Conservative interventions for managing urinary incontinence after prostate surgery

Eugenie Evelyne Johnson* (Corresponding Author), Charalampos Mamoulakis, Akvile Stoniute, Muhammad Imran Omar, Sanjay Sinha

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

4 Citations (Scopus)

Abstract

Background
Men may need to undergo prostate surgery to treat prostate cancer or benign prostatic hyperplasia. After these surgeries, men may experience urinary incontinence (UI). Conservative treatments such as pelvic floor muscle training (PFMT), electrical stimulation and lifestyle changes can be undertaken to help manage the symptoms of UI.

Objectives
To assess the effects of conservative interventions for managing urinary incontinence after prostate surgery.

Search methods
We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings (searched 22 April 2022). We also searched the reference lists of relevant articles.

Selection criteria
We included randomised controlled trials (RCTs) and quasi‐RCTs of adult men (aged 18 or over) with UI following prostate surgery for treating prostate cancer or LUTS/BPO. We excluded cross‐over and cluster‐RCTs. We investigated the following key comparisons: PFMT plus biofeedback versus no treatment; sham treatment or verbal/written instructions; combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions; and electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions.

Data collection and analysis
We extracted data using a pre‐piloted form and assessed risk of bias using the Cochrane risk of bias tool. We used the GRADE approach to assess the certainty of outcomes and comparisons included in the summary of findings tables. We used an adapted version of GRADE to assess certainty in results where there was no single effect measurement available.

Main results
We identified 25 studies including a total of 3079 participants. Twenty‐three studies assessed men who had previously undergone radical prostatectomy or radical retropubic prostatectomy, while only one study assessed men who had undergone transurethral resection of the prostate. One study did not report on previous surgery. Most studies were at high risk of bias for at least one domain. The certainty of evidence assessed using GRADE was mixed.

PFMT plus biofeedback versus no treatment, sham treatment or verbal/written instructions

Four studies reported on this comparison. PFMT plus biofeedback may result in greater subjective cure of incontinence from 6 to 12 months (1 study; n = 102; low‐certainty evidence). However, men undertaking PFMT and biofeedback may be less likely to be objectively cured at from 6 to 12 months (2 studies; n = 269; low‐certainty evidence). It is uncertain whether undertaking PFMT and biofeedback has an effect on surface or skin‐related adverse events (1 study; n = 205; very low‐certainty evidence) or muscle‐related adverse events (1 study; n = 205; very low‐certainty evidence). Condition‐specific quality of life, participant adherence to the intervention and general quality of life were not reported by any study for this comparison.

Combinations of conservative treatments versus no treatment, sham treatment or verbal/written instructions

Eleven studies assessed this comparison. Combinations of conservative treatments may lead to little difference in the number of men being subjectively cured or improved of incontinence between 6 and 12 months (RR 0.97, 95% CI 0.79 to 1.19; 2 studies; n = 788; low‐certainty evidence; in absolute terms: no treatment or sham arm: 307 per 1000 and intervention arm: 297 per 1000). Combinations of conservative treatments probably lead to little difference in condition‐specific quality of life (MD ‐0.28, 95% CI ‐0.86 to 0.29; 2 studies; n = 788; moderate‐certainty evidence) and probably little difference in general quality of life between 6 and 12 months (MD ‐0.01, 95% CI ‐0.04 to 0.02; 2 studies; n = 742; moderate‐certainty evidence). There is little difference between combinations of conservative treatments and control in terms of objective cure or improvement of incontinence between 6 and 12 months (MD 0.18, 95% CI ‐0.24 to 0.60; 2 studies; n = 565; high‐certainty evidence). However, it is uncertain whether participant adherence to the intervention between 6 and 12 months is increased for those undertaking combinations of conservative treatments (RR 2.08, 95% CI 0.78 to 5.56; 2 studies; n = 763; very low‐certainty evidence; in absolute terms: no intervention or sham arm: 172 per 1000 and intervention arm: 358 per 1000). There is probably no difference between combinations and control in terms of the number of men experiencing surface or skin‐related adverse events (2 studies; n = 853; moderate‐certainty evidence), but it is uncertain whether combinations of treatments lead to more men experiencing muscle‐related adverse events (RR 2.92, 95% CI 0.31 to 27.41; 2 studies; n = 136; very low‐certainty evidence; in absolute terms: 0 per 1000 for both arms).

Electrical or magnetic stimulation versus no treatment, sham treatment or verbal/written instructions

We did not identify any studies for this comparison that reported on our key outcomes of interest.

Authors' conclusions
Despite a total of 25 trials, the value of conservative interventions for urinary incontinence following prostate surgery alone, or in combination, remains uncertain. Existing trials are typically small with methodological flaws. These issues are compounded by a lack of standardisation of the PFMT technique and marked variations in protocol concerning combinations of conservative treatments. Adverse events following conservative treatment are often poorly documented and incompletely described. Hence, there is a need for large, high‐quality, adequately powered, randomised control trials with robust methodology to address this subject.
Original languageEnglish
Article numberCD014799.
Pages (from-to)CD014799
Number of pages145
JournalCochrane Database of Systematic Reviews
Volume4
Issue number4
DOIs
Publication statusPublished - 18 Apr 2023

Bibliographical note

Acknowledgements: We would like to thank Sheila Wallace, Lindsey Elstub, Nicole O'Connor and Claire Eastaugh for their editorial support on this review.
We are grateful to the following people for assisting with translations for the review:• Gabriela Azevedo Sansoni: Faculty of Medicine and Surgery, University of Milan• Yuan Chi: Health Network, China; Cochrane Campbell Global Ageing Partnership, UK • Elaine Martí • Benjamin Hernández Wolters: Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico • Fangfang Zhao: Chinese Journal of Integrated Traditional and Western Medicine, China; Xiyuan Hospital, Chinese Academy of Chinese Medical Sciences, China Editorial and peer-reviewer contributions
The following people conducted the editorial process for this
article. • Sign-oH Editor (final editorial decision): Luke Vale, Cochrane's editorial board. • Managing Editor (selected peer reviewers, collated peer-reviewer comments, provided editorial guidance to authors, edited the article): Samuel Hinsley, Central Editorial Service • Editorial Assistant (conducted editorial policy checks and supported editorial team): Leticia Rodrigues, Central Editorial Service
• Copy Editor (copy editing and production): Heather Maxwell • Peer-reviewers (provided comments and recommended an editorial decision): Dr. M.S. Rahnama'i st. Elisabeth - Tweesteden Hospital Tilburg - The Netherlands (clinical review), Akhil Das, MD FACS, University of California Irvine (clinical review), Brian Duncan (consumer review), Nuala Livingstone, Cochrane Evidence Production and Methods Directorate (methods review), Anne Littlewood, Cochrane Oral Health (search review). 1 of additional peer reviewers provided clinical peer review but chose not to be publicly acknowledged.

Funding Information:
Dr Moore's studies were funded for 4 years by a Doctoral Fellowship from the Kidney Foundation of Canada. Funding for the research project was received from the Oncology Nurses' Society, Canadian Nurses' Foundation, Caritas Health, Alberta Physiotherapy Association, Edna Minton Foundation, and the University of Edmonton, Canada
This study was supported by grant R01 DK60044 from the National Institute of Diabetes and Digestive and Kidney Diseases and by the Department of Veterans Affairs Birmingham–Atlanta Geriatric Research, Education, and Clinical Center.
We would like to thank the National Science Council Grant of Taiwan for financial support (NSC 96-2314-B-214-007; NSC 97-2314-B-214-009-MY2).
Four studies stated that they did not receive any funding, while seven were funded solely by governmental organisations and one solely by a foundation. One study was funded by a governmental organisation and a university, one by a charity and a university and one through both charity and a pharmaceutical company. Ten studies did not report where they had obtained funding for their study.
Supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), 2003/07656-7.
This study received financial support from the National Council for Scientific and Technological Development (CNPq) through scientific research grant to the author
This study was funded by the Foundation for Research Support of the State of São Paulo (FAPESP), under registration number 2011/12154-7.
This study was supported by a grant from the Fund of Scientific Research, Flanders, Belgium
Funded by the Alberta Heritage Foundation for Medical Research, the Northern Alberta Urology Foundation, and Pfizer Corporation (unrestricted).
Scientific Research Foundation of Zhuhai Science and Technology Industry and Trade Bureau, No.2012D0401990028

Conflicts of interest: Quote: "All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Goode reported receiving a research grant from Pfizer. Dr Bur-gio reported serving on the advisory board of Astellas, as a consultant to GlaxoSmithKline, and as receiving research grants and serving as a consultant to Pfizer. Dr Johnson reported receiving grant support from Astellas, Pfizer and Vantia and serving as a consultant for Boehringer-Ingelheim, Ferring, Johnson & Johnson, Pfizer, and Vantia. Dr Issa reported serving as a consultant for and on the speakers bureau and receiving honoraria from GlaxoSmithKline. Dr Lloyd reported receiving research support from Allergan, Indevus, and Pfizer; serving as a consultant to and on the speakers bureau of Astellas, Boehringer-Ingelheim, GlaxoSmithKline, Novartis, and Pfizer. No other authors reported having a financial conflict of interest"

Publisher Copyright:
Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Keywords

  • Male
  • Adult
  • Humans
  • Prostate
  • Electric Stimulation Therapy/methods
  • Exercise Therapy/methods
  • Pelvic Floor
  • Urinary Incontinence/etiology
  • Prostatic Neoplasms/surgery

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