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Behavioural therapy is often more effective than drugs for urinary incontinence in women, finds review

BMJ 2019; 364 doi: (Published 18 March 2019) Cite this as: BMJ 2019;364:l1223
  1. Susan Mayor
  1. London

Behavioural therapy to strengthen the pelvic floor or to change behaviour influencing bladder function, with or without other treatment, is generally more effective than drugs in treating stress or urgency urinary incontinence in women, a review of randomised trials has found.

Urinary incontinence affects nearly one in five (17%) non-pregnant women, and the prevalence increases with age, particularly after the menopause. The most common types are stress or urgency urinary incontinence, or a mix of both types.

A range of non-pharmacological and drug treatments are available, with evidence supporting their use either alone or in combination compared with no intervention. They differ greatly, however, in their potential adverse events.

To compare the efficacy of available non-surgical treatments for urinary incontinence in more detail researchers carried out a systematic review and network meta-analysis of randomised clinical trials reporting clinical outcomes.1

The study, reported in Annals of Internal Medicine, identified 84 trials evaluating 14 categories of interventions, most commonly behavioural therapies, anticholinergics, and neuromodulation.

Researchers assessed the strength of evidence using the Agency for Healthcare Research and Quality measures for grading a body of evidence, including the number of studies, the designs of studies, the consistency of results, likelihood of bias, and limitations.

Results analysing clinical outcomes showed that behavioural therapy was statistically significantly more effective than anticholinergics in achieving cure or improvement of urgency urinary incontinence (high strength of evidence). Both neuromodulation and onabotulinum toxin A were more effective than no treatment (high strength of evidence).

For stress incontinence, behavioural therapy was more effective than either α-agonists or hormones in achieving cure or improvement (moderate strength of evidence).

“Behavioural therapy, alone or combined with other interventions, is generally more effective than other first and second line monotherapies for both stress and urgency urinary incontinence,” said the researchers, led by Ethan Balk, from Brown University School of Public Health in Providence, Rhode Island, USA.

They added, “Besides being less effective than behavioural therapy . . . pharmacological treatments, when used alone, are associated with non-serious but bothersome adverse events, such as dry mouth, nausea, and fatigue.”

But they cautioned, “Large gaps remain in the literature regarding comparisons of individual interventions and subgroup analyses.”

Overall, the researchers noted that their study, which was funded by the US Agency for Healthcare Research and Quality and the Patient-Centered Outcomes Research Institute, showed that most active interventions were better than sham or no treatment, with the possible exception of hormones or periurethral bulking agents.


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