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Behavioral therapy with pelvic floor muscle exercises, strategies to prevent stress and urge leakage, fluid management, and self-monitoring using bladder diaries decreases episodes of postprostatectomy incontinence by half, according to a Jan. 12 report in JAMA.
In what researchers described as the first randomized, controlled trial of behavioral therapy involving men with incontinence persisting more than 1 year after radical prostatectomy, the intervention also improved symptoms of frequency, urgency, and nocturia; lessened the impact of incontinence on daily activities; and improved incontinence-specific quality of life, compared with a control condition, said Dr. Patricia S. Goode of the Department of Veterans Affairs Birmingham-Atlanta Geriatric Research, Education, and Clinical Center, and her associates.
Adding biofeedback training and pelvic floor electrical stimulation did not improve on the results compared with the behavioral intervention alone, they noted.
In the multicenter trial, 70 patients were randomly assigned to receive the behavioral intervention alone, 70 to receive the behavioral intervention plus biofeedback and pelvic floor electrical stimulation, and 68 were assigned to a control group. A total of 176 subjects completed the 8-week intervention and were followed-up at 6 months and 1 year.
The behavioral therapy entailed four office visits at 2-week intervals with a physician or nurse practitioner. Patients were instructed in using anal palpation and in pelvic floor muscle exercises that they were to practice in three daily sessions at home. They were given a handout to guide management of fluid intake, with attention to distributing fluid consumption throughout the day.
Patients with stress incontinence were taught to contract the pelvic floor muscles just before and after activities that caused leakage, such as coughing or lifting. Patients with urge incontinence were taught to stay still rather than rushing to a toilet when urinary urgency occurred and to contract the pelvic floor muscles repeatedly until the urgency abated, when they could then walk to a bathroom at a normal pace.
All the intervention patients kept daily bladder diaries and exercise logs through the 8-week therapy, which they discussed with caregivers at office visits.
Patients in the "behavior plus" group received this intervention plus in-office biofeedback to help them isolate the pelvic floor muscles. They also were instructed in daily home use of electrical stimulation of the pelvic floor muscles using an anal probe for 15-minute sessions.
Patients in the control group kept daily bladder diaries and discussed urinary incontinence at office visits every 2 weeks, to control for the effects of self-monitoring, clinic visits, and attention from clinic staff.
The primary outcome measure was the reduction in the number of incontinence episodes cited in the patient diaries at 8 weeks. Patients who received behavioral therapy alone showed a mean reduction of 55%, from 28 episodes to 13 per week. Those in the "behavior plus" group showed a similar 51% reduction, from 26 to 12 episodes per week.
This reflects a significantly greater decrease than the 24% reduction, from 25 to 20 episodes per week, reported in the control group, Dr. Goode and her colleagues said (JAMA 2011;305:151-9).
About 16% of the men who received behavioral therapy and 17% of those who received behavioral therapy plus biofeedback and electrical stimulation achieved complete urinary continence, compared with less than 6% of the control group.
Similarly, men in both active-treatment groups showed significant improvement on measures of quality of life and impact of incontinence on daily activities, while those in the control group did not. Men in both active-treatment groups also reported decreases in urinary frequency, urgency, and nocturia, while those in the control group did not.
Ninety percent of men in both active-treatment groups described their urinary leakage as "better" or "much better," compared with only 10% of the control group. Similarly, 47% of the men in both treatment groups said they were completely satisfied with their improvements. Episodes of urinary leakage were "extremely disturbing" to only 4% of the men who received active treatment, compared with 18% of the control group.
The men in both active treatment groups also were more likely to report that they needed fewer pads or diapers than before therapy (42%-55%), compared with only 5% of the control group.
The improvements in both active treatment groups largely persisted throughout the 1-year follow-up period.
Since biofeedback and electrical stimulation of the pelvic floor yielded no additive benefit, they don’t appear to be useful for postprostatectomy urinary incontinence. Dropping these techniques from the regimen will make behavioral therapy more practical and less costly, the investigators noted.
"Many of the participants in our trial reported that they had tried pelvic floor muscle exercises after their surgery, but had stopped when they failed to improve sufficiently." In contrast, more than 80% of the men in the active treatment groups continued to adhere to the exercise and bladder control strategies for months after this behavioral intervention, most likely because they perceived greater improvement.
The study findings clearly show that behavioral therapy should be offered to all men with persistent postprostatectomy urinary incontinence "because it can yield significant durable improvement in incontinence and quality of life, even years after radical prostatectomy," Dr. Goode and her associates noted.
They added that two good resources for locating qualified behavioral therapy in such patients are the National Association for Continence and the Wound, Ostomy, and Continence Nurses Society.
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the Department of Veterans Affairs Birmingham-Atlanta Geriatric Research, Education, and Clinical Center. Dr. Goode reported receiving a research grant from Pfizer. Her associates reported ties to Astellas, GlaxoSmithKline, Vantia, Boehringer-Ingelheim, Ferring, Johnson & Johnson, Allergan, Indevus, and Novartis.
The study findings appear encouraging at first glance, but it is important to examine them more closely before advocating this behavioral intervention in routine practice, said Dr. David F. Penson.
First, although episodes of urinary leakage declined from 28 to "only" 13 episodes per week with the active treatment, this still means that patients had an average of 2 such episodes per day instead of 3. This level of continuing incontinence certainly would be problematic for many men.
Second, although approximately 60% of the men who underwent active treatment used fewer urinary protection pads or diapers after 8 weeks, that still leaves approximately 40% who used the same number as they did at baseline. Would these patients conclude that behavioral treatment was successful?
Behavioral therapy "likely requires considerable patient and clinician time and effort," which many may not consider to be worth the limited benefits reported here.
Dr. Penson is in urologic surgery at Vanderbilt University and the VA Tennessee Valley Geriatric Research, Education, and Clinical Center, Nashville. He reported no financial conflicts of interest. These comments are taken from his editorial accompanying Dr. Goode’s report (JAMA 2011;305:197-8).
The study findings appear encouraging at first glance, but it is important to examine them more closely before advocating this behavioral intervention in routine practice, said Dr. David F. Penson.
First, although episodes of urinary leakage declined from 28 to "only" 13 episodes per week with the active treatment, this still means that patients had an average of 2 such episodes per day instead of 3. This level of continuing incontinence certainly would be problematic for many men.
Second, although approximately 60% of the men who underwent active treatment used fewer urinary protection pads or diapers after 8 weeks, that still leaves approximately 40% who used the same number as they did at baseline. Would these patients conclude that behavioral treatment was successful?
Behavioral therapy "likely requires considerable patient and clinician time and effort," which many may not consider to be worth the limited benefits reported here.
Dr. Penson is in urologic surgery at Vanderbilt University and the VA Tennessee Valley Geriatric Research, Education, and Clinical Center, Nashville. He reported no financial conflicts of interest. These comments are taken from his editorial accompanying Dr. Goode’s report (JAMA 2011;305:197-8).
The study findings appear encouraging at first glance, but it is important to examine them more closely before advocating this behavioral intervention in routine practice, said Dr. David F. Penson.
First, although episodes of urinary leakage declined from 28 to "only" 13 episodes per week with the active treatment, this still means that patients had an average of 2 such episodes per day instead of 3. This level of continuing incontinence certainly would be problematic for many men.
Second, although approximately 60% of the men who underwent active treatment used fewer urinary protection pads or diapers after 8 weeks, that still leaves approximately 40% who used the same number as they did at baseline. Would these patients conclude that behavioral treatment was successful?
Behavioral therapy "likely requires considerable patient and clinician time and effort," which many may not consider to be worth the limited benefits reported here.
Dr. Penson is in urologic surgery at Vanderbilt University and the VA Tennessee Valley Geriatric Research, Education, and Clinical Center, Nashville. He reported no financial conflicts of interest. These comments are taken from his editorial accompanying Dr. Goode’s report (JAMA 2011;305:197-8).
Behavioral therapy with pelvic floor muscle exercises, strategies to prevent stress and urge leakage, fluid management, and self-monitoring using bladder diaries decreases episodes of postprostatectomy incontinence by half, according to a Jan. 12 report in JAMA.
In what researchers described as the first randomized, controlled trial of behavioral therapy involving men with incontinence persisting more than 1 year after radical prostatectomy, the intervention also improved symptoms of frequency, urgency, and nocturia; lessened the impact of incontinence on daily activities; and improved incontinence-specific quality of life, compared with a control condition, said Dr. Patricia S. Goode of the Department of Veterans Affairs Birmingham-Atlanta Geriatric Research, Education, and Clinical Center, and her associates.
Adding biofeedback training and pelvic floor electrical stimulation did not improve on the results compared with the behavioral intervention alone, they noted.
In the multicenter trial, 70 patients were randomly assigned to receive the behavioral intervention alone, 70 to receive the behavioral intervention plus biofeedback and pelvic floor electrical stimulation, and 68 were assigned to a control group. A total of 176 subjects completed the 8-week intervention and were followed-up at 6 months and 1 year.
The behavioral therapy entailed four office visits at 2-week intervals with a physician or nurse practitioner. Patients were instructed in using anal palpation and in pelvic floor muscle exercises that they were to practice in three daily sessions at home. They were given a handout to guide management of fluid intake, with attention to distributing fluid consumption throughout the day.
Patients with stress incontinence were taught to contract the pelvic floor muscles just before and after activities that caused leakage, such as coughing or lifting. Patients with urge incontinence were taught to stay still rather than rushing to a toilet when urinary urgency occurred and to contract the pelvic floor muscles repeatedly until the urgency abated, when they could then walk to a bathroom at a normal pace.
All the intervention patients kept daily bladder diaries and exercise logs through the 8-week therapy, which they discussed with caregivers at office visits.
Patients in the "behavior plus" group received this intervention plus in-office biofeedback to help them isolate the pelvic floor muscles. They also were instructed in daily home use of electrical stimulation of the pelvic floor muscles using an anal probe for 15-minute sessions.
Patients in the control group kept daily bladder diaries and discussed urinary incontinence at office visits every 2 weeks, to control for the effects of self-monitoring, clinic visits, and attention from clinic staff.
The primary outcome measure was the reduction in the number of incontinence episodes cited in the patient diaries at 8 weeks. Patients who received behavioral therapy alone showed a mean reduction of 55%, from 28 episodes to 13 per week. Those in the "behavior plus" group showed a similar 51% reduction, from 26 to 12 episodes per week.
This reflects a significantly greater decrease than the 24% reduction, from 25 to 20 episodes per week, reported in the control group, Dr. Goode and her colleagues said (JAMA 2011;305:151-9).
About 16% of the men who received behavioral therapy and 17% of those who received behavioral therapy plus biofeedback and electrical stimulation achieved complete urinary continence, compared with less than 6% of the control group.
Similarly, men in both active-treatment groups showed significant improvement on measures of quality of life and impact of incontinence on daily activities, while those in the control group did not. Men in both active-treatment groups also reported decreases in urinary frequency, urgency, and nocturia, while those in the control group did not.
Ninety percent of men in both active-treatment groups described their urinary leakage as "better" or "much better," compared with only 10% of the control group. Similarly, 47% of the men in both treatment groups said they were completely satisfied with their improvements. Episodes of urinary leakage were "extremely disturbing" to only 4% of the men who received active treatment, compared with 18% of the control group.
The men in both active treatment groups also were more likely to report that they needed fewer pads or diapers than before therapy (42%-55%), compared with only 5% of the control group.
The improvements in both active treatment groups largely persisted throughout the 1-year follow-up period.
Since biofeedback and electrical stimulation of the pelvic floor yielded no additive benefit, they don’t appear to be useful for postprostatectomy urinary incontinence. Dropping these techniques from the regimen will make behavioral therapy more practical and less costly, the investigators noted.
"Many of the participants in our trial reported that they had tried pelvic floor muscle exercises after their surgery, but had stopped when they failed to improve sufficiently." In contrast, more than 80% of the men in the active treatment groups continued to adhere to the exercise and bladder control strategies for months after this behavioral intervention, most likely because they perceived greater improvement.
The study findings clearly show that behavioral therapy should be offered to all men with persistent postprostatectomy urinary incontinence "because it can yield significant durable improvement in incontinence and quality of life, even years after radical prostatectomy," Dr. Goode and her associates noted.
They added that two good resources for locating qualified behavioral therapy in such patients are the National Association for Continence and the Wound, Ostomy, and Continence Nurses Society.
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the Department of Veterans Affairs Birmingham-Atlanta Geriatric Research, Education, and Clinical Center. Dr. Goode reported receiving a research grant from Pfizer. Her associates reported ties to Astellas, GlaxoSmithKline, Vantia, Boehringer-Ingelheim, Ferring, Johnson & Johnson, Allergan, Indevus, and Novartis.
Behavioral therapy with pelvic floor muscle exercises, strategies to prevent stress and urge leakage, fluid management, and self-monitoring using bladder diaries decreases episodes of postprostatectomy incontinence by half, according to a Jan. 12 report in JAMA.
In what researchers described as the first randomized, controlled trial of behavioral therapy involving men with incontinence persisting more than 1 year after radical prostatectomy, the intervention also improved symptoms of frequency, urgency, and nocturia; lessened the impact of incontinence on daily activities; and improved incontinence-specific quality of life, compared with a control condition, said Dr. Patricia S. Goode of the Department of Veterans Affairs Birmingham-Atlanta Geriatric Research, Education, and Clinical Center, and her associates.
Adding biofeedback training and pelvic floor electrical stimulation did not improve on the results compared with the behavioral intervention alone, they noted.
In the multicenter trial, 70 patients were randomly assigned to receive the behavioral intervention alone, 70 to receive the behavioral intervention plus biofeedback and pelvic floor electrical stimulation, and 68 were assigned to a control group. A total of 176 subjects completed the 8-week intervention and were followed-up at 6 months and 1 year.
The behavioral therapy entailed four office visits at 2-week intervals with a physician or nurse practitioner. Patients were instructed in using anal palpation and in pelvic floor muscle exercises that they were to practice in three daily sessions at home. They were given a handout to guide management of fluid intake, with attention to distributing fluid consumption throughout the day.
Patients with stress incontinence were taught to contract the pelvic floor muscles just before and after activities that caused leakage, such as coughing or lifting. Patients with urge incontinence were taught to stay still rather than rushing to a toilet when urinary urgency occurred and to contract the pelvic floor muscles repeatedly until the urgency abated, when they could then walk to a bathroom at a normal pace.
All the intervention patients kept daily bladder diaries and exercise logs through the 8-week therapy, which they discussed with caregivers at office visits.
Patients in the "behavior plus" group received this intervention plus in-office biofeedback to help them isolate the pelvic floor muscles. They also were instructed in daily home use of electrical stimulation of the pelvic floor muscles using an anal probe for 15-minute sessions.
Patients in the control group kept daily bladder diaries and discussed urinary incontinence at office visits every 2 weeks, to control for the effects of self-monitoring, clinic visits, and attention from clinic staff.
The primary outcome measure was the reduction in the number of incontinence episodes cited in the patient diaries at 8 weeks. Patients who received behavioral therapy alone showed a mean reduction of 55%, from 28 episodes to 13 per week. Those in the "behavior plus" group showed a similar 51% reduction, from 26 to 12 episodes per week.
This reflects a significantly greater decrease than the 24% reduction, from 25 to 20 episodes per week, reported in the control group, Dr. Goode and her colleagues said (JAMA 2011;305:151-9).
About 16% of the men who received behavioral therapy and 17% of those who received behavioral therapy plus biofeedback and electrical stimulation achieved complete urinary continence, compared with less than 6% of the control group.
Similarly, men in both active-treatment groups showed significant improvement on measures of quality of life and impact of incontinence on daily activities, while those in the control group did not. Men in both active-treatment groups also reported decreases in urinary frequency, urgency, and nocturia, while those in the control group did not.
Ninety percent of men in both active-treatment groups described their urinary leakage as "better" or "much better," compared with only 10% of the control group. Similarly, 47% of the men in both treatment groups said they were completely satisfied with their improvements. Episodes of urinary leakage were "extremely disturbing" to only 4% of the men who received active treatment, compared with 18% of the control group.
The men in both active treatment groups also were more likely to report that they needed fewer pads or diapers than before therapy (42%-55%), compared with only 5% of the control group.
The improvements in both active treatment groups largely persisted throughout the 1-year follow-up period.
Since biofeedback and electrical stimulation of the pelvic floor yielded no additive benefit, they don’t appear to be useful for postprostatectomy urinary incontinence. Dropping these techniques from the regimen will make behavioral therapy more practical and less costly, the investigators noted.
"Many of the participants in our trial reported that they had tried pelvic floor muscle exercises after their surgery, but had stopped when they failed to improve sufficiently." In contrast, more than 80% of the men in the active treatment groups continued to adhere to the exercise and bladder control strategies for months after this behavioral intervention, most likely because they perceived greater improvement.
The study findings clearly show that behavioral therapy should be offered to all men with persistent postprostatectomy urinary incontinence "because it can yield significant durable improvement in incontinence and quality of life, even years after radical prostatectomy," Dr. Goode and her associates noted.
They added that two good resources for locating qualified behavioral therapy in such patients are the National Association for Continence and the Wound, Ostomy, and Continence Nurses Society.
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the Department of Veterans Affairs Birmingham-Atlanta Geriatric Research, Education, and Clinical Center. Dr. Goode reported receiving a research grant from Pfizer. Her associates reported ties to Astellas, GlaxoSmithKline, Vantia, Boehringer-Ingelheim, Ferring, Johnson & Johnson, Allergan, Indevus, and Novartis.
FROM JAMA
Major Finding: An 8-week behavioral intervention reduced episodes of urinary incontinence by 55% in men whose incontinence resulted from radical prostatectomy done more than 1 year previously.
Data Source: A multicenter, randomized clinical trial involving 208 patients treated for 8 weeks and followed for 1 year.
Disclosures: This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the Department of Veterans Affairs Birmingham-Atlanta Geriatric Research, Education, and Clinical Center. Dr. Goode reported receiving a research grant from Pfizer. Her associates reported ties to Astellas, GlaxoSmithKline, Vantia, Boehringer-Ingelheim, Ferring, Johnson & Johnson, Allergan, Indevus, and Novartis.