Both behavioral treatment and drug therapy have been shown to be effective treatments for urge incontinence in older women, but neither has proven to be completely satisfactory for all patients. In this study, women who had completed treatment with either behavior training or drug therapy were treated with the alternative regimen to investigate the benefits of combination therapy.
One hundred ninety-seven mentally and physically competent women with at least two documented urge accidents per week and urodynamic evidence of bladder dysfunction served as study subjects. They were randomly assigned into one of three groups for treatment with behavioral training, drug therapy, or placebo (control subjects). All women were seen in the clinic every 2 weeks for 8 weeks and kept a daily bladder diary.
Behavioral training consisted of four sessions of biofeedback-assisted behavioral training for 8 weeks. Drug treatment was initiated with 2.5 mg TID of oxybutynin chloride, and this dosage was increased until satisfactory control was achieved. After completion of the first 8 weeks of treatment, women who had not obtained complete continence or who were not satisfied with the results of their treatment were offered the alternative regimen. The daily diaries indicated an 81 percent reduction in incontinence in the behavioral treatment group, a 69 percent reduction in the drug group, and a 39 percent reduction in the control group. Eight women (13 percent) who underwent behavior training added drug therapy to their regimen for an additional 8 weeks. In these patients, the reduction in incontinence improved from 58 percent to 89 percent (P = .034). Twenty-seven women (42 percent) in the drug therapy group added behavioral training to their treatment, and the reduction in incontinence improved from 73 percent to 84 percent (P = .001). Nineteen patients with a 59 percent incontinence reduction with drug treatment alone stopped drug treatment and underwent behavioral training alone. Reduction improved to 77 percent. More than half of the women in the placebo group (55 percent) underwent behavioral training after the first 8 weeks. The reduction in incontinence improved from 23 percent to 64 percent (P = .002) in this group. The 10 women who chose drug therapy achieved a 77 percent reduction of incontinence (P = .012).
J Am Geriatr Soc 2000;48:370-374
(The 1996 Clinical Practice Guidelines for Urinary Incontinence developed by the Agency for Health Care Policy and Research list behavioral treatment and anticholinergic drug therapy as first-line management options for incontinence due to detrusor dysfunction. Behavioral modification, or bladder training, has many theoretical advantages, including active involvement of the woman in the rehabilitation process, the idea that there is no medicine and thus no disease, and reduced cost because there is no continuing cost of long-term medication. Fantl has reviewed the techniques of pelvic muscle rehabilitation, which is an extension of Kegel exercises incorporating biofeedback to allow the patient to observe the amplitude and duration of the pelvic muscle contraction (Urology 1998;51(Suppl 2A):30). He contrasts pelvic muscle rehabilitation, which has been largely used in the treatment of women with genuine stress incontinence, with bladder training, a true behavioral modification technique that includes adoption of a specific voiding schedule and techniques for managing symptoms of urgency. These techniques have been more frequently used in patients with detrusor dysfunction.
In a previous randomized study, these authors compared pharmacologic therapy (Ditropan) with a comprehensive bladder retaining program that included both pelvic muscle rehabilitation and bladder training techniques (Burgio et al., JAMA 1998;280:1995). In women with urge incontinence, the placebo-treated group experienced a 40 percent decrease in symptoms of urinary incontinence, whereas those treated with Ditropan reported a 69 percent reduction and those treated with behavioral techniques had an 81 percent reduction of incontinence. In a series of women with various types of urinary incontinence, Wyman et al. found that a combination of bladder training and pelvic muscle rehabilitation exercises was more effective than either approach used separately; however, 3 months after the program was stopped, the improvement seen in the combination therapy group was lost (Am J Obstet Gynecol 1998;179:999).
In the study abstracted above, the authors used a combination of drugs and a vigorous program of bladder training and pelvic muscle exercises in women with urge incontinence who had just completed their earlier randomized study. They were able to show that the addition of the second treatment modality further increased the improvement in symptoms of incontinence. All groups reported >80 percent reduction in incontinence episodes.
But, the behavioral modification and pelvic muscle exercise program is demanding and time consuming. Training consists of four sessions over 8 weeks and home exercises, including 45 pelvic floor muscle exercises daily. It has not been shown that this degree of participation and symptomatic improvement can be sustained over any length of time. Nevertheless, the cost and side effects of medications for urinary incontinence due to detrusor dysfunction make bladder training techniques an attractive alternative for some women, and it seems that a combination of both approaches can produce added benefits, at least over the short term.-HWJ III)