was included in the ICI 5 edition PFMT (24) vs PFMT + resistance device (28) 52 Women with SUI or MUI (stress predominant) PFMT: As below without device PFMT +resistance; 5 quick and 5 slow (sustained), high-intensity contractions daily. Advised to hold contractions as long as possible, relaxing their PFM for an equivalent time before repeating the process. Intravaginal resistance: instructions to use the Pelvic-Toner Device concurrently whilst exercising. Two clinic visits and one phone call Reported cure (based on the Q11 of the ICIQFluts) PFMT 0/13 PFMT+resistance 1/15 Non-sign. difference btw groups (p=0.429) Improvement (post-Tx) PFMT 10/19 PFMT+resistance 11/21 Non-sign. difference btw groups 16 weeks of treatment, outcomes assessed at post-Tx and at 6 month follow-up Dropouts (at 6 month) PFMT 9/24 PFMT + resistance 15/28

/pdf/adult-conservative-management-23g1y2j6gw.pdf

Adult conservative management

Background Urinary incontinence (UI) is the involuntary loss of urine and can be caused by several different conditions. The common types of UI are stress (SUI), urgency (UUI) and mixed (MUI). A wide range of interventions can be delivered to reduce the symptoms of UI in women. Conservative interventions are generally recommended as the first line of treatment. Objectives To summarise Cochrane Reviews that assessed the effects of conservative interventions for treating UI in women. Methods We searched the Cochrane Library to January 2021 (CDSR; 2021, Issue 1) and included any Cochrane Review that included studies with women aged 18 years or older with a clinical diagnosis of SUI, UUI or MUI, and investigating a conservative intervention aimed at improving or curing UI. We included reviews that compared a conservative intervention with 'control' (which included placebo, no treatment or usual care), another conservative intervention or another active, but non‐conservative, intervention. A stakeholder group informed the selection and synthesis of evidence. Two overview authors independently applied the inclusion criteria, extracted data and judged review quality, resolving disagreements through discussion. Primary outcomes of interest were patient‐reported cure or improvement and condition‐specific quality of life. We judged the risk of bias in included reviews using the ROBIS tool. We judged the certainty of evidence within the reviews based on the GRADE approach. Evidence relating to SUI, UUI or all types of UI combined (AUI) were synthesised separately. The AUI group included evidence relating to participants with MUI, as well as from studies that combined women with different diagnoses (i.e. SUI, UUI and MUI) and studies in which the type of UI was unclear. Main results We included 29 relevant Cochrane Reviews. Seven focused on physical therapies; five on education, behavioural and lifestyle advice; one on mechanical devices; one on acupuncture and one on yoga. Fourteen focused on non‐conservative interventions but had a comparison with a conservative intervention. No reviews synthesised evidence relating to psychological therapies. There were 112 unique trials (including 8975 women) that had primary outcome data included in at least one analysis. Stress urinary incontinence (14 reviews) Conservative intervention versus control: there was moderate or high certainty evidence that pelvic floor muscle training (PFMT), PFMT plus biofeedback and cones were more beneficial than control for curing or improving UI. PFMT and intravaginal devices improved quality of life compared to control. One conservative intervention versus another conservative intervention: for cure and improvement of UI, there was moderate or high certainty evidence that: continence pessary plus PFMT was more beneficial than continence pessary alone; PFMT plus educational intervention was more beneficial than cones; more‐intensive PFMT was more beneficial than less‐intensive PFMT; and PFMT plus an adherence strategy was more beneficial than PFMT alone. There was no moderate or high certainty evidence for quality of life. Urgency urinary incontinence (five reviews) Conservative intervention versus control: there was moderate to high‐certainty evidence demonstrating that PFMT plus feedback, PFMT plus biofeedback, electrical stimulation and bladder training were more beneficial than control for curing or improving UI. Women using electrical stimulation plus PFMT had higher quality of life than women in the control group. One conservative intervention versus another conservative intervention: for cure or improvement, there was moderate certainty evidence that electrical stimulation was more effective than laseropuncture. There was high or moderate certainty evidence that PFMT resulted in higher quality of life than electrical stimulation and electrical stimulation plus PFMT resulted in better cure or improvement and higher quality of life than PFMT alone. All types of urinary incontinence (13 reviews) Conservative intervention versus control: there was moderate to high certainty evidence of better cure or improvement with PFMT, electrical stimulation, weight loss and cones compared to control. There was moderate certainty evidence of improved quality of life with PFMT compared to control. One conservative intervention versus another conservative intervention: there was moderate or high certainty evidence of better cure or improvement for PFMT with bladder training than bladder training alone. Likewise, PFMT with more individual health professional supervision was more effective than less contact/supervision and more‐intensive PFMT was more beneficial than less‐intensive PFMT. There was moderate certainty evidence that PFMT plus bladder training resulted in higher quality of life than bladder training alone. Authors' conclusions There is high certainty that PFMT is more beneficial than control for all types of UI for outcomes of cure or improvement and quality of life. We are moderately certain that, if PFMT is more intense, more frequent, with individual supervision, with/without combined with behavioural interventions with/without an adherence strategy, effectiveness is improved. We are highly certain that, for cure or improvement, cones are more beneficial than control (but not PFMT) for women with SUI, electrical stimulation is beneficial for women with UUI, and weight loss results in more cure and improvement than control for women with AUI. Most evidence within the included Cochrane Reviews is of low certainty. It is important that future new and updated Cochrane Reviews develop questions that are more clinically useful, avoid multiple overlapping reviews and consult women with UI to further identify outcomes of importance. 

Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews

Background Urinary incontinence (UI), a common malady in women, most often is classified as stress, urgency, or mixed. Purpose To compare the effectiveness of pharmacologic and nonpharmacologic interventions to improve or cure stress, urgency, or mixed UI in nonpregnant women. Data sources MEDLINE, Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), EMBASE (Elsevier), CINAHL (EBSCO), and PsycINFO (American Psychological Association) from inception through 10 August 2018. Study selection 84 randomized trials that evaluated 14 categories of interventions and reported categorical cure or improvement outcomes. Data extraction 1 researcher extracted study characteristics, results, and study-level risk of bias, with verification by another independent researcher. The research team collaborated to assess strength of evidence (SoE) across studies. Data synthesis 84 studies reported cure or improvement outcomes (32 in stress UI, 16 in urgency UI, 4 in mixed UI, and 32 in any or unspecified UI type). The most commonly evaluated active intervention types included behavioral therapies, anticholinergics, and neuromodulation. Network meta-analysis showed that all interventions, except hormones and periurethral bulking agents (variable SoE), were more effective than no treatment in achieving at least 1 favorable UI outcome. Among treatments used specifically for stress UI, behavioral therapy was more effective than either α-agonists or hormones in achieving cure or improvement (moderate SoE); α-agonists were more effective than hormones in achieving improvement (moderate SoE); and neuromodulation was more effective than no treatment for cure, improvement, and satisfaction (high SoE). Among treatments used specifically for urgency UI, behavioral therapy was statistically significantly more effective than anticholinergics in achieving cure or improvement (high SoE), both neuromodulation and onabotulinum toxin A (BTX) were more effective than no treatment (high SoE), and BTX may have been more effective than neuromodulation in achieving cure (low SoE). Limitation Scarce direct (head-to-head trial) evidence and population heterogeneity based on UI type, UI severity, and history of prior treatment. Conclusion Most nonpharmacologic and pharmacologic interventions are more likely than no treatment to improve UI outcomes. Behavioral therapy, alone or in combination with other interventions, is generally more effective than pharmacologic therapies alone in treating both stress and urgency UI. Primary funding source Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42017069903).

Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes

Background
Several treatment options are available for stress urinary incontinence (SUI), including pelvic floor muscle training (PFMT), drug therapy and surgery. Problems exist such as adherence to PFMT regimens, side effects linked to drug therapy and the risks associated with surgery. We have evaluated an alternative treatment, electrical stimulation (ES) with non-implanted devices, which aims to improve pelvic floor muscle function to reduce involuntary urine loss.

Objectives
To assess the effects of electrical stimulation with non-implanted devices, alone or in combination with other treatment, for managing stress urinary incontinence or stress-predominant mixed urinary incontinence in women. Among the outcomes examined were costs and cost-effectiveness.

Search methods
We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearches of journals and conference proceedings (searched 27 February 2017). We also searched the reference lists of relevant articles and undertook separate searches to identify studies examining economic data.

Selection criteria
We included randomised or quasi-randomised controlled trials of ES with non-implanted devices compared with any other treatment for SUI in women. Eligible trials included adult women with SUI or stress-predominant mixed urinary incontinence (MUI). We excluded studies of women with urgency-predominant MUI, urgency urinary incontinence only, or incontinence associated with a neurologic condition. We would have included economic evaluations had they been conducted alongside eligible trials.

Data collection and analysis
Two review authors independently screened search results, extracted data from eligible trials and assessed risk of bias, using the Cochrane 'Risk of bias' tool. We would have performed economic evaluations using the approach recommended by Cochrane Economic Methods.

Main results
We identified 56 eligible trials (3781 randomised participants). Eighteen trials did not report the primary outcomes of subjective cure, improvement of SUI or incontinence-specific quality of life (QoL). The risk of bias was generally unclear, as most trials provided little detail when reporting their methods. We assessed 25% of the included trials as being at high risk of bias for a variety of reasons, including industry funding and baseline differences between groups. We did not identify any economic evaluations.

For subjective cure of SUI, we found moderate-quality evidence that ES is probably better than no active treatment (risk ratio (RR) 2.31, 95% CI 1.06 to 5.02). We found a similar result for cure or improvement of SUI (RR 1.73, 95% CI 1.41 to 2.11), but the quality of evidence was lower. We are very uncertain if there is a difference between ES and sham treatment in terms of subjective cure because of the very low quality of evidence (RR 2.21, 95% CI 0.38 to 12.73). For subjective cure or improvement, ES may be better than sham treatment (RR 2.03, 95% CI 1.02 to 4.07). The effect estimate was 660/1000 women cured/improved with ES compared to 382/1000 with no active treatment (95% CI 538 to 805 women); and for sham treatment, 402/1000 women cured/improved with ES compared to 198/1000 with sham treatment (95% CI 202 to 805 women).

Low-quality evidence suggests that there may be no difference in cure or improvement for ES versus PFMT (RR 0.85, 95% CI 0.70 to 1.03), PFMT plus ES versus PFMT alone (RR 1.10, 95% CI 0.95 to 1.28) or ES versus vaginal cones (RR 1.09, 95% CI 0.97 to 1.21).

Electrical stimulation probably improves incontinence-specific QoL compared to no treatment (moderate quality evidence) but there may be little or no difference between electrical stimulation and PFMT (low quality evidence). It is uncertain whether adding electrical stimulation to PFMT makes any difference in terms of quality of life, compared with PFMT alone (very low quality evidence). There may be little or no difference between electrical stimulation and vaginal cones in improving incontinence-specific QoL (low quality evidence). The impact of electrical stimulation on subjective cure/improvement and incontinence-specific QoL, compared with vaginal cones, PFMT plus vaginal cones, or drugs therapy, is uncertain (very low quality evidence).

In terms of subjective cure/improvement and incontinence-specific QoL, the available evidence comparing ES versus drug therapy or PFMT plus vaginal cones was very low quality and inconclusive. Similarly, comparisons of different types of ES to each other and of ES plus surgery to surgery are also inconclusive in terms of subjective cure/improvement and incontinence-specific QoL (very low-quality evidence).

Adverse effects were rare: in total nine of the women treated with ES in the trials reported an adverse effect. We identified insufficient evidence to compare the risk of adverse effects in women treated with ES compared to any other treatment. We were unable to identify any economic data.

Authors' conclusions
The current evidence base indicated that electrical stimulation is probably more effective than no active or sham treatment, but it is not possible to say whether ES is similar to PFMT or other active treatments in effectiveness or not. Overall, the quality of the evidence was too low to provide reliable results. Without sufficiently powered trials measuring clinically important outcomes, such as subjective assessment of urinary incontinence, we cannot draw robust conclusions about the overall effectiveness or cost-effectiveness of electrical stimulation for stress urinary incontinence in women.

/pdf/electrical-stimulation-with-non-implanted-devices-for-stress-1u91jsukgu.pdf

Electrical stimulation with non-implanted devices for stress urinary incontinence in women

BACKGROUND
Urinary incontinence (UI) is the involuntary loss of urine and can be caused by several different conditions. The common types of UI are stress (SUI), urgency (UUI) and mixed (MUI). A wide range of interventions can be delivered to reduce the symptoms of UI in women. Conservative interventions are generally recommended as the first line of treatment.


OBJECTIVES
To summarise Cochrane Reviews that assessed the effects of conservative interventions for treating UI in women.


METHODS
We searched the Cochrane Library to January 2021 (CDSR; 2021, Issue 1) and included any Cochrane Review that included studies with women aged 18 years or older with a clinical diagnosis of SUI, UUI or MUI, and investigating a conservative intervention aimed at improving or curing UI. We included reviews that compared a conservative intervention with 'control' (which included placebo, no treatment or usual care), another conservative intervention or another active, but non-conservative, intervention. A stakeholder group informed the selection and synthesis of evidence. Two overview authors independently applied the inclusion criteria, extracted data and judged review quality, resolving disagreements through discussion. Primary outcomes of interest were patient-reported cure or improvement and condition-specific quality of life. We judged the risk of bias in included reviews using the ROBIS tool. We judged the certainty of evidence within the reviews based on the GRADE approach. Evidence relating to SUI, UUI or all types of UI combined (AUI) were synthesised separately. The AUI group included evidence relating to participants with MUI, as well as from studies that combined women with different diagnoses (i.e. SUI, UUI and MUI) and studies in which the type of UI was unclear.


MAIN RESULTS
We included 29 relevant Cochrane Reviews. Seven focused on physical therapies; five on education, behavioural and lifestyle advice; one on mechanical devices; one on acupuncture and one on yoga. Fourteen focused on non-conservative interventions but had a comparison with a conservative intervention. No reviews synthesised evidence relating to psychological therapies. There were 112 unique trials (including 8975 women) that had primary outcome data included in at least one analysis. Stress urinary incontinence (14 reviews) Conservative intervention versus control: there was moderate or high certainty evidence that pelvic floor muscle training (PFMT), PFMT plus biofeedback and cones were more beneficial than control for curing or improving UI. PFMT and intravaginal devices improved quality of life compared to control. One conservative intervention versus another conservative intervention: for cure and improvement of UI, there was moderate or high certainty evidence that: continence pessary plus PFMT was more beneficial than continence pessary alone; PFMT plus educational intervention was more beneficial than cones; more-intensive PFMT was more beneficial than less-intensive PFMT; and PFMT plus an adherence strategy was more beneficial than PFMT alone. There was no moderate or high certainty evidence for quality of life. Urgency urinary incontinence (five reviews) Conservative intervention versus control: there was moderate to high-certainty evidence demonstrating that PFMT plus feedback, PFMT plus biofeedback, electrical stimulation and bladder training were more beneficial than control for curing or improving UI. Women using electrical stimulation plus PFMT had higher quality of life than women in the control group. One conservative intervention versus another conservative intervention: for cure or improvement, there was moderate certainty evidence that electrical stimulation was more effective than laseropuncture. There was high or moderate certainty evidence that PFMT resulted in higher quality of life than electrical stimulation and electrical stimulation plus PFMT resulted in better cure or improvement and higher quality of life than PFMT alone. All types of urinary incontinence (13 reviews) Conservative intervention versus control: there was moderate to high certainty evidence of better cure or improvement with PFMT, electrical stimulation, weight loss and cones compared to control. There was moderate certainty evidence of improved quality of life with PFMT compared to control. One conservative intervention versus another conservative intervention: there was moderate or high certainty evidence of better cure or improvement for PFMT with bladder training than bladder training alone. Likewise, PFMT with more individual health professional supervision was more effective than less contact/supervision and more-intensive PFMT was more beneficial than less-intensive PFMT. There was moderate certainty evidence that PFMT plus bladder training resulted in higher quality of life than bladder training alone.


AUTHORS' CONCLUSIONS
There is high certainty that PFMT is more beneficial than control for all types of UI for outcomes of cure or improvement and quality of life. We are moderately certain that, if PFMT is more intense, more frequent, with individual supervision, with/without combined with behavioural interventions with/without an adherence strategy, effectiveness is improved. We are highly certain that, for cure or improvement, cones are more beneficial than control (but not PFMT) for women with SUI, electrical stimulation is beneficial for women with UUI, and weight loss results in more cure and improvement than control for women with AUI. Most evidence within the included Cochrane Reviews is of low certainty. It is important that future new and updated Cochrane Reviews develop questions that are more clinically useful, avoid multiple overlapping reviews and consult women with UI to further identify outcomes of importance.

Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews.

Resume Objectifs Pour maintenir les effets de la reeducation perineale des incontinences urinaires d’effort, il est necessaire que la patiente poursuive des exercices de contraction de la musculature pelvienne a domicile. Cette etude prospective multicentrique randomisee a pour objectif d’evaluer l’utilite de GYNEFFIK®, un electro-stimulateur perineal, dans cette phase d’auto-prise en charge. Patientes et methodes Deux groupes paralleles de femmes avec incontinence urinaire d’effort ou mixte a predominance d’effort, ayant repondu a la kinesitherapie, ont suivi un programme de reeducation a domicile : un groupe beneficiant d’une prise en charge habituelle (groupe « usual care » [UC]) et un groupe beneficiant de seances d’electrostimulation par ce dispositif d’electrostimulation intravaginal (groupe GYNEFFIK® ou ESPD pour Electrostimulation perineale a domicile). La frequence du maintien du benefice de la reeducation perineale initiale (defini comme l’absence d’aggravation du score des echelles ICIQ et Ditrovie) a ete comparee entre les groupes au bout de 2,4 et 6 mois. Resultats L’analyse a porte sur 161 patientes (76 dans le bras ESPD et 85 dans le bras « usual care »). Le benefice therapeutique de la reeducation initiale, a la derniere mesure disponible (grande majorite a 6 mois de traitement), a ete maintenu chez 81,6 % des patientes du groupe ESPD contre 62,4 % des patientes du groupe « usual care » (p = 0,007). Cette difference significative en faveur du groupe ESPD traduit a la fois une evolution plus favorable de la symptomatologie clinique (amelioration de 44 % du score ICIQ versus 14 % pour le groupe UC ; [p  Discussion et conclusion L’impression globale du medecin est plus favorable en cas d’utilisation du dispositif (83 % des patientes versus 68 % sont considerees ameliorees). A la derniere evaluation, toutes les patiente du groupe ESPD se sont maintenues ou ont ete ameliorees alors qu’une aggravation a ete observee chez 16,5 % des patientes du groupe UC. L’utilisation de ce dispositif a un impact favorable sur la qualite de vie, notamment sur l’activite physique et la vitalite, et sur le retentissement emotionnel de la maladie objective par une amelioration significative des scores d’anxiete et de depression mesures sur l’echelle HAD.

Étude prospective multicentrique randomisée évaluant l’intérêt de l’électrostimulation intravaginale à domicile après rééducation périnéale pour incontinence urinaire

Resume Objectifs La reeducation perineale des incontinences urinaires d’effort aboutit dans 80 % des cas a un resultat favorable. Toutefois, pour que le benefice de la reeducation se perennise, il est necessaire de la poursuivre sous forme d’exercices a domicile. Cette etude a pour objectif d’evaluer l’utilite de GYNEFFIK®, un electrostimulateur perineal, dans cette phase d’auto-prise en charge. Patientes et methodes Deux groupes paralleles de femmes avec incontinence urinaire d’effort ou mixte a predominance d’effort, ayant repondu a la kinesitherapie, ont suivi un programme de reeducation a domicile. Les deux groupes differaient dans l’utilisation, ou non, de seances d’electrostimulation par GYNEFFIK® dans le programme de reeducation. La comparaison entre les groupes a porte sur la frequence du maintien du benefice de la reeducation perineale initiale (defini comme l’absence d’aggravation de score des echelles ICIQ et Ditrovie). Une analyse intermediaire, prevue par le protocole, a ete realisee sur 95 patientes (soit pres de la moitie de l’effectif calcule) disposant d’au moins une evaluation sous traitement dont 44 patientes ayant complete l’etude. Resultats Le benefice therapeutique de la reeducation initiale a ete maintenu chez 87,8 % des patientes du groupe GYNEFFIK® contre 52,2 % des patientes ayant beneficie d’une prise en charge habituelle sans utilisation d’electrostimulation (« usual care ») (p = 0,0001). Discussion et conclusion Cette difference significative se traduit pour la patiente par une impression subjective plus favorable en cas d’utilisation de GYNEFFIK® (83,7 % versus 60,0 % considerent que leur etat s’est ameliore). Aucune aggravation des signes n’a ete rapportee dans le groupe GYNEFFIK® alors que pres d’un cinquieme des patientes du groupe « usual care » a considere que son etat s’etait aggrave.

Étude prospective multicentrique randomisée évaluant l’intérêt de l’électrostimulation intravaginale à domicile après rééducation périnéale pour incontinence urinaire. Analyse intermédiaire

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Étude prospective multicentrique randomisée évaluant l’intérêt de l’électrostimulation intravaginale à domicile après rééducation périnéale pour incontinence urinaire

Étude prospective multicentrique randomisée évaluant l’intérêt de l’électrostimulation intravaginale à domicile après rééducation périnéale pour incontinence urinaire. Analyse intermédiaire