Conservative interventions for managing urinary incontinence after prostate surgery

BACKGROUND

Men may need to undergo prostate surgery to treat prostate cancer or benign prostatic hyperplasia. After these surgeries, men may experience urinary incontinence (UI). Conservative treatments such as pelvic floor muscle training (PFMT), electrical stimulation and lifestyle changes can be undertaken to help manage the symptoms of UI.

OBJECTIVES

To assess the effects of conservative interventions for managing urinary incontinence after prostate surgery.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings (searched 22 April 2022). We also searched the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of adult men (aged 18 or over) with UI following prostate surgery for treating prostate cancer or LUTS/BPO. We excluded cross-over and cluster-RCTs. We investigated the following key comparisons: PFMT plus biofeedback versus no treatment; sham treatment or verbal/written instructions; combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions; and electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions.

DATA COLLECTION AND ANALYSIS

We extracted data using a pre-piloted form and assessed risk of bias using the Cochrane risk of bias tool. We used the GRADE approach to assess the certainty of outcomes and comparisons included in the summary of findings tables. We used an adapted version of GRADE to assess certainty in results where there was no single effect measurement available.

MAIN RESULTS

We identified 25 studies including a total of 3079 participants. Twenty-three studies assessed men who had previously undergone radical prostatectomy or radical retropubic prostatectomy, while only one study assessed men who had undergone transurethral resection of the prostate. One study did not report on previous surgery. Most studies were at high risk of bias for at least one domain. The certainty of evidence assessed using GRADE was mixed. PFMT plus biofeedback versus no treatment, sham treatment or verbal/written instructions Four studies reported on this comparison. PFMT plus biofeedback may result in greater subjective cure of incontinence from 6 to 12 months (1 study; n = 102; low-certainty evidence). However, men undertaking PFMT and biofeedback may be less likely to be objectively cured at from 6 to 12 months (2 studies; n = 269; low-certainty evidence). It is uncertain whether undertaking PFMT and biofeedback has an effect on surface or skin-related adverse events (1 study; n = 205; very low-certainty evidence) or muscle-related adverse events (1 study; n = 205; very low-certainty evidence). Condition-specific quality of life, participant adherence to the intervention and general quality of life were not reported by any study for this comparison. Combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions Eleven studies assessed this comparison. Combinations of conservative treatments may lead to little difference in the number of men being subjectively cured or improved of incontinence between 6 and 12 months (RR 0.97, 95% CI 0.79 to 1.19; 2 studies; n = 788; low-certainty evidence; in absolute terms: no treatment or sham arm: 307 per 1000 and intervention arm: 297 per 1000). Combinations of conservative treatments probably lead to little difference in condition-specific quality of life (MD -0.28, 95% CI -0.86 to 0.29; 2 studies; n = 788; moderate-certainty evidence) and probably little difference in general quality of life between 6 and 12 months (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; n = 742; moderate-certainty evidence). There is little difference between combinations of conservative treatments and control in terms of objective cure or improvement of incontinence between 6 and 12 months (MD 0.18, 95% CI -0.24 to 0.60; 2 studies; n = 565; high-certainty evidence). However, it is uncertain whether participant adherence to the intervention between 6 and 12 months is increased for those undertaking combinations of conservative treatments (RR 2.08, 95% CI 0.78 to 5.56; 2 studies; n = 763; very low-certainty evidence; in absolute terms: no intervention or sham arm: 172 per 1000 and intervention arm: 358 per 1000). There is probably no difference between combinations and control in terms of the number of men experiencing surface or skin-related adverse events (2 studies; n = 853; moderate-certainty evidence), but it is uncertain whether combinations of treatments lead to more men experiencing muscle-related adverse events (RR 2.92, 95% CI 0.31 to 27.41; 2 studies; n = 136; very low-certainty evidence; in absolute terms: 0 per 1000 for both arms). Electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions We did not identify any studies for this comparison that reported on our key outcomes of interest.

AUTHORS' CONCLUSIONS

Despite a total of 25 trials, the value of conservative interventions for urinary incontinence following prostate surgery alone, or in combination, remains uncertain. Existing trials are typically small with methodological flaws. These issues are compounded by a lack of standardisation of the PFMT technique and marked variations in protocol concerning combinations of conservative treatments. Adverse events following conservative treatment are often poorly documented and incompletely described. Hence, there is a need for large, high-quality, adequately powered, randomised control trials with robust methodology to address this subject.

What's in a name? Choosing a title for a female pelvic medicine and reconstructive surgery clinic: A prospective questionnaire

AIMS

A new multidisciplinary clinic specializing in female pelvic medicine and reconstructive surgery (FPMRS) opened at our institution. We sought to assess patient preference in naming this new center, and how readability and word choice informs these preferences.

METHODS

We prospectively surveyed patient preference in naming this new center, as well as patient knowledge and societal perception of pelvic floor disorders. This survey was distributed to female patients presenting to general urology and gynecology clinics.

RESULTS

There were 300 respondents out of 1000 distributed surveys. Patients preferred titles with accessible readability scores and societally neutral vocabulary. Preferred titles for the clinic were at a 6th-grade readability level. Patients preferred neutral titles that included the word "health" and disliked titles that contained the words "pelvic floor" and "dysfunction." In general, survey participants believed that "incontinence" was associated with negative connotations.

CONCLUSION

Readable and neutral vocabulary in the title of the clinic are key components of patient-preferred titles for an FPMRS clinic and affect patient comfort levels in scheduling an appointment.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012.

OBJECTIVES

To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach.

MAIN RESULTS

The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes.

AUTHORS' CONCLUSIONS

Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.

Treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Twelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. BEHAVIOURAL INTERVENTIONS: Three trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide. SPECIALISED PROFESSIONAL INPUT INTERVENTIONS: Two trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care. COMPLEMENTARY THERAPY INTERVENTIONS: Three small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality. PHARMACOTHERAPY AND HORMONAL INTERVENTIONS: There were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62).

AUTHORS' CONCLUSIONS

Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.