S Evidence statements

Ten systematic reviews were identified that assessed the efficacy of a number of different interventions for urinary incontinence, though some of these contained data from the same trials (IIa). Four reviews examined the effectiveness of different behavioural bladder training programmes for urge, mixed and stress incontinence. The first review compared bladder training to no intervention, drug therapy (oxybutynin and flavoxate hydrochloride plus imipramine), pelvic floor muscle training and electrical stimulation. The results showed that there was weak evidence to suggest that bladder training is more effective than no treatment, and that bladder training is better than drug therapy. There was insufficient evidence that electrical stimulation is more effective than sham electrical stimulation.281 The second review assessed the efficacy of prompted voiding either alone or in combination with oxybutynin. The results indicated that prompted voiding was beneficial compared to no intervention, and that prompted voiding combined with oxybutynin was superior to prompted voiding alone.282 The third review compared the effectiveness of pelvic floor muscle training against placebo, electrical stimulation, vaginal cones and bladder training either alone or in combination. The results indicated that pelvic floor muscle training was superior to either no treatment or placebo, and that 'intensive' appeared to be better than 'standard' training. The effect of adding adjunctive treatments to pelvic floor training was unclear due to the limited amount of evidence.283 The last review compared bladder training to flavoxate hydrochloride and imipramine, electric prompting devices and combinations of training plus terodoline or oxybutynin. The results from the review tended to favour bladder training but data was only available for a limited number of prespecified outcomes.284

Four reviews were included that examined the use of different devices or surgical interventions as management options for incontinence. The first review compared suburethral slings to abdominal retropubic suspension and needle suspension. The results showed no differences between suburethral slings and abdominal retropubic suspension or needle suspension. However sling operations had a significantly higher complication rate.285 The second review compared the effect of weighted vaginal cones to control, electro stimulation, pelvic floor muscle training and these interventions in combination. The results showed that cones were better than no active treatment, but that there were no differences between cones and pelvic floor muscle training or electrostimulation. There was not enough evidence to show that cones plus pelvic floor muscle training was different to either cones alone or pelvic floor muscle training alone.286 The third review compared anterior vaginal repair to pelvic floor muscle training, open abdominal retropubic suspension and bladder neck needle suspension. The results indicated that anterior vaginal repair was less effective than open abdominal retropubic suspension both in the short and long term. There were no differences between anterior vaginal repair and bladder neck needle suspension.287 The last review assessed the efficacy of a number of different surgical procedures for stress incontinence. Overall, the results indicated that colposuspension may be more effective and the effect more long-lasting than that for anterior colporrhaphy and needle suspension. It was also found that second and subsequent operations to correct stress incontinence are less successful than first procedures.288

One small review compared the effectiveness of tolterodine to oxybutynin. The results showed that both drugs had similar effects on the number of micturitions in a 24-hour period, but that oxybutynin was marginally superior in decreasing incontinence and increasing the mean voided volume per micturation.289

The last review assessed the effects of different types of absorbent product for the containment of urinary and/or faecal incontinence. The results indicated favourable outcomes in terms of skin problems, the number of changes, ease of disposal and cost for disposable vs non-disposable body worns.290

Five RCTs and nine randomised crossover trials examined different interventions for bladder impairment (Ib).

Six placebo-controlled randomised crossover trials assessed the effect of desmopressin on voiding frequency and incontinence. Three of the trials specifically examined nocturia, whilst the other three assessed daytime voiding frequency. The three trials that reviewed nocturia all reported beneficial effects on the frequency of voiding, night-time urine volumes and sleep duration.291-293 No significant differences were reported in the number of episodes of incontinence. All three trials report a number of side effects of a minor nature. The trials that examined daytime voiding frequency reported significant effects upon both frequency and volume up to six hours after drug intake.294-296 However, no benefit was observed on the frequency of night-time voiding; the 24-hour urine volume was unaffected. None of the trials reported side effects of a significant nature.

Four placebo-controlled trials assessed the efficacy of different drug interventions. One RCT examined the effect of synthetic capsaicin solution in patients with hyperreflexic bladder.297 The results showed an overall significant benefit in terms of voiding patterns, leakage, bladder pressure and the need to use pads. There were no differences in the incidence of side effects between the groups. The second RCT reviewed the use of indoramin in male patients with symptoms of urinary tract dysfunction.298 The study reported significant effects upon two of the five outcome measures assessed (flow rates) but not upon the overall symptoms score. Two randomised crossover trials assessed the efficacy of different drugs in patients with detrusor hyperreflexia. The first trial examining the use of atropine reported significant differences in bladder capacity.299 The second trial assessed the intervention of flurbiprofen.300 The study reported beneficial effects on five of the seven outcomes assessed. However, side effects were more common during the intervention phases although all of these were minor.

Two further placebo-controlled RCTs addressed the effectiveness of biofeedback and electrical stimulation of the pelvic floor muscles. The first RCT addressed biofeedback in combination with behaviour modification, pharmacological adjustment and pelvic floor training.301 The results showed no significant differences between the groups on any of the outcome measures assessed. The other RCT examined the use of electrical stimulation of the pelvic floor muscles followed by pelvic floor exercises.302 Significant beneficial effects were observed on all but one of the outcomes measures assessed.

Two studies, one RCT and one randomised crossover trial, compared different interventions against active comparators. One RCT compared oxybutynin to propantheline and reported no significant differences between the groups either in terms of benefits or the side effects observed.303 The randomised crossover trial examined the three interventions; methantheline bromide, meladrazine tartrate and flavoxate chloride in patients with detrusor hyperreflexia.304 The results showed that methantheline bromide was superior to the other two interventions on the outcomes measures of patient preference, entire cystometric pattern and micturition reduction. No significant differences were observed on measures of incontinence or residual urine volumes between the interventions. Meladrazine tartrate caused side effects so severe that the drug was discontinued. No serious adverse events were reported for the other two interventions.

At the time of writing there is insufficient evidence to comment on the use of cannabinoids in MS. However, we are aware that further evidence is likely to be published and that NICE intend to conduct a technology appraisal on cannabinoids in MS with a projected publication date of April 2004.

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