Background
Pelvic floor muscle training is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed and, less commonly, urgency urinary incontinence.

Objectives
To determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments.

Search methods
We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL) (1999 onwards), MEDLINE (1966 onwards) and MEDLINE In-Process (2001 onwards), and handsearched journals and conference proceedings (searched 15 April 2013) and the reference lists of relevant articles.

Selection criteria
Randomised or quasi-randomised trials in women with stress, urgency or mixed urinary incontinence (based on symptoms, signs, or urodynamics). One arm of the trial included pelvic floor muscle training (PFMT). Another arm was a no treatment, placebo, sham, or other inactive control treatment arm.

Data collection and analysis
Trials were independently assessed by two review authors for eligibility and methodological quality. Data were extracted then cross-checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. Trials were subgrouped by diagnosis of urinary incontinence. Formal meta-analysis was undertaken when appropriate.

Main results
Twenty-one trials involving 1281 women (665 PFMT, 616 controls) met the inclusion criteria; 18 trials (1051 women) contributed data to the forest plots. The trials were generally small to moderate sized, and many were at moderate risk of bias, based on the trial reports. There was considerable variation in the interventions used, study populations, and outcome measures. There were no studies of women with mixed or urgency urinary incontinence alone.

Women with SUI who were in the PFMT groups were 8 times more likely than the controls to report that they were cured (46/82 (56.1%) versus 5/83 (6.0%), RR 8.38, 95% CI 3.68 to 19.07) and 17 times more likely to report cure or improvement (32/58 (55%) versus 2/63 (3.2%), RR 17.33, 95% CI 4.31 to 69.64). In trials in women with any type of urinary incontinence, PFMT groups were also more likely to report cure, or more cure and improvement than the women in the control groups, although the effect size was reduced. Women with either SUI or any type of urinary incontinence were also more satisfied with the active treatment, while women in the control groups were more likely to seek further treatment. Women treated with PFMT leaked urine less often, lost smaller amounts on the short office-based pad test, and emptied their bladders less often during the day. Their sexual outcomes were also better. Two trials (one small and one moderate size) reported some evidence of the benefit persisting for up to a year after treatment. Of the few adverse effects reported, none were serious.

The findings of the review were largely supported by the summary of findings tables, but most of the evidence was down-graded to moderate on methodological grounds. The exception was 'Participant perceived cure' in women with SUI, which was rated as high quality.

Authors' conclusions
The review provides support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress and any type of urinary incontinence. Long-term effectiveness of PFMT needs to be further researched.

/pdf/pelvic-floor-muscle-training-versus-no-treatment-or-inactive-6ve912sotz.pdf

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

Patient compliance with paper and electronic diaries

Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline

OBJECTIVE: To determine if urge urinary incontinence is associated with risk of falls and non-spine fractures in older women.

METHODS: Type and frequency of incontinent episodes were assessed by 6049 community-dwelling women using a self-completed questionnaire. Postcards were subsequently mailed every 4 months to inquire about falls and fractures. Incident fractures were confirmed by radiographic report. Logistic and proportional hazard models were used to assess the independent association of urge urinary incontinence and risk of falling or fracture.

RESULTS: The mean age of the women was 78.5 (± 4.6) years. During an average follow-up of 3 years, 55% of women reported falling, and 8.5% reported fractures. One-quarter of the women (1493) reported weekly or more frequent urge incontinence, 19% (1137) reported weekly or more frequent stress incontinence, and 708 (12%) reported both types of incontinence. In multivariate models, weekly or more frequent urge incontinence was associated independently with risk of falling (odds ratio = 1.26; 95% confidence interval (CI), 1.14-1.40) and with non-spine nontraumatic fracture (relative hazard 1.34; 95% CI, 1.06-1.69; P = .02). Stress incontinence was not associated independently with falls or fracture.

CONCLUSIONS: Weekly or more frequent urge incontinence was associated independently with an increased risk of falls and non-spine, nontraumatic fractures in older women. Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in fractures. Early diagnosis and appropriate treatment of urge incontinence may decrease the risk of fracture. J Am Geriatr Soc 48:721–725, 2000.

Urinary Incontinence: Does it Increase Risk for Falls and Fractures?

Background: Although emerging evidence during the past several decades suggests that psychosocial factors can directly influence both physiologic function and health outcomes, medicine had failed to move beyond the biomedical model, in part because of lack of exposure to the evidence base supporting the biopsychosocial model. The literature was reviewed to examine the efficacy of representative psychosocial-mind-body interventions, including relaxation, (cognitive) behavioral therapies, meditation, imagery, biofeedback, and hypnosis for several common clinical conditions. Methods: An electronic search was undertaken of the MEDLINE, PsycLIT, and the Cochrane Library databases and a manual search of the reference sections of relevant articles for related clinical trials and reviews of the literature. Studies examining mind-body interventions for psychological disorders were excluded. Owing to space limitations, studies examining more body-based therapies, such as yoga and tai chi chuan, were also not included. Data were extracted from relevant systematic reviews, meta-analyses, and randomized controlled trials. Results: Drawing principally from systematic reviews and meta-analyses, there is considerable evidence of efficacy for several mind-body therapies in the treatment of coronary artery disease (eg, cardiac rehabilitation), headaches, insomnia, incontinence, chronic low back pain, disease and treatment-related symptoms of cancer, and improving postsurgical outcomes. We found moderate evidence of efficacy for mind-body therapies in the areas of hypertension and arthritis. Additional research is required to clarify the relative efficacy of different mind-body therapies, factors (such as specific patient characteristics) that might predict more or less successful outcomes, and mechanisms of action. Research is also necessary to examine the cost offsets associated with mind-body therapies. Conclusions: There is now considerable evidence that an array of mind-body therapies can be used as effective adjuncts to conventional medical treatment for a number of common clinical conditions.

/pdf/mind-body-medicine-state-of-the-science-implications-for-2znbf5wp6y.pdf

Mind-Body Medicine: State of the Science, Implications for Practice

Context.—Urinary incontinence is a common condition
caused by many factors with several treatment options.Objective.—To compare the effectiveness of
biofeedback-assisted behavioral treatment with drug treatment and a
placebo control condition for the treatment of urge and mixed urinary
incontinence in older community-dwelling women.Design.—Randomized placebo-controlled trial conducted from
1989 to 1995.Setting.—University-based outpatient geriatric medicine
clinic.Patients.—A volunteer sample of 197 women aged 55 to 92
years with urge urinary incontinence or mixed incontinence with urge as
the predominant pattern. Subjects had to have urodynamic evidence of
bladder dysfunction, be ambulatory, and not have dementia.Intervention.—Subjects were randomized to 4 sessions (8
weeks) of biofeedback-assisted behavioral treatment, drug treatment
(with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0
mg 3 times daily), or a placebo control condition.Main Outcome Measures.—Reduction in the frequency of
incontinent episodes as determined by bladder diaries, and patients'
perceptions of improvement and their comfort and satisfaction with
treatment.Results.—For all 3 treatment groups, reduction of
incontinence was most pronounced early in treatment and progressed more
gradually thereafter. Behavioral treatment, which yielded a mean 80.7%
reduction of incontinence episodes, was significantly more effective
than drug treatment (mean 68.5% reduction;
P=.04) and both were more effective than the
placebo control condition (mean 39.4% reduction; P<.001 and
P=.009, respectively). Patient-perceived
improvement was greatest for behavioral treatment (74.1% "much
better" vs 50.9% and 26.9% for drug treatment and placebo,
respectively). Only 14.0% of patients receiving behavioral treatment
wanted to change to another treatment vs 75.5% in each of the other
groups.Conclusion.—Behavioral treatment is a safe and effective
conservative intervention that should be made more readily available to
patients as a first-line treatment for urge and mixed
incontinence.

https://jamanetwork.com/journals/jama/articlepdf/188273/joc6806.pdf

D. Candib

Papers

Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial

Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women. A Randomized Controlled Trial