Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Inconclusive evidence suggests that bladder training improves urge incontinence

ACP J Club. 1999 May-June;130:67. doi:10.7326/ACPJC-1999-130-3-067


Source Citation

Roe B, Williams K, Palmer M. Bladder training for the treatment of urinary urge incontinence. Cochrane Review, latest version 26 Aug 1998. In: The Cochrane Library. Oxford: Update Software.


Abstract

Question

Is bladder training an effective treatment for urinary urge incontinence?

Data sources

Studies were identified from the Cochrane Controlled Trials Register (Specialised Register of Controlled Trials of the Incontinence Reviews Group), which includes studies identified from MEDLINE and CINAHL searches and from hand searches of Neurology and Urodynamics.

Study selection

Randomized and quasi-randomized controlled trials of bladder training for treatment of urge incontinence in adults were selected if they compared bladder training with no bladder training, bladder training with other treatments, or bladder training alone with bladder training plus other treatments. Bladder training included a mandatory schedule or self-schedule, patient education, positive reinforcement, and follow-up.

Data extraction

Data were extracted on study methods, participants, interventions, and outcomes. The methodologic quality of individual studies was assessed on the basis of quality of random allocation and concealment, description of withdrawals, intention-to-treat analysis, and blinding during treatment and outcome assessment.

Main results

5 studies (n = 179, sample size range 14 to 60 participants) met the inclusion criteria. 4 trials involved only women, and the 5th included mostly women. 3 trials compared bladder training with no bladder training. 1 study (n = 60) found that at 6 months, more patients who underwent bladder training perceived that they were cured (90% vs 23%, {relative benefit improvement [RBI] 286%, 95% CI 115 to 670, number needed to treat [NNT] 2, CI 2 to 3}*) and reported no urinary symptoms (83% vs 23%, {RBI 257%, CI 97 to 617, NNT 2, CI 2 to 3}*). Another small study (n = 18) found similar results for patient perception of improvement (89% vs 0%), and a study of 14 women reported fewer mean episodes of incontinence during a 24-hour period. 1 trial (n = 50) found that more patients who underwent bladder training perceived that they were cured (84% vs 56% {RBI 50%, CI 4 to 132, NNT 4, CI 2 to 42}*) and reported no urinary symptoms (76% vs 48% {RBI 58%, CI 2 to 162, NNT 4, CI 2 to 121}*) compared with patients who received flavoxate hydrochloride, 200 mg 3 times/d, and imipramine, 25 mg 3 times/d. 1 study (n = 37) that compared bladder training with bladder training plus terodiline, 25 mg, found no group differences for perceived patient improvement at 6 weeks.

Conclusion

Evidence of the effectiveness of bladder training for urge incontinence is inconclusive but suggests a short-term benefit.

Source of funding: No external funding.

For correspondence: Professor B. Roe, Institute of Human Ageing, University of Liverpool, P.O. Box 147, Liverpool L69 3BX, England, UK. FAX 44-151-794-5077.

*Numbers calculated from data in article.


Commentary

Urinary incontinence, which affects > 35% of women older than 60 years of age, contributes to depression, restriction of activities, and social isolation. The frequent anticholinergic side effects and drug interactions of medications used to treat urge incontinence, including the newer anti- muscarinic agents, limit their long-term use. Bladder training, also known as behavioral therapy, has therefore been recommended as first-line treatment (1). The interpretation of the literature on behavioral therapy and its application in clinical practice, however, have been hindered by the heterogeneity and inadequate descriptions of the interventions used. Bladder training also requires time for patient education.

Roe and colleagues reviewed studies that emphasized step-increased timed voiding, in which the patient progressively lengthens the interval between scheduled voids, depending on the success of staying dry. However, stress incontinence occurs concomitantly in half of older women with urgency, and in these women, timed voiding is expected to be less successful. Techniques to increase urethral contraction without increasing intra-abdominal pressure may help both urge and stress incontinence by inhibiting bladder sensitivity. In a recent randomized trial involving 197 older women with urge or mixed incontinence, biofeedback-assisted bladder training led to an 81% decrease in episodes of incontinence per week compared with reductions of 69% and 39% in the drug and placebo groups, respectively (2).

Clinicians should routinely ask patients to keep a urinary diary to characterize the pattern and severity of incontinence. Keeping a diary may produce behavioral alterations that improve incontinence and helps to identify motivated patients who may benefit from bladder training. Drug therapy should be reserved for persons with urge incontinence who refuse bladder training alone or in whom this therapy fails. Fixed-interval and prompted voiding remain the preferred treatment of detrusor hyperreflexia from central nervous system disease (such as dementia), for which drug therapy adds little benefit.

Calvin H. Hirsch, MD
University of California, DavisSacramento, California, USA

Calvin H. Hirsch, MD
University of California, Davis
Sacramento, California, USA


References

1. Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Rockville, MD: U.S. Department of Health and Human Services, AHCPR Publication No. 96-0682; March 1996.

2. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA. 1998;280: 1995-2000.