Treating urinary incontinence in the elderly—conservative measures that work: A systematic review
Results of drug and behavioral therapy
In 3 studies, the effect of medication alone or in combination with behavioral therapy was examined (Table 1).
Biofeedback is superior. Burgio et al19 studied the effect of bladder-sphincter biofeedback vs oxybutynin and placebo in 190 women with urge or mixed incontinence. Oxybutynin is an anticholinergic drug that reduces detrusor muscle contractions. Anorectal biofeedback helped patients sense pelvic muscles and taught them how to contract and relax these muscles selectively while keeping abdominal muscles relaxed. Patients were taught not to rush to the toilet as a response to the bladder sensation but relax the whole body and contract the pelvic floor. The reduction of urinary accidents in the daily bladder report was significant. This effect was significantly better in the bladder-sphincter biofeedback group compared with the drug group; the drug group had results significantly better than the placebo group.
Success with augmented therapies. Subsequently, researchers offered the patients who were not completely dry to participate in an extension study, which added drug therapy for those in the behavioral therapy group and vice-versa.20 Thirty-five women participated in this study. Both groups had additional significant reductions in urinary accidents as documented in the bladder diary.
Pelvic floor exercises helpful. Wells et al21 compared 6 months of pelvic floor exercises without biofeedback with 2 weeks of phenylpropanolamine hydrochloride, an alpha-adrenergic agonist. (Note that in the US this product has been taken off the market.) Alpha-adrenergic agents stimulate the receptor located in the urethra, increasing urethral pressure. The subjects were 115 women with urodynamic mixed or stress incontinence.
The reduction in urinary accidents was similar in both groups—48% and 53%, respectively. Also the subjective improvement was similar. Only the digital test of pelvic floor muscle strength was significantly better in the pelvic floor exercise group.
TABLE 1
Effect of medication and exercises on urinary incontinence in the elderly
| Study, quality scores | N*, (drop-outs) | Population, age (mean, SD) | Definition of incontinence | Intervention and duration (design) | Measurements and outcomes† |
|---|---|---|---|---|---|
| Burgio19 (1998), 7.5/7 | 190 (7) | General, 55–92 (69.3 ± 7.9) | At least 2 urge accidents per week for 3 months (urodynamic predominant UI) | Bladder-sphincter bio-feedback twice weekly; 2.5 mg oxybutynin 3 times daily; placebo weeks (RCT) |
|
| Burgio20 (2000), 3/3 | 35 (0) | Subjects not dry or not satisfied after 1 intervention (1998 study), 55–91 (67.7 ± 7.5) | Not given | If behavorial training alone in 1998 study, added drug therapy; if drug therapy alone in study, added behavorial therapy for 8 weeks (B-A) |
|
| Wells21 (1991), 3.5/3 | 115 (38) | Open population, 55–66 (66 ± 8) | Urinary loss of any degree (urodynamic SI, UI, or MI) | PFE for 6 months or 100 mg/d for 2 weeks (RCT) |
|
| * N includes no men | |||||
| † Measurements and outcomes are: | |||||
| |||||
| SD, standard deviation; SI, stress incontinence; UI, urge incontinence; MI, mixed incontinence; RCT, randomized controlled trial; B-A, before-after; PFE, pelvic floor exercise; PPA, phenylpropanolamine | |||||
Results of behavioral therapy only
Five studies focused on the effect of behavioral therapy only (Table 2). Three surveys studied the effect of bladder-sphincter biofeedback, 1 the effect of bladder training without biofeedback, and 1 the effect of pelvic floor exercises with biofeedback.
McDowell et al22,23 used anorectal biofeedback, demonstrating the abdominal pressure and pelvic floor activity to teach patients to relax abdominal muscles selectively and contract/relax the pelvic floor in case of stress, urge, and mixed incontinence. The home exercises consisted of 10 to 15 contractions of the pelvic floor muscles for 10 seconds, followed by an equal period of relaxation in a lying, standing, and sitting position 3 times a day.
They also taught urge strategies. Patients were taught not to rush to the toilet but to relax the whole body, contract the pelvic floor, and increase their voiding interval until they achieved an interval of 2 to 3 hours.
In Burgio et al,24 researchers filled the bladder after voiding; this taught patients to be aware of bladder contractions before they felt any bladder sensation, and to relax the abdominal muscles, contract the pelvic floor, and try to diminish the bladder pressure.
The conclusion of all 3 studies was that bladder-sphincter biofeedback reduced the urinary accidents for stress, urge, and mixed incontinence significantly.
Fantl et al25 examined the effect of bladder training in 123 women with urge incontinence. They were asked to increase their voiding interval until a schedule of once every 3 hours was achieved, or they were admitted to a control group without intervention. Bladder training reduced the urinary accidents significantly for all 3 types of urinary incontinence.
