https://immattersacp.org/weekly/archives/2019/03/19/1.htm

Behavioral therapy appears more effective than pharmacologic therapy for urinary incontinence outcomes

The systematic review and network meta-analysis compared first-, second-, and third-line pharmacologic and nonpharmacologic interventions for improvement or cure of stress, urgency, or mixed incontinence.


Behavioral therapy, alone or with other interventions, is more effective than pharmacologic therapy alone for stress and urgency urinary incontinence, according to a systematic review and network meta-analysis.

Researchers reviewed studies published through Aug. 10, 2018, to compare the effectiveness of pharmacologic and nonpharmacologic interventions for improvement or cure of stress, urgency, or mixed urinary incontinence in women who were not pregnant. Included studies had a follow-up period of at least four weeks and reported categorical symptomatic cure, improvement, or satisfaction after treatment, as well as quality-of-life score after treatment and treatment-related adverse events. The results of the network meta-analysis were published March 19 by Annals of Internal Medicine.

Of the 84 included studies, 32 examined stress incontinence, 16 examined urgency incontinence, 4 examined mixed incontinence, and 32 examined any or unspecified incontinence. Behavioral therapies, anticholinergic agents, and neuromodulation were the most commonly evaluated active interventions. In network meta-analysis, all interventions besides hormones and periurethral bulking agents were more effective than no treatment for at least one favorable incontinence outcome. For stress incontinence, behavioral therapy was more effective than alpha-agonists or hormones for cure or improvement, alpha-agonists were more effective than hormones for improvement, and neuromodulation was more effective than no treatment for cure, improvement, and patient satisfaction. For urgency incontinence, a statistically significant difference was seen in favor of behavioral therapy versus anticholinergics for cure or improvement. In addition, neuromodulation and onabotulinum toxin A were more effective than no treatment, and onabotulinum toxin A may have been better than neuromodulation for cure.

The researchers noted that direct evidence for treatment comparisons was scarce and that incontinence type and severity as well as treatment history varied among trial populations. However, they said their results lead to four main conclusions for clinical management of urinary incontinence:

  1. 1. Most active interventions, with the possible exceptions of hormones and periurethral bulking agents, outperform sham or no treatment.
  2. 2. Behavioral interventions, alone or in combination with other interventions, are in general more effective than first- and second-line monotherapies for both stress and urgency incontinence.
  3. 3. Second-line pharmacologic treatments are less effective than behavioral therapy and are associated with such side effects as dry mouth, nausea, and fatigue when used alone.
  4. 4. Third-line interventions, such as neuromodulation and onabotulinum toxin A, are more effective in general than other approaches.

“Large gaps remain in the literature regarding comparisons of individual interventions and subgroup analyses,” the authors wrote. “For clinicians, patients, and payers to make informed decisions, specifically regarding patient subgroups with sparse evidence, new evidence is needed from studies comparing interventions.”