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What Are Alternatives to Medications for Incontinence?

  • Authors: News Author: Veronica Hackethal, MD; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 5/3/2019
  • Valid for credit through: 5/3/2020, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care physicians, obstetricians/gynecologists, geriatricians, nurses, pharmacists, and other clinicians on the healthcare team  who care for women with urinary incontinence (UI).

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Assess the efficacy of pelvic floor muscle training (PFMT) for UI among women
  • Compare different treatments for UI among women
  • Outline implications to the healthcare team


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News Author

  • Veronica Hackethal, MD

    Freelance writer, Medscape LLC


    Disclosure: Veronica Hackethal, MD, has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Genentech; GlaxoSmithKline
    Served as a speaker or a member of a speakers bureau for: Shire

Editor/CME Reviewer

  • Esther Nyarko, PharmD

    Associate CME Clinical Director, Medscape, LLC


    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

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What Are Alternatives to Medications for Incontinence?

Authors: News Author: Veronica Hackethal, MD; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 5/3/2019

Valid for credit through: 5/3/2020, 11:59 PM EST


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.

Study Highlights

  • The current study updated a previous review conducted in 2012. Researchers considered studies of ≥4 weeks’ duration which compared active treatment for UUI, SUI, or mixed incontinence with a control treatment. All included research had to report on the efficacy or adverse events of treatment, with cure or symptom improvement of particular interest.
  • 723 abstracts were accepted for review, and 110 new studies were combined with 134 articles analyzed in the 2012 review. The risk for bias was low or moderate in 85% of the included research.
  • The median sample size was 85 women, and the median age of participants was 55 years; 38% of studies focused on women with SUI, and 19% featured women with UUI; 5% of studies included women with mixed UI, and the remainder either included any UI or did not specify their inclusion criteria.
  • Behavioral therapy achieved an OR for cure of SUI of 3.06 (95% CI: 2.16, 4.35) compared with no treatment, and the respective OR for behavioral therapy plus hormones was 4.43 (95% CI: 1.42, 13.8).
  • Alpha-agonists and hormones alone were not associated with significant improvement in cure rates of SUI.
  • Neuromodulation and intravesical pressure release (IVPR) were associated with higher rates of cure of SUI compared with control treatment, but periurethral bulking agents were not.
  • The OR for improvement in SUI in comparing behavioral therapy with control treatment was 5.4 (95% CI: 3.6, 8.08). There was moderate SOE that behavioral therapy was superior to α agonists and hormones in this outcome.
  • Neuromodulation and IVPR also improved symptoms of SUI, but periurethral bulking agents did not.
  • The ORs for cure of UUI for behavioral therapy and anticholinergic agents vs. control therapy were 3.06 (95% CI: 2.16, 4.35) and 1.95 (95% CI: 1.32, 2.88). There was good evidence that behavioral therapy was superior to anticholinergic therapy in this outcome.
  • Botulinum toxin and neuromodulation were also more effective than control treatment in improving the rate of cure from UUI.
  • Beyond cure, behavioral therapy also appeared more effective than anticholinergic therapy in improving symptoms of UUI.

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.

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