What is the Best Way to Treat Incontinence: Behavioral or Drug Treatment?

Neurourology; Incontinence; Female Urology

REVIEWING THE LITERATURE Neurourology • Incontinence • Female Urology What Is the Best Way to Treat Incontinence: Behavioral or Drug Treatment? Michael B. Chancellor, MD University of Pittsburgh School of Medicine Pittsburgh [Rev Urol. 2000;2(1):30-31] T wo distinctive papers on incontinence management and the possible link between anorexia nervosa and voiding dysfunction are well worth your attention. The first, an important study of nonsurgical treatment of urge and mixed incontinence, was headed by Dr Kathryn Burgio, who is one of the leading practitioners and proponents of bladder behavioral therapy. Dr Burgio and associates concluded that behavioral therapy is better than drug treatment for urge incontinence. Regardless of whether you agree or disagree with the article’s conclusion, it is important to be familiar with the paper. The second is the first report of a possible correlation between voiding dysfunction and anorexia nervosa. women were randomized to one of three treatments for 8 weeks: four sessions (every second week) of biofeedbackassisted behavioral treatment, drug treatment with oxybutynin (2.5 to 5 mg bid), or a placebo-controlled condition. The main outcomes measure was reduction in the frequency of incontinence. Bladder diaries, patients’ perception of improvement, and their comfort and satisfaction with treatment determined outcome. Incontinence was reduced in all three treatment groups, with incontinence reduction most pronounced in the early part of the 8-week study period (Figure). For the behavioral treatment group, there was a mean 80.7% reduction of incontinence episodes. This treatment was significantly more effective than drug treatment, which had a mean Behavioral vs Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial Treatment group 100 Burgio KL, Locher JL, Goode PS, et al. JAMA. 1998;280:1995-2000. Behavior Drug 90 80.7 Placebo 80 30 REVIEWS IN UROLOGY WINTER 2000 70 68.5 60 % This high-powered article is a must-read for anyone interested in the field of urinary incontinence. The study was led by Dr Kathryn Burgio of the division of geriatric medicine at the University of Alabama, Birmingham. The objective of the study was to compare the effectiveness of biofeedback-assisted behavioral treatment with drug treatment and a placebo control condition for the management of urge and mixed incontinence in older communitydwelling women. This article is significant because it is the most quoted article on behavioral therapy since its publication. The article suggests the value of behavioral modification in patients with urge urinary incontinence. For the study, 468 women were screened, and 197 of them (ages 55 to 92 years) were included. Subjects had to have urodynamic evidence of bladder dysfunction, be ambulatory, and have no evidence of dementia. The 50 39.4 40 30 20 10 0 Reduction in urge incontinence Figure. In a study of women with urge and mixed stress and urge incontinence, behavioral treatment was significantly more effective than drug treatment. Both behavioral and drug treatment were more effective than placebo. Incontinence 68.5% reduction. Both behavioral and drug treatment were more effective than the placebo-controlled condition, which yielded a mean 39.4% reduction. Patients perceived that behavioral treatment gave them the greatest improvement. Of patients receiving behavioral treatment, 14% wanted to switch to another treatment, whereas 75.5% of those in each of the other groups wanted to change. The authors concluded that behavioral treatment is a safe and effective conservative intervention that should be made more readily available to patients as a first-line treatment for urge and mixed incontinence. What are some weaknesses of this study? First, drug therapy was used in isolation without any behavioral modification. This is not the common practice of most experts in the field of urinary incontinence that I know. If one gives drug therapy with no behavioral modification, then the best one can hope for is a decrease in the frequency of daily urgency episodes. In addition, leakage may increase, because bladder spasms can occur when the bladder has increased volume. Overall, the biofeedback patients received a lot of face-toface education, while those in the drug and placebo groups were given pills and sent home. I can see how those in the pill and placebo groups may have felt as if they were riding in coach class while those in the biofeedback group had the personal attention of first-class service. Second, only 48.7% of the women had pure urge incontinence, while 51.3% had mixed stress and urge incontinence. Anticholinergic drug therapy would not be expected to have a positive effect on stress incontinence, whereas behavioral modification can benefit patients with both stress and urge incontinence. A better study design would be to look only at women with urge incontinence. Comparison should be between behavioral modification plus drugs and behavioral modification plus placebo. The authors deserve much credit for carrying out this complex study. They have been long-term proponents of biofeedback, and they are simply the best in this field. In my practice, I try to incorporate behavioral therapy in the treatment regimen of every patient with incontinence and use biofeedback frequently. The message I took from this paper is that behavioral therapy for urge incontinence really works. I did not take home the message that behavioral therapy is better than drug treatment. I view behavioral therapy and drugs for overactive bladder as complementary rather than rival treatments. Lower Urinary Tract Symptoms and Their Impact on Women With Anorexia Nervosa Boos K, Hextall A, Cardozo L, et al. Br J Obstet Gynaecol. 1999;106:501-504. This paper is the first report of a possible correlation between voiding dysfunction and anorexia nervosa. And since anorexia is not an uncommon problem affecting younger women, this connection is something that urologists should know about. In a year-long prospective study, 29 women with a history of anorexia nervosa who were enrolled in a rehabilitation program were recruited at a teaching hospital in the United Kingdom. Investigators obtained detailed general, urinary, and gynecologic histories from each participant. The median age of the 28 women was 23.8 years; the mean body mass index was 14. The median duration of absent menses was 4.4 years. The mean duration of anorexia nervosa was 6.6 years. Of the 29 women, 18 (62%) were affected by irritative bladder symptoms. Of the 18 women, 16 associated their symptoms with anorexia nervosa. None of the women had any voiding symptoms before the development of anorexia nervosa and cessation of menses. What were the type and frequency of urinary symptoms? The most common symptom was urinary urgency (62%), followed by frequency (59%), nocturia (52%), urge incontinence (24%), recurrent urinary tract infections (31%), and stress incontinence (7%). The take-home messages of this paper are that irritative urinary symptoms are not uncommon in women with anorexia nervosa and that they can be distressing and disabling. It is suggested that estrogen deficiency is the factor contributing to the voiding dysfunction. Since this study was performed during rehabilitation care, it is unknown whether successful treatment for anorexia nervosa will result in a reversal or cure of these voiding symptoms. ■ WINTER 2000 REVIEWS IN UROLOGY 31