No Evidence-Based Guidance for Treating Post-Stroke Urinary Incontinence

By Marilynn Larkin

March 14, 2019

NEW YORK (Reuters Health) - Poor reporting of study details and small numbers of participants make it difficult to assess interventions for urinary incontinence after stroke, authors of a Cochrane review say.

"What surprised me was the fact that there were so many small studies - only three trials had more than 100 participants - and half had been carried out in China," Dr. Lois Thomas of the University of Central Lancashire, UK, told Reuters Health by email.

That said, she added, "the findings do suggest urinary incontinence is amenable to intervention and should be treated, rather than adopting strategies of containment (e.g., using indwelling urinary catheters or absorbent pads)."

For their report, online February 1 in the Cochrane Database of Systematic Reviews, Dr. Thomas and colleagues searched the Cochrane Incontinence and Cochrane Stroke Specialized Registers to identify "randomized or quasi-randomized" controlled trials of urinary incontinence interventions in adults at least one month after a stroke.

Twenty trials involving a total of 1,338 participants were included in the current review, which updates reviews on the topic published in 2005 and 2008.

"We found trials of complementary therapies - namely, acupuncture alone or combined with ginger‐salt‐partitioned moxibustion - that may be worth investigating further with a more rigorous study design," Dr. Thomas said.

"Evidence from five trials suggested that complementary therapy may increase the number of participants continent after treatment," she said. "Participants in the treatment group were three times more likely to be continent - equivalent to an increase from 193 to 544 per 1,000 patients."

"Transcutaneous electrical nerve stimulation (TENS) also shows promise in reducing the number of incontinent episodes," she noted, "and warrants further investigation with the stroke population, particularly given its simplicity and ease of use."

Overall, however, the authors concluded, "There is insufficient evidence to guide continence care of adults in the rehabilitative phase after stroke."

Dr. Thomas said, "Higher quality, larger trials are required to provide more robust evidence."

Dr. Brian Im, director of the brain injury rehabilitation program at NYU Langone's Rusk Rehabilitation, and a physiatrist at NYU Langone's Center for Stroke and Neurovascular Diseases, commented by email, "It is really important to note that urinary incontinence can be due to multiple different mechanisms and processes, even within the stroke population."

"Because there are all sorts of mechanisms for the cause of urinary incontinence after a brain injury, there is no one-size-fits-all solution," he told Reuters Health. "If my patient has urinary retention, we can catheterize them at a regular interval to prevent the buildup of pressure for overflow, not to mention prevent kidney injury."

"If a patient has functional incontinence," he said, "they may do well with a timed voiding schedule to schedule urination and reduce any urgency."

"A patient with frontal lobe issues can be the hardest to manage because their incontinent episodes can be harder to predict and they often are more difficult to do training with, but some may also do well with a timed voiding schedule, or calming strategies that might help limit accidents," he continued.

"People who experience urinary incontinence for a long period of time often should undergo urodynamic studies with urologists to better understand what is causing their urinary dysfunction," he noted. "Depending on the results, certain medications that target the problem may be helpful."

"Although this review may paint a grim picture in its conclusion that there doesn't seem to be effective treatments for urinary incontinence management, it's very important to emphasize that clinicians really have to do their due diligence and look for the root mechanism, rather than believing that nothing will work well for urinary incontinence in general, or treating all incontinence the same," Dr. Im concluded.

Dr. Sven Wenske, Assistant Professor of Urology at Columbia University Medical Center in New York City, also emphasized the importance of assessing each patient individually and determining the underlying cause.

"Behavioral modification techniques and pelvic floor muscle training (PFMT) are recommended first-line treatments," he told Reuters Health. "Not surprisingly, in this analysis they did decrease the number of incontinence episodes slightly (as did TENS and acupuncture), even though they did not have an impact on overall quality of life."

"While PFMT, Kegel exercises and behavioral interventions have a very low side-effect profile, they might be difficult to perform by stroke patients," he noted, "as these patients might suffer from residual mobility impairments, preventing the execution of certain exercises - i.e., possible reduced sensation and insufficient recognition of pelvic floor muscles."

"On the other hand, pharmacological treatments may have severe side effects," he said. "Anticholinergics, for example, might increase the risk of dementia. Judicious use of these medicines in patients with already underlying cerebrovascular disease is therefore recommended."


Cochrane Database Syst Rev 2019.