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Am Fam Physician. 1999;59(6):1631-1635

Urge urinary incontinence is most often treated with pharmacologic therapy, with oxybutynin frequently prescribed. Burgio and colleagues conducted this randomized trial to compare oxybutynin treatment with behavioral biofeedback-assisted treatment in women with urge incontinence.

Women who were at least 55 years of age and had urge incontinence at least twice a week for at least three months were eligible. Patients were excluded if they were cognitively impaired, if their postvoid residual volume was greater than 200 mL or if they had medical conditions that would preclude the use of oxybutynin, such as glaucoma, heart problems or a prolapsed uterus. Patients were classified as having mild, moderate or severe incontinence (based on the number of incontinent episodes per week) and were then randomized to one of three groups: the control group, the behavioral treatment group and the medication group. Patients in the behavioral treatment group received anorectal biofeedback training, learned strategies for reducing the urge sensation and were instructed in home practice of pelvic muscle exercises. The medication group received oxybutynin in a dosage of 2.5 mg, three times a day, with dosage adjustment to minimize side effects while maximizing effectiveness.

All patients completed four clinic visits at two-week intervals for an eight-week period. At each visit, patients submitted a diary of daily incontinence episodes, completed an adverse event questionnaire and submitted a urine specimen. Vital signs were also recorded, and anal sphincter pressure was measured. Patients were asked after the study to rate their own progress and satisfaction.

The study randomized 197 women, with 65 each in the behavioral and control groups and 67 in the medication arm. Not unexpectedly, the medication group reported a higher incidence of side effects (almost 97 percent reported dry mouth). The control group had the highest rate of incontinence at the end of the study, with the behavioral group reporting the lowest rate of incontinence. From baseline to posttreatment, there was an 80.7 percent reduction in incontinence episodes in the behavioral group, compared with a 68.5 percent reduction in the medication group and a 39.4 percent reduction in the control group. Patients in the behavioral group were the most satisfied with their treatment; only 14 percent wished to add medication treatment to their behavioral regimen. In contrast, 75.5 percent of those receiving oxybutynin wished to receive another form of treatment.

The authors conclude that behavioral intervention for the treatment of urge incontinence in older women is safe, effective and well-liked by patients. Of note, the control group also achieved a significant reduction in incontinence episodes, showing that attention from the physician and expectations about the possibility of improvement can, in and of themselves, be beneficial.

In an accompanying editorial, Resnick points out that individualized attention (be it behavioral or pharmacologic) may be the most important factor for women with urge incontinence. However, he does note that the Burgio study was restricted to a specific cohort in which the women were cognitively intact, healthy and fairly young. In addition, some of the patients included had some element of stress incontinence, which may lend itself somewhat more to a behavioral approach.

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Copyright © 1999 by the American Academy of Family Physicians.

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