Introduction

Urinary incontinence affects over a third of the women over 60 years in the USA. "Urge incontinence" - a need to urinate but the inability to control the urge and make it to the toilet soon enough - is especially common among older women; it leads to embarrassing incidents and significant restriction of activity. A clinical study summarized here shows that behavioral therapy (bladder training, exercises, etc) is an effective and safe treatment for the condition.¹

Urge incontinence usually results from abnormal contractions of the muscle controlling emptying of the bladder. To make matters worse, elderly women sometimes cannot empty the bladder completely on urination. Several types of drugs are used to treat the condition, the most widely used being those which suppress both normal and involuntary bladder contractions. One of these, oxybutynin, has the added advantage of a direct relaxing effect on the muscle controlling bladder emptying.

Behavioral treatment (bladder training, pelvic muscle exercises and biofeedback) has been reported to be effective treatment in highly functional and motivated patients. This study compared drug treatment (oxybutynin) with behavioral treatment. A third group of patients had no treatment other than regular visits to the clinic.

Method

Women over 55 who had at least two incontinent episodes a week were entered into the study. They kept a diary recording the time of each normal urination and each incontinent episode, the amount of urine leaked (large or small), and the circumstances of each episode.

A total of 197 subjects were assigned randomly to receive behavioral treatment, drug treatment or no treatment. They all visited the clinic every 2 weeks for 8 weeks. At each visit they had their bladder diaries checked, urine analyzed, side effects solicited, and anal sphincter pressure measured.

Patients in the behavior group were taught strategies and skills to prevent incontinence, and given instructions for daily practice at home. By demonstrating the effects of various pelvic muscle contraction efforts on their anorectal pressure (biofeedback), they were taught to contract and relax the right muscles, while keeping their abdominal muscles relaxed. They were then taught to develop "urge strategies" - how to respond to the need to urinate. For instance, they might pause, sit down, relax the whole body, and contract their pelvic muscles repeatedly; when the urge is diminished, they should urinate normally. Pelvic muscle exercises were intensified and refined for the third and fourth visits. These patients were taught to do 15 pelvic muscle exercises three times a day at home.

Those patients assigned to drug treatment were given oxybutynin 2.5 mg three times a day. This dose could be adjusted during the 8 weeks, depending on the effectiveness, or appearance of side effects (dry mouth, inability to urinate). The "no-treatment" patients were given dummy capsules as a placebo.

At the end of the 8-week treatment period, the women completed a further 2 weeks of bladder diaries and then returned for a full examination and appraisal interview.

Results

The frequency of incontinent episodes was reduced early in treatment period in all three groups, with slower improvement after that. Before treatment, the women in the study had, on average, 15.7 episodes of incontinence per week. After 8 weeks, the women in the behavior group averaged 2.8 episodes per week, those on oxybutynin 5.7 per week and those given no treatment 8.2 per week. Behavior treatment was clearly more effective than drug therapy. It reduced the episodes of incontinence by 81%, whereas drug treatment accomplished a 69% reduction and no-treatment a 39% reduction.

Other evaluations covered patients' perception of improvement, the extent of accidents, the need for protective clothing or pads, and their overall satisfaction with progress. For all of them, the behavior treatment group showed the greatest improvement.

Conclusions

This study shows clearly that behavioral training was quite effective in treating urge incontinence. It was more successful than oxybutynin, a drug commonly prescribed for this condition, and it didn't cause that drug's side effects. It is interesting to note that the "no-treatment" group had measurable improvement (almost 40% reduction in incontinence episodes); this might be related to the keeping of detailed bladder diaries and interaction with nurse practitioners at the clinic visits.

The behavioral procedures used in this study go a step further than the traditional conservative approach to urge incontinence - simple bladder training strategies. However, the results obtained are superior, and are worth the extra effort involved in establishing the biofeedback training. Family practitioners should be able to refer patients to an appropriate center for this sort of approach.