Cathryn Ma Glazener

Systematic review of sacral nerve stimulation for faecal incontinence and constipation.

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).

Desmopressin for nocturnal enuresis in children.

BACKGROUNDnEnuresis (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 to the children can be great.nnnOBJECTIVESnTo assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions.nnnSEARCH STRATEGYnThe following electronic databases were searched: MEDLINE to June 1997; AMED; ASSIA; BIDS; BIOSIS Previews (1985-1996); CINAHL; DHSS Data; EMBASE (1974 to June 1997); PsycLIT and SIGLE. Organisations, manufacturers, researchers and health professionals concerned with enuresis were contacted for information. The reference sections of obtained studies were also checked for further trials. Date of the most recent search: July 1997.nnnSELECTION CRITERIAnAll randomised trials of desmopressin for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if: children were randomised to receive desmopressin compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting; participants with organic causes for their bedwetting were excluded; and baseline assessments of the level of bedwetting were reported. Trials focused solely on daytime wetting were excluded.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently assessed the quality of the eligible trials, and extracted data.nnnMAIN RESULTSnTwenty one randomised trials involving 948 children treated with desmopressin, met the inclusion criteria. The quality of many of the trials was poor. Desmopressin was compared with a tricyclic drug in two trials, and with alarms in one. Desmopressin was effective in reducing bedwetting in a variety of doses and forms. Each dose of desmopressin reduced bedwetting by at least one night per week during treatment (eg 20microg: 1.56 fewer wet nights per week, 95% CI -1.94 to -1.19). Participants on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights (95% CI 1.38 to 15.02) compared with placebo. However, there was no difference after treatment was finished. There was no apparent dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive. Desmopressin and imipramine (a tricyclic drug) were equally effective in one small trial. Amitriptyline (another tricyclic) was not consistently better than desmopressin either alone or when used as a supplement. In a single trial, desmopressin was initially superior to using an alarm in reducing the number of wet nights per week: WMD -1.7 (95% CI: -2.96 to -0.45), but this result was not sustained; after three months of treatment, patients using the alarm had 1.4 fewer wet nights per week than with desmopressin: (95% CI: 0.14 to 2.65). Participants receiving the alarm intervention were also nine times less likely to relapse than those given desmopressin: RR 9.2 (95% CI: 1.28 to 65.9). Combining alarm and drug therapy was found to be superior to alarm treatment alone. The addition of desmopressin to an alarm schedule resulted in one less wet night per week: (95% CI: -1.55 to -0.45).nnnREVIEWERS CONCLUSIONSnDesmopressin rapidly reduced the number of wet nights per week, but there was some evidence that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects, but that alarms produced more sustained benefits. However, based on the available evidence, these conclusions can only be tentative. There was some evidence of minor side effects of desmopressin in the included trials, such as nasal irritation and nose bleeds. However, the risk of water intoxication associated with over-drinking before bedtime has been reported. Patients and their families need to be warned of potential adverse effects and advise

Persistent urinary incontinence and delivery mode history: a six-year longitudinal study.

Objectiveu2002 To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery.

Anterior vaginal repair for urinary incontinence in women

BACKGROUNDnAnterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence (SUI) in women. About a third of adult women experience urinary incontinence. SUI imposes significant health and economic burden to the society and the women affected.nnnOBJECTIVESnTo determine the effects of anterior vaginal repair (anterior colporrhaphy) on urinary incontinence in comparison with other management options.nnnSEARCH METHODSnWe searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 September 2009) and the reference lists of relevant articles.nnnSELECTION CRITERIAnRandomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently extracted data and assessed trial quality. Three trial investigators were contacted for additional information.nnnMAIN RESULTSnTen trials were identified which included 385 women having an anterior vaginal repair and 627 who received comparison interventions.A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with bladder neck needle suspension appeared similar (risk ratio (RR) for failure after one year 1.16, 95% confidence interval (CI) 0.86 to 1.56), but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic colposuspensions, or compared alternative vaginal operations.Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the medium term (failure rate within one to five years after anterior repair 97/259 (38%) versus 57/327 (17%); RR 2.29, 95% confidence Interval (CI) 1.70 to 3.08) and in the long term (after five years, (49/128 (38%) versus 31/145 (21%); RR 2.02, 95% CI 1.36 to 3.01). There was evidence from three of these trials that this was reflected in a need for more repeat operations for incontinence (25/107 (23%) versus 4/164 (2%); RR 8.87, 95% CI 3.28 to 23.94). These findings held, irrespective of the co-existence of prolapse (pelvic relaxation). Although fewer women had a prolapse after anterior repair (RR 0.24, 95% CI 0.12 to 0.47), later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation.In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension.nnnAUTHORS CONCLUSIONSnThere were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in eight trials, even in women who had prolapse in addition to stress incontinence (six trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about postoperative complications and morbidity.A Brief Economic Commentary (BEC) identified one study suggesting that vaginoplasty may be more cost-effective compared with tension-free vaginal tape (TVT-O).

Urodynamic investigations for management of urinary incontinence in children and adults

BACKGROUNDnUrodynamic 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.nnnOBJECTIVESnThe objective of this review was to discover if treatment according to a urodynamic-based diagnosis led to clinical improvements in urinary incontinence, compared to treatment based on history and examination.nnnSEARCH STRATEGYnWe searched the Cochrane Incontinence Group trials register. Date of the most recent search: April 2002.nnnSELECTION CRITERIAnRandomised 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.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently assessed trial quality and extracted data. Authors of one study were contacted for more information, including adverse effects.nnnMAIN RESULTSnTwo small trials involving 128 women were included. In one small trial, women who were investigated with urodynamics were more likely to receive active treatment with drugs or surgery. However, the numbers in both trials were too small to determine if this affected clinical outcomes such as a reduction in incontinence.nnnREVIEWERS CONCLUSIONSnA larger definitive trial is needed, in which people are randomly allocated to management according to urodynamic findings or to standard management based on history and clinical examination.

Elective caesarean section versus expectant management for delivery of the small baby

BACKGROUNDnElective caesarean delivery for women in labour with a small or immature baby might reduce the chances of fetal or neonatal death, but it might also increase the risk of maternal morbidity.nnnOBJECTIVESnTo assess the effects of a policy of elective caesarean delivery versus expectant management for small babies.nnnSEARCH STRATEGYnThe Cochrane Pregnancy and Childbirth Group trials register was searched. Date of last search: December 2000.nnnSELECTION CRITERIAnRandomised trials comparing a policy of elective caesarean delivery versus expectant management with recourse to caesarean section.nnnDATA COLLECTION AND ANALYSISnOne reviewer assessed eligibility and trial quality, and both contributed to the update.nnnMAIN RESULTSnSix studies involving 122 women were included. All trials reported recruiting difficulties. Babies in the elective group were less likely to have respiratory distress syndrome (odds ratio (OR) 0.43, 95% confidence interval (CI) 0.18 to 1.06) although they were more likely to have a low cord pH immediately after delivery (OR 10.82, 95% CI 1.60 to 73.24). They were less likely to have neonatal seizures (0/39 versus 2/42) and there were fewer deaths (2/62 versus 6/60) but these differences did not reach statistical significance. However, their mothers were more likely to have serious morbidity (OR 6.44, 95% CI 1.48 to 27.89).nnnREVIEWERS CONCLUSIONSnThere is not enough evidence to evaluate the use of a policy for elective caesarean delivery for small babies. Randomised trials in this area are likely to continue to experience recruitment problems. However, it still may be possible to investigate elective caesarean delivery in small babies with cephalic presentations.

Sacral nerve stimulation for fecal incontinence and constipation in adults: A short version cochrane review†‡

Fecal incontinence and constipation are disabling conditions that reduce quality of life. If conservative treatment fails, one option is sacral nerve stimulation (SNS), a minimally invasive technique allowing modulation of the nerves and muscles of the pelvic floor and hindgut.

Bladder neck needle suspension for urinary incontinence in women

BACKGROUNDnBladder 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. Stress urinary incontinence (SUI) imposes significant health and economic burdens on society and the women affected.nnnOBJECTIVESnTo determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options.nnnSEARCH METHODSnWe 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.nnnSELECTION CRITERIAnRandomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence.nnnDATA COLLECTION AND ANALYSISnAt least two authors assessed trials and extracted data independently. Two trial investigators provided additional information.nnnMAIN RESULTSnWe 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.nnnAUTHORS CONCLUSIONSnBladder 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. A Brief Economic Commentary (BEC) identified no cost-effectiveness studies comparing bladder neck needle suspension with other surgeries.

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics).

BACKGROUNDnEnuresis (bedwetting) is a socially unacceptable 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.nnnOBJECTIVESnTo assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children, and to compare them with other interventions.nnnSEARCH STRATEGYnThe following electronic databases were searched: MEDLINE to June 1997; AMED; ASSIA; BIDS; BIOSIS Previews (1985-1996); CINAHL; DHSS Data; EMBASE (1974 to June 1997); PsycLIT and SIGLE. Organisations, manufacturers, researchers and health professionals concerned with enuresis were contacted for information. The reference sections of obtained studies were also checked for further trials. Date of the most recent search: July 1997.nnnSELECTION CRITERIAnAll 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; participants with organic causes for their bedwetting were excluded; and baseline assessments of the level of bedwetting were provided. Trials focused solely on daytime wetting were excluded.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently assessed the quality of the eligible trials, and extracted data.nnnMAIN RESULTSnNone of the drugs (phenmetrazine, amphetamine sulphate/ephedrine + atropine, furosemide (sic) or chlorprotixine) were better than placebo during treatment. The numbers were too small to draw reliable conclusions, and none are used in current practice in the UK. Imipramine (a tricyclic) was better than each of the three drugs with which it was compared (meprobamate, ephedrine sulphate and furosemide) even though the numbers were small. Alarm treatment was better than drugs in one small trial.nnnREVIEWERS CONCLUSIONSnThere was not enough evidence to suggest that the included drugs reduced bedwetting. There was limited evidence to suggest that imipramine and alarms were better, and in other reviews, desmopressin, tricyclics and alarm interventions have tentatively been shown to be effective.

Complex behavioural and educational interventions for nocturnal enuresis in children

BACKGROUNDnNocturnal 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.nnnOBJECTIVESnTo assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions.nnnSEARCH STRATEGYnWe searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002.nnnSELECTION CRITERIAnAll 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.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently assessed the quality of the eligible trials, and extracted data.nnnMAIN RESULTSnSixteen 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.nnnREVIEWERS CONCLUSIONSnAlthough 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.