
PubMed: 23913199]
- 10.
- 11.
- 12.
- 13.
Dumoulin C, Hay-Smith EJ, Mac Habee-Seguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.
Cochrane Database Syst Rev. 2014;(5):CD005654. [
PubMed: 24823491]
- 14.
Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians.
Ann Intern Med. 2014;161(6):429–440. [
PubMed: 25222388]
- 15.
- 16.
Stenzelius K, Molander U, Odeberg J, Hammarstrom M, Franzen K, Midlov P, et al. The effect of conservative treatment of urinary incontinence among older and frail older people: a systematic review.
Age Ageing. 2015;44(5):736–744. [
PubMed: 26112402]
- 17.
French B, Thomas LH, Harrison J, Coupe J, Roe B, Booth J, et al. Client and clinical staff perceptions of barriers to and enablers of the uptake and delivery of behavioural interventions for urinary incontinence: qualitative evidence synthesis.
J Adv Nurs. 2017;73(1):21–38. [
PubMed: 27459911]
Appendix 1. Selection of Included Studies
Appendix 2. Characteristics of Included Publications
Characteristics of Included Systematic Review
Characteristics of Included Guideline
Appendix 3. Critical Appraisal of Included Publications
View in own window
| First Author, Publication Year | Strengths | Limitations |
|---|
| Critical appraisal of included systematic review (AMSTAR11) |
|---|
| Dumoulin13 | a priori design provided independent studies selection and data extraction procedure in place comprehensive literature search performed list of included studies, studies characteristics provided list of excluded studies provided quality assessment of included studies provided and used in formulating conclusions assessment of publication bias performed conflict of interest stated
| heterogeneity across trials in interventions, comparators, length of follow-up, was present in a number of pooled analyses
|
| Critical appraisal of included guidelines (AGREE12) |
|---|
| Qaseem14 | scope and purpose of the guidelines are clear the recommendations are specific and unambiguous the method for searching for and selecting the evidence are clear methods used for formulating the recommendations are clearly described health benefits, side effects and risks were stated in the recommendations procedure for updating the guidelines provided target users of the guideline are clearly defined potential cost implications of applying the recommendation are included
| |
Appendix 4. Main Study Findings and Author’s Conclusions
Main Study Findings and Authors’ Conclusions
About the Series
Rapid Response Report: Summary with Critical Appraisal
Suggested citation:
Behaviour Modification for Urinary Incontinence from Neurogenic Bladder: A Review of Clinical Effectiveness and Guidelines. Ottawa: CADTH; 2017; Sep. (CADTH rapid response report: summary with critical appraisal).
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