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Am Fam Physician. 2000;62(7):1635-1636

Studies have shown that up to 38 percent of women suffer from urinary incontinence. Current clinical practice guidelines recommend the use of anticholinergic agents as first-line pharmacologic treatment, as well as behavioral training to decrease episodes of incontinence. Other studies have shown that neither approach reduces incontinence in all patients. Burgio and associates conducted a crossover study to determine if medication, behavioral therapy or a combination of the two provided satisfactory results in women with urge incontinence.

Women included in the study were at least 55 years of age, community-dwelling and ambulatory, and had a diagnosis of urge incontinence (occurring at least twice a week for three months). Women with a postvoid residual volume greater than 200 mL, cardiac problems or impaired mental status were excluded from the study. Participants were randomly assigned to the behavioral arm (which included anorectal biofeedback, pelvic muscle biofeedback and daily pelvic floor muscle exercises), the medication arm (administration of 2.5 mg of oxybutynin three times daily, with adjustments up or down to a minimum of 2.5 mg daily or a maximum of 5.0 mg three times daily) or the placebo arm for a period of eight weeks. The women who were not satisfied with their level of dryness at the end of the eight-week period were encouraged to enroll in a combined behavioral treatment/drug therapy group for eight additional weeks. Each patient completed a daily bladder diary. The primary outcome was frequency of incontinent episodes, with zero percent meaning no improvement and 100 percent representing complete dryness.

One hundred ninety-seven women participated in the first part of the study. The behavioral group had an 80.7 percent decrease in incontinence compared with a 68.5 percent decrease in the drug treatment group and a 39.4 percent decrease in the placebo group. Of the 197 participants, 27 from the drug arm and eight from the behavioral arm continued with combined treatment. Those who added drug treatment to behavioral treatment had an 88.5 percent overall decrease in incontinence episodes. Those who added behavioral treatment to drug treatment had an overall decrease in incontinence of 84.3 percent on the combined treatment.

The authors conclude that a combination of anticholinergic and behavioral therapy is associated with an improvement in outcome—specifically, a decreased frequency of urinary incontinence—in older women with urge incontinence. Although not 100 percent effective, the combination of therapies may be more effective in patients with urge incontinence. Unfortunately, it is not clear which patients are more likely to benefit from the combined therapy. Combination therapy may be a way to obtain quick results and thus motivate the patient to continue with treatment.

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