Ethan M. Balk, MD, MPH; Valerie N. Rofeberg, ScM; Gaelen P. Adam, MLIS; Hannah J. Kimmel, MPH; Thomas A. Trikalinos, MD, PhD; Peter C. Jeppson, MD
Disclaimer: The authors of this manuscript are responsible for its content. Statements in the article should not be construed as endorsement by PCORI, AHRQ, or the U.S. Department of Health and Human Services. AHRQ retains a license to display, reproduce, and distribute the data and the report from which this manuscript was derived under the terms of the agency's contract with the author.
Acknowledgment: The authors thank Aysegul Gozu, MD, MPH, their AHRQ Task Order Officer; Jennifer Croswell, MD, MPH, their PCORI Senior Program Officer; and Kimberly Bailey, MS, their PCORI Program Officer, for their contributions. They also thank and acknowledge the other research associates and staff who helped conduct this systematic review: Georgios Markozannes, MSc; Katherine Corsi, PharmD; Amanda Mogul, PharmD; Iman Saeed, ScM; Mengyang Di, PhD; Gowri Raman, MBBS, MS; Esther Avendano, MS; Andrew Zullo, PharmD, PhD; Jenni Quiroz, BS; and Anya Rader Wallack, PhD.
Financial Support: Under contract 290-20-1500002-I from AHRQ, U.S. Department of Health and Human Services, Rockville, Maryland.
Disclosures: All authors received a grant from AHRQ for the conduct of the study. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3227.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Available from PROSPERO (www.crd.york.ac.uk/PROSPERO/; registration CRD42017069903). Statistical code: Available at www.brown.edu/public-health/cesh/resources/code-data-repository. Data set: Available at https://srdr.ahrq.gov/projects/1153.
Corresponding Author: Ethan Balk, MD, MPH, Brown University School of Public Health, Box G-S121-8, Providence, RI 02912; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Balk and Trikalinos, Ms. Rofeberg, Ms. Adam, and Ms. Kimmel: Brown University School of Public Health, Box G-S121-8, Providence, RI 02912.
Dr. Jeppson: Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, 2425 Camino de Salud, Albuquerque, NM 87106.
Author Contributions: Conception and design: E.M. Balk, T.A. Trikalinos, P.C. Jeppson.
Analysis and interpretation of the data: E.M. Balk, V.N. Rofeberg, G.P. Adam, H.J. Kimmel, P.C. Jeppson.
Drafting of the article: E.M. Balk, V.N. Rofeberg, G.P. Adam, H.J. Kimmel, P.C. Jeppson.
Critical revision for important intellectual content: E.M. Balk, T.A. Trikalinos, P.C. Jeppson.
Final approval of the article: E.M. Balk, V.N. Rofeberg, G.P. Adam, H.J. Kimmel, T.A. Trikalinos, P.C. Jeppson.
Statistical expertise: E.M. Balk, V.N. Rofeberg, H.J. Kimmel, T.A. Trikalinos.
Obtaining of funding: E.M. Balk, G.P. Adam, T.A. Trikalinos, P.C. Jeppson.
Administrative, technical, or logistic support: G.P. Adam, T.A. Trikalinos, P.C. Jeppson.
Collection and assembly of data: E.M. Balk, V.N. Rofeberg, G.P. Adam, H.J. Kimmel, P.C. Jeppson.
Urinary incontinence (UI), a common malady in women, most often is classified as stress, urgency, or mixed.
To compare the effectiveness of pharmacologic and nonpharmacologic interventions to improve or cure stress, urgency, or mixed UI in nonpregnant women.
MEDLINE, Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), EMBASE (Elsevier), CINAHL (EBSCO), and PsycINFO (American Psychological Association) from inception through 10 August 2018.
84 randomized trials that evaluated 14 categories of interventions and reported categorical cure or improvement outcomes.
1 researcher extracted study characteristics, results, and study-level risk of bias, with verification by another independent researcher. The research team collaborated to assess strength of evidence (SoE) across studies.
84 studies reported cure or improvement outcomes (32 in stress UI, 16 in urgency UI, 4 in mixed UI, and 32 in any or unspecified UI type). The most commonly evaluated active intervention types included behavioral therapies, anticholinergics, and neuromodulation. Network meta-analysis showed that all interventions, except hormones and periurethral bulking agents (variable SoE), were more effective than no treatment in achieving at least 1 favorable UI outcome. Among treatments used specifically for stress UI, behavioral therapy was more effective than either α-agonists or hormones in achieving cure or improvement (moderate SoE); α-agonists were more effective than hormones in achieving improvement (moderate SoE); and neuromodulation was more effective than no treatment for cure, improvement, and satisfaction (high SoE). Among treatments used specifically for urgency UI, behavioral therapy was statistically significantly more effective than anticholinergics in achieving cure or improvement (high SoE), both neuromodulation and onabotulinum toxin A (BTX) were more effective than no treatment (high SoE), and BTX may have been more effective than neuromodulation in achieving cure (low SoE).
Scarce direct (head-to-head trial) evidence and population heterogeneity based on UI type, UI severity, and history of prior treatment.
Most nonpharmacologic and pharmacologic interventions are more likely than no treatment to improve UI outcomes. Behavioral therapy, alone or in combination with other interventions, is generally more effective than pharmacologic therapies alone in treating both stress and urgency UI.
Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42017069903)
Balk EM, Rofeberg VN, Adam GP, et al. Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes. Ann Intern Med. 2019;170:465–479. [Epub ahead of print 19 March 2019]. doi: 10.7326/M18-3227
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Published: Ann Intern Med. 2019;170(7):465-479.
Published at www.annals.org on 19 March 2019
Nephrology, Urological Disorders.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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