Furthermore, subjects were self-selected: They chose to continue with an additional 8 weeks of therapy after their initial suboptimal outcome. It is possible that some subjects who were neither totally continent nor completely satisfied with initial therapy chose not to continue with the crossover segment of the trial because it posed too great a burden or because they were discouraged with the initial degree of improvement.
Generalizing these results to all older women with UUI is difficult. The authors point out, however, that, in practice, patients may be more likely than not to choose combination therapy in the hope of shortening the duration of medical therapy. Although it isn’t known whether providing combination therapy from the outset would have yielded better outcomes than either single therapy did, the authors hypothesize that initial combination therapy may result in greater improvement because patients have a high level of motivation and expectation of improvement at the beginning of treatment.
Importance of this article. The investigators demonstrated that a combination of behavioral and drug therapies can provide increased effectiveness in patients for whom each treatment alone led to suboptimal satisfaction. Furthermore, by targeting women older than 55 years, the investigators were able to demonstrate this effectiveness in a group for whom pelvic-floor training may be more difficult than it is for younger women.
It will be interesting to see if future research will 1) validate these findings and 2) determine whether combined therapy can reduce the duration of drug therapy in this older population through behavioral modification and pelvic floor reeducation.
6 tenets of behavioral therapy for urge urinary incontinence
Fluid management
This first-step therapy can involve providing a handout to the patient that details techniques she can use to monitor and control her fluid intake in a manner that addresses her problem. Among such steps:
- avoiding caffeine and artificial sweeteners
- tracking her diet to identify any other bladder irritants
- limiting fluids before times she is more likely to be incontinent—during a long drive, for example, or, in the case of nocturia, after the evening meal.
Scheduled voiding
With scheduled, or prompted, voiding, the patient empties her bladder at a set interval—usually, every 1.5 to 2 hours. If nocturia, or the more severe enuresis, is a problem, the patient can be prompted by an alarm clock or (if she is institutionalized) by nursing staff. Combining scheduled voiding with fluid management principles helps the patient avoid reaching a bladder volume at which an episode of incontinence becomes more likely.
Bladder training
This is a modification of scheduled voiding that attempts to establish a normal voiding interval in patients who have significant frequency but a small voided volume. It imposes a regimented voiding schedule that gradually (over 7 to 10 days) extends the duration between voids.
Pelvic floor-muscle exercises
The focus here is on using pelvic-floor muscles to prevent incontinence. The muscles are strengthened by having the patient perform Kegel exercises (named for Arnold H. Kegel, MD, who, in 1948, recognized the role of pelvic floor-muscle rehabilitation in the treatment of incontinence). The exercises involve simultaneous 1) contraction of the pelvic and periurethral musculature and 2) relaxation of other muscles, including abdominal muscles, which can increase pressure on the bladder.
Once the patient learns to perform Kegel exercises, she can use them to suppress urgency: Instead of hurrying to the bathroom when urgency arises, she is encouraged to sit down, relax, and contract the pelvic-floor muscles repeatedly until the urge to void diminishes. Once it does, the patient proceeds to the toilet to void normally.
Pelvic exam
By self-exam, the patient can identify and familiarize herself with her purposeful contractions of the pelvic-floor musculature and thereby strengthen those muscles with effective exercise.
Biofeedback
Direct feedback about contractions of the pelvic-floor muscles—by a display of data on a gauge or computer monitor, gathered using an intravaginal or anorectal sensor or probe—allows a patient who is exercising those muscles to better target her efforts and maximize their effectiveness.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Combining behavioral therapy and an anticholinergic medication for urge urinary incontinence may yield a superior result after either modality alone has been disappointing by the patient’s account of success.—JOHN P. JUDD, MD, AND CINDY L. AMUNDSEN, MD
Does oxybutynin for UUI further erode cognition in elderly women who are cognitively impaired?
Lackner TE, Wyman JF, McCarthy TC, Monigold M, Davey C. Randomized, placebo-controlled trial of the cognitive effect, safety, and tolerability of oral extended-release oxybutynin in cognitively impaired nursing home residents with urge urinary incontinence. J Am Geriatr Soc. 2008;56:862–870.
Although anticholinergic therapy is modestly effective against UUI in nursing home residents, past studies have suggested that such treatment can impair, or further impair, cognition in this population—a concern that may lead to underuse. This double-blinded, randomized, placebo-controlled trial compared short-term oral extended-release oxybutynin with placebo.