Background: Overactive bladder, which can include symptoms such as urinary urgency, increased urinary frequency, and involuntary urine leakage, affects at least 11 million American women and led to an estimated $6.9 billion in direct health care costs in the year 2000. Despite the negative effects these symptoms have on emotional well-being and other quality-of-life measures, many women do not seek help from physicians, and only a minority receive treatment. Treatment options for overactive bladder include prescription medications, surgical and other procedures, behavioral interventions, and complementary and alternative therapies. Hartmann and colleagues systematically reviewed the incidence and prevalence of overactive bladder, the short- and long-term outcomes of individual and combined treatment approaches, and the costs associated with treatment.
The Study: Multiple electronic databases were searched for English-language publications through October 2008 that addressed one or more topics relevant to overactive bladder. A total of 2,559 abstracts were retrieved in initial searches. Of these abstracts, 232 articles met inclusion criteria for the review; most were rated “fair” quality. Common measures of treatment outcomes in the literature included the number of voids per day, urge incontinence episodes, degree of distress from symptoms, and interference with daily activities. The authors performed meta-analyses of selected studies to compare outcomes across different treatments. The contribution of pharmaceutical industry–sponsored research studies (which were considered more likely to be biased in favor of treatments) to the results was also assessed.
Results: Studies conducted in the United States and international populations estimated a 15 percent prevalence of overactive bladder in adult women. A minority of cases (23 to 35 percent) resolve during the course of one year, but most women experience persistent symptoms. Prescription medications modestly reduced the number of incontinence episodes and voids per day in placebo-controlled trials, with extended-release formulations being modestly more effective than immediate-release formulations. Even small changes in symptoms appeared to improve patients' quality of life and reduce distress. Comparative studies have been done, but the evidence for choosing one agent over another is weak. The 12-month costs of oxybutynin (Ditropan; patch, Oxytrol) or tolterodine (Detrol) therapy in newly diagnosed patients ranged from $56 to $360.
The evidence of benefit for procedures was considerably weaker than that for medications, with sacral neuromodulation reducing episodes of incontinence in patients who had failed medical management in one randomized trial. Multicomponent behavioral approaches that incorporated some combination of pelvic muscle training, biofeedback, and caffeine reduction produced symptom improvements that were similar in degree to those achieved with prescription medications. Little high-quality evidence on complementary and alternative therapies (acupuncture, foot reflexology, hypnotherapy) was available to draw conclusions about effectiveness.
Conclusion: The authors conclude that although both medical and behavioral interventions provide symptom relief in women with overactive bladder, large gaps in the evidence remain to be addressed. To assist decision-making for this common condition, the authors recommend that future investigators use intention-to-treat analyses, adjust their results for baseline severity of symptoms, and seek sources of funding independent from the pharmaceutical industry to pursue longer-term studies on the clinical effectiveness of different treatment strategies.