Bladder Training for Urinary Incontinence

Comment: The quality of evidence is downgraded by imprecise results (wide confidence intervals) and study limitations (lack of blinding).

Bladder training is suggested for women with overactive bladder and urinary incontinence along with pelvic floor muscle training.

The recommendation is weak because the evidence is low. However, training is cheap and harmless and improvement in urinary incontinence is a patient important outcome for most women. Values and preferences probably vary.

Twelve trials were included in the update of a Cochrane review [Abstract] 1, with a total of 1473, predominantly female patients. In 4 trials not all participants with overactive bladder had urinary incontinence, hence data from 8 trials with 858 participants with urinary incontinence is included.

Bladder training vs. no bladder training

• Three trials (n=172) with varying prespecified outcomes. Point estimates of effect favoured bladder training; however, confidence intervals were wide and no statistically significant differences were found for primary outcome variables.

Bladder training vs. other treatments

• Three trials (n=159) compared bladder training with drugs: 2 with oxybutynin and one with imipramine plus flavoxate. In the former, the only outcomes demonstrating a statistically significant difference were participant's perception of cure at six months (RR 1.69; 95% CI 1.21 to 2.34), quality of life (WMD 9.00; 95% CI 1.64 to 16.36) and adverse events, all favouring bladder training. In the latter trial, participant's perception of cure immediately after treatment just achieved statistical significance (RR 1.50; 95% CI 1.02 to 2.21) favouring bladder training, and this difference was maintained at approximately two months post treatment. One comparison of bladder training with pelvic floor muscle training plus biofeedback included 164 women: none of the differences in the primary outcomes achieved statistical significance.

Combination of bladder training with another treatment vs. other treatment alone

• Two trials including 331 participants compared the combination of bladder training plus an anticholinergic drug with the drug alone. For the largest trial, data for only one prespecified outcome were available: the median number of incontinent episodes was the same for both treatment groups. One trial (n=125) compared pelvic floor muscle training plus biofeedback supplemented with bladder training versus pelvic floor muscle training plus biofeedback alone. Of the primary outcomes both participants' perception of improvement and quality of life, both immediately after treatment, achieved statistical significance, favouring the bladder training combined with pelvic floor muscle training and biofeedback group (perception of improvement: RR 1.18; 95% CI 1.01 to 1.39; quality of life: MD -47.20; 95% CI -87.03 to -7.37), this was not sustained at three months.

A randomized controlled trial 3 assessed whether bladder training (BT) combined with high-intensity pelvic floor muscle training (BT + PFMT) results in better outcomes in the short term than BT alone on female urinary incontinence (UI). 108 women with diagnoses of stress UI (SUI, n = 50), urgency UI (UUI, n = 16), or mixed UI (MUI, n = 42) randomly assigned to 6 weeks of BT + PFMT or BT alone (control group). The primary outcome measure was self-reported improvement. Overall and in the SUI and MUI subgroups, significantly more patients in the BT + PFMT group reported cured and improved symptoms. Overall and in SUI patients, the BT + PFMT group also improved to significantly greater degree in UI severity, symptom distress, QOL, daily UI episodes, and pelvic floor muscle strength and endurance. The only parameter showing more improvement in patients with UUI was QOL, and UI severity in patients with MUI (p < 0.05).

Another systematic review 2 including 15 RCTs with a total of 838 subjects was abstracted in DARE. According to the authors, there was strong evidence that bladder retraining was more effective than placebo, and weak evidence that bladder retraining is more effective than no treatment and drug treatment.

References

• Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev 2004;(1):CD001308. [PubMed]
• Berghmans LC, Hendriks HJ, De Bie RA, van Waalwijk van Doorn ES, Bø K, van Kerrebroeck PE. Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU Int 2000 Feb;85(3):254-63. [PubMed] [DARE]
• Kaya S, Akbayrak T, Gursen C et al. Short-term effect of adding pelvic floor muscle training to bladder training for female urinary incontinence: a randomized controlled trial. Int Urogynecol J 2015;26(2):285-93. [PubMed]