Behavioral training for post-prostatectomy urinary incontinence

Non-pharmacological and nonsurgical interventions in male urinary incontinence: A scoping review

AIMS

To describe and synthesize non-pharmacological and nonsurgical interventions for male urinary incontinence from the existing literature.

METHODS

A scoping review was conducted following the methodology suggested by Arksey and O'Malley: (1) identification of the research questions; (2) identification of relevant studies using a three-step search recommended by JBI: an initial search within PubMed and CINAHL, a comprehensive literature search within PubMed, CINAHL, EMBASE, PsycINFO, Cochrane Library, and literature search of references lists; (3) study selection; (4) data extraction and charting; (5) collation, summarization, and reporting of the results. The PRISMA-ScR Checklist was used to report.

RESULTS

A total of 4602 studies were identified, of which 87 studies were included. Approximately 78% were randomized controlled trials. More than 88% of the participants were men with prostate cancer. Exercising pelvic floor muscles 30 times per day for 12 weeks was the most frequently reported. Parameters of electrical stimulation were typically set up to 50 Hz and 300 μs for frequency and width of pulse, respectively, and lasted for 15 min. Pure pelvic floor muscle training, Pilates, Yoga, whole body vibration, diaphragm/abdominal muscle training, micturition interruption exercise, acupuncture, and auriculotherapy showed positive effects on reducing urinary incontinence.

CONCLUSION

The findings suggested implementing pelvic floor muscle training alone before or after surgery can both prompt the recovery of continence in men after prostate cancer surgery. The decision to use biofeedback or electrical stimulation to enhance the therapeutic effect of pelvic floor muscle training should be approached with caution. More rigorous designed studies are needed to validate the effectiveness of Traditional Chinese Medicine techniques and diverse novel methods.

RELEVANCE TO CLINICAL PRACTICE

Physicians and nurses need to be up to date on the latest evidence-based non-pharmacological and nonsurgical interventions in male urinary incontinence and select appropriate interventions based on available medical resources and patient preferences.

The Impact of Prostate Cancer Treatment on Quality of Life: A Narrative Review with a Focus on Randomized Data

Despite excellent oncologic outcomes, the management of localized prostate cancer remains complex and is dependent on multiple factors, including patient life expectancy, medical comorbidities, tumor characteristics, and genetic risk factors. Decades of iterative clinical trials have improved the optimization and utilization of surgical and radiation-based modalities, as well as their combinatorial use with anti-androgen and systemic therapies. While cure rates are high and converging on equivalent disease control should an upfront surgical or radiotherapeutic approach be optimized, the long-term side effects of surgical and radiation-based treatments can differ significantly in nature. Decisions regarding the selection of therapy are therefore best made in an informed and shared medical decision-making process between clinician and patient with respect to cancer control as well as adverse effects. We outline in this narrative review an understanding regarding implications of surgical and radiation treatment on quality of life after treatment, and how these data may be considered in the context of advising patients regarding the selection of therapy. This narrative review largely focuses on the quality of life data obtained from prospective randomized trials of men treated for prostate cancer. We believe this provides the best assessment of the quality of life and can be used to inform patients when making treatment decisions.

A Pilot Study to Determine Reasons for Patient Withdrawal From a Pelvic Muscle Rehabilitation Program for Urinary Incontinence

This project explored reasons why patients with urinary incontinence withdrew from a behavioral treatment program before completion of all sessions. In-depth, semistructured interviews were conducted with 10 of 25 patients who had not completed prescribed behavioral treatment at the University of North Carolina–Chapel Hill School of Medicine Continence Clinic. The women interviewed made positive or neutral comments about Kegel exercises and understood the relationship between urinary incontinence and pelvic muscle weakness. They perceived a relationship between age and urinary incontinence but did not think that incontinence was inevitable with aging. Treatment of urinary incontinence became less of a priority when work, physical impairments, or illness intervened and when there appeared to be some misunderstanding about the treatment. These findings suggest that clinicians need to better understand perceived barriers to adherence in order to discuss these barriers and to design a more individualized approach for each patient in a continence clinic.

Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training

Behavioral and physical therapies have been used for many years to treat incontinence and overactive bladder (OAB). This paper focuses on programs that include pelvic floor muscle training (PFMT) as a component in treatment for women or men. PFMT was long used almost exclusively for treatment of stress incontinence. When it became evident that voluntary pelvic floor muscle contraction can be used to control bladder function, PFMT was also integrated into the treatment of urge incontinence and OAB as part of a broader behavioral urge suppression strategy. PFMT has evolved over decades, both as a behavioral therapy and a physical therapy, combining principles from behavioral science, nursing, and muscle physiology into a widely recommended conservative treatment. The collective literature indicates that PFMT is effective for incontinence, as well as urgency, frequency, and nocturia. It can be combined with all other treatment modalities and holds potential for prevention of bladder symptoms.

Adult urinary incontinence: Assessment, intervention, and the role of clinical health psychology in program development

Urinary incontinence (UI) is a disorder receiving little attention from clinical health psychologists. This paper establishes the importance of addressing the issue of UI within the clinical and research practices of clinical health psychologists. Over 10 million Americans suffer from loss of bladder control. Incontinence affects over half of older individuals in long-term care institutions, about one-third of hospitalized elderly, and up to 30% of Americans over the age of 60 living at home. Because of social stigma and misconceptions attached to urinary incontinence, it is estimated that less than half of those affected see a physician about their condition. Since UI is generally associated with medical, social, psychological, and economic consequences, a multidisciplinary perspective is important because these factors are integral in the selection of appropriate treatment. Definitions of UI, its incidence and costs, and brief reviews of treatment and management techniques are presented. Psychological sequelae and treatments are presented as a foundation for developing further treatment and research approaches. Guidelines for collaboration and consultation by clinical health psychologists with medical professionals in the area of UI are also discussed.

Urodynamic quantification of decrease in sphincter function after radical prostatectomy: relation to postoperative continence status and the effect of intensive pelvic floor muscle exercises

AIMS

We analyzed the impact of radical retropubic prostatectomy (RRP) on the urethral sphincter function as assessed by urethral pressure profilometry (UPP) and its relation to post-radical prostatectomy continence status. Furthermore, we analyzed the effect of intensive pelvic floor muscle exercises (PFME) on the urethral sphincter function.

METHODS

Sixty-six patients were included in the study. UPP was performed before RRP and 26 weeks after catheter removal. All patients were instructed in PFME, however, the intensity of PFME varied between instructions based on an information folder only (F-PFME) and intensive guidance by a physiotherapist, in addition to the folder (PG-PFME).

RESULTS

In 66 patients, pre- as well as postoperative UPP was evaluable. After surgery, the functional profile length and the maximum urethral closure pressure (MUCP) showed a median decrease of 64% and 41%, respectively. For men who had regained continence after 6 months the median MUCP was significantly higher both before and after operation as compared to men who were still incontinent. In multivariate analysis, non-nerve sparing approach was a prognostic factors for a higher relative decrease of the MUCP after RRP. Comparing the PG-PFME group with the F-PFME group there were no significant differences in changes in UPP parameters.

CONCLUSIONS

A poor preoperative MUCP seems to be an important prognostic factor for persistent incontinence after RRP. Non-nerve sparing approach seems to be an important prognostic factor for impairment of the urethral sphincter function as measured by UPP. More intensive physiotherapy seems to have no additional effect on the postoperative urethral sphincter function as measured by UPP.

Developing a pelvic floor muscle training regimen for use in a trial intervention

This paper explains the rationale behind the intervention used for a large multi-centred randomised controlled trial for men following transurethral resection of prostate or radical prostatectomy. It shows the content of the protocol used and explains why this particular protocol of pelvic floor muscle exercises and urge suppression techniques was chosen for men in the intervention group. The trial will evaluate whether this intervention will be effective for men with urinary incontinence and sexual dysfunction after prostate surgery. ISRCTN number: ISRCTN87696430.

Rehabilitation Therapy and Urinary Incontinence after Radical Retropubic Prostatectomy

INTRODUCTION

To assess the efficacy and evidence-based data in the literature about rehabilitation therapy in patients with post-prostatectomy urinary incontinence.

MATERIALS AND METHODS

An analysis of published full-length papers identified by a Medline search from 1990 through 2004 was carried out. Abstracts published in peer-reviewed journals in the same period of time were also considered.

RESULTS

Efficacy, tolerability and safety of rehabilitation therapy were evaluated, according to the available data in the literature, with special regard to randomized controlled trials in order to define a clear-cut, evidence-based efficacy of this form of therapy.

CONCLUSIONS

Rehabilitation therapy is a simple and safe way of managing post-prostatectomy urinary incontinence. Nonetheless, few randomized controlled studies have been carried out so far to establish its evidence-based efficacy and it is thus not possible to be scientifically sure of its value. It is therefore necessary to undertake well-designed randomized controlled studies, with a large number of patients, a well-matched control group and an adequate follow-up.

Preoperative Biofeedback Assisted Behavioral Training to Decrease Post-Prostatectomy Incontinence: A Randomized, Controlled Trial

PURPOSE

We tested the effectiveness of preoperative biofeedback assisted behavioral training for decreasing the duration and severity of incontinence, and improving quality of life in the 6 months following radical prostatectomy.

MATERIALS AND METHODS

We performed a prospective, randomized, controlled trial comparing preoperative behavioral training to usual care. The volunteer sample included 125 men 53 to 68 years old who elected radical prostatectomy for prostate cancer. Patients were stratified according to age and tumor differentiation, and randomized to 1 preoperative session of biofeedback assisted behavioral training plus daily home exercise or a usual care control condition, consisting of simple postoperative instructions to interrupt the urinary stream. The main outcome measurements were duration of incontinence (time to continence), as derived from bladder diaries, incontinence severity (the proportion with severe/continual leakage), pad use, Incontinence Impact Questionnaire, psychological distress (Hopkins Symptom Checklist) and health related quality of life (Medical Outcomes Study Short Form Health Survey).

RESULTS

Preoperative behavioral training significantly decreased time to continence (p = 0.03) and the proportion of patients with severe/continual leakage at the 6-month end point (5.9% vs 19.6%, p = 0.04). There were also significant differences between the groups for self-reported urine loss with coughing (22.0% vs 51.1%, p = 0.003), sneezing (26.0% vs 48.9%, p = 0.02) and getting up from lying down (14.0% vs 31.9%, p = 0.04). No differences were found on return to work and usual activities or quality of life measures.

CONCLUSIONS

Preoperative behavioral training can hasten the recovery of urine control and decrease the severity of incontinence following radical prostatectomy.

Preliminary results of the effect of extracorporeal magnetic stimulation on urinary incontinence after radical prostatectomy: a pilot study

INTRODUCTION

Radical prostatectomy is a common procedure for the treatment of clinically localized prostate cancer. However, urinary incontinence is a significant potential source of morbidity following surgery. Extracorporeal magnetic stimulation (ExMS) is a new technology used for pelvic muscle strengthening in the treatment of stress urinary incontinence. We investigated the clinical effects of ExMS on urinary incontinence after retropubic radical prostatectomy.

PATIENTS AND METHODS

Ten patients who had suffered from urinary incontinence for more than 12 months following radical prostatectomy were enrolled in this study. The Neocontrol system was used. Treatment sessions were for 20 min, twice a week for 2 months. The frequency of the pulse field was 10 Hz for 10 min, followed by a second treatment at 50 Hz for 10 min. Objective and subjective measures included voiding diaries, 1-hour pad weight testing, and a quality of life survey at 1, 2, 3, and 6 months after starting the treatment. Urodynamic studies were performed before and after treatment.

RESULTS

Three patients became dry (30%), 3 patients improved (30%), and 4 patients showed stationary symptoms (40%). In the 1-hour pad weight testing, the mean pad weight decreased from 25 to 10.3 g, and the quality of life scores had improved from 70.5 to 84.9 2 months after treatment. The frequency of leak episodes per day was reduced from 5.0 times before to 1.9 times after treatment. In the urodynamic study, mean maximum cystometric capacity and Valsalva leak point pressure increased from 197 +/- 53.2 to 309 +/- 85.3 ml and from 67.3 +/- 22.6 to 97.1 +/- 22.7 cm H2O after treatment, respectively (p < 0.05). 3 of 6 patients who showed improvement returned to the baseline values within 12 months after treatment and requested maintenance ExMS therapy. No side effects were observed.

CONCLUSIONS

ExMS therapy offered a new option for urinary incontinence treatment after radical prostatectomy. Further studies are required to determine how long the benefits of treatment last and whether maintenance therapy is necessary.

Die Elektrostimulation in der Therapie der postoperativen Harninkontinenz

Worldwide use of electrical stimulation for therapy of postoperative incontinence is based on a few prospective randomized controlled studies. We present a three-arm prospective randomized study evaluating physiotherapeutic pelvic floor training alone and in combination with transanal or perineal electrical stimulation. The study compared specific continence training (CT) and a combination of CT with transanal or perineal electrostimulation. The groups included 60 patients each and were analyzed with regard to self-assessment, objective characteristics of incontinence, standard quality of life questionnaire (QLQ-C 30), and recorded data of the stimulation device. The patients participated in a specific inpatient rehabilitation program and were assessed at the time of admittance, upon discharge, and again after 3 months. Significant improvement could be achieved in every group concerning urinary incontinence and quality of life. Additional use of electrical stimulation was significantly superior to physiotherapeutic training alone. However, these results could only be detected in a highly compliant subgroup. Analysis of device data indicated a high score of errors and lack of patient compliance. Perineal electrical stimulation was better accepted than transanal and showed less side effects and better outcome in the characteristics of incontinence. Improvement in the quality of life was mostly achieved during the weeks of inpatient rehabilitation. Electrical stimulation could not improve quality of life items. Electrical stimulation is an efficient instrument for treatment of postoperative high-grade incontinence, however, only with sufficient patient compliance.

Timed voiding for the management of urinary incontinence in adults

BACKGROUND

Timed voiding is a fixed time interval toileting assistance program that has been promoted for the management of people with urinary incontinence who cannot participate in independent toileting. For this reason, it is commonly assumed to represent current practice in residential aged care settings.

OBJECTIVES

To assess the effects of timed voiding for the management of urinary incontinence in adults who cannot participate in independent toileting.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (9 May 2002), MEDLINE (January 1966 to December 2002), EMBASE (January 1980 to Week 18 2002), CINAHL (January 1982 to February 2001), PsycINFO (January 1972 to current), Biological Abstracts (January 1980 to December 2000), Current Contents (January 1993 to December 2001) and the reference lists of relevant articles. We also contacted experts in the field, searched relevant websites and handsearched journals and conference proceedings.

SELECTION CRITERIA

We selected all randomised and quasi-randomised trials that addressed timed voiding in an adult population and that had an alteration in continence status as a primary outcome. We included those trials that had assessed timed voiding delivered either alone or in combination with another intervention and compared it with either usual care, or no timed voiding, or another intervention.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by at least two people working independently of each other. Any differences were resolved by discussion until agreement was reached. The relative risk for dichotomous data were calculated with 95% confidence intervals. Where data were insufficient to support a quantitative analysis, a narrative overview was undertaken.

MAIN RESULTS

Two trials with a total of 298 participants met the inclusion criteria. Both compared timed voiding plus additional intervention with usual care. In one of these timed voiding was combined with continence products, placement of a bedside commode for each participant, education to staff on transfer techniques, feedback and encouragement to staff, praise to participants for "successful responses" and administration of oxybutynin in small doses. The mean percentage who were incontinent when checked daily was 20% in the intervention group compared with 80% in the control group. No further between group analysis was possible from the data reported. The other trial combined timed voiding with a medical assessment and individualised medical management that was based on clinical data. Reduction in the number of participants with daytime and night-time incontinence was greater in the intervention group but this difference was statistically significant only for night-time wetting. There was no difference in the volume of urine lost as determined by pad weighing. The methodological quality of these trials was not high based on the quality appraisal criteria of the Cochrane Incontinence Group. In particular, there was a lack of clarity regarding levels of blinding. It was not possible to combine data from trials. In both trials, the fixed schedule of toileting was combined with other interventions. The extent to which the results reflect the contribution of timed voiding is unknown because the trials' design did not allow assessment of the effects of the fixed schedule of toileting separately from other components of the interventions.

REVIEWER'S CONCLUSIONS

The data were too few and of insufficient quality to provide empirical support for or against the intervention of timed voiding.

Protocol- and therapist-related variables affecting outcomes of behavioral interventions for urinary and fecal incontinence

Biofeedback techniques used to treat urinary and fecal incontinence lack standardization. Most early protocols used a pressure device placed within the vagina or anal canal, or electromyographic (EMG) sensors in the same locations, to measure the external anal sphincter (EAS) or pelvic floor muscle (PFM) contractile function, and most early studies provided feedback from a single physiological transducer. The goal was to improve bowel and bladder control by improving EAS or PFM contractile function. Protocols that have resulted in the most consistent reductions in urinary incontinent episodes used 2 or more channels of physiological information to reinforce stable abdominal and bladder pressures concurrently with PFM contraction. For fecal incontinence, more significant treatment results were derived when protocols measured (1) patient perception of sensory cues associated with rectal distention and potential loss of stool, (2) short-latency EAS contraction when perceiving rectal distention, (3) inhibition of (extraneous muscle) activity that would increase intra-abdominal pressure during EAS contraction, and (4) reinforcement of sustained (up to 30 seconds) contractions rather than only brief 1- to 2-second contractions. Limited data support the use of surface abdominal EMG measures as indices of extraneous muscle activity associated with increased intra-abdominal pressure and anal or vaginal EMG probes to obtain measures of PFM function. Better results may also be obtained when there are at least 4 training sessions, when daily home exercises are prescribed, and when the therapist is well trained and experienced. These inferences are based for the most part on indirect evidence, and more studies are needed that compare different treatment protocols.

Behavioral treatment options for urinary incontinence

Behavioral treatments improve bladder control by changing the incontinent patient's behavior, especially his or her voiding habits, and by teaching skills for preventing urine loss. These treatments are effective for most outpatient men and women with stress, urge, or mixed incontinence. The average reduction in the frequency of incontinence ranges from 57% to 86%. In long-term care settings, treatment is generally more challenging and yields more modest results. The advantages of behavioral interventions include the absence of side-effects, patient comfort, and high levels of patient satisfaction. Although most patients who receive behavioral treatment achieve significant improvement, most are not completely dry. Thus, there is a need for research to explore ways to enhance the effectiveness of these conservative therapies. Combining behavioral treatment with other treatments may have additive effects. Research is also needed to understand better the mechanisms of therapeutic change, the best methods for teaching pelvic floor muscle control, the optimal exercise regimens, the predictors of outcome, and the efficacy of behavioral treatments in men. Although behavioral interventions are more accepted today than 20 years ago, they are still not widely available or integrated into most clinical practices, and we know little of how effective they will be in these settings. Thus, it will be important to develop and evaluate creative modes of delivery, such as group intervention (especially by nonphysician providers), in a variety of clinical settings.

Habit retraining for the management of urinary incontinence in adults

BACKGROUND

Habit retraining is toileting assistance given by a caregiver to adults with urinary incontinence. It involves the identification of an incontinent person's natural voiding pattern and the development of an individualised toileting schedule which pre-empts involuntary bladder emptying.

OBJECTIVES

To assess the effects of habit retraining for the management of urinary incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (9 May 2002), MEDLINE (January 1966 to December 2002), EMBASE (January 1980 to Week 18 2002), CINAHL (January 1982 to February 2001), PsycINFO (January 1972 to current), Biological Abstracts (January 1980 to December 2000), Current Contents (January 1993 to December 2001) and the reference lists of relevant articles. We also contacted experts in the field, searched relevant websites and hand searched journals and conference proceedings.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing habit retraining delivered either alone or in conjunction with another intervention for urinary incontinence in adults.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by at least two people working independently of each other. Any differences were resolved by discussion. The relative risks for dichotomous data were calculated with 95% confidence intervals. Where data were insufficient for a quantitative analysis, a narrative overview was undertaken.

MAIN RESULTS

Three trials with a total of 337 participants met the inclusion criteria, describing habit retraining combined with other approaches compared with usual care. Participants were primarily care-dependent elderly women with concurrent cognitive and/or physical impairment, residing in either a residential aged-care facility or in their own home. Outcomes included incidence and/or severity of urinary incontinence, the prevalences of urinary tract infection, skin rash and skin breakdown, cost and caregiver preparedness, role strain and burden. Caregivers found it difficult to maintain voiding records and to implement the toileting program. A 61% compliance rate was reported in one trial. There were no statistically significant differences in the incidence and in the volume of incontinence between groups. Within group analyses did however show improvements on these measures. Reductions were also reported for the intervention group in one study for skin rash, skin breakdown and in caregivers' perceptions of their level of stress. Descriptive data on the intervention suggests that habit retraining is a labour-intense activity. Electronic loggers, used as an adjunct to caregiver-delivered wet/dry checks, were reported as providing more accurate data than that from caregiver conducted wet/dry checks. To date, no analysis of the time and resources associated with these comparisons is available.

REVIEWERS' CONCLUSIONS

Data on habit retraining are few and of insufficient quality to provide a firm basis for practice.

Pelvic floor exercises, electrical stimulation and biofeedback after radical prostatectomy: results of a prospective randomized trial

PURPOSE

We assessed the effect of pelvic muscle exercises (PMEs), electrical stimulation (ES) and biofeedback (BFB) on urinary incontinence after radical retropubic prostatectomy.

MATERIALS AND METHODS

We randomized 139 patients who underwent radical retropubic prostatectomy into 3 groups. Group 1 received instructions about postoperative PMEs. Group 2 received the same instructions and ES for 15 minutes twice daily. Patients in group 3 were also treated with BFB for 15 minutes twice daily. Treatment was started immediately after catheter removal and performed for 3 months. The outcome was assessed using the 20-minute pad test and a urine symptom inventory. Results at baseline, and 3 and 12 months postoperatively were available for 139, 120 and 128 (questionnaire), and 116, 79 and 124 (pad test) patients, respectively.

RESULTS

An overall subjective spontaneous continence rate (questionnaire) 1 day after catheter removal of 21.4% increased within the first 3 months up to 59.2%. There was no significant difference among the 3 groups. The continence rate increased from 3 to 12 months postoperatively from 59.2% to 85.9%. An overall objective spontaneous continence rate (pad test) 1 day after catheter removal of 32.9% increased within the first 3 months up to 65% and up to 83% after 12 months without any significant difference in all 3 groups.

CONCLUSIONS

A treatment program of ES and BFB enhanced PMEs did not affect continence after radical prostatectomy after 3 or 12 months. Up to 711 euro can be saved per patient.

Assessing health care needs and clinical outcome with urological case complexity: a study using INTERMED

Urinary tract symptoms and, particularly, urinary incontinence are often chronic and complex conditions that cause diagnosis, treatment, and management problems. In many cases, psychosocial factors contribute to the development of a chronic condition. The authors investigated whether INTERMED, an instrument for assessing case complexity and health care needs, was able to identify such complex cases, to estimate the amount of comorbidity, and to predict clinical outcome for 31 consecutive patients suffering from urinary tract symptoms. To assess clinical outcome, the authors used the American Urologic Association Symptom Score, the Brief Symptom Inventory, and the Hospital Anxiety and Depression Scale. On the basis of the patients' INTERMED scores, the authors distinguished between low-complexity patients (INTERMED score <21, N=25, 80.6%) and high-complexity patients (INTERMED score >or=21, N=6; 19.4%). Low-complexity patients had fewer depressive and anxiety symptoms, less distress, and better clinical outcome at their 3-month follow-up than high-complexity patients. The data confirmed the ability of the instrument to detect patients at risk of complex urinary tract symptoms and to predict clinical outcome.

Polypropilene sling of the bulbar urethra for post-radical prostatectomy incontinence

OBJECTIVE

We present details of a modification of the Stamey procedure using a polypropilene mesh to compress the corpus spongiosum of the bulbar urethra in the treatment of sphincteric incompetence following radical prostatectomy.

MATERIALS AND METHODS

Between September 1999 and June 2000 nine patients 66-80 years old (mean age 74) with severe incontinence due to radical prostatectomy underwent the bulbourethral sling procedure with polypropilene (Prolene) mesh implant. After transperineal incision a 5cmx4cm rectangular prolene mesh was placed against the bulbar urethra and suspended by four prolene sutures transferred to a suprapubic incision through ligature carriers as in the four corner bladder and bladder neck suspension. If leakage recurred in the follow-up, a retightening procedure was performed in local anesthesia rescuing the prolene threads over a polypropilene mesh placed against the rectus fascia. Mean follow-up was 14 months (range 12-20). Continence status and post-void residual volume were evaluated after 1, 3 and 6 months post-operatively and successively every 3 months.

RESULTS

At the present follow-up considering the results of the retightening procedure five out of nine patients were cured, two out of nine improved and two were unchanged. Five out of nine patients reported slight to mild perineal/genital discomfort which disappeared in four at three months post-operatively. No patients required mesh removal for complications.

CONCLUSIONS

The male bulbourethral sling procedure using a polypropilene mesh is safe but further experience is needed to establish this procedure as plausible alternative for the treatment of post-radical prostatectomy urinary incontinence.

Influence of behavior modification on overactive bladder

Behavioral interventions have been used for decades to treat urge incontinence and other symptoms of overactive bladder. Perhaps the earliest form of treatment was the bladder drill, an intensive intervention designed to increase the interval between voids to establish a normal frequency of urination and normalization of bladder function. Bladder training is a modification of bladder drill that is conducted more gradually on an outpatient basis and has resulted in significant reduction of incontinence in older, community-dwelling women. Multicomponent behavioral training is another form of behavioral treatment that includes pelvic floor muscle training and exercise. This intervention focuses less on voiding habits and more on altering the physiologic responses of the bladder and pelvic floor muscles. Using biofeedback or other teaching methods, patients learn strategies to inhibit bladder contraction using pelvic floor muscle contraction and other urge suppression strategies. Although behavioral and drug therapies are known to be highly effective for reducing urge incontinence, few patients are cured with either treatment alone. Thus, future research should explore ways to enhance the effectiveness of these conservative therapies. Although the mechanisms by which behavioral treatments work have not been established, there is some evidence that behavioral and drug interventions may operate by different mechanisms, suggesting that they may have additive effects and that combining them may result in better outcomes. Future research needs to examine the mechanisms by which these therapies reduce incontinence and whether combining behavioral and drug treatment will result in better outcomes than either therapy alone.

Outcome measures for erectile dysfunction 2: evaluation

This article, the second of two parts, discusses and evaluates the range of outcome measures for erectile dysfunction (ED) identified from the literature review in part one (Vol 11(1): 54-64). The literature review identified 14 subjective and 12 objective measures. These outcome measures are needed for the components: rigidity, vascular flow, nerve conductivity, intracavernosus muscle power, partner satisfaction and quality of life. Instruments selected should provide good validity, reliability and responsiveness. Quick, simple, inexpensive and efficient outcome measures can be used by nurses.

Outcome measures for erectile dysfunction. 1: Literature review

This article describes and evaluates critically the outcome measures available for the assessment of the conservative treatment of erectile dysfunction (ED). The literature review identified 26 outcome measures. Of these, 14 were subjective and 12 were objective. Objective measures can provide more accurate information. However, owing to the sensitive nature of the problem, questionnaires which are reliable and sensitive to change can provide valuable data. Different outcome measures were needed for each of the separate components of ED. These components were found to be rigidity, vascular flow, nerve conductivity, intracavemosal pressure, ischiocavernosus muscle power, partner satisfaction and quality of life. An evaluation of outcome measures for each component of ED is provided in the second part of this article. Quick, simple, inexpensive and efficient outcome measures can be used by nurses to evaluate the impact of conservative treatment for ED.

Prevention and management of incontinence following radical prostatectomy

Incontinence after radical prostatectomy can have a significant impact on quality of life. Although several risk factors have been identified, the surgical technique and advancing age are important factors associated with postprostatectomy incontinence. Despite advances in technique, incontinence still occurs in a small group of men. Sphincteric dysfunction is the most common cause of postradical prostatectomy incontinence, but bladder dysfunction cannot be discounted. Treatments range from conservative to surgical and should be tailored to the individual based on the degree of bother and patient willingness to accept different therapeutic options.

Incontinence after radical prostatectomy: pathophysiology and management

Despite improvements in surgical technique designed to preserve the functional integrity of the urethral sphincteric mechanism, incontinence after radical prostatectomy still occurs in many patients. Most patients have stress incontinence secondary to intrinsic sphincter deficiency, but many also have bladder dysfunction. The treatment of choice for post- prostatectomy stress incontinence is the artificial urinary sphincter. Other treatment options include collagen injection therapy and the male bulbourethral sling.

Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy

OBJECTIVES

To determine whether preoperative biofeedback training improves urinary continence overall or the rate of return of continence in men undergoing radical prostatectomy.

METHODS

One hundred men scheduled to undergo radical prostatectomy were randomized to receive graded pelvic muscle exercise training with biofeedback 2 to 4 weeks before surgery or to a control group performing pelvic muscle exercises without biofeedback. The biofeedback group was instructed to continue exercises four times per day until surgery and to resume exercises when the urethral catheter was removed following surgery. The control group received written and brief verbal instructions in pelvic muscle exercises before surgery and again after catheter removal. Urinary continence was assessed by personal or phone interviews.

RESULTS

Six months following surgery, the continence rates, as defined by the use of one pad or less per day, were 94% (44 of 47) and 96% (48 of 50) in the biofeedback and control groups, respectively (P = 0.596). Also, the rate of return as determined at time points 1, 2, 3, and 4 months after surgery was not significantly different between the two groups.

CONCLUSIONS

Preoperative biofeedback training did not improve the outcome of pelvic muscle exercises on overall continence or the rate of return of urinary control in men undergoing radical prostatectomy.

Interference pattern in perineal muscles: a quantitative electromyographic study in patients before and after transurethral surgery of the prostate

The study aimed at assessing alterations in muscular activity in the external urethral sphincter when the internal sphincter located at the bladder neck was resected during TUR-P, and at determining whether activity in the external urethral sphincter increased to compensate for the loss of the internal sphincter. Perineal muscles were examined with quantitative EMG recordings, including interference pattern and fiber density before and after surgery. Fiber density increased in the external urethral sphincter after surgery. This indicates a reinnervation in the muscle, probably due to a peripheral nerve lesion that occurs during TUR-P, and may also explain the reduction in penile erectibility observed after surgery. The lack of compensatory activity in the external urethral sphincter expressed as unchanged number of turns may be explained as a disturbed feedback mechanism and a decreased central activation or to the lithotomy position at examination. The internal part of the external sphincter not available for measurement may compensate for the loss in bladder-neck sphincter function.

Combined behavioral and drug therapy for urge incontinence in older women

OBJECTIVE

The purpose of this study was to examine the effects of combining behavioral treatment and drug treatment for urge incontinence in community-dwelling older women.

DESIGN

Modified crossover design (extension of a randomized clinical trial). Eligible subjects were stratified according to type and severity of incontinence and randomized to behavioral treatment, drug treatment, or a control condition (placebo). Subjects not totally continent or not satisfied after 8 weeks of a single treatment were offered the opportunity to cross over into combined therapy.

SETTING

A university-based outpatient geriatric medicine clinic.

PARTICIPANTS

Subjects in the clinical trial were 197 ambulatory, nondemented, community-dwelling women (age 55 years or older) with persistent urge urinary incontinence. Thirty-five subjects participated in combined treatment.

INTERVENTION

One group of subjects received four sessions (over 8 weeks) of biofeedback-assisted behavioral training followed by 8 weeks of behavioral training combined with drug therapy (oxybutynin chloride individually titrated from 2.5 mg to 15 mg daily). The second group received drug therapy first, followed by 8 weeks of drug therapy combined with behavioral training.

MEASUREMENTS

Bladder diaries completed by subjects before and after each treatment phase were used to calculate change in the frequency of incontinent episodes.

RESULTS

Eight subjects (12.7%) crossed from behavioral treatment alone to combined behavioral and drug therapy. Additional benefit was seen in improvement from a mean 57.5% reduction of incontinence with single therapy to a mean 88.5% reduction of incontinence with combined therapy (P = .034). Twenty-seven subjects (41.5%) crossed from drug therapy alone to combined drug and behavioral treatment. They also showed additional improvement, from a mean 72.7% reduction of incontinence with single therapy to a mean 84.3% reduction of incontinence with combined therapy (P = .001).

CONCLUSIONS

This study shows that combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence.

Effect of pelvic-floor re-education on duration and degree of incontinence after radical prostatectomy: a randomised controlled trial

BACKGROUND

Urinary incontinence is a common long-term complication after radical prostatectomy. Spontaneous recovery of normal urinary control after surgery can take 1-2 years. We aimed to investigate whether there was any beneficial effect of pelvic-floor re-education for patients with urinary incontinence as a result of radical prostatectomy.

METHODS

102 consecutive incontinent patients who had had radical retropubic prostatectomy for clinically localised prostate cancer and who could comply with the ambulatory treatment schedule in our hospital were randomised, after catheter removal, into a treatment group (n=50) and a control group (n=52). Patients in the treatment group took part in a pelvic-floor re-education programme for as long as they were incontinent, and for a maximum of 1 year. The control group received placebo therapy. The primary endpoint was continence rate at 3 months. Incontinence was assessed objectively with the 1 h and 24 h pad tests and subjectively by the visual analogue scale. The groups were analysed on an intention-to-treat basis by ANOVA and chi2-test.

FINDINGS

In the treatment group continence was achieved after 3 months in 43 (88%) of 48 patients. In the control group, continence returned after 3 months in 29 (56%) of 52 patients. At 1 year, the difference in proportion between treatment and control group was 14% (95% CI 2-27). In the treatment group improvement in both duration (log-rank test, p=0.0001) and degree of incontinence (Wald test, p=0.0010) was significantly better than in the control group.

INTERPRETATION

Pelvic-floor re-education should be considered as a first-line option in curing incontinence after radical prostatectomy.

Urinary incontinence in the older man

Older men experience UI less often than older women, but the disruption and bother they experience because of UI is significant. Several anatomic differences between men and women account for different pathophysiology of incontinence. In men, overflow incontinence and detrusor instability predominate; stress incontinence is seen only in cases in which men have had prostate surgery. Reported symptoms of urgency and urge incontinence may be particularly difficult to interpret clinically in men because they might indicate detrusor instability or bladder outlet obstruction causing uninhibited contractions. The medical evaluation of UI is similar for men and women; men being evaluated for UI need a postvoid residual. Noninvasive measurement of urine flow may add to the diagnostic accuracy of detecting bladder outlet obstruction, but the results may not agree with results obtained by pressure-flow studies. Prostate surgery can result in UI, and biofeedback can be an effective treatment. Near-continual leakage after prostate surgery seems to be most responsive to artificial sphincter implantation. Male nursing home patients with UI present a different challenge in that mental and physical dysfunction must be addressed. Staff-dependent interventions are the most appropriate.

Behavioral interventions for incontinence in ambulatory geriatric patients

Behavioral intervention is a group of therapies used to modify stress, urge, or mixed urinary incontinence by changing patient bladder habits or by teaching new skills. Three broad categories of behavioral treatment are reviewed: pelvic muscle exercise, biofeedback, and bladder training. The literature concerning each of these methods indicates that the treatments are effective for most community-dwelling older adults. More research is needed to identify the best methods for implementing these treatments, to explore the role of various components of treatment packages, to examine issues of durability, and to improve adherence to behavioral protocols necessary for long-term effectiveness.

Treatment of postprostatectomy urinary incontinence with behavioral methods

Prostate cancer is the most commonly diagnosed cancer in men. The radical prostatectomy is the treatment of choice for localized cancer; however, this surgery carries with it the potential complication of urinary incontinence postoperatively. The increasing number of radical prostatectomies each year will thus lead to a growing number of patients suffering from postprostatectomy urinary incontinence. According to the medical literature, the treatment of postprostatectomy incontinence is almost always limited to pharmacological or surgical therapy. Because of the failure of the standard treatment options, many men are left to live with their incontinence. The guidelines for the treatment of urinary incontinence recommend the use of behavioral methods as first-line treatment for stress and urge incontinence. The potential treatment of postprostatectomy incontinence with the use of behavioral methods has a promising future for the advanced practice nurse and for the men who are affected.