Baigis-Smith et al26 investigated the influence of behavioral intervention in 54 patients who received pelvic floor biofeedback without measuring the abdominal pressure as in previous studies. Patients had to relax and contract their pelvic floor 50 times for 10 seconds, 3 times a day, until they experienced improvement. The number of urinary accidents reduced from 17.4 times a week to 4.2 times a week for stress, urge, and mixed incontinence.
TABLE 2
Effect of behavioral therapy in the elderly with urinary incontinence
| Study, quality scores | N* (% men), dropouts | Population, age UI (mean, SD) | Definition of (type of incontinence | Intervention + duration of intervention (design) | Measurements and outcomes† |
|---|---|---|---|---|---|
| Baigis-Smith26 (1989), 3/3 | 54 (17%), 0 | General population 60–86 (74.4 ± 7.2) | At least once every 2 weeks (SI, UI, MI by history) | PFE and bio-feedback until improvement (B–A) |
|
| Burgio24 (1985), 3/2.5 | 39 (23%) 0 | General population, 65–86 (74.4 ± 7.2) | At least once a month (urodynamic SI, UI, DI) | Bladder and sphincter biofeed-back 2–4 times weekly, 1–8 ses-sions depending on progress (B–A) |
|
| Fantl25 (1991), 4.5/4.5 | 123 (0%) 0 | General population, 55–90 (67 ± 8) | Not given (urodynamic UI, SI, or MI) | Bladder training/control for 6 weeks (RCT) |
|
| McDowell22 (1992), 3/3 | 29 (7%), 18 | Self-referred to incontinence program or referred by physicians/geeriatricians, 56–90 (74.6 ± 8.1) | At least once every 2 weeks for at least 3 months (SI, UI, MI in bladder diary) | Bladder-sphincter biofeedback twice weekly, duration depanding on the patient’s progress and abilities,average 5.6 sessions (B-A) |
|
| McDowell23 (1999), 5/5 | 93 (10%), 10 | Individuals with incontinence were identified from 2 large HHA and asked to par-ticipate, 60–97 (76.7 ± 7.2) | At least twice a week for at least 3 months (SI, UI, MI in bladder diary) | Bladder-sphincter biofeedback weekly/placebo (crossover) for 8 weeks (RCT) |
|
| * N = number of completers | |||||
† Measurements and outcomes are:
| |||||
| SD, standard deviation; SI, stress incontinence; UI, urge incontinence; MI, mixed incontinence; B-A, before-after; RCT, randomized controlled trial; PFE, pelvic floor exercise; HHA, home health agency | |||||
Discussion
Conservative therapy effective
This review discusses 3 types of behavioral therapy for urinary incontinence: bladder training for urge incontinence (sometimes in combination with pelvic floor exercises), pelvic floor exercises for stress incontinence, and both for mixed incontinence. All 3 types of behavioral therapy reduced urinary accidents in the elderly.
Remarkable is the conclusion of Fantl et al25 that bladder training is also effective for stress incontinence alone. In almost all previous studies on the effectiveness of bladder training, patients with stress incontinence were excluded. More research is needed before we can recommend this therapy for stress incontinence.
Few studies met our methodological quality criteria. The selected studies were difficult to compare because of differences in treatment, methods, and outcomes. For that reason, more research with standardized outcome measures can help establish the relative effectiveness of behavioral therapy—with or without biofeedback—and to evaluate the effect of each therapy in different types of incontinence.
We found 2 methodologically good surveys about the effect of pharmacotherapy in elderly with urinary incontinence. Just 1 study focused on the effect of anticholinergic agents on urge incontinence and mixed incontinence; it found these agents less efficacious than behavioral therapy but better than placebo.
We also found 1 study on alpha-adrenergic agents for stress or mixed incontinence—their ability to reduce urinary accidents seemed comparable with pelvic floor exercise. The weakness of this study was the lack of a control group.
It was remarkable, however, that pelvic floor exercise was less efficacious compared with the other studies. We need more doubleblinded randomized controlled trials to prove clinical efficacy of pharmacology in the elderly with urinary incontinence. In studies with a younger population, anticholinergic agents seem to be effective for urge incontinence, but the effect of adrenergic agents in a younger population is unclear, and has never been investigated in men.27-29
Conclusion
Conservative therapy is effective for elderly patients with stress, urge, or mixed incontinence. Given the effectiveness of behavioral therapy, the absence of the side effects, and its low cost and ease of practice at home, we recommend it as the therapy of choice for urge incontinence in the elderly. We propose pharmacotherapy as second-line therapy for urge incontinence. Surgical treatment should be reserved for those who doo not respond to either of these.