Evidence profile: urinary incontinence...1 Evidence profile: urinary incontinence ICOPE guidelines...

Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity

Evidence profile: urinary incontinence Scoping question: Do non-pharmacological interventions (prompted voiding, timed voiding, toilet training, habit retraining, pelvic floor muscle training) produce any benefit and/or harm for older people with urinary incontinence? The full ICOPE guidelines and complete set of evidence profiles are available at who.int/ageing/publications/guidelines-icope

Painting: “Wet in Wet” by Gusta van der Meer. At 75 years of age, Gusta has an artistic style that is fresh, distinctive and vibrant. A long-time lover of art, she finds that dementia is no barrier to her artistic expression. Appreciated not just for her art but also for the support and encouragement she gives to other artists with dementia, Gusta participates in a weekly art class. Copyright by Gusta van der Meer. All rights reserved

http://www.who.int/ageing/publications/guidelines-icope

Evidence profile: urinary incontinence

ICOPE guidelines – World Health Organization

Contents

Background ........................................................................................................................................................................................................ 1

Part 1: Evidence review ..................................................................................................................................................................................... 2 Scoping question in PICO format (population, intervention, comparison, outcome) .............................................................................................. 2 Search strategy .................................................................................................................................................................................................... 3 List of systematic reviews identified by the search process .................................................................................................................................. 3 PICO table ........................................................................................................................................................................................................... 4 Narrative description of the systematic reviews included in the analysis .............................................................................................................. 5 Brief descriptions of the included non-pharmacological interventions ................................................................................................................... 6 GRADE table 1: Prompted voiding versus no prompted voiding for adults with urinary incontinence ................................................................... 8 GRADE table 2: Pelvic floor muscle training (PFMT) with or without biofeedback plus other interventions versus no active control for older people with urinary incontinence ........................................................................................................................................................................ 10 GRADE table 3: Habit retraining plus others compared with usual care for older people (men and women) with urinary incontinence .............. 12 GRADE table 4: Pelvic floor muscle training (PFMT) compared with no treatment for older women with urinary incontinence ........................... 13 GRADE table 5: Bladder training versus no treatment for older people with urinary incontinence ...................................................................... 15 GRADE table 5.1: Bladder training versus other behavioural interventions for older people with other incontinence .......................................... 16 GRADE table 6: Timed voiding plus other versus usual care for older people with urinary incontinence ............................................................ 17

Part 2: From evidence to recommendations .................................................................................................................................................. 18 Summary of evidence ........................................................................................................................................................................................ 18 Evidence-to-recommendations table .................................................................................................................................................................. 20

Guideline development group recommendation and remarks ..................................................................................................................... 24

References ....................................................................................................................................................................................................... 26

Annex 1: Search strategy ................................................................................................................................................................................ 28

Annex 2: PRISMA 2009 flow diagram for non-pharmacological intervention for managing urinary incontinence .................................. 30

© World Health Organization 2017

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1 Evidence profile: urinary incontinence


Background

Urinary incontinence, the involuntary loss of urine, is a highly

prevalent condition in older people aged 60 years and over (1).

The common types of urinary incontinence in older people are

stress incontinence and urge incontinence. Stress incontinence is

the involuntary leaking of urine during efforts or exertion, or while

sneezing or coughing. Urge incontinence, or overactive bladder

syndrome, involves a constellation of symptoms including

frequency, urgency and leakage immediately preceded by urgency.

The prevalence of urinary incontinence reported in population-

based studies ranges from 9.9% to 36.1% (2–4), and is twice as

high in older women as in older men. Urinary incontinence has a

profound impact on the quality of life of older people, their

subjective health status (5, 6), levels of depression (7) and need

for care (8).

Several chronic conditions and environmental factors increase

the risk of urinary incontinence in older people. Chronic diseases

that are associated with urinary incontinence include diabetes

mellitus, Parkinson’s disease, dementia, stroke, prostatic cancer,

chronic obstructive pulmonary disease (COPD) and arthritis.

Environmental factors such as inaccessible or unsafe toilet

facilities, and the absence of caregivers for toileting assistance

are also associated with urinary incontinence. Non-

pharmacological interventions are mostly preferred and remain

the mainstay of urinary incontinence management for patients

with mild urinary incontinence. The primary goal of urinary

incontinence interventions is to improve continence by reducing

the frequency of urinary incontinence episodes. The non-

pharmacological interventions addressed in this guideline include

pelvic floor muscle training (PFMT), bladder training and habit

retraining, and timed or prompted voiding.



Part 1: Evidence review

Scoping question in PICO format (population,

intervention, comparison, outcome)

Population

• Older people with urgency or stress or mixed urinary incontinence

Interventions

• Prompted voiding

• Timed voiding

• Bladder training

• Habit retraining

• Pelvic floor muscle training (PFMT)

Comparison

• No intervention/usual care

Outcomes

• Critical: Proportion of mean change in frequency of urinary

incontinence, change in mean proportion of hourly checks that are

wet, number of patients with reductions in incidence of daytime

incontinence, number of patients with reductions in incidence of

night-time incontinence, incontinent episodes in 24 hours, mean

urinary incontinence incidence per 24 hours, urinary incontinence

symptoms

• Important: Perceived cure, self-initiated toileting, median percentage

of checks wet, number of incontinent episodes, urinary incontinence

urgency, urinary incontinence frequency, nocturia, quality of life



Search strategy

A systematic literature search for reviews was conducted in Ovid

MEDLINE, Embase, PsycINFO and Cochrane databases. The

details of the search terms used for retrieving studies are provided

in Annex 1. The search retrieved 188 reviews and 798 randomized

controlled trials (RCTs). After initial screening for eligibility, 111

reviews and 161 RCTs were considered for full-text review.

Ultimately, five systematic reviews that included 25 RCTs and two

additional studies investigating the benefits of non-pharmacological

interventions were included in this review (see Annex 2).

List of systematic reviews identified by the search

process

Included in GRADE1 tables

— Wallace SA, Roe B, Williams K, Palmer M. Bladder training for

urinary incontinence in adults. Cochrane Database Syst Rev.

2004;(1):CD001308. Updated in 2009. [Systematic review was

updated by WHO in 2015] (9)

— Ostaszkiewicz J, Johnston L, Roe B. Habit retraining for the

management of urinary incontinence in adults. Cochrane Database

Syst Rev. 2004;(2):CD002801. Updated in 2009. [Systematic

review was updated by WHO in 2015] (10)

— Eustice S, Roe B, Paterson J. Prompted voiding for the




— Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the




— Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor

muscle training versus no treatment, or inactive control treatments,

for urinary incontinence in women. Cochrane Database Syst Rev.

2014;(5):CD005654 (13)

_______________________________ 1 GRADE: Grading of Recommendations Assessment, Development and Evaluation. More information: http://gradeworkinggroup.org

http://gradeworkinggroup.org/



PICO table

Intervention/

comparison

Outcomes Studies used for GRADE

1 Timed voiding plus others

vs usual care

• Number of patients with reductions in incidence of

daytime urinary incontinence

• Number of patients with reductions in incidence of

night-time incontinence

• Number of patients whose pad test indicates

reduction in the volume of incontinence

Ostaszkiewicz J, Johnston L, Roe B. Timed

voiding for the management of urinary

incontinence in adults. Cochrane Database

Syst Rev. 2004;(1):CD002802. Updated in

2009. (12)

2 Prompted voiding vs no

prompted voiding

• Number of patients with no improvement in urinary

incontinence episodes

• Change in mean proportion of hourly checks that are

wet

• urinary incontinence episodes in 24 hours

• Self-initiated toileting

Eustice S, Roe B, Paterson J. Prompted

voiding for the management of urinary



2006. (11)

3 Habit retraining plus

others vs usual care

• Number of incontinent episodes

• Incontinent volume

Ostaszkiewicz J, Johnston L, Roe B. Habit

retraining for the management of urinary



2009. (10)

4 Bladder training vs no

treatment or active

treatment controls

• Cure rate

• Number of micturition episodes

Wallace SA, Roe B, Williams K, Palmer M.

Bladder training for urinary incontinence in

adults. Cochrane Database Syst Rev.

2004;(1):CD001308. Updated in 2009. (9)

(continued next page)



5 Pelvic floor muscle

training plus bladder

retraining vs control

• Mean urinary incontinence incidence per 24 hours

• Urinary incontinence urgency

• Urinary incontinence frequency

• Nocturia

Dumoulin C, Hay-Smith EJC, Mac Habée-

Séguin G. Pelvic floor muscle training versus

no treatment, or inactive control treatments,

for urinary incontinence in women. Cochrane

Database Syst Rev. 2014;(5):CD005654. (13)

Narrative description of the systematic reviews

included in the analysis

The Cochrane systematic review by Wallace et al. (updated in

2009) aimed to synthesise evidence for effectiveness of bladder

training for urinary incontinence in adults (9). Relevant trials were

identified from the Cochrane Incontinence Review Group’s

specialized register of controlled trials, which contains trials

identified from MEDLINE, the Cumulative Index to Nursing and

Allied Health Literature (CINAHL) and the Cochrane Central

Register of Controlled Trials (CENTRAL). The specialized register

was searched using the Review Group’s own keywords and

medical search terms. The review included 12 RCTs (total of 1473

participants). The participants were predominantly female (75%).

Eight included trials had useable data but only four of them included

older people aged over 60 years. Three of the trials were conducted

in the United States of America and another study is a multicentre

trial that included participants from Denmark, Norway and Sweden.

The Cochrane systematic review by Ostaszkiewicz et al aimed to

investigate the benefit of habit retraining in the management of

urinary incontinence in adults (10). Trials were identified from the

search conducted in the Cochrane Incontinence Review Group’s

specialized register of controlled trials, MEDLINE, Embase,

CINAHL, PsycINFO, Biological Abstracts, Current Contents and the

reference lists of relevant articles. Experts in the field were also

contacted for potential papers. The search included relevant

websites and hand searches of journals and conference

proceedings. Four trials with a total of 378 participants met the

inclusion criteria. Participants in these trials (mean age 80 years)

were mainly women and they were physically and/or cognitively

impaired, dependent on caregivers and residing either in nursing

homes or in their own homes. Three trials tested habit retraining

combined with other treatment, compared with usual care (14–16)

and another trial compared the combination treatment with habit

retraining alone (17).

The Cochrane systematic review by Eustice et al. (updated in 2006)

aimed mainly to examine the effectiveness of prompted voiding in

the management of urinary incontinence in adults (11). The search

for trials was conducted in the Cochrane Incontinence Review

Group’s specialized register of controlled trials (31 January 2006)

as well as the reference lists of relevant articles. Investigators in the

field were also contacted for additional studies. As a result, nine

trials with a total 674 participants (mean age 84 years) were

included in the review. The majority of participants included in the

trials were older women. Prompted voiding was compared with no




prompted voiding in nine trials. One trial was excluded as the ages

of the trial participants were not reported (18).

Ostaszkiewicz et al. (updated in 2009) is a Cochrane systematic

review on timed voiding for the management of urinary incontinence

in adults (12). The search for trials was conducted in Cochrane

Incontinence Review Group’s specialized register of controlled trials

(searched 2 April 2009), MEDLINE (January 1966 to November

2003), Embase (January 1980 to Week 18 2002), CINAHL (January

1982 to February 2001), PsycINFO (January 1972 to August 2002),

Biological Abstracts (January 1980 to December 2000), Current

Contents (January 1993 to December 2001) and the reference lists

of relevant articles. Experts in the field were contacted for potential

studies. The search included relevant websites and conference

proceedings. Hand searches were also conducted in relevant

journals. Two trials with a total of 298 participants met the inclusion

criteria (19, 20). Both compared timed voiding plus additional

intervention with usual care. Most of the participants from the two

selected trials were cognitively impaired elderly women (mean age

86.7 years) and all resided in facilities that provided nursing care.

The majority of participants (82%) in one study were older

women (19) while the other study did not report the sex of

participants (20).

Dumoulin et al. is a Cochrane systematic review of pelvic floor

muscle training (PFMT) versus no treatment, or inactive control

treatments, for urinary incontinence in women (13). The search for

relevant trials was conducted in the Cochrane Incontinence Review

Group’s specialized register of controlled trials, which contains trials

identified from CENTRAL (1999 onwards), MEDLINE (1966

onwards) and MEDLINE In-Process (2001 onwards). Conference

proceedings were searched (15 April 2013), and hand searches

were done in the journals and reference lists of relevant articles to

identify potential studies. Twenty-one trials involving 1281 women

(665 PFMT, 616 controls) met the inclusion criteria. Seven of them

recruited older people aged over 60 years or had mean participant

age of more than 60 years (21–27).

Two additional RCTs, not listed in the above-mentioned Cochrane

systematic reviews, were identified in an independent literature

search and were also included (28, 29).

Brief descriptions of the included non-

pharmacological interventions

Prompted voiding is administered for older people with or without

cognitive impairment to initiate their own toileting through requests

for help, and includes the use of positive reinforcement from carers

when they do this. This is distinct from some other therapies

because of the participation of the individual in the process. In

contrast, habit retraining attempts to determine the micturition

pattern for an individual, which can be used to achieve continence

but does not necessarily rely on the individual’s participation.

Timed voiding is fixed by time or event, and is carer led and is not

an individualized intervention. Bladder training actively includes the

individual in attempting to increase the interval between the desire

to void and the actual void, and hence would not be suitable for

those who are cognitively impaired. It comprises three components:

(a) patient education – information about the bladder and how

continence is usually maintained; (b) scheduled voiding – a

“timetable for voiding” which may be fixed or flexible to suit the

participant’s rate of increase in the interval between voids (the aim

is usually to achieve an interval of 3–4 hours between voids); and

(c) positive reinforcement – psychological support and




encouragement is generally considered important and is usually

provided by a health care professional. Pelvic floor muscle training

(PFMT) is an exercise programme of repeated pelvic floor muscle

contractions taught and supervised by a health care professional, at

times combined with bladder training for individuals with mixed

urinary incontinence.

Other physical exercise interventions – such as

functional incidental training, mobility and toileting training – focus

on improving the ability of older people to reach the toilet or

developing related skills (e.g. getting up from bed or a chair,

walking 5 metres, undoing clothing hooks, zippers and buttons,

letting down the garment, sitting down on the toilet, rising up from

the toilet seat and adjusting the garment) to improve toilet timing.

Functional incidental training combines prompted voiding with

functionally oriented, low-intensity endurance exercises (e.g. timed

sit-to-stands, walking or wheelchair mobility) and strengthening

exercises (e.g. bicep curls, straight-arm raises, knee extensions

and hip abductions and flexions).

Treatment adherence. There is limited evidence on adherence to

non-pharmacological treatments. Adherence reported in four

included RCTs ranges from 72% to 89% (30–33).

Adverse events. The included trials neither performed explicit

assessment for adverse events nor reported any major risks.



GRADE table 1: Prompted voiding versus no prompted voiding for

adults with urinary incontinence

Author: WHO systematic review team

Date: 11 November 2015

Question: Is prompted voiding more effective than no prompted voiding when

used for adults with urinary incontinence (urge, stress, mixed)?

Settings: Community

Bibliography: (11) Eustice S, Roe B, Paterson J. Prompted voiding for the


Syst Rev. 2000;(2):CD002113. Updated in 2006

Quality assessment Number of patients Effect

Quality Importance

Number of

studies Design

Risk of

bias Inconsistency Indirectness Imprecision

Other

considerations

Prompted

voiding

No prompted

voiding

Relative

(95% CI) Absolute

Mean proportion of hourly checks that are wet (follow-up 32 weeks; measured with diary and report; lower score = better performance)

1 randomized

trials

serious a not serious serious b serious c none 73 74 – MD -12.00

lower (-18.79

to -5.21

lower)

VERY LOW

CRITICAL

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Change in mean proportion of hourly checks that are wet (follow-up 8 weeks; measured with diary and self-report; lower score = better performance)

1 randomized

trials

serious d no serious

imprecision

no serious

indirectness

very serious e none 9 10 – MD 17.60

higher (-14.58

lower to 49.78

higher)

VERY LOW

CRITICAL

Number of incontinent episodes in 24 hours (follow-up 3–13 weeks; measured with diary and self-report; lower score = better performance)

2 randomized

trials

serious f serious g serious h no serious

imprecision

none 127 130 – MD –0.92

lower (-1.32-

to –0.53

lower)

VERY LOW

CRITICAL

Self-initiated toileting (follow-up 3 weeks; measured with self-report; lower score = better performance)

1 randomized

trials

serious i no serious

imprecision

serious j serious k none 63 63 – MD –1.90

lower (-2.29

to -1.51

lower)

LOW

IMPORTANT

CI: confidence interval; MD: mean difference a. Risk of bias: Downgraded once as allocation concealment was unclear in one trial. b. Indirectness: Downgraded once as trial was conducted in nursing home setting, and generalizing the evidence to other settings is doubtful. c. Imprecision: Downgraded once as sample size was small (smaller than 200). d. Risk of bias: Downgraded once as method applied for allocation concealment was unclear. e. Imprecision: Downgraded twice as sample size was very small (smaller than 50). f. Risk of bias: Downgraded once as allocation concealment method was unclear in two trials. g. Inconsistency: Downgraded once as considerable heterogeneity was observed: Chi2 = 18.07, df = 1 (P = 0.00002); I2 = 94%. h. Indirectness: Downgraded once as included trials were conducted in nursing home settings and generalizing the interventions to other settings is doubtful. i. Risk of bias: Downgraded once as allocation concealment was unclear. j. Indirectness: Downgraded once as trial was conducted in nursing home setting and generalizing the interventions to other settings is doubtful. k. Imprecision: Downgraded once as sample size was small (smaller than 200).



GRADE table 2: Pelvic floor muscle training (PFMT) with or without biofeedback plus

other interventions versus no active control for older people with

urinary incontinence



Question: Is multicomponent behavioural interventions (PFMT with or without biofeedback, bladder

control strategy, education and self-monitoring) more effective than no active control when

used for older people (women and men) with urinary incontinence?

Setting: Community

Bibliography: (34) McFall SL, Yerkes AM, Cowan LD. Outcomes of a small group educational

intervention for urinary incontinence: episodes of incontinence and other urinary

symptoms. J Aging Health. 2000;12(2):250–67.

(21) Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M et al.

Behavioral vs drug treatment for urge urinary incontinence in older women: a

randomized controlled trial. JAMA. 1998;280(23):1995–2000.

(35) Goode PS, Burgio KL, Locher JL, Umlauf MG, Lloyd LK, Roth DL. Urodynamic

changes associated with behavioral and drug treatment of urge incontinence in older

women. J Am Geriatr Soc. 2002;50(5):808–16.

(36) Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of

behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet

Gynecol. 2002;100(1):72–8.

(37) Dougherty MC, Dwyer JW, Pendergast JF, Boyington AR, Tomlinson BU, Coward

RT et al. A randomized trial of behavioral management for continence with older rural

women. Res Nurs Health. 2002;25(1):3–13.

(38) Johnson TM, Burgio KL, Redden DT, Wright KC, Goode PS. Effects of behavioral

and drug therapy on nocturia in older incontinent women. J Am Geriatr Soc.

2005;53(5):846–50.





Quality Importance Number

of

studies

Design Risk of


Other

considerations

Multicomponent

behavioural

interventions (PFMT

with or without

biofeedback plus

bladder control

strategy and self-

monitoring)

No active

control

Relative

(95% CI) Absolute

Total number of incontinent episodes per week (post treatment) (follow-up 6–24 weeks; assessed with bladder diary; lower score = better performance)

5 randomized

trials

serious a no serious

inconsistency

no serious

indirectness

no serious

imprecision

none 382 327 – WMD -3.63

lower (-5.19

to -0.99

lower)

MODERATE

CRITICAL

Patients’ perception of improvement in urinary incontinence (follow-up 6–8 weeks; assessed with self-report and bladder diary; improvement was

defined as self-reported improvement or no restriction in daily activities)

3 randomized

trials

serious b no serious

inconsistency

no serious

indirectness

no serious

imprecision

none 165/234

(70.5%)

65/174

(37.4%) RR 4.15

(2.70 to 6.37)

339 more per

1000 (from

243 more to

418 more)

MODERATE

IMPORTANT

CI: confidence interval; RR: relative risk; WMD: weighted mean difference a. Risk of bias: Downgraded once as method applied for allocation concealment was unclear in all five included trials b. Risk of bias: Downgraded once as method applied for allocation concealment was not clear in all three included trials.



GRADE table 3: Habit retraining plus others compared with usual care for older

people (men and women) with urinary incontinence



Question: Is habit retraining plus others more effective than usual care when used for older

people (men and women) with urinary incontinence?

Setting: Community

Bibliography: (10) Ostaszkiewicz J, Johnston L, Roe B. Habit retraining for the management of

urinary incontinence in adults. Cochrane Database Syst Rev. 2004;(2):

CD002801. Updated in 2009. [Systematic review was updated by WHO in 2015].


Quality Importance

Number

of

studies

Design Risk of


Other

considerations

Habit retraining

plus other

Usual

care

Relative

(95% CI) Absolute

Number of incontinent episodes (follow-up 6–36 weeks; assessed with bladder diary; lower score = better performance)

2 randomized

trials

serious a no serious

inconsistency

no serious

indirectness

serious b none 76 54 – SMD 0.12

lower (0.47

lower to 0.23

higher)

LOW

CRITICAL

CI: confidence interval; MD: mean difference a. Risk of bias: Downgraded once as allocation concealment was unclear in one of the included trial. b. Imprecision: Downgraded once as sample size was small (smaller than 200).



GRADE table 4: Pelvic floor muscle training (PFMT) compared with no treatment for

older women with urinary incontinence



Question: Is PFMT more effective than no treatment or placebo when used for older women with

urinary incontinence?

Settings: Primary care or community

Bibliography: (13) Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training

versus no treatment, or inactive control treatments, for urinary incontinence in women.

Cochrane Database Syst Rev. 2014;(5):CD005654.


Quality Importance

Number of

studies Design

Risk of


Other

considerations

Pelvic floor

muscle

training

No treatment

or education

Relative

(95% CI) Absolute

Participant perceived cure (all types of urinary incontinence) (follow-up 12 weeks; assessed with self-reported information)

3 randomized

trials

serious a serious b no serious

indirectness

no serious

imprecision

none 50/144

(34.7%)

9/146

(6.2%)

RR 5.34 (2.78

to 10.26)

268 more per

1000 (from 110

more to 571

more)

LOW

IMPORTANT

Quality of life (follow-up 6 weeks; measured with King’s Health Questionnaire (KHQ)/severity measure after treatment; lower score = better performance)

1 randomized

trials

serious c not serious

applicable

no serious

indirectness

very serious d none 30 15 – MD -24.92

lower (-39.06

lower to -10.78

lower)

VERY LOW

IMPORTANT

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Urinary incontinence symptoms (follow-up 6 weeks; measured with: King’s health questionnaire; Better indicated by lower values)

2 randomized

trials

serious e not serious no serious

indirectness


lower

(-47.45 lower

to -20.88 lower)

VERY LOW

CRITICAL

CI: confidence interval; MD: mean difference; RR: relative risk. a. Risk of bias: Downgraded once as allocation concealment method and procedure for masking outcome assessor was unclear in one trial. b. Inconsistency: Downgraded once as moderate heterogeneity was observed: Chi2 = 7.56, df = 2 (P = 0.02); I2 = 74%. c. Risk of bias: Downgraded once as outcome assessor was not masked and method applied for allocation concealment was unclear. d. Imprecision: Downgraded twice as sample size was very small (smaller than 100). e. Risk of bias: Downgraded once as allocation concealment method was unclear in one trial.



GRADE table 5: Bladder training versus no treatment for older people with




Question: Is bladder training more effective than no treatment, placebo or control when

used for older people (male and female) with urinary incontinence?

Settings: Community

Bibliography: (9) Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary

incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD001308.

Updated in 2009. [Systematic review was updated by WHO in 2015]


Quality Importance

Number of

studies Design

Risk of


Other

considerations

Bladder

training

No treatment

control

Relative

(95% CI) Absolute

Cure of incontinent episodes (follow-up 6 weeks; assessed with diary, number of participants cured, immediately after treatment)

1 randomized

trials

serious a not serious no serious

indirectness

serious b none 7/60

(11.7%)

2/63

(3.2%)

RR 3.68

(0.79 to

16.99)

85 more per

1000 (from 7

fewer to 508

more)

LOW

CRITICAL

Number of micturition episodes per week (daytime) (follow-up 6 weeks; assessed with diary immediately after the treatment phase; lower score = better performance)

1 randomized

trials

serious c not serious no serious

indirectness


lower (-0.73

lower to 0.11

higher)

VERY

LOW

IMPORTANT

CI: confidence interval; MD: mean difference; RR: relative risk. a. Risk of bias: Downgraded once as method applied for allocation concealment was unclear. b. Imprecision: Downgraded once as sample size was small (smaller than 200). c. Risk of bias: Downgraded once as information on incomplete data not described adequately. d. Imprecision: Downgraded twice as sample size was very small (smaller than 100).



GRADE table 5.1: Bladder training versus other behavioural interventions for

older people with other incontinence



Question: Is bladder training more effective than other behavioural, physical,

psychological treatments when used for older people with other incontinence?


Bibliography: (9) Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary

incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD001308.

Updated in 2009. [Systematic review was updated by WHO in 2015]


Quality Importance

Number of

studies Design Risk of bias Inconsistency Indirectness Imprecision

Other

considerations

Bladder

training

Other behavioural,

physical,

psychological

treatment

Relative

(95% CI) Absolute

Participant’s perception of improvement: improved, cured vs unchanged, worse; minimum of 2 months post-treatment (follow-up 12 weeks)

1 randomized

trials

serious a not serious no serious

indirectness

serious b none 37/60

(61.7%)

45/60

(75%)

RR 0.88

(0.68 to 1.13)

90 fewer

per 1000

(from 240

fewer to 97

more)

LOW

IMPORTANT

CI: confidence interval; RR: relative risk. a. Risk of bias: Downgraded once as outcome assessor was not masking in the trial and incomplete data was not managed adequately. b. Imprecision: Downgraded once as sample size was smaller than 200.



GRADE table 6: Timed voiding plus other versus usual care for older people with




Question: Is timed voiding plus other more effective than usual care when used for older

people (men and women) with urinary incontinence?


Bibliography: (12) Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of

urinary incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD002802.

Updated in 2009. [Systematic review updated by WHO in 2015]


Quality Importance

Number of

studies Design

Risk of


Other

considerations

Timed

voiding plus

other

Usual care Relative

(95% CI) Absolute

Number of patients with reductions in incidence of daytime incontinence (follow-up 8 weeks)

1 randomized

trials

serious a not serious serious b serious 4 none 40/120

(33.3%)

26/89

(29.2%)

RR 1.34 (0.9

to 2.01)

99 more per

1000 (from

29 fewer to

295 more)

VERY LOW

CRITICAL

Number of patients with reductions in incidence of night-time incontinence (follow-up 8 weeks)

1 randomized

trials a

serious c not serious serious b serious d none 39/95

(41.1%)

18/79

(22.8%)

RR 1.80

(1.12 to 2.89)

182 more

per 1000

(from 27

more to 431

more)

VERY LOW

CRITICAL

CI: confidence interval; RR: relative risk

a. Risk of bias: Downgraded once as trial method was quasi-experimental design.

b. Indirectness: Downgraded once as trial was conducted in nursing home settings in high income country and generalizing the evidence to other settings is doubtful.

c. Risk of bias: Downgraded once as allocation concealment method and procedure for masking of outcome assessor was unclear in the trial.

d. Imprecision: Downgraded once as sample size was small.



Part 2: From evidence to recommendations

Summary of evidence

Outcome Effect size

Prompted voiding

vs no promoted

voiding

Habit retraining

plus other vs

usual care

Pelvic-floor

muscle training

(PFMT) with or

without

biofeedback,

bladder

retraining and

self-monitoring

vs control

PFMT vs no

treatment,

placebo,

controls

Bladder training

vs no treatment

control

Timed voiding vs

usual care

GRADE table 1

Eustace et al. (11)

Mean proportion of

hourly checks that are

wet

MD -12 lower

(-18.79 lower to -5.21

lower)

Favours treatment

VERY LOW

Change in mean

proportion of hourly

checks that are wet

MD -17.60 higher

(-14.58 lower to 49.78

higher)

VERY LOW

Total number of urinary

incontinence episodes

MD -0.92 lower

(-1.32 lower to -0.53

lower)

Favours treatment

VERY LOW

SMD -0.12 lower

(-0.47 lower to

0.23 higher)

LOW

WMD -3.63 lower

(-5.19 lower

to -0.99 lower)

Favours treatment

MODERATE




Self-initiated toileting MD -1.9 lower

(-2.29 lower to -1.51

lower)

Favours treatment

LOW

GRADE table 5

Wallace et al. (9)

Patients’ perception of

improvement in urinary

incontinence

RR 4.15

(2.70 to 6.37)

Favours treatment

MODERATE

RR 0.88

(0.68 to 1.13)

LOW

Cure of incontinent

episodes

RR 3.68

(0.79 to 16.99)

LOW

Number of micturition per

week (daytime)

MD -0.31 lower

(-0.73 lower to 0.11

higher)

VERY LOW

GRADE table 6

Ostaszkiewicz et al. (12)

Number of patients with

reductions in incidence

of daytime incontinence

RR 1.34

(0.90 to 2.01)

VERY LOW

Number of patients with

reductions in incidence

of nighttime incontinence

RR 1.80

(1.12 to 2.89)

Favours treatment

VERY LOW

GRADE table 4 Dumoulin et al. (13)

Participant perceived cure

RR 5.34

(2.78 to 10.26)

Favours treatment

LOW




Urinary incontinence symptoms

MD -34.16 lower

(-47.45 to -20.88

lower)

Favours treatment

VERY LOW

Quality of life

MD -24.92 lower

(-39.06 lower

to -10.78 lower)

Favours treatment

VERY LOW

Evidence-to-recommendations table

Problem Explanation

Is the problem a priority?

Yes No Uncertain

✓

The prevalence of urinary incontinence reported in population-based studies ranges from 9.9%

to 36.1%, and is twice as high in older women as in older men. Urinary incontinence has a

profound impact on the quality of life of older people, their subjective health status, levels of

depression and need for care.

Benefits and harms Explanation

Do the desirable effects outweigh the

undesirable effects?

Yes No Uncertain

✓

No studies reported harm associated with non-pharmacological management of urinary

incontinence.

There is limited low-quality evidence which suggests that prompted voiding may benefit older

people in managing urinary incontinence. Eight trials included in this analysis investigated the

benefit of prompted voiding compared with no prompted voiding for older people with urinary

incontinence. All of the analysed trials were conducted in the United States. Seven of the eight

studies were carried out in nursing home settings. The duration of the interventions ranged from




(continued from previous page)



Yes No Uncertain

✓

20 days to 32 weeks. Two trials reported the effectiveness of prompted voiding in terms of

reducing the number of urinary incontinence episodes in 24 hours. Both Hu et al. (39) and

Schnelle et al. (40) found a reduction in the number of incontinent episodes per day in the

prompted voiding group. The pooled result was statistically significant (weighted mean

difference [WMD]: -0.92, CI: 95% -1.32 to -0.53). Two other trials reported a similar outcome,

but could not be included in the meta-analysis. One of them reported a substantial reduction in

the number of incontinent episodes (60% lower) in the treatment group compared with the

control group (37%). Another trial found a significant decrease in incontinence, falling from 80%

to 20%, in the treatment group, whereas the control group remained almost the same.

There is adequate moderate-quality evidence suggesting that pelvic floor muscle training

(PFMT) combined with bladder training benefits older women to manage urinary incontinence.

Six randomized controlled trials (RCTs), with a total of 1132 participants, investigated the

benefit of PFMT combined with bladder training with or without biofeedback. All six RCTs

recruited older people living in the community; five of them recruited older people aged over 55

years, while in the other trial, participants were aged 65 years and over. The intervention was

delivered at home or in clinical settings. The mean age of the study participants ranged from

65.4 to 74.7 years. In one trial, nearly 34% of study participants were older men; all other

studies only recruited older women.

Three of the six trials tested PFMT with biofeedback and a bladder control strategy with or

without self-monitoring. One RCT examined PFMT without biofeedback, bladder training or self-

monitoring. Two other RCTs combined PFMT with other behavioural interventions: one used a

group education approach consisting of bladder training, a strategy to manage the urge to

urinate, and group support for PFMT, while the other trial administered PFMT and bladder

training with individualized voiding schedules. Apart from one trial that offered a self-help

booklet to the control group, the control groups in all the other trials received no active

intervention.

Five of the analysed trials reported outcome data on the number of incontinence episodes per

week. The overall pooled effect of PFMT plus bladder training, with or without biofeedback, was




(continued from previous page)



Yes No Uncertain

✓

WMD: -3.63 (-5.19 to -0.99 lower), favouring the treatment (P < 0.001). Three trials reported

data on participants’ perception of improvement in urinary incontinence. The pooled estimate for

this outcome was relative risk [RR]: 4.14 (95% CI: 2.70 to 6.37) in favour of the treatment group.

No trial has reported adverse effects, and the guideline development group guideline

development group believed that the potential for harm is likely to be minimal.

Values and preferences/ acceptability Explanation

Is there important uncertainty or

variability about how much people value

the options?

Major

variability

Minor

variability

Uncertain

✓

Urinary incontinence in older people is associated with significant societal cost, and it impacts

older people and family caregivers profoundly. The magnitude of the problem is larger in low-

and middle-income countries (LMICs): 9% to 36% of older people suffer from urinary

incontinence. The majority of them receive care from a close family member, who may be at risk

of caregiver strain and burden.

Is the option acceptable to key

stakeholders?

Major

variability

Minor

variability

Uncertain

✓

Although there is an absence of evidence from low- and middle-income countries, the evidence

reported in high-income countries indicates that non-pharmacological interventions may be

acceptable to older people in low-resource settings.




Feasibility/resource use Explanation

How large are the resource

requirements?

Major Minor Uncertain

✓

Non-pharmacological interventions recommended for urinary incontinence are not resource

intensive.

Is the option feasible to implement?

Yes No Uncertain

✓

The feasibility of these interventions is not an important limitation; these interventions can be

safely administered by family caregivers. Delivery of care through non-specialist health workers

seems to be a successful model for low- and middle-income countries. Delivering an

educational intervention has been shown to be feasible and to have promising results. Drawing

on these experiences, the guideline development group believed the recommendation was

feasible to implement in high- and low-resource settings.

Equity Explanation

Would the option improve equity in

health?

Yes No Uncertain

✓

The guideline development group strongly believed that this recommendation would increase

equity in health.



Guideline development group recommendation and remarks

Recommendation

Prompted voiding for the management of urinary incontinence can be offered for older

people with cognitive impairment.

Strength of the recommendation: Conditional

Quality of evidence: Very low

Pelvic floor muscle training (PFMT), alone or combined with bladder control strategies

and self-monitoring, should be recommended for older women with urinary

incontinence (urge, stress or mixed).

Strength of the recommendation: Strong

Quality of evidence: Moderate

Remarks

• Apart from one study, all of the trials were conducted in high-income countries.

• Although the majority of PFMT trials involved older women, the recommendation for

PFMT may be applicable to older men.

• The duration of the PFMT intervention trials ranged from 6 to 12 weeks and most of the

trials administered the interventions on a daily regimen.

• Using continence products should be considered for older people who are bedridden or

experiencing severe declines in mental and/or physical capacities.

• Health care providers should take a detailed history and ask specific questions about

urinary incontinence, such as the time of onset, symptoms and frequency.




• At least half of women with urinary incontinence do not report this issue to their general

practitioner; therefore, health care professionals should routinely check for urinary

incontinence in older women and men.

• Identifying and managing conditions that may cause urinary incontinence, including

urinary tract infections, metabolic disorders, excess fluid intake and impaired mental

conditions (e.g. delirium), are important and should not be neglected.

• Clinicians should review current medications that may cause or worsen urinary

incontinence.

• Although pharmacological therapy can reduce urinary incontinence and even provide

complete continence, many older people discontinue medication because of adverse

effects. Specialist care providers should be consulted when initiating pharmacological

treatment.

• As a first-line treatment, provide advice on bladder training for a minimum of six weeks.

Bladder training involves advising the older people to follow a strict schedule for bathroom

visits. The schedule starts with bathroom visits every 2 hours, but the time between visits

should be gradually increased to improve bladder control.



References

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3. Sims J, Browning C, Lundgren-Lindquist B, Kendig H. Urinary incontinence in a community sample of older adults: prevalence and impact on quality of life. Disabil Rehabil. 2011;33(15–16):1389–98.

4. Smith AL, Wang PC, Anger JT, Mangione CM, Trejo L, Rodriguez LV et al. Correlates of urinary incontinence in community-dwelling older Latinos. J Am Geriatr Soc. 2010;58(6):1170–6.

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6. DuBeau CE, Kuchel GA, Johnson T, Palmer MH, Wagg A. Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence. Neurourol Urodyn. 2010;29(1):165–78.

7. Mohd SS. The prevalence of urinary incontinence among the elderly in a rural community in Selangor. Malays J Med Sci. 2010(2):18–23.

8. Chen YM, Hwang SJ, Chen LK, Chen DY, Lan CF. Urinary incontinence among institutionalized oldest old Chinese men in Taiwan. Neurourol Urodyn. 2009;28(4):335–8.

9. Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD001308. Updated in 2009. [Systematic review was updated by WHO in 2015]

10. Ostaszkiewicz J, Johnston L, Roe B. Habit retraining for the management of urinary incontinence in adults. Cochrane Database Syst Rev. 2004(2):CD002801.

11. Eustice S, Roe B, Paterson J. Prompted voiding for the management of urinary incontinence in adults. Cochrane Database Syst Rev. 2000;(2):CD002113.

12. Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of urinary incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD002802.

13. Dumoulin C, Hay-Smith EJ, Mac Habee-Seguin G: Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014;(5):CD005654.

14. Colling J, Ouslander J, Hadley BJ, Eisch J, Campbell E. The effects of patterned urge-response toileting (PURT) on urinary incontinence among nursing home residents. J Am Geriatr Soc. 1992;40(2):135–41.

15. Colling J, Owen TR, McCreedy M, Newman D: The effects of a continence program on frail community-dwelling elderly persons. Urologic nursing 2003, 23(2):117–22, 127–31.

16. Jirovec MM, Templin T: Predicting success using individualized scheduled toileting for memory-impaired elders at home. Research in nursing & health 2001, 24(1):1–8.

17. Nikoletti S, Young J, King M. Evaluation of an electronic monitoring device for urinary incontinence in elderly patients in an acute care setting. J Wound Ostomy Continence Nurs. 2004;31(3):138–49.

18. Linn JG. Prompted voiding in the treatment of urinary incontinence. In: Rehabilitation: R & D Progress Reports, Vol. 32. Washington (DC): United States Department of Veterans Affairs, Rehabilitation Research and Development Service; 1995.

19. Tobin GW, Brocklehurst JC. The management of urinary incontinence in local authority residential homes for the elderly. Age Ageing. 1986;15(5):292–8.

20. Smith DA, Newman DK, McDowell BJ, Burgio LD. Reduction of incontinence among elderly in a nursing home setting. In: Funk SG, Tornquist EM, Champagne MT, Wiese RA, editors. Key aspects of elder care: managing falls, incontinence, and cognitive impairment.


http://www.wpro.who.int/publications/pub_9290610662/en/



New York (NY): Springer Publishing; 1992:196–204. 21. Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ,

Dombrowski M, Candib D. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA. 1998;280(23):1995–2000.

22. Burns PA, Pranikoff K, Nochajski TH, Hadley EC, Levy KJ, Ory MG. A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women. J Gerontology. 1993;48(4):M167–74.

23. Kim H, Suzuki T, Yoshida Y, Yoshida H. Effectiveness of multidimensional exercises for the treatment of stress urinary incontinence in elderly community-dwelling Japanese women: a randomized, controlled, crossover trial. J Am Geriatr Soc. 2007;55(12):1932–9.

24. Kim H, Yoshida H, Suzuki T. The effects of multidimensional exercise treatment on community-dwelling elderly Japanese women with stress, urge, and mixed urinary incontinence: a randomized controlled trial. Int J Nurs Stud. 2011;48(10):1165–72.

25. Miller JM, Ashton-Miller JA, DeLancey JO. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46(7):870–4.

26. Pereira VS, Correia GN, Driusso P. Individual and group pelvic floor muscle training versus no treatment in female stress urinary incontinence: a randomized controlled pilot study. Eur J Obstet Gynecol Reprod Biol. 2011;159(2):465–71.

27. Goode PS, Burgio KL, Kraus SR, Kenton K, Litman HJ, Richter HE, Urinary Incontinence Treatment N. Correlates and predictors of patient satisfaction with drug therapy and combined drug therapy and behavioral training for urgency urinary incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct. 2011;22(3):327–34.

28. Pereira VS, de Melo MV, Correia GN, Driusso P. Vaginal cone for postmenopausal women with stress urinary incontinence: randomized, controlled trial. Climacteric. 2012;15(1):45–51.

29. Lee HH, Lee SW, Song CH,. The influence of pelvic muscle training program on lower urinary tract symptom, maximum vaginal contraction pressure, and pelvic floor muscle activity in aged women with stress urinary incontinence. Korean J Sport Sci. 2009;20(3):466–74.

30. Engberg S, Sereika SM, McDowell BJ, Weber E, Brodak I. Effectiveness of prompted voiding in treating urinary incontinence in

cognitively impaired homebound older adults. J Wound Ostomy Continence Nurs. 2002;29(5):252–65.

31. McDowell BJ, Engberg S, Sereika S, Donovan N, Jubeck ME, Weber E et al. Effectiveness of behavioral therapy to treat incontinence in homebound older adults. J Am Geriatr Soc. 1999;47(3):309–18.

32. Tobin GW, Brocklehurst JC. The management of urinary incontinence in local authority residential homes for the elderly. Age Ageing. 1986;15(5):292–8.

33. Ouslander JG, Griffiths PC, McConnell E, Riolo L, Kutner M, Schnelle J. Functional incidental training: a randomized, controlled, crossover trial in Veterans Affairs nursing homes. J Am Geriatr Soc. 2005;53(7):1091–100.

34. McFall SL, Yerkes AM, Cowan LD. Outcomes of a small group educational intervention for urinary incontinence: episodes of incontinence and other urinary symptoms. J Aging Health. 2000;12(2):250–67.

35. Goode PS, Burgio KL, Locher JL, Umlauf MG, Lloyd LK, Roth DL. Urodynamic changes associated with behavioral and drug treatment of urge incontinence in older women. J Am Geriatr Soc. 2002;50(5):808–16.

36. Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2002;100(1):72–8.

37. Dougherty MC, Dwyer JW, Pendergast JF, Boyington AR, Tomlinson BU, Coward RT et al. A randomized trial of behavioral management for continence with older rural women. Res Nurs Health.2002;25(1):3–13.

38. Johnson TM, Burgio KL, Redden DT, Wright KC, Goode PS. Effects of behavioral and drug therapy on nocturia in older incontinent women. J Am Geriatr Soc. 2005;53(5):846–50.

39. Hu TW, Igou JF, Kaltreider DL, Yu LC, Rohner TJ, Dennis PJ et al. A clinical trial of a behavioral therapy to reduce urinary incontinence in nursing homes: outcome and implications. JAMA. 1989;261(18):2656–62.

40. Schnelle JF, Traughber B, Sowell VA, Newman DR, Petrilli CO, Ory M. Prompted voiding treatment of urinary incontinence in nursing home patients. A behavior management approach for nursing home staff. J Am Geriatr Soc. 1989;37(11):1051–7.



Annex 1: Search strategy

MEDLINE database

1. exp behavior therapy/

2. (behav$ adj25 therapy).mp. [mp=protocol supplementary

concept, rare disease supplementary concept, title, original title,

abstract, name of substance word, subject heading word, unique

identifier]

3. exp cognitive therapy/

4. (cognit$ adj25 therapy).mp. [mp=protocol supplementary

concept, rare disease supplementary concept, title, original title,

abstract, name of substance word, subject heading word, unique

identifier]

5. (conservat$ adj25 intervention$).mp. [mp=protocol

supplementary concept, rare disease supplementary concept, title,

original title, abstract, name of substance word, subject heading

word, unique identifier]

6. toilet training.mp. [mp=protocol supplementary concept, rare

disease supplementary concept, title, original title, abstract, name

of substance word, subject heading word, unique identifier]

7. (habit training or habit retraining).mp. [mp=protocol




8. timed void$.mp. [mp=protocol supplementary concept, rare



9. prompted void$.mp. [mp=protocol supplementary concept, rare



10. (nursing homes and urinary incontinence).mp. [mp=protocol




11. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 9 or 10

12. exp Urinary Incontinence/ or urinary incontinence.mp.

[mp=protocol supplementary concept, rare disease

supplementary concept, title, original title, abstract, name of

substance word, subject heading word, unique identifier]

13. 11 and 12

14. 13 not child.mp. [mp=protocol supplementary concept, rare



15. exp randomized controlled trials/

16. randomized controlled trial.pt.

17. exp random allocation/

18. exp double blind method/

19. exp single blind method/

20. exp Clinical Trial/

21. clinical trial.pt.

22. (clin$ adj25 trial$).ti,ab.

23. ((singl$ or doubl$ or treb$ or tripl$) adj25 (blind$ or

mask$)).ti,ab.

24. placebo$.ti,ab.

25. random$.ti,ab.

26. research design/

27. placebos.mp. [mp=protocol supplementary concept, rare



28. or/15-27

29. 14 and 28




30. exp Aged/ or exp Aging/

31. exp Frail Elderly/

32. 30 or 31

33. 29 and 32

Embase database

1. Randomized Controlled Trial/

2. controlled study/

3. clinical study/

4. major clinical study/

5. prospective study/

6. meta-analysis/

7. exp clinical trial/

8. randomization/

9. crossover procedure/ or double blind procedure/ or parallel

design/ or single blind procedure/

10. Placebo/

11. latin square design/

12. exp comparative study/

13. follow up/

14. pilot study/

15. family study/ or feasibility study/ or pilot study/ or study/

16. placebo$.tw.

17. random$.tw.

18. (clin$ adj25 trial$).tw.

19. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or

mask$)).tw.

20. factorial.tw.

21. crossover.tw.

22. latin square.tw.

23. (balance$ adj2 block$).tw.

24. or/1-23

25. (nonhuman not human).sh.

26. 24 not 25

27. behavior modification/ or behavior therapy/

28. (conservat$ adj25 (intervention$ or therap$)).tw.

29. conservative treatment/

30. (behav$ adj25 (therap$ or train$ or treatment$ or

intervention$)).tw.

31. (habit adj2 (train$ or retrain$)).tw.

32. (void$ adj2 (time$ or prompt$ or schedul$)).tw.

33. toilet$.tw.

34. or/27-33

35. bladder disease/ or bladder dysfunction/ or detrusor

dyssynergia/ or neurogenic bladder/

36. (continen$ or incontinen$).tw.

37. exp Incontinence/

38. 37 or 35 or 36

39. 26 and 34 and 38

40. limit 39 to (embryo or infant or child or preschool child <1 to 6

years> or school child <7 to 12 years> or adolescent <13 to 17

years>)

41. limit 39 to (adult <18 to 64 years> or aged <65+ years>)

42. 40 not 41

43. 39 not 42

44. aging/ or aging.mp.

45. frail elderly.mp. or frail elderly/

46. 44 or 45

47. 43 and 46



Annex 2: PRISMA2 2009 flow diagram for non-pharmacological intervention

for managing urinary incontinence

_______________________________ 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For more information: http://www.prisma-statement.org

Records identified through database

searching (n = 1893)

Records after duplicates removed (n = 986)

Records excluded (n = 714)

• Conference abstract (n = 146)

• Pharmacological intervention (n = 568)

Full-text articles assessed for eligibility (n = 272)

• Systematic reviews (SR) = 111

• Randomized controlled trials (RCTs) = 161

Full-text articles excluded, with reasons (n = 265) Reasons for RCT exclusion:

• Inappropriate age group (n = 123)

• Insufficient information on outcomes (n = 36) Reasons for review exclusion:

• Not SR (n = 54)

• Quality assessment not performed (n = 29)

• More recent reviews available (n = 23)

Studies included in qualitative synthesis

• SR = 111

• RCTs = 161

Studies included in quantitative synthesis (meta-analysis) (n = 27)

• SR = 25 RCTs

• Additional studies = 2 RCTs

Additional records identified through

other sources (n = 19)

Records screened (n = 986)

Inclu

sio

n

Scre

en

ing

Elig

ibili

ty

Iden

tificatio

n

http://www.prisma-statement.org/

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