Yoga for treatment of urinary incontinence in women

  • Protocol
  • Intervention

Authors


Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effectiveness and safety of yoga for treatment of urinary incontinence in women, compared to no specific treatment, to another active treatment, or to an active treatment without adjuvant yoga, with a focus on patient symptoms and quality of life.

Background

Description of the condition

The International Incontinence Society (ICS) and the International Urogynecological Association define the symptom of urinary incontinence as "the complaint of involuntary loss of urine" (Haylen 2010). Estimates of the prevalence of urinary incontinence are contested, and vary widely according to case definitions as well as methods of ascertainment. Women often delay seeking help for urinary incontinence, and it is likely that this stigmatised condition is underreported (Wójtowicz 2014). In pregnant or postpartum women, estimates of the prevalence of urinary incontinence are 30% or higher (Milsom 2013). In women in the general population who are middle aged or older, daily urinary incontinence is estimated to be between 5% and 15%, while the prevalence of any incontinence is estimated to be between 30% and 60% (Milsom 2013). Increasing age is the most widely accepted risk factor, although parity (particularly assisted vaginal births), obesity, and menopausal status are also often considered to be important risk factors (Milsom 2013).

There are three major types of urinary incontinence that are defined according to symptoms: stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence (MUI). Although the specific prevalence rates are inconsistent between studies, SUI is consistently the most common type of urinary incontinence, responsible for approximately half of all cases of urinary incontinence, followed by MUI and then by UUI (Milsom 2013).

SUI is defined as the involuntary loss of urine on effort or physical exertion, or on sneezing or coughing (Haylen 2010). SUI occurs when intra-abdominal pressure rises with exertion or during a sneeze or cough, and the pressure upon the bladder is greater than the closure pressure of the urethral sphincter (Cannon 2004). Although SUI may involve a number of causes, it is often associated with weakened pelvic muscles and collagen-dependent tissue, which may lead to a lack of urethral support and the inability to maintain urethral sphincter pressure (Long 2008).

UUI is defined as involuntary loss of urine associated with urgency (Haylen 2010). Urgency is defined as a sudden and compelling desire to void urine, which is difficult to defer (Abrams 2013). UUI is a form of overactive bladder, which includes symptoms of urgency, frequency, and waking at night to urinate (nocturia). The causes of overactive bladder and UUI specifically are unclear but it is believed that the underlying pathophysiological factors include disturbances in the urothelium and overactivity of the detrusor smooth muscle and nerves (Steers 2002).

MUI is defined as when symptoms of both SUI and UUI are present (Haylen 2010).

Urinary incontinence in women is associated with poor quality of life, and negatively impacts social, psychological, and sexual functioning (Sinclair 2011). Depression appears to be associated with urinary incontinence, although it is unclear whether the physical and social effects of incontinence lead to development of depression, or the presence of depression accentuates the bother of incontinence symptoms (Abrams 2013). Although all forms of urinary incontinence are associated with poor quality of life, and more severe incontinence appears to have a greater impact on quality of life, women with UUI or MUI may be more likely than women with SUI to report 'great' bother due to incontinence. Also women with severe levels of MUI may experience greater impact upon their quality of life compared to women with severe levels of UUI or SUI (Minassian 2013; Monz 2007).

Description of the intervention

Yoga, a system of philosophy, lifestyle, and physical practice which originated in ancient India, has become popular in the West during the last century. Although yoga is traditionally described as having eight limbs or rungs of practice, many styles of yoga as currently practiced primarily emphasize the integration of three limbs: physical poses (asanas), controlled breathing (pranayama), and sometimes concentration (dharana) or meditation (dhyana) (Hewitt 2001; Taneja 2014). The popularity of yoga in the West has continued to increase over the past decade. For example, according to the U.S. National Health Interview Survey (NHIS) conducted in 2002, 2007, and 2012, the use of yoga in the USA increased from approximately 5.1% of adults reporting use of yoga during the previous year in 2002 to over 9.5% reporting such use in 2012 (Clarke 2015). In the 2012 NHIS, use of yoga was higher among women than men, and higher among adults aged 18 to 44 years than for older age groups (Cramer 2016).

Yoga has been suggested to be useful in managing a range of medical conditions, including musculoskeletal conditions, cardiovascular conditions, stress, depression, and anxiety (Taneja 2014). In the 2012 NHIS, the most common therapeutic uses of yoga were for back pain (19.7%), stress (6.4%), and arthritis (6.4%) (Cramer 2016). Several reviews have examined the use of yoga for stress, depression, and anxiety, which may be primary complaints or concomitant with other medical conditions (Kirkwood 2005; Pascoe 2015; Pilkington 2005; Uebelacker 2016), and there is some support for this use.

Yoga appears to be a relatively safe practice. A review of case reports and case series of adverse events of yoga identified musculoskeletal adverse events as the most common type of adverse events, and headstand, shoulder stand, lotus position, and forceful breathing as the most common types of yoga techniques associated with adverse events (Cramer 2013). Cramer 2013 advised that yoga practices should be adapted to pre-existing medical conditions and practiced under the supervision of a qualified teacher. A recent review of randomized trials of yoga found that yoga is associated with a greater risk of intervention-related and non-serious adverse effects than psychological or educational interventions, but not with an increase in risk of serious adverse effects. The review also found that yoga is associated with the same risk of serious, non-serious, and intervention-related adverse effects as usual care or non-yoga exercise interventions (Cramer 2015). The overall rate of serious adverse events in the yoga arms of the trials was 0.6% (Cramer 2015).

How the intervention might work

Urinary incontinence is usually initially managed by conservative therapies (Abrams 2013). Many reviews of these conservative interventions, such as lifestyle advice, bladder training, and pelvic floor muscle training used either alone or in combination with other active treatments such as biofeedback, are available (Ayeleke 2015; Dumoulin 2014; Herderschee 2011; Imamura 2015; Wallace 2004).

There is good evidence to support the use of pelvic floor muscle training as a first approach to managing urinary incontinence, particularly SUI (Dumoulin 2014). With pelvic floor muscle training, appropriately timed conscious pelvic floor muscle contractions may increase urethral pressure and prevent the urinary leakage associated with SUI (DeLancey 1988; Miller 1998). Strengthening of the pelvic floor muscles may also improve support of the bladder neck, which may reduce urinary incontinence (Bø 2004). Finally, pelvic floor muscle contractions may inhibit detrusor muscle contractions, which could prevent the urinary leakage associated with UUI (Bø 2000).

A few studies suggest that some yoga breathing, relaxation, and muscle control techniques may assist in the strengthening of the pelvic floor (Bø 2013; Tenfelde 2014). Specific yoga poses that are believed to be helpful and have been tested include the Utkatasana (chair pose), Trikonasana (triangle pose), and the Malasana (squat pose) (Huang 2014). Yoga may help improve general body alignment, flexibility, strength, control, and awareness, all of which are thought to assist in strengthening the pelvic floor muscles (Tenfelde 2014). Yoga may therefore function as either an alternative method of pelvic floor muscle training or a supplement to such training. Yoga may also address mental health and quality of life issues, through potential effects on depression, stress, and anxiety, and help patients manage their medical condition.

Why it is important to do this review

Urinary incontinence is a highly prevalent and distressing condition in women. Although many treatments are available for urinary incontinence, there is no universally effective and acceptable treatment and additional approaches to treatment may be of value. Yoga is a mind-body practice that is increasingly popular in the West, and is particularly popular with women. A pre-post trial of pelvic floor muscle training with adjunctive Hatha yoga in women with stress incontinence reported that the combined intervention was effective in improving incontinence (Kim 2015). Also, at least one randomized trial of Iyengar yoga for urinary incontinence has provided promising results in the treatment of SUI and UUI with yoga (Huang 2014). It is therefore important to assess whether yoga may be effective as either a primary or adjuvant treatment for urinary incontinence in women.

Objectives

To assess the effectiveness and safety of yoga for treatment of urinary incontinence in women, compared to no specific treatment, to another active treatment, or to an active treatment without adjuvant yoga, with a focus on patient symptoms and quality of life.

Methods

Criteria for considering studies for this review

Types of studies

We will include randomized controlled trials (RCTs) and the first period of cross-over RCTs. We will exclude quasi-randomized controlled trials (qRCTs) (i.e. trials in which assignment to treatment was made by a non-random method such as alternation), because the method of allocation may lead to biased estimates of effect. We will not restrict study eligibility by language or publication status. We will only include health economics studies conducted alongside effectiveness studies included in the effectiveness component of the review (Shemilt 2011).

Types of participants

We will include studies with women aged 18 years or more who have been diagnosed as having urinary incontinence on the basis of symptoms, signs, or urodynamic evaluation (as defined by the trial authors). We will only include trials that have recruited both men and women if at least 90% of participants are women or if the trial reports demographic and outcome data separately for women. We will include trials with women diagnosed as having stress, urgency, or mixed urinary incontinence, as well as trials with participants who have mixed or undefined diagnoses of urinary incontinence.

We will include trials carried out in women who were experiencing urinary incontinence during the antenatal or postnatal period. However, because this group has physiological differences from women who are not pregnant or postpartum, and the natural history of incontinence in this population differs from that in non-pregnant women, the observed effects of the intervention may differ in this group. Therefore, we will not group this population with that of women who are not pregnant or postpartum, and we will analyse the studies separately throughout the review.

We will exclude studies of women who have urinary incontinence that is thought to be due to factors beyond the urinary tract, such as neurological or psychiatric disorders, cognitive impairment, or mobility problems. We will also exclude studies that focused on women who were experiencing nocturnal enuresis.

Types of interventions

We will include studies of yoga as a treatment for urinary incontinence. We will require that the study report specify that the intervention is 'yoga' and we will exclude studies of interventions based on yoga (e.g. exercises based on yoga postures) but not characterized as yoga. We will exclude studies of multimodal interventions in which yoga is only one component amongst others, such as mindfulness-based stress reduction (MBSR).

We will include interventions that belong to any yoga tradition, but we will exclude studies in which yoga does not include a physical practice component. We will include studies in which the yoga intervention is provided at any dose, with any frequency, and for any duration.

We will include studies that compare yoga to no treatment or to another active treatment. We will also include studies that compare yoga as an adjunct to other treatments versus those same treatments without yoga. The types of comparisons will be as follows.

  • Yoga versus no specific active intervention (e.g. usual care, a waiting list).

  • Yoga versus an active intervention (e.g. a lifestyle advice intervention or pelvic floor training), for which we will consider different active comparators separately (e.g. yoga versus lifestyle advice, yoga versus pelvic floor training).

  • Yoga plus an intervention versus the same intervention without yoga (e.g. yoga as an add-on intervention to pelvic floor training, versus pelvic floor training alone), for which we will consider different interventions separately.

Studies that compare yoga to a sham yoga intervention do not appear to be common (Park 2014), and we do not expect to find such studies. However, if we encounter such studies, we will consider them to represent an additional type of comparison (i.e. yoga versus sham yoga) and will analyse them separately.

We will include studies in which there are co-interventions provided the co-interventions are similar between intervention groups (e.g. both the yoga and the comparison groups receive lifestyle advice).

Types of outcome measures

We will use outcomes as suggested by the Standardisation Committee of the International Continence Society. The Committee recommends the following five categories of outcomes for research investigating the effect of therapeutic interventions for women with urinary incontinence (Lose 2001).

  • The woman’s observations (e.g. symptoms).

  • Quantification of the woman's symptoms (e.g. urine loss).

  • The clinician’s observations (anatomical and functional).

  • The woman's quality of life (urinary incontinence-specific and general).

  • Economic measures.

In this review we will consider at least one outcome from each of the first four categories. We will include specific outcomes that are commonly found in other Cochrane Incontinence Group reviews of interventions for urinary incontinence in women, so that this review may produce results that are easily compared to or combined with those of other reviews of treatment for the same condition.

We will group all outcomes into three time points: short-term (closest to three months after randomisation), intermediate-term (closest to six months after randomisation), and long-term (closest to one year after randomisation). When an included trial presents multiple time points, we will consider the short-term time point as primary.

Primary outcomes
  • Number of women who report continence.

  • Number of women who report continence or improvement of urinary incontinence.

  • Urinary incontinence condition- or symptom-specific quality of life, as measured by any relevant scale (e.g. the Urinary Incontinence Quality of Life scale (Patrick 1999), or the Incontinence Impact Questionnaire (Uebersax 1995)).

Secondary outcomes
  • Quantification of symptoms:

    • Number of micturitions (daily).

    • Number of episodes of incontinence (daily).

    • Urine loss as measured with a pad or paper towel weight test (either the short or long-term test).

    • Symptoms as reported by study participants on any condition-specific scale (e.g. the Severity Index for Urinary Incontinence in Women (Sandvik 1993)).

  • Clinician's observations (anatomical and functional):

    • Clinical assessment of presence of incontinence, such as urine leakage during a cough test.

    • Measurement of pelvic floor muscle function, such as by electromyography, vaginal squeeze pressure, pelvic floor muscle force, and morphological measurements (dynamometry, ultrasound).

  • Quality of life:

    • Quality of life measured on a scale that is not condition- or symptom-specific (e.g. the 36-Item Short Form Health Survey (SF-36).

    • Depression, anxiety, or distress as measured on relevant scales (e.g. Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS)).

    • Other measures of emotional and social impact of the disorder such as the bothersomeness of the condition, the social impact of the condition, and sexual functioning.

  • Adverse effects:

    • Number of adverse effects (e.g. pain, discomfort).

Search methods for identification of studies

We will not impose any restrictions, for example language or publication status, on the literature searches described below.

Electronic searches

Cochrane Incontinence Group Specialised Register

This review will draw on the search strategy developed for the Cochrane Incontinence Group. We will identify relevant trials from the Cochrane Incontinence Group Specialised Register. For more details of the search methods used to build the Specialised Register please see the Group's module in the Cochrane Library. The register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) portal (http://apps.who.int/trialsearch/) and handsearches of journals and conference proceedings. Most trials in the Cochrane Incontinence Group Specialised Register are also contained in CENTRAL.

The terms that we will use to search the Incontinence Group Specialised Register are in Appendix 1.

We will search for all eligible published and unpublished trials in all languages. We will translate the non-English language abstract for potential inclusion. We will base our search strategy on concepts of types of study population, types of study design, and symptoms of urinary incontinence such as dribbling of urine.

Other electronic bibliographic databases

We will also use the terms in Appendix 1 to search the Cochrane Complementary Medicine Field Specialised Register for relevant trials of yoga. The Complementary Medicine Field Specialised Register contains trials identified from CENTRAL, Chinese databases, Korean databases, and multiple small databases that have been identified as good sources of complementary medicine trials (Wieland 2013).

We will perform searches of the NHS Economic Evaluation Database (NHS EED) in order to identify potential economic studies. As the last database searches for NHS EED were carried out in December 2014, we will use the NHS EED search filters to search MEDLINE and Embase for economics studies from January 2015 onwards. See Appendix 2 for the NHS EED search filters.

We had planned to search the following additional databases, detailed below. However, after preliminary test searches and deduplication against the Cochrane Incontinence Group Specialised Register, they did not appear to yield any additional records of relevance to the review and we will not search them for the first version of this review.

  • AMED (Allied and Complementary Medicine): we conducted a preliminary test search (Appendix 3) on AMED on OvidSP (1985 to November 2015) on 30 November 2015 to gauge how useful this database would be as a source of records for this review. A broad search designed to identify RCTs or qRCTs related to urinary incontinence, overactive bladder, or enuresis did not find any additional randomised (or qRCTs) in this area after deduplication against the Cochrane Incontinence Group Speciaised Register.

  • CINAHL (Cumulative Index to Nursing & Allied HealthLiterature): we tested a preliminary search (Appendix 4) in CINAHL (on EBSCOhost) on 2 December 2015 (December 1981 to most recent entry date 20151201) and after deduplication against the Cochrane Incontinence Group Specialized Trial Register we did not retrieve any extra records.

  • IndMED: we performed a preliminary search on 2 December 2015 using the strategy in Appendix 5. We only identified one irrelevant record.

Searching other resources

We will check reference lists of all included studies and systematic reviews for additional references. We will contact experts in the field and authors of included studies to identify additional unpublished studies. We will also check the proceedings of the following conferences for relevant research.

  • International Congress on Complementary Medicine Research (ICCMR).

  • European Congress for Integrative Medicine (ECIM).

Data collection and analysis

We will conduct data collection and analysis in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Selection of studies

Two review authors will independently screen titles and abstracts of all retrieved references. We will retrieve the full-text study reports for all citations that at least one review author considers potentially relevant. Two review authors will independently screen the full-text articles and identify studies for inclusion, and identify and record reasons for exclusion of ineligible studies in a 'Characteristics of excluded studies' table. We will resolve any disagreement through discussion or, if required, we will consult a third review author. We will identify and exclude duplicates and collate multiple reports of the same study so that each study, rather than each report, is the unit of interest in the review. We will record the selection process in sufficient detail to complete a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Moher 2009).

Data extraction and management

We will use a piloted data collection form for study characteristics and outcome data. We will extract the following study characteristics.

  • Methods: study design.

  • Participants: number randomized, number with each type(s) of incontinence and how incontinence was diagnosed, if participants were pregnant or postpartum how many were pregnant and how many were postpartum, severity and duration of urinary incontinence if reported, study participant mean age or age range, study location and setting, recruitment methods, inclusion and exclusion criteria.

  • Interventions: description of yoga intervention characteristics, dose and duration of yoga intervention, description of comparison intervention characteristics, adherence to the yoga and comparison interventions, description of any co-interventions, length of follow-up, number of withdrawals, and reasons for withdrawal.

  • Outcomes: description of primary and secondary outcomes for the review that were reported in the trial, listing of other outcomes collected in the trial.

  • Notes: funding for trial and notable conflicts of interest of trial authors.

  • 'Risk of bias' assessment (see below).

Two review authors will independently extract outcome data from included studies into Covidence (Covidence 2017), and use the Covidence software to compare the identify any discrepancies in data entry. We will resolve disagreements by consensus or by involving a third review author. We will note in the 'Characteristics of included studies’ table if a trial did not report outcome data in a usable way. We will transfer data from Covidence into Cochrane’s statistical software, Review Manager (RevMan) (Review Manager 2014).

When both endpoint and change data are available, we will use endpoint data for our primary analysis, and will carry out a sensitivity analysis to check whether the results vary according to endpoint versus change data. In cases where study participants are lost to follow-up and intention-to-treat analyses are conducted using imputation alongside available-case analyses, we will use the observed data for our primary analysis, and perform a sensitivity analysis to check whether the results vary according to imputed versus available case data. In cases where both unadjusted and adjusted data are available, we will use the unadjusted data for our primary analysis, and undertake a sensitivity analysis to check whether the results vary according to adjusted versus unadjusted data. See the 'Sensitivity analysis' section.

In addition to extracting data from included studies as described above, we will include an appendix of bibliographic detail of potential economic studies. We will not conduct a further review of potential economic studies.

Assessment of risk of bias in included studies

Two review authors will independently assess the risk of bias for each included trial using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We will resolve any disagreements by discussion or by involving a third review author. We will assess the risk of bias according to the following domains.

  • Random sequence generation.

  • Allocation concealment.

  • Blinding of participants and personnel.

  • Blinding of outcome assessment for each outcome.

  • Incomplete outcome data.

  • Selective outcome reporting.

  • Other bias such as validity of outcome measure and baseline comparability.

We will assess each potential source of bias as either high, low, or unclear and we will provide a quote from the study report together with a justification for our judgment in the 'Risk of bias’ tables. We will summarize the 'Risk of bias' judgements across different studies for each of the domains listed.

The participants and personnel in most yoga trials are not blinded. As the primary outcomes of this review depend upon the perception and reporting of the study participant, we will not include blinding of personnel, participants, or outcome assessors in our dichotomizing of trials into high versus low risk of bias. Instead, for sensitivity analyses of the primary outcomes by high versus. low risk of bias, we will classify studies as having a low risk of bias if they have a low risk of bias for random allocation, allocation concealment, and incomplete outcome assessment, and do not have a high risk of bias for selective outcome reporting or other bias (Sensitivity analysis).

Measures of treatment effect

We will upload the outcome data for each study into the data tables in RevMan to calculate the treatment effects (Review Manager 2014). We will use the risk ratio (RR) for dichotomous outcomes related to benefit of treatment (e.g. cure). We will use the absolute risk difference (RD) for adverse events. We will use the mean difference (MD) for continuous outcomes reported on the same scale, and the standardized mean difference (SMD) for continuous outcomes reporting the same outcome but measured on different scales in different trials included in the same meta-analysis. We will express the uncertainty with 95% confidence intervals (CIs) for all effect estimates. If the included studies only report effect estimates and their CIs, standard errors, or exact P values, we will upload these data into RevMan so as to use the generic inverse variance method (Review Manager 2014). We will ensure that higher scores for continuous outcomes have the same meaning for the particular outcome and explain the direction to the reader. When we are unable to enter the results in either way, we will describe them in the 'Characteristics of included studies’ tables or enter the data into the ’Additional tables’ section.

Unit of analysis issues

We will include cross-over studies, but we will include only the first period of the trials in order to avoid carry-over effects. We do not expect to find cluster-randomized studies on this topic. However, if we find such studies, we will follow the guidance in Chapter 16.3 of the Cochrane Handbook for Systematic Reviews of Interventions to assess their suitability and will include these studies in the analysis if appropriate (Higgins 2011a).

Dealing with missing data

We will contact investigators or study sponsors in order to verify key study characteristics and obtain missing numerical outcome data where possible (e.g. when we identify a study as an abstract only). If we do not find a full report even after we contact the study authors, we will list such an abstract as a 'study awaiting classification’. If numerical outcome data are missing, such as standard deviations (SDs) or correlation coefficients, and we cannot obtain these from the study authors, we will calculate them from other available statistics, such as P values, according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Assessment of heterogeneity

We will assess clinical heterogeneity (i.e. differences in study populations, interventions, and outcomes) between studies qualitatively. For studies that we judge to have sufficient clinical homogeneity to combine in a meta-analysis, we will assess heterogeneity in three ways: visual examination of the forest plots; Chi² test (P ≤ 0.10) for heterogeneity; and the I² statistic, which describes the percentage of the variability in the estimate that is due to clinical or methodological heterogeneity rather than to chance. We will consider the implications of the observed value of the I² statistic as follows.

  • 0% to 40%: as perhaps not important.

  • 30% to 60%: as perhaps representing moderate heterogeneity.

  • 50% to 90%: as perhaps representing substantial heterogeneity.

  • 75% to 100%: as perhaps representing considerable heterogeneity (Deeks 2011).

We will assess the importance of the value of the I² statistic in light of the range and direction of effects as observed from the forest plots and the strength of the evidence for heterogeneity based upon the Chi² test (Deeks 2011). We will seek and discuss plausible explanations for observed statistical heterogeneity. We will investigate causes of heterogeneity between trials, using qualitative assessment of any differences in the populations and interventions between individual trials. We will also use subgroup analyses (Subgroup analysis and investigation of heterogeneity) and sensitivity analyses (Sensitivity analysis) to explore heterogeneity.

Assessment of reporting biases

We will search study registries of prospectively registered trials to identify completed, but not published, trials. If we are able to pool more than 10 trials in any meta-analysis, we will use a funnel plot and the Egger’s test to assess the potential for publication bias (Egger 1997; Sterne 2011).

Data synthesis

If trials are clinically comparable (i.e. clinical comparability of population, intervention, comparison, outcome, and timing of measurement), we will combine the outcome data from the individual trials in a meta-analysis using RevMan (Review Manager 2014). We will analyse pregnant and postpartum women separately at all times. However for non-pregnant, non-postpartum populations, we will group together women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI), mixed urinary incontinence (MUI), and mixed or unclear urinary incontinence diagnoses in the primary analysis, and examine different types of urinary incontinence diagnoses using subgroup analyses (see the 'Subgroup analysis and investigation of heterogeneity' section).

As yoga is a complex intervention with variations in practice components and implementation, and we expect some between-study variation due to these factors, we plan to use the random-effects model for meta-analysis. We will include 95% CIs for all estimates.

Should we consider that the outcome data from individual trials is not sufficiently similar to be combined quantitatively, we will narratively describe the results from clinically comparable trials.

GRADE and 'Summary of findings' tables

We will create a ’Summary of findings’ table using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (Guyatt 2011a; Guyatt 2011b). Two review authors (LSW and ZSL) will undertake GRADE assessments independently and will compare results. If there is disagreement on GRADE assessments, we will reach consensus through discussion. We will justify all decisions to downgrade the certainty of the evidence using footnotes and we will make comments to aid readers’ understanding of the review where necessary.

We will consider the following factors when we assess the certainty of evidence.

  • Limitations in the study design and conduct (i.e. risk of bias).

  • Inconsistency of results.

  • Indirectness of evidence.

  • Imprecision.

  • Publication bias.

We will downgrade the certainty of the evidence for a specific outcome by one level according to the performance of the included studies against each of the five factors.

The GRADE working group recommends including up to seven critical outcomes in a systematic review (Guyatt 2011a; Guyatt 2011b). In this systematic review, we will consider six critical outcomes for assessing the quality of evidence.

  • Number of women who report urinary continence.

  • Number of women who report urinary continence or improvement of urinary incontinence symptoms.

  • Urinary incontinence condition-specific or symptom-specific quality of life, as measured on any relevant scale.

  • Urine loss as measured with a pad or paper towel weight test.

  • Quality of life as measured on a scale that is not condition- or symptom-specific.

  • Adverse effects.

We will prepare separate Summary of findings tables for trials carried out with women who were pregnant or postpartum.

Subgroup analysis and investigation of heterogeneity

As the mechanisms of SUI and UUI are different, the effect of yoga may vary across types of urinary incontinence. Therefore, if there is sufficient data we will carry out subgroup analyses by type of urinary incontinence in the following groups.

  • SUI.

  • UUI.

  • MUI (both SUI and UUI).

  • A range of diagnoses, where data are not reported separately by urinary incontinence subgroup.

If trials contain women with different types of urinary incontinence, and we are unable to extract outcome data separately for women diagnosed with the different types of incontinence, but most women included in the trial are diagnosed with one of SUI, UUI, or MUI, we will consult with the Cochrane Incontinence Group editors and statisticians on how to include the study data appropriately in the subgroup analysis.

We will also conduct subgroup analyses of trials conducted in older (mean age 65 years or greater) versus younger populations as populations from different age groups may vary in their ability to perform yoga. Among women who are pregnant or postpartum, we will perform subgroup analyses of trials conducted in women who are pregnant versus postpartum, as the natural history of incontinence is different in the two states. If the data permit, we will carry out subgroup analyses by style (e.g. Iyengar yoga, Viniyoga, Yin yoga), dose, and duration of yoga intervention, to see whether type of yoga, amount of yoga, or duration of yoga modifies the effect of the yoga intervention.

Sensitivity analysis

We will assess the robustness of our conclusions by excluding studies that we judge to have a high risk of bias from our meta-analyses for the primary outcomes. We will also carry out sensitivity analyses to compare analyses using imputed and available case data, analyses using change and endpoint data, and analyses using adjusted and unadjusted data.

Acknowledgements

We thank Dr Muhammad Imran Omar, former Managing Editor of the Cochrane Incontinence Group, for providing administrative and logistical support for this protocol during his time in post; Sheila Wallace, Information Specialist of the Cochrane Incontinence Group, for developing and executing the search strategies; and Dr Soumyadeep Bhaumik for assistance in the protocol development. We also thank the editors and peer reviewers for the Cochrane Incontinence Group and the staff of the Cochrane Editorial Unit for their input into the protocol.

Appendices

Appendix 1. Cochrane Incontinence Group Specialised Register search strategy

We will use the following strategy to search the Cochrane Incontinence Group Specialised Register.

(({DESIGN.CCT*} OR {DESIGN.RCT*})

AND ({TOPIC.URINE.INCON*} OR {TOPIC.URINE.OVERACTIVE*} OR {TOPIC.URINE.frequency*} OR {TOPIC.URINE.URGENCY*})

AND {INTVENT.LIFESTYLE.YOGA.} OR {INTVENT.PHYS.YOGA.} OR {INTVENT.PHYS.Exercise.Yoga.} OR {INTVENT.PHYS.RELAXATION.} OR {INTVENT.PSYCH.Relaxation.} OR {INTVENT.PSYCH.MEDITATION.})

(All searches will be of the keyword field of Reference Manager 2012).

Appendix 2. NHS EED search strategies

NHS EED search strategies for economics evidence are referenced in Section 15.3.1 of the Cochrane Handbook for Systematic Reviews of Interventions (Shemilt 2011), and the most current versions may be found online at http://www.crd.york.ac.uk/crdweb/searchstrategies.asp.

MEDLINE search for NHS EED using OVIDSP

1Economics/
2exp "costs and cost analysis"/
3Economics, Dental/
4exp economics, hospital/
5Economics, Medical/
6Economics, Nursing/
7Economics, Pharmaceutical/
8(economic$ or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic$).ti,ab.
9(expenditure$ not energy).ti,ab.
10value for money.ti,ab.
11budget$.ti,ab.
12or/1-11
13(energy or oxygen) adj cost).ti,ab.
14(metabolic adj cost).ti,ab.
15((energy or oxygen) adj expenditure).ti,ab.
16or/13-15
1712 not 16
18letter.pt.
19editorial.pt.
20historical article.pt.
21or/18-20
2217 not 21
23exp animals/ not humans/
2422 not 23
25bmj.jn.
26"cochrane database of systematic reviews".jn.
27health technology assessment winchester england.jn.
28or/25-27
2924 not 28
30limit 29 to yr="2014 -Current"

Embase search for NHS EED using OVIDSP

1Health Economics/
2exp Economic Evaluation/
3exp Health Care Cost/
4pharmacoeconomics/
51 or 2 or 3 or 4
6(econom$ or cost or costs or costly or costing or price or prices or pricing or parmacoeconomic$).ti,ab.
7(expenditure$ not energy).ti,ab.
8(value adj2 money).ti,ab.
9budget$.ti,ab.
106 or 7 or 8 or 9
115 or 10
12letter.pt.
13editorial.pt.
14note.pt.
1512 or 13 or 14
1611 not 15
17(metabolic adj cost).ti,ab.
18((energy or oxygen) adj cost).ti,ab.
19((energy or oxygen) adj expenditure).ti,ab.
2017 or 18 or 19
2116 not 20
22animal/
23exp animal experiment/
24nonhuman/
25(rat or rats or mouse or mice or hamster or hamsters or animal or animals or dog or dogs or cat or cats or bovine or sheep).ti,ab,sh.
2622 or 23 or 24 or 25
27exp human/
28human experiment/
2927 or 28
3026 not (26 and 29)
3121 not 30
320959-8146.is.
33(1469-493X or 1366-5278).is.
341756-1833.en.
3532 or 33 or 34
3631 not 35
37conference abstract.pt.
3836 not 37
39limit 38 to yr="2014 -Current"

Appendix 3. AMED test search strategy

We performed a preliminary test search on AMED on OvidSP (covering 1985 to November 2015) on 30 November 2015 using the broad search strategy below to gauge roughly how many randomized trials there might be in the area of urinary incontinence, overactive bladder, or enuresis. After deduplication against the Cochrane Incontinence Group Specialised Register, we did not identify any additional records. Therefore we will not search this database for the first version of this Cochrane Review.

1.controlled clinical trial.pt.
2.randomized controlled trial.pt.
3.randomized controlled trials/
4.random allocation/
5.double blind method/
6.single blind method/
7.clinical trial$.pt.
8.exp clinical trial/
9.placebos/
10.placebo$.tw.
11.random$.tw.
12.research design/
13.volunteer$.tw.
14.(clin$ adj25 trial$).tw.
15.((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).tw.
16.factorial.tw.
17.cross-over studies/
18.crossover.tw.
19.latin square.tw.
20.(balance$ adj2 block$).tw.
21.(animals not humans).sh.
22.or/1-20
23.22 not 21
24.exp clinical trial/
25.(clinical trial or clinical trial phase iii or clinical trialb or clinical trials or comparative studies or comparative study or controlled clinical trial or controlled trial or evaluation studies or multicenter study or multicentre study or randomised controlled trial or randomized controlled trial).pt.
26.or/1-20,24-25
27.26 not 21
28.toilet$.tw.
29.(incontinen$ or continen$).tw.
30.exp urinary incontinence/ or urination disorders/
31.incontinence pads/
32.urodynamics/
33.urinary sphincter, artificial/
34.urodynamic$.tw.
35.urinary catheterization/ or Urinary Catheters/
36.bladder fistula/ or urinary fistula/ or urinary bladder fistula/
37.toilet training/
38.cutaneous fistula/
39.vaginal fistula/
40.vesicovaginal fistula/
41."pelvic floor"/
42.pelvic floor disorders/
43.(pelvi$ adj2 floor).tw.
44.perineomet$.tw.
45.interferential.tw.
46.cystitis, interstitial/
47.nycturia.tw.
48.((vesic$ or bladder or vagina$) adj5 (support$ or prosthes$)).tw.
49.(bladder adj6 (train$ or retrain$ or empt$)).tw.
50.mmk.tw.
51.marshall marchetti krantz.tw.
52.burch.tw.
53.((bladder or neck or vesic$) adj5 suspen$).tw.
54.colposuspension$.tw.
55.guittes.tw.
56.colporrhaph$.tw.
57.pereyra.tw.
58.urethrosuspension$.tw.
59.cystoplast$.tw.
60.urethropex$.tw.
61.lyodura$.tw.
62.colpoperineoplast$.tw.
63.urethrocervicopex$.tw.
64.stamey.tw.
65.interstitial cystitis.tw.
66.(fistula$ adj5 (bladder or vesic$ or bladder-vagina$ or urin$ or vagina$ or uretero-vagina$ or ureterovagina$ or urogenital or genitourin$)).tw.
67.raz.tw.
68.((urin$ or bladder) adj5 sphincter$).tw.
69.((bladder or detrusor or vesic$) adj5 (instability or stab$ or unstable or irritab$ or hyperreflexia or dys?ynerg$ or dyskinesi$ or irritat$)).tw.
70.(void$ adj5 (prompt$ or diar$)).tw.
71.urethral syndrome.tw.
72.(urethra$ adj2 sphincter$).tw.
73.(bladder adj2 neck).tw.
74.(urin$ adj2 (leak$ or urge$ or frequen$)).tw.
75.urinary fistula/
76.dribbl$.tw.
77.diaper$.tw.
78.bladder, neurogenic/ or bladder neurogenic/ or bladder disease/
79.(bladder adj1 ulcer$).tw.
80.(hunner? adj1 ulcer$).tw.
81.(vesic$ adj1 (neck$ or cervi$)).tw.
82.cystostomy.tw.
83.cystostomy/
84.vesicostom$.tw.
85.cystostom$.tw.
86.colporraph$.tw.
87.(fistula$ adj1 (urethra$ or colovesic$ or cystocol$ or cystovagina$ or vagino$)).tw.
88.(sling$ adj1 procedure$).tw.
89.(pelvi$ adj5 rehab$).tw.
90.((bladder or detrusor or vesic$) adj2 (hyper$ or overactiv$)).tw.
91.(urin$ adj2 extravasat$).tw.
92.((urin$ or bladder or urethra$) adj1 (prosthes$ or endoprosthes$)).tw.
93.(detrusor adj1 sphincter$).tw.
94.(spinal adj2 bladder$).tw.
95.(bladder$ adj2 (neuropath$ or neurogen$ or neurolog$)).tw.
96.bodyworn$.tw.
97.underpad$.tw.
98.(nervous adj1 (pollakisur$ or pollakiur$)).tw.
99.urinary bladder, overactive/
100.or/28-99
101.*prostate/
102.*prostatectomy/
103.*prostatic hyperplasia/
104.*prostatic neoplasm/
105.*prostatic neoplasms/
106.*bladder neoplasms/
107.*prostatitis/
108.*prostatic diseases/
109.or/101-108
110.100 not 109
111.27 and 110
112.exp enuresis/
113.enure$.tw.
114.bedwet$.tw.
115.bed-wet$.tw.
116.(bed adj5 wet$).tw.
117.(diurnal adj5 wet$).tw.
118.diurnal-wet$.tw.
119.((daytime or day-time or nighttime or night-time or nightime) adj5 wet$).tw.
120.urotherap*.tw.
121.(void$ adj2 dysfunct$).tw.
122.or/112-121
123.27 and 122

Appendix 4. CINAHL preliminary search strategy

We tested the following search strategy in CINAHL (on EBSCOhost) on 2 December 2015 (covering December 1981 to the most recent entry date 20151201). After deduplication against the Cochrane Incontinence Group Specialised Register, we did not retrieve any additional records, therefore we will not search CINAHL for this Cochrane Review.

# Query
S44S31 AND S43
S43S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42
S42TX pranayama
S41TX kundalini
S40TX qigong
S39TX relax*
S38TX meditat*
S37TX yogic
S36TX yoga
S35(MH "Qigong")
S34(MH "Relaxation") OR (MH "Muscle Relaxation")
S33(MH "Relaxation Techniques") OR (MH "Meditation")
S32(MH "Yoga+")
S31S23 AND S30
S30S24 OR S25 OR S26 OR S27 OR S28 OR S29
S29TI overactiv* N3 bladder* OR AB overactiv* N3 bladder*
S28TI urin* N3 leak* OR AB urin* N3 leak*
S27TI ( incontinen* OR continen* ) OR AB ( incontinen* OR continen* )
S26MH incontinence
S25MH overactive bladder
S24MH Urinary incontinence+
S23S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22
S22TI ( singl* N25 blind* OR singl* N25 mask* OR doubl* N25 blind* or doubl* N25 mask* OR trebl* N25 blind* OR trebl* N25 mask*OR tripl* N25 blind* OR tripl* N25 mask* ) or AB ( singl* N25 blind* OR singl* N25 mask* OR doubl* N25 blind* or doubl* N25 mask* OR trebl* N25 blind* OR trebl* N25 mask*OR tripl* N25 blind* OR tripl* N25 mask* )
S21(MH "Comparative Studies")
S20(MH "Clinical Research+")
S19(MH "Static Group Comparison")
S18(MH "Quantitative Studies")
S17(MH "Crossover Design") or (MH "Solomon Four-Group Design")
S16(MH "Factorial Design")
S15(MH "Community Trials")
S14(MH "Random Sample")
S13TI balance* N2 block* or AB balance* N2 block*
S12TI "latin square" or AB "latin square"
S11TI factorial or AB factorial
S10TI clin* N25 trial* or AB clin* N25 trial*
S9(MH "Study Design")
S8(AB random*) OR (TI random*)
S7(AB placebo*) OR (TI placebo*)
S6(MH "Placebos")
S5PT Clinical Trial OR (PT "randomized controlled trial")
S4(MH "Clinical Trials+")
S3MH (random assignment) OR (crossover design)
S2cross-over
S1crossover

Appendix 5. IndMED preliminary strategy

We performed a preliminary search of IndMED on 2 December 2015 using the following terms in Advanced Strategy, applying no limits, and using the default setting to search in: Any Where.

yoga OR yogic OR meditation OR relaxation OR kundalini OR pranayama

AND

incontinent OR incontinence OR continent OR incontinence

Contributions of authors

Nipun Shrestha and Sougata Panda conceived the protocol.
L. Susan Wieland, Nipun Shrestha, and Sougata Panda designed the protocol.
L. Susan Wieland, Nipun Shrestha, Zohra S Lassi, Sougata Panda, Delia Chiaramonte, and Nicole Skoetz wrote the protocol.

Declarations of interest

L. Susan Wieland has no known conflicts of interest.
Nipun Shrestha has no known conflicts of interest.
Zohra S Lassi has no known conflicts of interest.
Sougata Panda has no known conflicts of interest.
Delia Chiaramonte has no known conflicts of interest.
Nicole Skoetz has no known conflicts of interest.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • National Institute for Health Research (NIHR), UK.

    This project was supported by the NIHR, via Cochrane Infrastructure, Cochrane Programme Grant, or Cochrane Incentive funding to the Cochrane Incontinence Group. The views and opinions expressed therein are those of the protocol authors and do not necessarily reflect those of the Systematic Reviews Programme, the NIHR, the NHS or the Department of Health.

  • National Institutes of Health (NIH), USA.

    This project was supported by the National Center for Complementary and Integrative Health (NCCIH) grant R24 AT001293. The views and opinions expressed herein are those of the protocol authors and do not necessarily reflect those of the NIH or the NCCIH.

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