Self-Monitoring Techniques May Be Effective for Urinary Incontinence in Women

Laurie Barclay, MD

May 11, 2007

May 11, 2007 — Self-monitoring techniques are effective for treating urinary incontinence in women, according to a presentation at the American Geriatrics Society (AGS) annual meeting held in Seattle, Washington.

"Uncomplicated self-monitoring techniques, selected appropriately using a bladder diary, have been shown to reduce urine loss and improve quality of life," principal investigator Jean E. Kincade, PhD, formerly from the University of North Carolina at Chapel Hill, told Medscape. "Healthcare professionals should consider teaching these techniques as first steps to treat women with urinary incontinence."

Earlier studies have suggested that urinary incontinence may respond to simple, noninvasive self-monitoring techniques, such as monitoring the timing and amount of fluid and caffeine intake, monitoring voiding frequency, performing quick pelvic floor muscle (PFM) contractions, and managing constipation.

"Clearly, patient awareness of inciting factors (such as food intake) and the ability to modify same is extremely important in order to optimize the behavioral component of broad spectrum therapy," Roger R. Dmochowski, MD, FACS, a professor of urologic surgery and director of the Vanderbilt University Continence Center at the Vanderbilt University School of Medicine in Nashville, Tennessee, told Medscape. He was not involved with this study but was asked to provide independent commentary.

"Awareness of the pelvic floor activity using activities such as [PFM] contraction also would appear to add benefit over and above just simple behavior modification," Dr. Dmochowski said. "It is apparent that a well-educated and counseled patient obtains the best benefit from any therapy."

The present study was a 2-group, randomized controlled clinical trial with a wait-list control group
and a 3-week intervention group in 224 community-dwelling women aged 18 years and older with urinary incontinence. Exclusion criteria were involuntary urine loss of less than 1 g in 24 hours, positive urine test for bacteria, diagnosis of bladder cancer or kidney disease, prior treatment of urinary incontinence with biofeedback, use of urinary catheter, available to participate for less than 1 year, post void residual of 100 cc or more, unable or unwilling to keep bladder diaries, and pregnancy.

Women in the intervention group received individualized counseling about fluid and caffeine intake, quick PFM contractions using the quick Kegel, and constipation management. The main end point was grams of urine loss in 24 hours, and secondary outcome measures included episodes of urine loss in 24 hours, quality of life, and caffeine and fluid consumption.

Self-monitoring had a significant effect on the main outcome of grams of urine loss. Compared with the wait-list group, the self-monitoring group lost 13.3 g less urine and improved 26 points more on a quality-of-life scale, after adjustment for baseline urine loss, length of study period, age, hormone status, and ethnicity.

"A very important implication of this study is that behavior modification and pelvic floor therapy are only a component of therapy given the fact that most of these patients would demonstrate some level of improvement," Dr. Dmochowski said. "Therefore, the ability to provide additive therapy with direct interventions, whether they be pharmacologic or device-related, will amplify those responses to pain on the basis of behavioral and other noninterventive therapies."

Although the effect of self-monitoring on episodes of urine loss was not significant in the total sample, it was more effective for women who had 9 or more episodes of urine loss, were aged 65 years or older, or were using hormone replacement therapy. Self-monitoring was associated with reduced caffeine intake and no increase in total fluid intake compared with the wait-list control group.

According to Dr. Dmochowski, the strengths of this study are the randomized controlled design with a delayed therapy group as a treatment arm, allowing a better determination of the effect of therapy both immediately and in those individuals who delay the onset of intervention.

"It is important to realize patients across the age ranges will probably benefit from behavioral modifications, but it is very interesting that older patients appear to do better in this trial," Dr. Dmochowski said. "We know nothing about these older patients in terms of their cognitive and other general health status, which obviously impacts upon a patient's ability to participate in behavioral management."

Findings from this study were published online on March 15 ahead of print in an upcoming article in Neurourology Urodynamics, authored by Dr. Kincade and colleagues from the University of North Carolina at Chapel Hill.

"Since these techniques are safe, inexpensive, noninvasive, and easy to teach, they should be considered as first steps to treat women with urinary incontinence and are within the scope of practice for most health professionals," the authors conclude in their abstract. "If these techniques are found to be effective, improvements should be monitored to determine if they are maintained. If they are ineffective, this opens the door to more rigorous interventions."

Dr. Dmochowski recommends that further studies evaluate unique patient groups, especially the advanced elderly and the elderly who are either cognitively impaired or who have other significant comorbidities. These populations may be less able to respond to behavioral and other types of modifications and may depend more on direct interventions.

"This study simply underscores the importance of combined therapeutic intervention for the lower urinary tract," Dr. Dmochowski concluded. "It has been my personal experience that a combination of behavioral and other interventional therapies derives the best benefits for patients. An implication of this study, somewhat overtly stated, is that education is a crucial component to patient buy-in and patient response to intervention and indeed that has been the experience of our institution dealing with pelvic floor dysfunction."
The National Institute of Nursing Research, the National Institutes of Health, Just for You, Humanicare International, Inc, Proctor and Gamble, and The Biofeedback Foundation of Europe supported this study. The study authors report no relevant financial relationships. Dr. Dmochowski also reports no relevant financial relationships.

AGS 2007 Annual Scientific Meeting: Abstract P42. May 2-6, 2007.


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