Review: Nonpharmacologic and pharmacologic interventions improve urinary incontinence in women

Abstract

Question In women with stress, urgency, or mixed urinary incontinence (UI), what is the comparative effectiveness of nonpharmacologic and pharmacologic interventions? Review scope Included studies compared nonpharmacologic interventions, pharmacologic interventions, and placebo (sham or no therapy) in nonpregnant, adult women with stress, urgency, or mixed UI for 4 weeks. Exclusion criteria were surgical interventions and UI due to urinary tract infections or neurogenic bladder; women who were hospitalized or institutionalized were also excluded. Outcomes included symptomatic cure (resolution of incontinence) and improvement. Interventions were categorized by UI type and the recommended line of therapy. Review methods MEDLINE (2011 to Aug 2018); EMBASE/Excerpta Medica, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, and PsycINFO (all from 2011 to Dec 2017); US Food and Drug Administration and ClinicalTrials.gov (both to Aug 2018); and a systematic review from 2012 were searched for randomized and nonrandomized comparative studies. 84 studies (median age 55 y) met selection criteria; 32 studies were of stress UI, 16 of urgency UI, 4 of mixed UI, and 32 of any or unspecified type of UI. Risk for bias was low or moderate for 85% of studies. This abstract reports only results with high strength of evidence for cure. Main results The results of network meta-analysis for cure, which included indirect comparisons, are in the Table. Conclusion Nonpharmacologic and pharmacologic interventions resolve urinary incontinence in women with stress, urgency, or mixed urinary incontinence compared with no therapy. Effect of nonpharmacologic vs pharmacologic vs no therapy on cure in women with urinary incontinence (UI)* Comparisons Line of therapy Type of UI Number of studies with direct comparisons (n) Odds ratio (95% CI) Behavioral vs no therapy First All 15 (1530) 3.06 (2.16 to 4.35) Stress 6 (305) 5.62 (2.28 to 13.9) Urgency 1 (130) 2.75 (1.53 to 4.92) Behavioral vs anticholinergic drug First vs second All 3 (348) 1.57 (1.02 to 2.43) Urgency 2 (191) 1.53 (0.90 to 2.60) Anticholinergic drug vs no therapy Second All 6 (1871) 1.95 (1.32 to 2.88) Urgency 4 (655) 1.80 (1.29 to 2.52) Neuromodulation vs no therapy Third All 7 (454) 3.34 (2.12 to 5.26) Stress 6 (402) 3.49 (1.67 to 7.30) BTX vs no therapy Third All 2 (119) 5.66 (2.80 to 11.4) Urgency 2 (119) 4.94 (2.82 to 8.65) *BTX = onabotulinum toxin A; other abbreviations defined in Glossary. Number of studies and sample size of studies comparing the interventions directly. Results of network meta-analysis of all studies, including indirect comparisons. All results presented had high strength of evidence. For example, bladder training, biofeedback, bladder support, cones, education, heat therapy, weight loss, yoga. For example, tolterodine, oxybutynin, or trospium. Transcutaneous electrical nerve stimulation. Commentary The review by Balk and colleagues confirms previously reported efficacy of treatments for UInamely that treatment, particularly pharmacotherapy, is superior to no intervention (1). The network meta-analysis enhances our understanding of treatment options by allowing interventions to be ranked. The odds ratios indicate the relative effect of the different treatments. Compared with no treatment, neuromodulation and onabotulum toxin A performed the best but are the most technically sophisticated and costly and the least available. These interventions are recommended for third-line therapy, after behavioral therapy (first-line) or pharmacotherapies (second-line) have been tried. Pharmacotherapies, while effective, can be complicated by dry mouth, constipation, and confusion (1). The most remarkable finding was the utility of behavioral therapies. Given our directive to first do no harm, the take-home message from this meta-analysis is that practitioners should inform patients and encourage them to embrace behavioral therapies as a first-line approach to UI and as adjuncts to other treatments.