Clinical Context

Urinary incontinence affects approximately 17% of nonpregnant women, and it can have severe effects on women’s quality of life and function. Pelvic floor muscle training (PFMT) is frequently recommended for women with mild to moderate UI, but is it effective? Dumoulin and colleagues performed a systematic review and meta-analysis, which was published in the October 4, 2018 issue of the Cochrane Database of Systematic Reviews,^[1] to answer this question.

The review included 31 studies, which enrolled a total of 1817 women. Rates of cure in the PFMT and control groups at the end of treatment among women with stress urinary incontinence (SUI) were 56% and 6% [risk ratio (RR) 8.38; 95% CI, 3.68-19.07]. The respective RR among women with any UI was 5.34 (95% CI, 2.78-10.26). Pelvic floor muscle training was associated with approximately one less urinary leakage episode per day compared with control therapy, and PFMT was associated with a significant reduction the volume of urine leaked. Women were more satisfied with PFMT vs control therapy.

The current study by Balk and colleagues compared behavioral therapy with pharmacotherapy and more invasive treatment for UI among women.

Study Synopsis and Perspective

Behavioral therapy is as good as, and in some cases may be better than, medication alone for treating UI in women, according to a network meta-analysis.

The study also found that hormones and periurethral bulking agents may not be much better than no treatment at all.

The results, published online on March 19 in the Annals of Internal Medicine,^[2] confirm past systematic reviews and are consistent with international guidelines.

"[B]ehavioral therapy, alone or combined with other interventions, is generally more effective than other first- and second-line monotherapies for both [SUI] and [UUI]," wrote Ethan Balk, MD, MPH, of Brown University School of Public Health, Providence, Rhode Island, and colleagues.

Medications have the disadvantage of bothersome adverse effects, such as dry mouth, nausea, and fatigue.

Many women experience UI, especially if they are older or have had children. The condition can have wide-ranging effects on physical, psychological, and social well-being. Restrictions in lifestyle are not uncommon.

To compare the effectiveness of treatments for UI, researchers searched 6 databases, without language restriction, from inception to August 2018. Ultimately, their meta-analysis included 84 randomized controlled trials of nonsurgical therapies for UI in nonpregnant women. All trials had a minimum follow-up of 4 weeks. Urinary incontinence was classified as SUI (involuntary loss of urine with physical exertion, sneezing, or coughing) or urge (UUI) (compulsion to urinate that cannot be delayed). Cure was defined as resolution of incontinence, not necessarily a permanent cure of the underlying problem.

Among first- and second-line interventions for SUI, α agonists alone and hormones alone were no different from no treatment for achieving cure (odds ratio [OR]=1.22 [95% CI: 0.61, 2.45], moderate strength of evidence [SOE]; OR=2.89 [95% CI: 0.76, 11.0], low SOE, respectively).

Behavioral therapy was more effective than α agonists alone for achieving cure (OR=2.50 [95% CI: 1.19, 5.28], moderate SOE).

Indirect evidence suggested that adding behavioral therapy to hormone therapy was also more effective than α agonists alone for achieving cure (OR=3.62 [95% CI : 0.98, 13.4], moderate SOE).

For improving SUI, behavioral therapy was more effective than either hormones alone (OR=10.2 [95% CI: 3.61, 28.9], moderate SOE) or α agonists alone (OR=2.5 [95% CI: 1.39, 4.5], moderate SOE).

Among third-line interventions for SUI, neuromodulation was more effective than no treatment for achieving cure (OR=3.34 [95% CI: 2.12, 5.26], high SOE). In contrast, intravesical pressure release and periurethral bulking were generally not effective for achieving cure or improvement.

Among first- and second-line interventions for UUI, behavioral therapy was significantly more effective than anticholinergics alone for achieving cure (OR=1.57 [95% CI: 1.02, 2.43], high SOE).

Among third-line interventions for UUI, Botox and neuromodulation were more effective than no treatment for achieving cure (OR=5.66 [95% CI: 2.8, 11.4], high SOE; OR=3.34 [95% CI: 2.12, 5.26], high SOE, respectively).

The authors noted that most studies showed low or moderate risk for bias. The analyses were limited by few head-to-head comparisons and by differences across studies with respect to severity of UI and past treatment.

The study was funded by the Agency for Healthcare Research and Quality of the US Department of Health and Human Services. The authors have disclosed no relevant financial relationships.

Clinical Implications

• A previous meta-analysis by Dumoulin and colleagues found that PFMT was associated with a rate of cure for SUI in excess of 50%, and PFMT was substantially more effective in this outcome vs control treatment. Pelvic floor muscle training was also associated with reduced urine leakage and stronger patient satisfaction.
• The current meta-analysis by Balk and colleagues suggested that behavioral therapy is superior to drug therapy in the treatment of UI among women. Periurethral bulking agents and α agonists appear ineffective in the treatment of UI.
• Implications for the Healthcare Team: Women with UI should be considered for behavioral therapy before more invasive interventions.

CME Test