Lifestyle interventions for the treatment of urinary incontinence in adults.

BACKGROUND: Low cost, non-invasive alterations in lifestyle are frequently recommended by healthcare professionals or those presenting with incontinence. However, such recommendations are rarely based on good evidence. OBJECTIVES: The objective of the review was to determine the effectiveness of specific lifestyle interventions (i.e. weight loss; dietary changes; fluid intake; reduction in caffeinated, carbonated and alcoholic drinks; avoidance of constipation; stopping smoking; and physical activity) in the management of adult urinary incontinence. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process, and handsearching of journals and conference proceedings (searched 3 July 2013), and the reference lists of relevant articles. We incorporated the results of these searches fully in the review. We undertook an updated search of the Specialised Register, which now includes searches of ClinicalTrials.gov and WHO ICTRP, on 27 October 2014; potentially eligible studies from this search are currently awaiting classification. SELECTION CRITERIA: Randomised and quasi-randomised studies of community-based lifestyle interventions compared with no treatment, other conservative therapies, or pharmacological interventions for the treatment of urinary incontinence in adults. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study quality and extracted data. We collected information on adverse effects from the trials. Data were combined in a meta-analysis when appropriate. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: We included 11 trials in the review, involving a total of 5974 participants.Four trials involving 4701 women compared weight loss programmes with a control intervention. Low quality evidence from one trial suggested that more women following weight loss programmes reported improvement in symptoms of incontinence at six months (163/214 (76%) versus 49/90 (54%), risk ratio (RR) 1.40, 95% confidence interval (CI) 1.14 to 1.71), and this effect was sustained at 18 months (N = 291, 75% versus 62%, RR not estimable, reported P value 0.02). No data were available for self-reported cure and quality of life. One of the weight loss trials involving 1296 women reported very low quality evidence for a reduction in weekly urinary incontinence a mean of 2.8 years after following a lifestyle weight loss intervention that had been compared with a pharmacological weight loss intervention.Three trials involving 181 women and 11 men compared change in fluid intake with no change. Limited, very low quality evidence suggested that symptom-specific quality of life scores improved when fluid intake was reduced, although some people reported headaches, constipation or thirst. A further three trials involving 160 women and nine men compared reduction in caffeinated drinks with no change, and one trial involving 42 women compared a soy-rich diet with soy-free diet. However, it was not possible to reach any conclusions about the effects of these changes, due to methodological limitations, that resulted in very low quality evidence.Adverse effects appeared relatively uncommon for all interventions studied.All included studies had a high or unclear risk of bias across all bias parameters, but most notably for allocation concealment. The main factors for our downgrading of the evidence were risk of bias, indirect evidence (less than 12 months of follow-up; and not all participants having confirmed urinary incontinence at baseline in some studies), and imprecise results with wide confidence intervals.Other interventions such as reduction in consumption of sweetened fizzy or diet drinks; reduction in alcohol consumption; avoiding constipation; smoking cessation; restricting strenuous physical forces; or reducing high levels of, or increasing low levels of, physical activity, could not be assessed in this review, as no evidence from randomized controlled trials or quasi-randomised trials was available. AUTHORS' CONCLUSIONS: Evidence for the effect of weight loss on urinary incontinence is building and should be a research priority. Generally, there was insufficient evidence to inform practice reliably about whether lifestyle interventions are helpful in the treatment of urinary incontinence.

The effect of caffeinated versus decaffeinated drinks on overactive bladder: a double-blind, randomized, crossover study.

PURPOSE: The primary aims of this study were to test the methodology for use in a future randomized control trial and to investigate the effect of drinking caffeinated versus decaffeinated fluids on symptoms of overactive bladder (OAB) in women. DESIGN: A double-blind, randomized, crossover study was conducted. METHODS: Fourteen community-dwelling women newly diagnosed with OAB and a history of caffeine consumption were randomly allocated to group A (14-day caffeinated drink period followed by 14-day decaffeinated drink period) or group B (14-day decaffeinated drink period followed by 14-day caffeinated drink period). The periods were preceded by a 14-day run-in period and interspersed with a 14-day washout period. Primary outcomes were episodes of urgency, frequency, volume per void, and incontinence obtained each period on 3-day bladder diaries. Secondary outcome measures were OAB symptom severity and health-related quality of life (QOL) recorded each period using International Consultation on Incontinence-Overactive Bladder Module (ICIQ-OAB) and ICIQ-OAB-Quality of Life (ICIQ-OABqol) tools. Effects of caffeine reduction were measured each day using visual analogue scales. RESULTS: Eleven participants completed the study. A significant reduction in urgency (P < .01) and frequency (P < .05) of urinary voids on day 3 of the diary, total ICIQ-OAB score (P < .01), and a non-significant directional change for the total ICIQ-OABqol score (P = .065) was found using sign tests for the period of decaffeinated compared to caffeinated drink intake. No significant differences were found for any caffeine withdrawal measures. CONCLUSIONS: Despite the small sample size, this pilot study demonstrated that reducing caffeine intake may alleviate the severity of some symptoms and health-related QOL factors associated with OAB. Furthermore, caffeine substitutes were well tolerated.

Can district nurses and care home staff improve bowel care for older people using a clinical benchmarking tool?

A quasi-experimental study tested a clinical benchmarking tool (Essence of Care) to improve bowel-related care for older people living in six care homes. In the intervention care homes, district nurses and care home staff used the clinical benchmarking tool to discuss and plan how to improve bowel care for residents. In the control care homes, staff were provided with detailed information about the residents and continence services contact details. The intervention was acceptable to care home and district nursing staff, and possible to incorporate into existing working patterns. The study did not demonstrate a significant reduction in bowel-related problems, although there was evidence in one care home of reduction in episodes of avoidable faecal incontinence. At an individual level of care, there were observable benefits, and examples of person-centred care were prompted through participating in the intervention and improved staff awareness. Clinical benchmarking tools can be used to structure discussion between district nurses and care home staff to review and plan care for residents. However, it takes time to achieve change and embedding this kind of approach requires either robust pre-existing working relationships or the involvement of a facilitator.

Any qualified provider and its role in bladder and bowel care.

The Department of Health's Any Qualified Provider (AQP) policy blindsided specialist continence services in 2011. Continence AQP services, once qualified, can bid to provide additional continence services to areas in the country where local commissioners have decided they would like competition in the local area to give patients greater choice in service provision and drive up clinical standards. This short article looks at this subject in more depth.

Laxative use in care homes.

AIM: This paper is a report of an investigation into the factors associated with laxative-taking by older people in care homes. BACKGROUND: Constipation is a common source of discomfort, pain and morbidity for care home residents, and laxative-taking is prevalent. Differences in the extent to which older people suffer from constipation may result from care routines rather than demographic or clinical factors. DATA SOURCES: Primary data were gathered from care records as part of a larger study in seven care homes (without on-site nursing) in London, England in 2003-2004. METHODS: Backward stepwise logistic regression modelling was used to investigate factors (age, sex, level of dependency [Barthel]), number of comorbidities, number of medications, constipating medications, length of stay in care home, diagnosis of dementia/Alzheimer disease) associated with regular laxative-taking. RESULTS: Of 168 residents, 99 (58.9%) were routinely given laxatives. Taking more medicines (moving up one category: 0, 1-2, 3-4, 5-6, > or = 7) increased the likelihood of taking laxatives more than threefold, after controlling for all other factors. Women were 2.9 times more likely to take laxatives than men. Having dementia/Alzheimer disease increased the likelihood of taking laxatives by 2.6 times. Laxative-taking was statistically significantly lower in two of the care homes. CONCLUSION: Laxative use amongst older people in care homes varies and may not be based on rational criteria. Nurses working in care homes and with care staff can help to implement appropriate bowel care for older people.

Managing urinary incontinence with BioDerm external continence device.

Urinary incontinence (UI) is a common problem, experienced by both men and women, and has a significant impact on quality of life. For male patients, UI can be caused by a number of conditions, including post-prostatectomy, neurogenic problems (such as Parkinson's disease, multiple sclerosis and spinal cord injury), dementia, and an overactive bladder. One way of managing male UI is through the use of urinary sheaths - containment devices which capture the urine that is voided involuntarily. This article discusses male UI and its management, looking at common problems encountered when using urinary sheaths. It goes on to describe BioDerm, a new type of continence device that could meet the needs of some groups of men, and is an alternative to the previously used external condom catheter-based system of urinary drainage.

Integrated continence services and the female Bangladeshi population.

UNLABELLED: Continence services should be developed to cater for the needs of the entire population, including those of ethnic minority groups. This study undertook focus groups and meetings with the local Bangladeshi community and with local GPs to assess the needs for continence care provision and to assess current understanding of the problem in this community. The aim was to identify appropriate models for provision of care. METHOD: Questionnaires were devised which related to access to services for bowel and bladder problems for women and GPs. Focus groups which people's views and suggestions on improving service accessibility were ascertained. RESULTS: A 50% return was achieved for the GP questionnaire. GPs did not routinely enquire about bladder and bowel function and did not feel that Bangladeshi women needed any different service to that in the white population. The majority of the women in the focus groups considered bladder weakness as a loss of self-control, and emphasized the major impact on everyday life. There was little awareness of available services. CONCLUSION: Despite the cultural differences this study found that women tended to accept their bladder problem; did not consider it important enough to discuss with their doctor (who may also not take the problem seriously) and considered bladder problems as a normal part of womanhood or ageing.

Translating research on incontinence into practice.

BACKGROUND: Translating research evidence into clinical practice (TRIP) is an important initiative for health services so that care delivered is cost-effective, is efficient, and improves patient outcomes. Most TRIP studies have reported on disseminating and implementing clinical practice guidelines, protocols, or care pathways and have been undertaken in acute rather than community settings. OBJECTIVES: To identify the factors that influence incontinence TRIP and to present key international studies on incontinence TRIP. METHODS: Existing literature on TRIP was analyzed to generate a plan for future research. RESULTS: Several methods to effect incontinence TRIP are described, including clinical practice guidelines and protocols, clinical pathways, partnerships between organizations, a model for incorporating UI research based on generic questions, and implementation strategies that incorporate change theory and consideration of barriers. CONCLUSIONS: Future research is needed on incontinence TRIP in the following areas: barriers, the best theoretical approaches, the effectiveness of empowerment approaches, the value of mentors, effective strategies for nurses and unlicensed personnel, the impact of international collaboration, and regulations across settings.

Using bladder instillations to manage indwelling catheters.

Indwelling urinary catheters are commonly used in both acute and primary care settings but patients often experience problems with blockage of the catheter as a result of encrustation. Bladder instillations of differing solutions are used in an attempt to prevent and treat this problem of encrustation. This article looks at some of the issues surrounding the use and methods of these solutions. Based on an audit performed by a group of continence clinical nurse specialists in five areas of the UK, results of a questionnaire sent to acute and primary care nursing staff in 2003 are presented and discussed. The questionnaire covered a variety of clinical issues involved in performing bladder instillations and the results show that there is a wide variation of practice across the UK. The authors conclude that there are issues pertaining to bladder instillations which warrant further work.