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BMJ 2008; 337 doi: (Published 12 August 2008) Cite this as: BMJ 2008;337:a1260

Adding behavioural therapy to drug treatment brings no long term benefit in urge incontinence

Behavioural therapy and antimuscarinic drugs are both effective treatments for urge incontinence, but few patients achieve full continence with either treatment. In a multicentre trial, 237 women either took tolterodine tartrate alone or in addition to behavioural therapy, which taught them exercises and strategies to prevent urge incontinence. After 10 weeks, more women randomised to the combined treatment reported 70% or greater reduction in frequency of incontinence episodes compared with baseline (69% v 58%; difference 11 percentage points, 95% CI −0.3 to 22.1) than those taking the drug only. However, no difference was seen eight weeks after the treatments were stopped—41% of women in both groups were free of any treatment and still reported 70% or greater reduction of episodes. Women who received combined treatment were more satisfied and reported better perceived improvement, although health related quality of life was comparable between the groups.

Two factors may explain the lack of effect. Women in the drug-only group were exposed to components of behavioural therapy—they were asked to keep daily bladder diaries and received recommendations for fluid management. Also, behavioural therapy should ideally be conducted in a context similar to that in which new motor skills will later be performed—that is, without drug treatment. Still, the authors conclude that optimal treatment might be to adopt a stepped approach, where one intervention is started and a second one is added if a satisfactory outcome is not achieved.

Hope for treating extensively drug resistant tuberculosis

Extensively drug resistant tuberculosis, defined as resistance to rifampicin, isoniazid, and at least one fluoroquinolone and one injectable agent, has been associated with poor treatment outcomes in both poor and rich countries. At worst it has been deemed potentially untreatable.

Hope now comes from a retrospective study from Peru, where good treatment outcomes were achieved in 29 of 48 (60%) patients with extensively …

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