- Email: [email protected]
Influence of behavior modification on overactive bladder
INFLUENCE OF BEHAVIOR MODIFICATION ON OVERACTIVE BLADDER KATHRYN L. BURGIO
ABSTRACT Behavioral interventions have been used for decades to treat urge incontinence and other symptoms of overactive bladder. Perhaps the earliest form of treatment was the bladder drill, an intensive intervention designed to increase the interval between voids to establish a normal frequency of urination and normalization of bladder function. Bladder training is a modification of bladder drill that is conducted more gradually on an outpatient basis and has resulted in significant reduction of incontinence in older, community-dwelling women. Multicomponent behavioral training is another form of behavioral treatment that includes pelvic floor muscle training and exercise. This intervention focuses less on voiding habits and more on altering the physiologic responses of the bladder and pelvic floor muscles. Using biofeedback or other teaching methods, patients learn strategies to inhibit bladder contraction using pelvic floor muscle contraction and other urge suppression strategies. Although behavioral and drug therapies are known to be highly effective for reducing urge incontinence, few patients are cured with either treatment alone. Thus, future research should explore ways to enhance the effectiveness of these conservative therapies. Although the mechanisms by which behavioral treatments work have not been established, there is some evidence that behavioral and drug interventions may operate by different mechanisms, suggesting that they may have additive effects and that combining them may result in better outcomes. Future research needs to examine the mechanisms by which these therapies reduce incontinence and whether combining behavioral and drug treatment will result in better outcomes than either therapy alone. UROLOGY 60 (Suppl 5A): 72–77, 2002. © 2002, Elsevier Science Inc.
R
ecent years have seen great strides in improving the pharmacologic treatment of overactive bladder (OAB). Likewise, progress has continued in the development of behavioral interventions, which have been used for decades to treat urge incontinence and other symptoms of OAB. The purpose of behavioral treatments is to improve bladder control through systematic changes in patient behavior and environmental conditions. There are a number of behavioral treatments for OAB, including bladder drill and bladder training, pelvic floor muscle training and exercise, urge suppression techniques (urge strategies), self-monitoring (bladder or voiding diaries), and dietary and fluid alterations. These treatments offer an effective means of improving continence without the
From the Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Birmingham, Alabama, USA; and School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. Reprint requests: Kathryn L. Burgio, PhD, Birmingham VA Medical Center, GRECC/11G, 700 19th Street South, Birmingham, Alabama 35233. E-mail: [email protected]
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© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
adverse effects that so often accompany drug therapies, and nonphysician practitioners can administer them. Most community-dwelling adults with OAB can be treated in an outpatient setting, where the patient learns skills for restoring continence and learns prescribed exercise and practice to be performed at home. Many studies1–17 have demonstrated that outpatient behavioral treatments are effective for reducing urge incontinence. They have been recognized for their efficacy by the 1988 Consensus Conference on Urinary Incontinence in Adults,1 which recommended that the least invasive or dangerous procedures should be tried first, a criterion met by many behavioral treatments for OAB. Later, behavioral treatment was recommended as a first-line therapy by the guideline for urinary incontinence in adults developed by the Agency for Health Care Policy and Research.2 At first, behavioral interventions focused on altering the voiding patterns of the patient in an effort to increase bladder capacity and restore normal bladder function. Later, the focus expanded to 0090-4295/02/$22.00 PII S0090-4295(02)01800-9
include treatments that target the bladder outlet and pelvic floor muscles as ways to control detrusor instability and resist urine loss. This article reviews developments in the behavioral treatment of OAB symptoms, identifies the role of behavior modification, and proposes future directions for research and clinical practice using behavioral treatments. BLADDER DRILL AND BLADDER TRAINING Perhaps the earliest form of behavioral treatment for OAB was the bladder drill, an intensive intervention that was usually conducted on an inpatient basis. Bladder drill procedures imposed a lengthened interval between voids to establish a normal frequency of urination and were purported to result in normalization of bladder function. Bladder training is a modification of bladder drill that is conducted more gradually on an outpatient basis. The rationale for this treatment approach is based on the premise that frequent urination is not only a precursor but also a precipitant of detrusor instability. Similarly, urgency is not simply an indicator or result of uninhibited detrusor contraction but an initiating factor, because it increases voiding frequency. Increased voiding frequency leads to reduced bladder capacity and eventually results in detrusor instability. In bladder training, this cycle is broken when patients resist the sensation of urgency to postpone urination and gradually increase the voiding interval. This increases bladder capacity and reduces detrusor instability. In the 1970s and early 1980s, Frewen3,4 recommended that women with urge incontinence be treated in the hospital for 7 to 10 days, where they were placed on a strict voiding schedule and monitored by nurses. Bladder drills were often combined with anticholinergic therapy and sedatives to help cope with severe urgency. He reported 82% to 86% cure rates in women 15 to 77 years of age. Similar results have been demonstrated in other studies using less intensive, outpatient procedures or a mixture of inpatient and outpatient intervention. Cure rates ranged from 44% to 90%.5–11 The first randomized clinical trial of bladder training was conducted by Fantl et al.,11 who demonstrated that older women reduced their episodes of incontinence by a mean of 57% using bladder training, whereas little improvement occurred with a no-treatment control condition. MULTICOMPONENT BEHAVIORAL TRAINING In bladder drill and bladder training, voiding habits are the primary targets of behavioral change. Multicomponent behavioral training is another form of behavioral treatment, which includes pelUROLOGY 60 (Supplement 5A), November 2002
vic floor muscle training and exercise, and focuses less on voiding habits and more on altering the physiologic responses of the bladder and pelvic floor muscles. Using biofeedback or other teaching methods, patients learn strategies to inhibit bladder contraction using pelvic floor muscle contraction and other urge suppression strategies. Biofeedback is a form of behavioral training that improves continence by altering physiologic responses of the bladder and pelvic muscles, which mediate incontinence. The targets of the intervention are the striated muscles of the pelvic floor and abdominal wall and the smooth detrusor muscle. Using biofeedback, physiologic change takes place through operant conditioning in which patients gain better control by observing the results of their attempts to control bladder and sphincter responses voluntarily. Early work used bladder pressure biofeedback to facilitate patients’ ability to inhibit detrusor contraction.12,13 Later, feedback of bladder pressure was given simultaneously with feedback of pelvic floor muscle activity.14 This combined biofeedback allows patients to visualize detrusor contractions and practice responding with pelvic floor muscle contraction. Filling the bladder also simulates their in vivo experiences of bladder fullness and urgency and provides patients with an opportunity to change how they respond to these sensations. Specifically, they can learn how to contract pelvic floor muscles selectively and quickly in response to urgency. The pelvic floor muscle contractions help to increase intraurethral resistance, reducing or preventing urine loss, and in many patients it is a way to inhibit detrusor contraction. Combined bladder and sphincter biofeedback has not been widely adopted, perhaps because of reluctance to catheterize patients. Eventually, however, pelvic floor biofeedback has been more widely disseminated, as have other methods of pelvic floor training, including pelvic floor electrical stimulation and simply using verbal feedback during a pelvic or rectal examination. Biofeedback-assisted behavioral training has been tested in several clinical series using pre–post designs. Mean reductions of incontinence ranged from 76% to 86%.14 –18 The first randomized clinical trial of this treatment compared biofeedback-assisted behavioral training with standard drug therapy, which at that time was oxybutynin chloride.19 Older women (55 to 92 years of age) with urge incontinence were evaluated and randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment, or a placebo control condition. Subjects achieved a mean 80.7% improvement with behavioral treatment, which was significantly more effective than drug treatment (mean improvement, 73
68.5%). Similarly, a larger proportion of subjects in the behavioral group achieved ⱖ50% and ⱖ75% reductions of incontinence (P ⫽ 0.002, P ⬍0.001). Although the values for full recovery of continence (100%) followed a similar pattern, the differences were not statistically significant (P ⫽ 0.07). This study showed that biofeedback-assisted behavioral training was at least as effective as oxybutynin for the treatment of urge incontinence. The mean 81% reduction of incontinence achieved is similar to that of previous studies of bladdersphincter biofeedback and was obtained with a less intensive approach than had been described in earlier reports.14 –18 Previous studies had repeated biofeedback in as many as 8 sessions. In this study, patients received anorectal biofeedback in their first treatment visit and repeated it or progressed to bladder and sphincter biofeedback only if they failed to achieve ⱖ50% improvement after 4 weeks. Most patients (73.8%) had a single session of biofeedback, and no patients had ⬎2 sessions. This finding indicates that patients can usually identify their pelvic floor muscles in a single session and that treatment requires less repetition of biofeedback than was previously thought. Several secondary outcome measures were used to assess the patient’s perceptions of treatment. On every parameter, the behavioral group reported the highest perceived improvement and satisfaction with treatment progress (P ⬍0.001). Of particular interest are the findings that 96.5% of the behavior group reported being comfortable enough with the treatment to continue indefinitely, and only 14.0% wished to receive another form of treatment. Despite the beneficial effects of drug treatment, only 54.7% said they could continue indefinitely, and 75.5% said they wished to receive another form of treatment. An advantage of behavioral treatments, in addition to the absence of adverse effects, is that the procedures can be implemented effectively by nonphysician providers in outpatient office settings.14 –18
part by the lack of availability of practitioners trained in these methods. Although both behavioral and drug therapies are known to be highly effective for reducing urge incontinence, they are also limitated in that few patients are actually cured with either treatment alone. In a recent clinical trial, only 23% of patients were dry after treatment with individually titrated oxybutynin and only 30% of patients were dry after behavioral training.19 The literature on urge incontinence makes it clear that no single method has provided a solution to this problem. All treatments are ⬍100% effective, all treatments have disadvantages, and no single treatment is helpful for everyone. Thus, there is a need for research to explore ways to enhance the effectiveness of these conservative therapies. A potential way to improve the efficacy of conservative therapies for overactive bladder is to combine behavioral and drug treatments. Some clinicians combine these treatments with the idea that relaxing the bladder with a pharmacologic agent provides a measure of control that will allow the patient to be better able to learn volitional control of detrusor contraction. Some point to the hypothesis that drugs help to inhibit detrusor contraction, but patients will not become dry without their own efforts exercised to suppress the bladder and reach the toilet in time to void. There are 2 reasons to believe that combining drug and behavioral treatment might enhance patient outcomes. First, although the mechanisms by which these therapies work have not been established completely, there is evidence that they operate by means of different mechanisms, suggesting that they may have additive effects and be ideal for combination therapy.11,20 Second, there is some evidence of significant added benefit of combination therapy in a small number of patients who did not have a satisfactory outcome with a single therapy.21
LIMITATIONS OF BEHAVIORAL TREATMENT
Early studies of bladder training reported that patients with detrusor instability demonstrated a return to normal bladder function after treatment with this method. However, in the controlled trial of bladder training, pretreatment and posttreatment urodynamic testing showed that reduction of incontinence occurred in the absence of urodynamic improvement.11 Furthermore, bladder training, which is intended to modify bladder function and urge incontinence, produced similar results when applied to patients with sphincter insufficiency. Thus, it seems clear that these patients did not need to alter their bladder function, at least
A significant limitation of behavioral treatments in outpatients is their reliance on the active participation and cooperation of an involved and motivated patient. Improvements are based on the ability to learn and retain skills and on conscious changes in daily behavior. This limits the usefulness of behavioral treatments in patients who have cognitive impairment or those who are not interested in exerting the effort required by a consistent daily regimen. Their utility has also been limited in 74
MECHANISMS OF THERAPEUTIC CHANGE IN BEHAVIORAL AND DRUG THERAPY
UROLOGY 60 (Supplement 5A), November 2002
as measured by urodynamic testing, to reduce the frequency of their incontinent episodes. In the controlled trial of biofeedback-assisted behavioral training, 198 subjects also underwent pretreatment and posttreatment urodynamic testing to examine changes in bladder sensation and function that might reveal mechanisms of therapeutic change in behavioral and drug treatment.19,20 Cystometry was performed before randomization in all subjects and repeated after treatment in a subsample of 105 subjects (53%) who consented. After intervention, patients who received drug therapy showed the largest change scores and a significant increase in the thresholds for first desire to void, strong desire to void, and cystometric capacity (69 mL, P ⬍0.001). The behavioral group demonstrated a significant increase in the threshold for strong desire to void (40.4 mL), but the mean 17-mL increase in cystometric capacity in the behavioral group was not a significant change. Previous research has shown that changes in bladder sensation and function may mediate the therapeutic effects of drug therapy. However, the findings of these behavioral studies suggest that such changes are not necessary for improvement of incontinence with behavioral intervention. These findings are consistent with the conceptualization of biofeedback-assisted behavioral training as a skill acquisition therapy. Patients are taught specific skills to prevent loss of urine for a very short period until they can reach a toilet. These motor skills, rather than a change in underlying function, may be responsible for improved continence status. Although the mechanisms by which behavioral treatments work have not been established, these studies provide evidence that the 2 interventions may operate by different mechanisms. This suggests that they may have additive effects and combining them may result in better outcomes. COMBINING BEHAVIORAL AND DRUG THERAPIES Little is known of the effectiveness, potential, or acceptability of combining therapies for incontinence. Although they are sometimes used together in clinical practice, the combination of these 2 therapies has rarely been investigated. Only 3 studies have addressed whether behavioral intervention combined with a drug might produce better results than behavioral intervention alone. Fantl et al.22 examined the role of medication in a controlled study of bladder drill with and without anticholinergic medication. They found that combining medication with bladder drill did not significantly increase the cure rate (83%) over that achieved with bladder drill alone (79%). OusUROLOGY 60 (Supplement 5A), November 2002
lander et al.23 studied the combined treatment of prompted voiding and oxybutynin or a placebo among functionally impaired nursing home patients with detrusor instability. Although the change in percentage of wetness checks (26.5% to 23.7%) was statistically significant, neither oxybutynin nor the placebo demonstrated clinically significant benefits when added to prompted voiding therapy in the nursing home setting. Although the results of these studies were not encouraging, a study21 of drug therapy and behavioral training indicated that combined therapy may be more effective than either alone. Combined therapy was studied in subgroups of patients who were not completely dry and not completely satisfied after 8 weeks of behavioral training or drug treatment with immediate-release oxybutynin. Using a conditional crossover design, patients not completely satisfied with behavioral treatment were offered drug therapy to supplement behavioral treatment for an additional 8 weeks. Similarly, those not completely satisfied with drug treatment could add behavioral treatment to their drug regimen for an additional 8 weeks. Among subjects who first received behavioral treatment, only a few (8 of 65) agreed to add drug therapy to their behavioral program. Bladder diaries showed significant clinical improvement, from a mean 57.5% reduction of incontinence after behavior therapy alone to a mean 88.5% overall reduction after the addition of oxybutynin (P ⫽ 0.034). Among subjects who first received drug therapy, 27 of 67 added behavior therapy to their drug regimen. They also demonstrated added improvement from a mean 72.7% reduction of incontinence after drug therapy alone to a mean 84.3% overall reduction with combined therapy (P ⫽ 0.001). Thus, the data demonstrated added benefit of combination therapy in patients who did not have acceptable outcomes after behavioral training or drug therapy alone. These results are encouraging but not definitive because of the small sample size and because the patients were self-selected. Thus, future research should examine further the mechanisms by which these therapies reduce incontinence and whether combining behavioral and drug treatment will result in better outcomes than either therapy alone. OTHER SYMPTOMS OF OVERACTIVE BLADDER Most of what is known about behavioral interventions for urgency, frequency, and nocturia is anecdotal or incidental to the study of treatments for urge incontinence. Research has focused on the effectiveness of various treatments for urge incontinence and 75
has generally used outcome measures of incontinence frequency, severity, or impact. In clinical practice, behavioral treatments are commonly used for other symptoms of overactive bladder. Anecdotal reports have been positive, but few published data exist. In studies of bladder training, reduction in the frequency of urination is described as the mechanism by which incontinence is treated rather than as an outcome itself. In studies of behavioral training, nocturia and voiding frequency have been decreased incidental to the treatment of incontinence. Although bothersome to patients, these symptoms have not generally been targeted as outcomes and therefore have not been measured as such or reported in articles. Although frequency and nocturia are measurable behaviors, urgency is a sensation as challenging as any other sensation to measure. The study of urgency is complicated as much by issues of definition as by debate about how to conceptualize urgency. Some studies of bladder training make reference to patients being free of symptoms after treatment. Instruments such as the American Urological Association Symptom Index rely on questions to evoke such symptom reporting. However, variability in phrasing makes it clear that there is little agreement as to what urgency is. Conceptualizations of urgency range from the “normal” sensation of strong desire to void and uncomfortable bladder fullness to urgency associated with “abnormal” uninhibited detrusor contraction, urgency that is abnormal because of its unusual frequency, or because it reflects a fear of urine loss. CONCLUSION Behavioral interventions have long been used to treat urge incontinence and other symptoms of overactive bladder. Research on bladder training and multicomponent behavioral training has shown clearly that these treatments are highly effective for reducing urge incontinence. However, only a small percentage of patients are completely dry after behavioral treatment. Thus, future research should examine the mechanisms by which these therapies reduce incontinence and explore ways to enhance their effectiveness, including the effects of combining behavioral and drug therapies. In addition, research is needed on the effectiveness of behavioral interventions for frequency, urgency, and nocturia as other bothersome symptoms of overactive bladder. REFERENCES 1. NIH Consensus Conference: Urinary incontinence in adults. JAMA 261: 2685–2696, 1989. 2. Fantl JA, Newman DK, Colling J, et al: Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Prac76
tice Guideline, No. 2, 1996 Update. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, March 1996. AHCPR Publication No. 96-0682. 3. Frewen WK: Role of bladder training in the treatment of the unstable bladder in the female. Urol Clin North Am 6: 273–277, 1979. 4. Frewen WK: A reassessment of bladder training in detrusor dysfunction in the female. Br J Urol 54: 372–373, 1982. 5. Elder DD, and Stephenson TP: An assessment of the Frewen regime in the treatment of detrusor dysfunction in females. Br J Urol 52: 467–471, 1980. 6. Jarvis GJ, and Millar DR: Controlled trial of bladder drill for detrusor instability. BMJ 281: 1322–1323, 1980. 7. Jarvis GJ: A controlled trial of bladder drill and drug therapy in the management of detrusor instability. J Urol 53: 565–566, 1981. 8. Jarvis GJ: The management of urinary incontinence due to primary vesical sensory urgency by bladder drill. Br J Urol 54: 374 –376, 1982. 9. Pengelly AW, and Booth CM: A prospective trial of bladder training as treatment for detrusor instability. Br J Urol 52: 463–466, 1980. 10. Svigos JM, and Matthews CD: Assessment and treatment of female urinary incontinence by cystometrogram and bladder retraining programs. Obstet Gynecol 50: 9 –12, 1977. 11. Fantl JA, Wyman JF, McClish DK, et al: Efficacy of bladder training in older women with urinary incontinence. JAMA 265: 609 –613, 1991. 12. Cardozo LD, Abrams PD, Stanton SL, et al: Idiopathic bladder instability treated by biofeedback. Br J Urol 50: 27–30, 1978. 13. Cardozo LD, Stanton SL, Hafner J, et al: Biofeedback in the treatment of detrusor instability. Br J Urol 50: 250 –254, 1978. 14. Burgio KL, Whitehead WE, and Engel BT: Urinary incontinence in the elderly: bladder/sphincter biofeedback and toileting skills training. Ann Intern Med 103: 507–515, 1985. 15. Burgio KL, Robinson JC, and Engel BT: The role of biofeedback in Kegel exercise training for stress urinary incontinence. Am J Obstet Gynecol 154: 58 –64, 1986. 16. Burton JR, Pearce KL, Burgio KL, et al: Behavioral training for urinary incontinence in elderly ambulatory patients. J Am Geriatr Soc 36: 693–698, 1988. 17. Burgio KL, Stutzman RE, and Engel BT: Behavioral training for post-prostatectomy urinary incontinence. J Urol 141: 303–306, 1989. 18. McDowell BJ, Burgio KL, Dombrowski M, et al: An interdisciplinary approach to the assessment and behavioral treatment of urinary incontinence in geriatric outpatients. J Am Geriatr Soc 40: 370 –374, 1992. 19. Burgio KL, Locher JL, Goode PS, et al: Behavioral versus drug treatment for urge incontinence in older women: a randomized clinical trial. JAMA 23: 1995–2000, 1998. 20. Goode PS, Burgio KL, Locher JL, et al: Urodynamic changes associated with behavioral and drug treatment of urge incontinence in older women. J Am Geriatr Soc 50: 808 – 816, 2002. 21. Burgio KL, Locher JL, and Goode PS: Combined behavioral and drug therapy of urge incontinence in older women. J Am Geriatr Soc 48: 370 –374, 2000. 22. Fantl JA, Hunt WG, and Dunn LJ: Detrusor instability syndrome: the use of bladder retraining drills with and without anticholinergics. Am J Obstet Gynecol 140: 885–890, 1981. 23. Ouslander JG, Schnelle JF, Uman G, et al: Does oxybutynin add to the effectiveness of prompted voiding for urinary incontinence among nursing home residents? A placebo-controlled trial. J Am Geriatr Soc 43: 610 –617, 1995. UROLOGY 60 (Supplement 5A), November 2002
ABSTRACT Behavioral interventions have been used for decades to treat urge incontinence and other symptoms of overactive bladder. Perhaps the earliest form of treatment was the bladder drill, an intensive intervention designed to increase the interval between voids to establish a normal frequency of urination and normalization of bladder function. Bladder training is a modification of bladder drill that is conducted more gradually on an outpatient basis and has resulted in significant reduction of incontinence in older, community-dwelling women. Multicomponent behavioral training is another form of behavioral treatment that includes pelvic floor muscle training and exercise. This intervention focuses less on voiding habits and more on altering the physiologic responses of the bladder and pelvic floor muscles. Using biofeedback or other teaching methods, patients learn strategies to inhibit bladder contraction using pelvic floor muscle contraction and other urge suppression strategies. Although behavioral and drug therapies are known to be highly effective for reducing urge incontinence, few patients are cured with either treatment alone. Thus, future research should explore ways to enhance the effectiveness of these conservative therapies. Although the mechanisms by which behavioral treatments work have not been established, there is some evidence that behavioral and drug interventions may operate by different mechanisms, suggesting that they may have additive effects and that combining them may result in better outcomes. Future research needs to examine the mechanisms by which these therapies reduce incontinence and whether combining behavioral and drug treatment will result in better outcomes than either therapy alone. UROLOGY 60 (Suppl 5A): 72–77, 2002. © 2002, Elsevier Science Inc.
R
ecent years have seen great strides in improving the pharmacologic treatment of overactive bladder (OAB). Likewise, progress has continued in the development of behavioral interventions, which have been used for decades to treat urge incontinence and other symptoms of OAB. The purpose of behavioral treatments is to improve bladder control through systematic changes in patient behavior and environmental conditions. There are a number of behavioral treatments for OAB, including bladder drill and bladder training, pelvic floor muscle training and exercise, urge suppression techniques (urge strategies), self-monitoring (bladder or voiding diaries), and dietary and fluid alterations. These treatments offer an effective means of improving continence without the
From the Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Birmingham, Alabama, USA; and School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. Reprint requests: Kathryn L. Burgio, PhD, Birmingham VA Medical Center, GRECC/11G, 700 19th Street South, Birmingham, Alabama 35233. E-mail: [email protected]
72
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
adverse effects that so often accompany drug therapies, and nonphysician practitioners can administer them. Most community-dwelling adults with OAB can be treated in an outpatient setting, where the patient learns skills for restoring continence and learns prescribed exercise and practice to be performed at home. Many studies1–17 have demonstrated that outpatient behavioral treatments are effective for reducing urge incontinence. They have been recognized for their efficacy by the 1988 Consensus Conference on Urinary Incontinence in Adults,1 which recommended that the least invasive or dangerous procedures should be tried first, a criterion met by many behavioral treatments for OAB. Later, behavioral treatment was recommended as a first-line therapy by the guideline for urinary incontinence in adults developed by the Agency for Health Care Policy and Research.2 At first, behavioral interventions focused on altering the voiding patterns of the patient in an effort to increase bladder capacity and restore normal bladder function. Later, the focus expanded to 0090-4295/02/$22.00 PII S0090-4295(02)01800-9
include treatments that target the bladder outlet and pelvic floor muscles as ways to control detrusor instability and resist urine loss. This article reviews developments in the behavioral treatment of OAB symptoms, identifies the role of behavior modification, and proposes future directions for research and clinical practice using behavioral treatments. BLADDER DRILL AND BLADDER TRAINING Perhaps the earliest form of behavioral treatment for OAB was the bladder drill, an intensive intervention that was usually conducted on an inpatient basis. Bladder drill procedures imposed a lengthened interval between voids to establish a normal frequency of urination and were purported to result in normalization of bladder function. Bladder training is a modification of bladder drill that is conducted more gradually on an outpatient basis. The rationale for this treatment approach is based on the premise that frequent urination is not only a precursor but also a precipitant of detrusor instability. Similarly, urgency is not simply an indicator or result of uninhibited detrusor contraction but an initiating factor, because it increases voiding frequency. Increased voiding frequency leads to reduced bladder capacity and eventually results in detrusor instability. In bladder training, this cycle is broken when patients resist the sensation of urgency to postpone urination and gradually increase the voiding interval. This increases bladder capacity and reduces detrusor instability. In the 1970s and early 1980s, Frewen3,4 recommended that women with urge incontinence be treated in the hospital for 7 to 10 days, where they were placed on a strict voiding schedule and monitored by nurses. Bladder drills were often combined with anticholinergic therapy and sedatives to help cope with severe urgency. He reported 82% to 86% cure rates in women 15 to 77 years of age. Similar results have been demonstrated in other studies using less intensive, outpatient procedures or a mixture of inpatient and outpatient intervention. Cure rates ranged from 44% to 90%.5–11 The first randomized clinical trial of bladder training was conducted by Fantl et al.,11 who demonstrated that older women reduced their episodes of incontinence by a mean of 57% using bladder training, whereas little improvement occurred with a no-treatment control condition. MULTICOMPONENT BEHAVIORAL TRAINING In bladder drill and bladder training, voiding habits are the primary targets of behavioral change. Multicomponent behavioral training is another form of behavioral treatment, which includes pelUROLOGY 60 (Supplement 5A), November 2002
vic floor muscle training and exercise, and focuses less on voiding habits and more on altering the physiologic responses of the bladder and pelvic floor muscles. Using biofeedback or other teaching methods, patients learn strategies to inhibit bladder contraction using pelvic floor muscle contraction and other urge suppression strategies. Biofeedback is a form of behavioral training that improves continence by altering physiologic responses of the bladder and pelvic muscles, which mediate incontinence. The targets of the intervention are the striated muscles of the pelvic floor and abdominal wall and the smooth detrusor muscle. Using biofeedback, physiologic change takes place through operant conditioning in which patients gain better control by observing the results of their attempts to control bladder and sphincter responses voluntarily. Early work used bladder pressure biofeedback to facilitate patients’ ability to inhibit detrusor contraction.12,13 Later, feedback of bladder pressure was given simultaneously with feedback of pelvic floor muscle activity.14 This combined biofeedback allows patients to visualize detrusor contractions and practice responding with pelvic floor muscle contraction. Filling the bladder also simulates their in vivo experiences of bladder fullness and urgency and provides patients with an opportunity to change how they respond to these sensations. Specifically, they can learn how to contract pelvic floor muscles selectively and quickly in response to urgency. The pelvic floor muscle contractions help to increase intraurethral resistance, reducing or preventing urine loss, and in many patients it is a way to inhibit detrusor contraction. Combined bladder and sphincter biofeedback has not been widely adopted, perhaps because of reluctance to catheterize patients. Eventually, however, pelvic floor biofeedback has been more widely disseminated, as have other methods of pelvic floor training, including pelvic floor electrical stimulation and simply using verbal feedback during a pelvic or rectal examination. Biofeedback-assisted behavioral training has been tested in several clinical series using pre–post designs. Mean reductions of incontinence ranged from 76% to 86%.14 –18 The first randomized clinical trial of this treatment compared biofeedback-assisted behavioral training with standard drug therapy, which at that time was oxybutynin chloride.19 Older women (55 to 92 years of age) with urge incontinence were evaluated and randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment, or a placebo control condition. Subjects achieved a mean 80.7% improvement with behavioral treatment, which was significantly more effective than drug treatment (mean improvement, 73
68.5%). Similarly, a larger proportion of subjects in the behavioral group achieved ⱖ50% and ⱖ75% reductions of incontinence (P ⫽ 0.002, P ⬍0.001). Although the values for full recovery of continence (100%) followed a similar pattern, the differences were not statistically significant (P ⫽ 0.07). This study showed that biofeedback-assisted behavioral training was at least as effective as oxybutynin for the treatment of urge incontinence. The mean 81% reduction of incontinence achieved is similar to that of previous studies of bladdersphincter biofeedback and was obtained with a less intensive approach than had been described in earlier reports.14 –18 Previous studies had repeated biofeedback in as many as 8 sessions. In this study, patients received anorectal biofeedback in their first treatment visit and repeated it or progressed to bladder and sphincter biofeedback only if they failed to achieve ⱖ50% improvement after 4 weeks. Most patients (73.8%) had a single session of biofeedback, and no patients had ⬎2 sessions. This finding indicates that patients can usually identify their pelvic floor muscles in a single session and that treatment requires less repetition of biofeedback than was previously thought. Several secondary outcome measures were used to assess the patient’s perceptions of treatment. On every parameter, the behavioral group reported the highest perceived improvement and satisfaction with treatment progress (P ⬍0.001). Of particular interest are the findings that 96.5% of the behavior group reported being comfortable enough with the treatment to continue indefinitely, and only 14.0% wished to receive another form of treatment. Despite the beneficial effects of drug treatment, only 54.7% said they could continue indefinitely, and 75.5% said they wished to receive another form of treatment. An advantage of behavioral treatments, in addition to the absence of adverse effects, is that the procedures can be implemented effectively by nonphysician providers in outpatient office settings.14 –18
part by the lack of availability of practitioners trained in these methods. Although both behavioral and drug therapies are known to be highly effective for reducing urge incontinence, they are also limitated in that few patients are actually cured with either treatment alone. In a recent clinical trial, only 23% of patients were dry after treatment with individually titrated oxybutynin and only 30% of patients were dry after behavioral training.19 The literature on urge incontinence makes it clear that no single method has provided a solution to this problem. All treatments are ⬍100% effective, all treatments have disadvantages, and no single treatment is helpful for everyone. Thus, there is a need for research to explore ways to enhance the effectiveness of these conservative therapies. A potential way to improve the efficacy of conservative therapies for overactive bladder is to combine behavioral and drug treatments. Some clinicians combine these treatments with the idea that relaxing the bladder with a pharmacologic agent provides a measure of control that will allow the patient to be better able to learn volitional control of detrusor contraction. Some point to the hypothesis that drugs help to inhibit detrusor contraction, but patients will not become dry without their own efforts exercised to suppress the bladder and reach the toilet in time to void. There are 2 reasons to believe that combining drug and behavioral treatment might enhance patient outcomes. First, although the mechanisms by which these therapies work have not been established completely, there is evidence that they operate by means of different mechanisms, suggesting that they may have additive effects and be ideal for combination therapy.11,20 Second, there is some evidence of significant added benefit of combination therapy in a small number of patients who did not have a satisfactory outcome with a single therapy.21
LIMITATIONS OF BEHAVIORAL TREATMENT
Early studies of bladder training reported that patients with detrusor instability demonstrated a return to normal bladder function after treatment with this method. However, in the controlled trial of bladder training, pretreatment and posttreatment urodynamic testing showed that reduction of incontinence occurred in the absence of urodynamic improvement.11 Furthermore, bladder training, which is intended to modify bladder function and urge incontinence, produced similar results when applied to patients with sphincter insufficiency. Thus, it seems clear that these patients did not need to alter their bladder function, at least
A significant limitation of behavioral treatments in outpatients is their reliance on the active participation and cooperation of an involved and motivated patient. Improvements are based on the ability to learn and retain skills and on conscious changes in daily behavior. This limits the usefulness of behavioral treatments in patients who have cognitive impairment or those who are not interested in exerting the effort required by a consistent daily regimen. Their utility has also been limited in 74
MECHANISMS OF THERAPEUTIC CHANGE IN BEHAVIORAL AND DRUG THERAPY
UROLOGY 60 (Supplement 5A), November 2002
as measured by urodynamic testing, to reduce the frequency of their incontinent episodes. In the controlled trial of biofeedback-assisted behavioral training, 198 subjects also underwent pretreatment and posttreatment urodynamic testing to examine changes in bladder sensation and function that might reveal mechanisms of therapeutic change in behavioral and drug treatment.19,20 Cystometry was performed before randomization in all subjects and repeated after treatment in a subsample of 105 subjects (53%) who consented. After intervention, patients who received drug therapy showed the largest change scores and a significant increase in the thresholds for first desire to void, strong desire to void, and cystometric capacity (69 mL, P ⬍0.001). The behavioral group demonstrated a significant increase in the threshold for strong desire to void (40.4 mL), but the mean 17-mL increase in cystometric capacity in the behavioral group was not a significant change. Previous research has shown that changes in bladder sensation and function may mediate the therapeutic effects of drug therapy. However, the findings of these behavioral studies suggest that such changes are not necessary for improvement of incontinence with behavioral intervention. These findings are consistent with the conceptualization of biofeedback-assisted behavioral training as a skill acquisition therapy. Patients are taught specific skills to prevent loss of urine for a very short period until they can reach a toilet. These motor skills, rather than a change in underlying function, may be responsible for improved continence status. Although the mechanisms by which behavioral treatments work have not been established, these studies provide evidence that the 2 interventions may operate by different mechanisms. This suggests that they may have additive effects and combining them may result in better outcomes. COMBINING BEHAVIORAL AND DRUG THERAPIES Little is known of the effectiveness, potential, or acceptability of combining therapies for incontinence. Although they are sometimes used together in clinical practice, the combination of these 2 therapies has rarely been investigated. Only 3 studies have addressed whether behavioral intervention combined with a drug might produce better results than behavioral intervention alone. Fantl et al.22 examined the role of medication in a controlled study of bladder drill with and without anticholinergic medication. They found that combining medication with bladder drill did not significantly increase the cure rate (83%) over that achieved with bladder drill alone (79%). OusUROLOGY 60 (Supplement 5A), November 2002
lander et al.23 studied the combined treatment of prompted voiding and oxybutynin or a placebo among functionally impaired nursing home patients with detrusor instability. Although the change in percentage of wetness checks (26.5% to 23.7%) was statistically significant, neither oxybutynin nor the placebo demonstrated clinically significant benefits when added to prompted voiding therapy in the nursing home setting. Although the results of these studies were not encouraging, a study21 of drug therapy and behavioral training indicated that combined therapy may be more effective than either alone. Combined therapy was studied in subgroups of patients who were not completely dry and not completely satisfied after 8 weeks of behavioral training or drug treatment with immediate-release oxybutynin. Using a conditional crossover design, patients not completely satisfied with behavioral treatment were offered drug therapy to supplement behavioral treatment for an additional 8 weeks. Similarly, those not completely satisfied with drug treatment could add behavioral treatment to their drug regimen for an additional 8 weeks. Among subjects who first received behavioral treatment, only a few (8 of 65) agreed to add drug therapy to their behavioral program. Bladder diaries showed significant clinical improvement, from a mean 57.5% reduction of incontinence after behavior therapy alone to a mean 88.5% overall reduction after the addition of oxybutynin (P ⫽ 0.034). Among subjects who first received drug therapy, 27 of 67 added behavior therapy to their drug regimen. They also demonstrated added improvement from a mean 72.7% reduction of incontinence after drug therapy alone to a mean 84.3% overall reduction with combined therapy (P ⫽ 0.001). Thus, the data demonstrated added benefit of combination therapy in patients who did not have acceptable outcomes after behavioral training or drug therapy alone. These results are encouraging but not definitive because of the small sample size and because the patients were self-selected. Thus, future research should examine further the mechanisms by which these therapies reduce incontinence and whether combining behavioral and drug treatment will result in better outcomes than either therapy alone. OTHER SYMPTOMS OF OVERACTIVE BLADDER Most of what is known about behavioral interventions for urgency, frequency, and nocturia is anecdotal or incidental to the study of treatments for urge incontinence. Research has focused on the effectiveness of various treatments for urge incontinence and 75
has generally used outcome measures of incontinence frequency, severity, or impact. In clinical practice, behavioral treatments are commonly used for other symptoms of overactive bladder. Anecdotal reports have been positive, but few published data exist. In studies of bladder training, reduction in the frequency of urination is described as the mechanism by which incontinence is treated rather than as an outcome itself. In studies of behavioral training, nocturia and voiding frequency have been decreased incidental to the treatment of incontinence. Although bothersome to patients, these symptoms have not generally been targeted as outcomes and therefore have not been measured as such or reported in articles. Although frequency and nocturia are measurable behaviors, urgency is a sensation as challenging as any other sensation to measure. The study of urgency is complicated as much by issues of definition as by debate about how to conceptualize urgency. Some studies of bladder training make reference to patients being free of symptoms after treatment. Instruments such as the American Urological Association Symptom Index rely on questions to evoke such symptom reporting. However, variability in phrasing makes it clear that there is little agreement as to what urgency is. Conceptualizations of urgency range from the “normal” sensation of strong desire to void and uncomfortable bladder fullness to urgency associated with “abnormal” uninhibited detrusor contraction, urgency that is abnormal because of its unusual frequency, or because it reflects a fear of urine loss. CONCLUSION Behavioral interventions have long been used to treat urge incontinence and other symptoms of overactive bladder. Research on bladder training and multicomponent behavioral training has shown clearly that these treatments are highly effective for reducing urge incontinence. However, only a small percentage of patients are completely dry after behavioral treatment. Thus, future research should examine the mechanisms by which these therapies reduce incontinence and explore ways to enhance their effectiveness, including the effects of combining behavioral and drug therapies. In addition, research is needed on the effectiveness of behavioral interventions for frequency, urgency, and nocturia as other bothersome symptoms of overactive bladder. REFERENCES 1. NIH Consensus Conference: Urinary incontinence in adults. JAMA 261: 2685–2696, 1989. 2. Fantl JA, Newman DK, Colling J, et al: Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Prac76
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