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Anticholinergic drugs versus non‐drug active therapies for overactive bladder syndrome in adults

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Abstract

Background

Overactive Bladder Syndrome (OAB) is defined as urgency, with or without urgency incontinence, usually with frequency and nocturia. Pharmacotherapy with anticholinergic drugs is often the first line medical therapy, either alone or as an adjunct to various non‐pharmacological therapies. The commonest non‐pharmacologic therapies are: bladder training, pelvic floor muscle training with or without biofeedback and electric stimulation to affect detrusor muscle activity.

Objectives

To compare the effects of various anticholinergic drugs with various non‐pharmacologic therapies for idiopathic overactive bladder syndrome in adults.

Search methods

We searched the Cochrane Incontinence Group Specialised Register (searched 29 November 2005), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to September 2004), PREMEDLINE, Dissertation Abstracts and the reference lists of relevant articles.

Selection criteria

All randomised, or quasi‐randomised, controlled trials of treatment with anticholinergic drugs for overactive bladder syndrome or urge urinary incontinence in adults, in which at least one management arm involved a non‐drug new therapy. Trials amongst patients with neuropathic bladder dysfunction were excluded.

Data collection and analysis

Two authors evaluated the trials for appropriateness for inclusion and methodological quality. Three authors were involved in the data extraction. Data extracted was based on predetermined criteria. Data analysis was based on standard statistical approaches used in Cochrane reviews.

Main results

Thirteen trials with 1770 participants were included; all were designed as parallel groups except for one cross‐over trial. Trial groups were well matched for baseline characteristics in all trials. Treatment duration was 3 to 12 weeks, with one trial carrying out a follow‐up analysis at 24 weeks after starting treatment.

During treatment, symptomatic improvement was more common amongst those on anticholinergic drugs compared with bladder training (RR 0.73; 95% CI 0.59 to 0.90). Combination of anticholinergics with bladder training was also associated with more improvement than bladder training alone but with wide confidence intervals (RR 0.55; 95% 0.32 to 0.93). Similarly, the limited data favoured a combination of anticholinergics with bladder training compared with anticholinergics during treatment but the difference was not statistically significant (RR for improvement 0.81; 95% CI 0.61 to 1.06). For all comparisons, there were too few data to compare symptoms after treatment had ended. Adverse effects, such as dry mouth, were reported by around a third of those taking anticholinergics.

Authors' conclusions

The use of anticholinergic drugs in the management of OAB is well established. During initial treatment there was more symptomatic improvement when (a) anticholinergics were compared with bladder training alone, and (b) anticholinergics combined with bladder training were compared with each modality alone. Anticholinergics have well recognised side effects, such as dry mouth. There were too few data to assess whether or not effects are sustained after stopping treatment.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

Anticholinergic drugs versus non‐drug active therapies (e.g. bladder training, pelvic floor muscle training or electrical stimulation) in the management of over active bladder syndrome in adults.

Over active bladder syndrome is defined as urgency, with or without urge incontinence, usually with frequency and nocturia. It is a major health problem giving an estimated prevalence of over 22 million people affected. It affects both sexes with a female preponderance and its prevalence increases with age. There is also a significant economic and quality of life implication. The exact disease process is yet to be fully elucidated and the treatments are varied from drugs to non‐drug modalities, with various efficacy, tolerability and side effect profiles and treatment remains empirical at its best.
The aim of this review is to examine the evidence of the above treatment modalities. Thirteen trials with 1770 participants were included; symptomatic improvement was more common amongst those on an anticholinergic drug compared with bladder training and more symptomatic improvement was seen amongst those on combination therapy with an anticholinergic plus bladder training than bladder training alone. Dry mouth being the main adverse effect was reported in about a third of those taking an anticholinergic drug. The included trials are generally small and of moderate quality, with no data addressing long‐term performance are the main limitations of this review.