Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Bladder training reduced urinary incontinence in older women

ACP J Club. 1991 May-June;114:67. doi:10.7326/ACPJC-1991-114-3-067


Source Citation

Fantl JA, Wyman JF, McClish DK, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA. 1991;265:609-13.


Abstract

Objective

To evaluate the effect of behavioral training in reducing urinary incontinence in older women living in the community.

Design

Randomized controlled trial of 6 weeks duration.

Setting

Ambulatory clinic, not otherwise described.

Participants

131 community-dwelling, mentally intact women (age range, 55 to 90 y) who had at least 1 episode of urinary incontinence a week, and were functionally capable of independent or assisted toileting were recruited, mostly through advertisements (52%) and referrals (23%). Only women with detrusor instability or sphincteric incompetence or both, diagnosed urodynamically, were included. Exclusion criteria were evidence of metabolic decompensation; lower-urinary-tract infection or obstruction; or reversible cause of urinary incontinence. 123 (94%) completed the 6-week trial.

Intervention

Bladder training was based on behavior modification principles and consisted of audiovisual, written, and verbal instruction in self-implementing a schedule of voluntary control of micturition, with progressive increases in the interval between voidings to a goal of 3 hours. Positive reinforcement was offered at weekly clinic visits (n = 65). The control group received no intervention (n = 66) .

Main outcome measures

Participant-reported episodes of urinary incontinence occurring in a 1-week period in standardized diaries; fluid loss was assessed during stress testing.

Main results

After 6 weeks of treatment, the mean number of reported episodes of incontinence had decreased from 21 to 9 per week; episodes for the control group had decreased from 22 to 19 per week (P < 0.001 for difference between groups). Treatment effectiveness was not related to initial urodynamic findings, age, or baseline frequency of incontinence. At the end of the trial, 12% of treated women compared with 3% of control women had no episodes of urinary incontinence, and 75% compared with 24% had reduced the number of incontinent episodes by at least half. Mean quantity of fluid loss during testing was reduced from 37 g to 17 g in the treatment group and increased from 39 g to 47 g in the control group.

Conclusion

Bladder training over a period of 6 weeks reduced the frequency of incontinence and quantity of fluid loss in older ambulatory women.

Sources of funding: National Institute on Aging and National Center on Nursing Research.

Address for article reprint: Dr. J.A. Fantl, SUNY Stony Brook, Department of Obstetrics and Gynecology, HSC-T9-033, Stony Brook, NY 11794, USA.


Commentary

Urinary incontinence among community-dwelling older women has a prevalence between 9% and 42% and causes severe psychosocial and financial burdens. Sphincteric ("stress") incontinence and detrusor instability constitute the principal causes in older women, with the latter becoming increasingly prevalent with advancing age. Previous studies of the effect of behavioral therapy have been based largely on uncontrolled series, which report cure rates of 44% to 97%. In a controlled trial, bladder training was found to be superior to medication (1). The addition of anticholinergics did not augment the benefit of bladder training in a series of women with urge incontinence (2). Biofeedback also is effective but is more complicated and appears to be no better than bladder training (3).

The present study justifies the clinican application of bladder training. Unfortunately, the authors do not provide a detailed description of the educational process, and, because the control group received no intervention, it cannot be determined how much of the results were because of the voiding schedules, the educational interventions, or positive reinforcement during clinic visits. Because bladder training is less expensive and less potentially harmful than medication, it should be a first-line treatment for urinary incontinence after the patient has had appropriate diagnostic evaluation. The diagnosis can usually be made noninvasively from the history and physical examination by the primary care physician (4).

Calvin H. Hirsch, MD
University of CaliforniaSacramento, California, USA


References

1. Jarvis GJ. A controlled trial of bladder drill and drug therapy in the management of detrusor instability. Br J Urol. 1981;53:565-6.

2. Fantl JA, Hurt WG, Dunn LJ. Detrusor instability syndrome: the use of bladder retraining drills with and without anticholinergics. Am J Obstet Gynecol. 1981;140:885-90.

3. Burton JR, Pearce KL, Burgio KL, Engel BT, Whitehead WE. Behavioral training for urinary incontinence in elderly ambulatory patients. J Am Geriatr Soc. 1988;36:693-8.

4. Resnick NM. Noninvasive diagnosis of the patient with complex incontinence. Gerontology. 1990;36(Suppl 2):8-18.