Group-Based Pelvic Floor Telerehabilitation to Treat Urinary Incontinence in Older Women: A Feasibility Study.

Less than half of women with urinary incontinence (UI) receive treatment, despite the high prevalence and negative impact of UI and the evidence supporting the efficacy of pelvic floor muscle training (PFMT). A non-inferiority randomized controlled trial aiming to support healthcare systems in delivering continence care showed that group-based PFMT was non-inferior and more cost-effective than individual PFMT to treat UI in older women. Recently, the COVID-19 pandemic highlighted the importance of providing online treatment options. Therefore, this pilot study aimed to assess the feasibility of an online group-based PFMT program for UI in older women. Thirty-four older women took part in the program. Feasibility was assessed from both participant and clinician perspectives. One woman dropped out. Participants attended 95.2% of all scheduled sessions, and the majority (32/33, 97.0%) completed their home exercises 4 to 5 times per week. Most women (71.9%) were completely satisfied with the program's effects on their UI symptoms after completion. Only 3 women (9.1%) reported that they would like to receive additional treatment. Physiotherapists reported high acceptability. The fidelity to the original program guidelines was also good. An online group-based PFMT program appears feasible for the treatment of UI in older women, from both participant and clinician perspectives.

Acupuncture for treating overactive bladder in adults.

BACKGROUND: Overactive bladder is a common, long-term symptom complex, which includes frequency of micturition, urgency with or without associated incontinence and nocturia. Around 11% of the population have symptoms, with this figure increasing with age. Symptoms can be linked to social anxiety and adaptive behavioural change. The cost of treating overactive bladder is considerable, with current treatments varying in effectiveness and being associated with side effects. Acupuncture has been suggested as an alternative treatment. OBJECTIVES: To assess the effects of acupuncture for treating overactive bladder in adults, and to summarise the principal findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (including In-Process, Epub Ahead of Print, Daily), ClinicalTrials.gov and WHO ICTRP (searched 14 May 2022). We also searched the Allied and Complementary Medicine database (AMED) and bibliographic databases where knowledge of the Chinese language was necessary: China National Knowledge Infrastructure (CNKI); Chinese Science and Technology Periodical Database (VIP) and WANFANG (China Online Journals), as well as the reference lists of relevant articles.  SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs and cross-over RCTs assessing the effects of acupuncture for treating overactive bladder in adults. DATA COLLECTION AND ANALYSIS: Four review authors formed pairs to assess study eligibility and extract data. Both pairs used Covidence software to perform screening and data extraction. We assessed risk of bias using Cochrane's risk of bias tool and assessed heterogeneity using the Chi2 testand I2 statistic generated within the meta-analyses. We used a fixed-effect model within the meta-analyses unless there was a moderate or high level of heterogeneity, where we employed a random-effects model. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included 15 studies involving 1395 participants in this review (14 RCTs and one quasi-RCT). All included studies raised some concerns regarding risk of bias. Blinding of participants to treatment group was only achieved in 20% of studies, we considered blinding of outcome assessors and allocation concealment to be low risk in only 25% of the studies, and random sequence generation to be either unclear or high risk in more than 50% of the studies. Acupuncture versus no treatment One study compared acupuncture to no treatment. The evidence is very uncertain regarding the effect of acupuncture compared to no treatment in curing or improving overactive bladder symptoms and on the number of minor adverse events (both very low-certainty evidence). The study report explicitly stated that no major adverse events occurred. The study did not report on the presence or absence of urinary urgency, episodes of urinary incontinence, daytime urinary frequency or episodes of nocturia. Acupuncture versus sham acupuncture Five studies compared acupuncture with sham acupuncture. The evidence is very uncertain about the effect of acupuncture on curing or improving overactive bladder symptoms compared to sham acupuncture (standardised mean difference (SMD) -0.36, 95% confidence interval (CI) -1.03 to 0.31; 3 studies; 151 participants; I2 = 65%; very low-certainty evidence). All five studies explicitly stated that there were no major adverse events observed during the study. Moderate-certainty evidence suggests that acupuncture probably makes no difference to the incidence of minor adverse events compared to sham acupuncture (risk ratio (RR) 1.28, 95% CI 0.30 to 5.36; 4 studies; 222 participants; I² = 0%). Only one small study reported data for the presence or absence of urgency and for episodes of nocturia. The evidence is of very low certainty for both of these outcomes and in both cases the lower confidence interval is implausible. Moderate-certainty evidence suggests there is probably little or no difference in episodes of urinary incontinence between acupuncture and sham acupuncture (mean difference (MD) 0.55, 95% CI -1.51 to 2.60; 2 studies; 121 participants; I2 = 57%). Two studies recorded data regarding daytime urinary frequency but we could not combine them in a meta-analysis due to differences in methodologies (very low-certainty evidence). Acupuncture versus medication Eleven studies compared acupuncture with medication. Low-certainty evidence suggests that acupuncture may slightly increase how many people's overactive bladder symptoms are cured or improved compared to medication (RR 1.25, 95% CI 1.10 to 1.43; 5 studies; 258 participants; I2 = 19%). Low-certainty evidence suggests that acupuncture may reduce the incidence of minor adverse events when compared to medication (RR 0.34, 95% CI 0.26 to 0.45; 8 studies; 1004 participants; I² = 51%). The evidence is uncertain regarding the effect of acupuncture on the presence or absence of urinary urgency (MD -0.40, 95% CI -0.56 to -0.24; 2 studies; 80 participants; I2 = 0%; very low-certainty evidence) and episodes of urinary incontinence (MD -0.33, 95% CI -2.75 to 2.09; 1 study; 20 participants; very low-certainty evidence) compared to medication. Low-certainty evidence suggests there may be little to no effect of acupuncture compared to medication in terms of daytime urinary frequency (MD 0.73, 95% CI -0.39 to 1.85; 4 studies; 360 participants; I2 = 28%). Acupuncture may slightly reduce the number of nocturia episodes compared to medication (MD -0.50, 95% CI -0.65 to -0.36; 2 studies; 80 participants; I2 = 0%, low-certainty evidence). There were no incidences of major adverse events in any of the included studies. However, major adverse events are rare in acupuncture trials and the numbers included in this review may be insufficient to detect these events. AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effect acupuncture has on cure or improvement of overactive bladder symptoms compared to no treatment. It is uncertain if there is any difference between acupuncture and sham acupuncture in cure or improvement of overactive bladder symptoms. This review provides low-certainty evidence that acupuncture may result in a slight increase in cure or improvement of overactive bladder symptoms when compared with medication and may reduce the incidence of minor adverse events. These conclusions must remain tentative until the completion of larger, higher-quality studies that use relevant, comparable outcomes. Timing and frequency of treatment, point selection, application and long-term follow-up are other areas relevant for research.

How did the COVID-19 pandemic affect urinary incontinence and its management in the nursing homes? A descriptive phenomenological study.

BACKGROUND: Management of urinary incontinence (UI) in nursing homes (NHs) represents a complex process that may have become more challenging during a period in which front-line health professionals (HPs) must deal with the outbreak of a new infectious disease. We aimed to investigate how UI and its management was affected in NHs during the COVID-19 pandemic based on the perception of health professionals. METHODS: This qualitative study was conducted between January and March 2021 with 16 health professionals working in nine NHs in the Osona county (Barcelona, Spain) during the COVID-19 pandemic. The individual interviews were conducted via online videoconferencing and each session was audio recorded. RESULTS: The HPs highlighted that the COVID-19 pandemic affected the management of continence in NHs, resulting in increased UI. Two main factors were identified: workforce-related and resident-related factors. Considering the workforce, three main topics emerged: pandemic as the priority, lack of personnel and use of personal protective equipment as an obstacle to communication with residents and attending to their needs. CONCLUSION: Managing UI in NHs always has been a challenging point of care, and these challenges were worsened by the restrictions and additional difficulties that arose during the COVID-19 pandemic.

Impact of COVID-19 pandemic on diagnosis and surgical management of common urological conditions: results from multi-institutional database analysis from the United States.

OBJECTIVE: To determine real life impact during the first pandemic year on diagnosis and surgical management of common urological diseases and 90-day postoperative mortality following common urological surgeries. METHODS: Cross-sectional study from 2016 to 2021. We used TriNetX to obtain the data. Patients with a diagnosis of six common non-oncologic and five oncologic urologic conditions were included. Twenty-four surgical interventions were also analyzed. The total number of diagnosis and surgical procedures were compared yearly from 2016 to 2021 and Chi-square test was used for statistical analysis. Additionally, monthly changes were evaluated during the first pandemic year and a z score period time was reported. The 90-day post-operative mortality rates during the first pandemic year were compared to the preceding year. RESULTS: Overall, a decrease in diagnosis and surgeries were observed during the first pandemic year, with maximum drop in April 2020. Among non-oncological conditions, the decrease in diagnosis of enlarged prostate (5.3%), nephrolithiasis (9.4%), urinary incontinence (18.7%), and evaluation for male sterilization (14.8%) reached statistical significance (P < 0.05 in all). Prostate cancer was the only cancer whose diagnosis showed statistically significant decrease (6.2%, P < 0.05). The surgical case load for benign conditions showed higher reduction (13.1-25%) than for malignant conditions (5.9-16.3%). There was no change in 90-day post-operative mortality in any of the analyzed surgeries. CONCLUSIONS: Our study showed that although healthcare delivery decreased in the first pandemic year, causing a decline in the diagnosis and surgical treatment of several diseases, surgical interventions did not increase the risk of death.

Systematic voiding programme in adults with urinary incontinence following acute stroke: the ICONS-II RCT.

BACKGROUND: Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively. OBJECTIVE: The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital. DESIGN: This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot. SETTING: Eighteen NHS stroke services with stroke units took part. PARTICIPANTS: Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment. INTERVENTION: Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit. MAIN OUTCOME MEASURES: The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained blinded until clinical effectiveness analysis was complete. RESULTS: The planned sample size was 1024 participants, with 512 allocated to each of the intervention and the usual-care groups. The internal pilot did not meet the target for recruitment and was extended to March 2020, with changes made to address low recruitment. The trial was paused in March 2020 because of COVID-19, and was later stopped, at which point 157 participants had been randomised (intervention, n = 79; usual care, n = 78). There were major issues with attrition, with 45% of the primary outcome data missing: 56% of the intervention group data and 35% of the usual-care group data. In terms of the primary outcome, patients allocated to the intervention group had a lower score for severity of urinary incontinence (higher scores indicate greater severity in urinary incontinence) than those allocated to the usual-care group, with means (standard deviations) of 8.1 (7.4) and 9.1 (7.8), respectively. LIMITATIONS: The trial was unable to recruit sufficient participants and had very high attrition, which resulted in seriously underpowered results. CONCLUSIONS: The internal pilot did not meet its target for recruitment and, despite recruitment subsequently being more promising, it was concluded that the trial was not feasible owing to the combined problems of poor recruitment, poor retention and COVID-19. The intervention group had a slightly lower score for severity of urinary incontinence at 3 months post randomisation, but this result should be interpreted with caution. FUTURE WORK: Further studies to assess the effectiveness of an intervention starting in or continuing into the community are required. TRIAL REGISTRATION: This trial is registered as ISRCTN14005026. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 31. See the NIHR Journals Library website for further project information.

Urinary incontinence affects around half of stroke survivors. It causes embarrassment and distress, affecting patients' ability to take part in rehabilitation. It also has a major impact on families and may determine whether or not patients are able to return home. Finding the underlying cause and addressing it can prevent, cure or reduce problems. Doing this in a systematic way for everyone with incontinence problems as early as possible after the stroke, while they are still in hospital, may work best. We also wanted to avoid using catheters in the bladder to drain the urine away, as these are often unnecessary and can cause urinary tract infections. This study aimed to test whether or not continence problems and the use of urinary catheters could be reduced if everyone with incontinence was fully assessed and given the right management and support early after hospital admission. We also wanted to find out if the benefits outweighed the costs. We planned to involve 1024 men and women with incontinence from 18 stroke units in the study, with 512 people receiving the intervention and 512 receiving usual care. However, the trial was paused because of COVID-19, at which time only 157 participants had been recruited. When we were thinking about restarting the study and looked at its progress, we found that not enough people had agreed to take part and, of those who had agreed, many had not returned their outcome questionnaires. This indicated that the trial was not feasible and should not restart. We could not make any firm conclusions about whether or not the intervention worked, as not enough people were involved. We found that stays in hospital after stroke are shorter than they were in the past. This suggests that future studies investigating ways of treating incontinence should consider interventions with management and support for incontinence that continue after patients leave the hospital.

Experiences of Urinary Incontinence Management in Older Women: A Qualitative Study.

INTRODUCTION: Older women have various experiences regarding the management of urinary incontinence depending on the societies they live in and their cultural backgrounds. The present study aimed to determine older women's experiences in urinary incontinence management. METHODS: The present qualitative study employed a conventional content analysis approach and was conducted in Iran from 2019 to 2020. In this research, the data were collected through face-to-face unstructured in-depth interviews with 22 older women suffering from urinary incontinence selected via purposeful sampling. The interviews were continued until reaching the data saturation point. Data analysis was performed simultaneously with data collection. The interviews were recorded, transcribed, and analyzed through Graneheim and Lundman style content analysis, and data management was done using the MAXQDA software. In order to achieve the accuracy and validity of the study, the Four-Dimensions Criteria (FDC) by Lincoln and Guba, namely credibility, dependability, conformability, and transformability, were considered and used. RESULTS: This study was conducted on 22 older women suffering from urinary incontinence with the mean age of 66.54 ± 5.76 years. The acquired data were put in four main categories of "resilience" with three subcategories, "change in lifestyle" with six subcategories, "attempt for treatment of the condition" with three subcategories, and "receiving support" with two subcategories. CONCLUSION: The study results indicated that the older women suffering from urinary incontinence were resilient against the condition, had changed their lifestyles to manage the condition, and sought treatment. In addition, receiving support from the family and the society played a significant role in the follow-up and management of the condition. The present study findings can help healthcare team members focus on urinary incontinence, design care programs for older women with this condition, and improve their quality of life. Furthermore, focusing on young and middle-aged women's health, providing them with the necessary training for taking care of the genitourinary system, and raising their awareness for preventing urinary incontinence during old ages can be helpful. Moreover, increasing the healthcare team's sensitivity and following the patients up can help diagnose, manage, and treat the condition before exerting adverse impacts on their quality of life.

Effect of Acupuncture for Mixed Urinary Incontinence in Women: A Systematic Review.

Background: Mixed urinary incontinence increasingly undermines women's quality of life. Previous studies showed some effects of acupuncture for MUI, but no systematic review has been done to evaluate the efficacy and safety of acupuncture for MUI in women. Objective: To systematically review the efficacy and safety of acupuncture for women with MUI. Methods: Ten databases (i.e., PubMed, Web of Science, Embase, ClinicalTrials.gov, the Cochrane Library, CBM, Scoups, CNKI, VIP and WANFANG DATA) were searched up to July 19th, 2021, using tailored search strategies with keywords not limited to "female," "mixed urinary incontinence," "acupuncture," and "randomized controlled trial," etc. RCTs and quasi-RCTs were included if investigating effect of any type of acupuncture for female patients with MUI. Data were extracted from eligible studies, and risks of bias were assessed according to the Cochrane Handbook from seven aspects using the RevMan 5.4 software. Results: A total of three randomized studies with 591 women were included. The risk of bias among the studies varied, with major concerns on blinding of participants and outcome assessor. Liu's study (497) mainly showed that electroacupuncture's effect on reduction of numbers of incontinence, urgency, nocturia episodes, and amount of urine leakage etc. was not inferior to that of PFMT-Solifenacin group at 12, 24, and 36 weeks. Zhan's study (60) showed that electroacupuncture reduced significantly more amount of urine leakage than Tolterodine at 8 weeks, with no data on incontinence episodes frequency. All 3 studies reported that acupuncture significantly increased the quality of life assessed by ICIQ score. In addition, incidence of acupuncture-related adverse events was rare, while antimuscarinic agents related adverse events were common in two studies. Conclusion: Although acupuncture showed some benefit for women with MUI, more evidences were required to draw a solid conclusion of effectiveness and safety of acupuncture for women with MUI. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42021224600.

Effects of a disposable home electro-stimulation device (Pelviva) for the treatment of female urinary incontinence: a randomised controlled trial.

AIMS: To compare current General Medical Practitioner treatment as usual (TAU) for the treatment of female urinary incontinence with a novel disposable home electro-stimulation device (Pelviva). METHODS: Open label, Primary Care post-market evaluation. 86 women with urinary incontinence were randomly assigned to one of two 12-week treatments: TAU or Pelviva for 30 min every other day plus TAU. Outcome measures included ICIQ-UI (primary), PISQ-IR, PGI-S / PGI-I and FSFI (secondary) at recruitment and immediately after intervention, 1-h pad test at recruitment and usage diaries throughout. RESULTS: Pelviva plus TAU produced significantly better outcome than TAU alone: 3 versus 1 point for ICIQ-UI (Difference - 1.8 95% CI: - 3.5 to - 0.1, P = 0.033). Significant differences were also observed for PGI-I at both 6 weeks (P = 0.001) and 12 weeks (P < 0.001). In the Pelviva group, 17% of women described themselves as feeling very much better and 54% a little or much better compared to 0% and 15% in the TAU. Overall PISQ-IR score reached statistical significance (P = 0.032) seemingly related to impact (P = 0.027). No other outcome measures reached statistical significance. Premature termination due to COVID-19 meant only 86 women were recruited from a sample size of 264. TAU did not reflect NICE guidelines. CONCLUSIONS: This study suggests Pelviva is more successful than TAU in treating urinary incontinence in Primary Care. The study had reduced power due to early termination due to COVID-19 and suggests TAU does not follow NICE guidelines.

Importance of infection control and continence management plans in assisted living communities during the COVID-19 pandemic.

A robust and comprehensive infection control plan in a senior living community is a must. Delirium manifestations of Covid-19 and or Urinary Tract Infections, may be confused or misdiagnosed with dementia symptoms in memory care residents. A robust incontinence care program is a key pillar of infection control to reduce symptoms causing hospitalization. Misdiagnosis, transfer infections, acute treatment dementia challenges, worsening incontinence are all risks of residents being hospitalized. A comprehensive incontinence assessment, plan, and education program are all paramount to seeing a reduction in hospitalizations and misdiagnosis of Covid-19 and other symptoms.

Telehealth in Urology: A Systematic Review of the Literature. How Much Can Telemedicine Be Useful During and After the COVID-19 Pandemic?

CONTEXT: Coronavirus disease 2019 (COVID-19) pandemic has caused increased interest in the application of telehealth to provide care without exposing patients and physicians to the risk of contagion. The urological literature on the topic is sparse. OBJECTIVE: To perform a systematic review of the literature and evaluate all the available studies on urological applications of telehealth. EVIDENCE ACQUISITION: After registration on PROSPERO, we searched PubMed and Scopus databases to collect any kind of studies evaluating any telehealth interventions in any urological conditions. The National Toxicology Program/Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies was used to estimate the risk of bias. A narrative synthesis was performed. EVIDENCE SYNTHESIS: We identified 45 studies (11 concerning prostate cancer [PCa], three hematuria management, six urinary stones, 14 urinary incontinence [UI], five urinary tract infections [UTIs], and six other conditions), including 12 randomized controlled trials. The available literature indicates that telemedicine has been implemented successfully in several common clinical scenarios, including the decision-making process following a diagnosis of nonmetastatic PCa, follow-up care of patients with localized PCa after curative treatments, initial diagnosis of hematuria, management diagnosis and follow-up care of uncomplicated urinary stones and uncomplicated UTIs, and initial evaluation, behavioral therapies, and pelvic floor muscle training in UI patients, as well as follow-up care after surgical treatments of stress urinary incontinence or pelvic organ prolapse. The methodological quality of most of the reports was good. CONCLUSIONS: Telehealth has been implemented successfully in selected patients with PCa, UI, pelvic organ prolapse, uncomplicated urinary stones, and UTIs. Many urological conditions are suitable for telehealth, but more studies are needed on other highly prevalent urological malignant and benign conditions. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine. More robust data on long-term efficacy, safety, and health economics are necessary. PATIENT SUMMARY: The diffusion of coronavirus disease 2019 (COVID-19) infections has recently increased the interest in telehealth, which is the adoption of telecommunication to deliver any health care activity. The available literature indicates that telemedicine has been adopted successfully in selected patients with several common clinical urological conditions, including prostate cancer, uncomplicated urinary stones, uncomplicated urinary infections, urinary incontinence, or pelvic organ prolapse. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine, but more robust data on long-term efficacy, safety, and costs are necessary.

Management of Female and Functional Urology Patients During the COVID Pandemic.

CONTEXT: Coronavirus disease 19 (COVID-19) has changed standard urology practice around the world. The situation is affecting not only uro-oncological patients but also patients with benign and disabling conditions who are suffering delays in medical attention that impact their quality of life. OBJECTIVE: To propose, based on expert advice and current evidence where available, a strategy to reorganize female and functional urological (FFU) activity (diagnosis and treatment). EVIDENCE ACQUISITION: The present document is based on a narrative review of the limited data available in the urological literature on SARS-Cov-2 and the experience of FFU experts from several countries around the world. EVIDENCE SYNTHESIS: In all the treatment schemes proposed in the literature on the COVID-19 pandemic, FFU surgery is not adequately covered and usually grouped into the category that is not urgent or can be delayed, but in a sustained pandemic scenario there are cases that cannot be delayed that should be considered for surgery as a priority. The aim of this document is to provide a detailed management plan for noninvasive and invasive FFU consultations, investigations, and operations. A classification of FFU surgical activity by indication and urgency is proposed, as well as recommendations adopted from the literature for good surgical practice and by surgical approach in FFU in the COVID-19 era. CONCLUSIONS: Functional, benign, and pelvic floor conditions have often been considered suitable for delay in challenging times. The long-term implications of this reduction in functional urology clinical activity are currently unknown. This document will help functional urology departments to reorganize their activity to best serve their patients. PATIENT SUMMARY: Many patients will suffer delays in urology treatment because of COVID-19, with consequent impairment of their physical and psychological health and deterioration of their quality of life. Efforts should be made to minimize the burden for this patient group, without endangering patients and health care workers.