Internet-based treatment of stress urinary incontinence: a randomised controlled study with focus on pelvic floor muscle training

Malin Sjöström, Göran Umefjord, Hans Stenlund, Per Carlbring, Gerhard Andersson, Eva Samuelsson, Malin Sjöström, Göran Umefjord, Hans Stenlund, Per Carlbring, Gerhard Andersson, Eva Samuelsson

Abstract

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Stress urinary incontinence (SUI) affects 10-35% of women, and it is sometimes very distressful. Pelvic floor exercises are the first line of treatment, but access barriers or embarrassment may prevent women from seeking help. There is a need for new, simple, and effective ways to deliver treatment. Management of SUI without face-to-face contact is possible, and Internet-based treatment is a new, promising treatment alternative.

Objective: To compare two treatment programmes for stress urinary incontinence (SUI) without face-to-face contact: one Internet-based and one sent by post.

Patients and methods: Randomised, controlled trial conducted in Sweden 2009-2011. Computer-generated block-randomisation, allocation by independent administrator. No 'blinding'. The study included 250 community-dwelling women aged 18-70 years, with SUI ≥1 time/week. Consecutive online recruitment. The women had 3 months of either; (i) An Internet-based treatment programme (124 women), including e-mail support and cognitive behavioural therapy assignments or (ii) A treatment programme sent by post (126). Both programmes focused mainly on pelvic floor muscle training.

Primary outcomes: symptom-score (International Consultation on Incontinence Questionnaire Short Form, ICIQ-UI SF) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life, ICIQ-LUTSQoL).

Secondary outcomes: (i) Patient Global Impression of Improvement, (ii) Incontinence aids, (iii) Patient satisfaction, (iv) Health-specific QoL (EQ5D-Visual Analogue Scale), and (v) Incontinence episode frequency. Follow-up after 4 months via self-assessed postal questionnaires.

Results: In all, 12% (30 women) were lost to follow-up. Intention-to-treat analysis showed highly significant improvements (P < 0.001) with large effect sizes (>0.8) with both interventions, but there were no significant differences between groups in primary outcomes. The mean (sd) changes in symptom-score were: Internet 3.4 (3.4), Postal 2.9 (3.1) (P = 0.27). The mean (sd) changes in condition-specific QoL were: Internet 4.8 (6.1), Postal 4.6 (6.7) (P = 0.52). Compared with the postal-group, more participants in the Internet-group perceived they were much or very much improved (40.9% (43/105) vs 26.5% (30/113), P = 0.01), reported reduced usage of incontinence aids (59.5% (47/79) vs 41.4% (34/82), P = 0.02) and were satisfied with the treatment programme (84.8% (89/105) vs 62.9% (71/113), P < 0.001). Health-specific QoL improved in the Internet-group (mean change 3.7 (10.9), P = 0.001), but not in the postal-group (1.9 (13.0), P = 0.13). Overall, 69.8% (120/172) of participants reported complete lack of leakage or reduced number of leakage episodes by >50%.

Conclusions: Concerning primary outcomes, treatment effects were similar between groups whereas for secondary outcomes the Internet-based treatment was more effective. Internet-based treatment for SUI is a new, promising treatment alternative.

Trial registration: ClinicalTrials.gov NCT01032265.

Keywords: Internet; cognitive behavioural therapy; pelvic floor muscle training; randomised controlled study; self-management; stress urinary incontinence.

© 2013 BJU International.

Figures

Figure 1
Figure 1
Flow of study participants.
Figure 2
Figure 2
The mean ICIQ-UI SF scores at follow-up by baseline severity and treatment group.
Figure 3
Figure 3
Distribution of responses on the PGI-I rating scale by treatment group. P value based on the Mann–Whitney rank sum test.

References

    1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167–178.
    1. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. J Clin Epidemiol. 2000;53:1150–1157.
    1. Milsom IAD, Lapitan MC, Nelson R, Sillén U, Thom D. Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP) In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence, 4th International Consultation on Incontinence, Paris July 5–8 2008. 4th edn. Paris: Health Publication Ltd; 2009. pp. 35–113.
    1. Coyne KS, Kvasz M, Ireland AM, Milsom I, Kopp ZS, Chapple CR. Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States. Eur Urol. 2012;61:88–95.
    1. Shamliyan T, Wyman J, Kane RL. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness [Internet] Rockville: Agency for Healthcare Research and Quality (US); 2012. (Comparative Effectiveness Reviews, No. 36.). Available at: . Accessed October 2012.
    1. Imamura M, Abrams P, Bain C, et al. Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence. Health Technol Assess. 2010;14:1–188.
    1. National Institute for Health and Clinical Excellence. Urinary Incontinence: The Management of Urinary Incontinence in Women. London: RCOG Press; Available at: . Accessed October 2012.
    1. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010;(1):CD005654.
    1. Garley A, Unwin J. A case series to pilot cognitive behaviour therapy for women with urinary incontinence. Br J Health Psychol. 2006;11:373–386.
    1. Dowd T, Kolcaba K, Steiner R. Using cognitive strategies to enhance bladder control and comfort. Holist Nurs Pract. 2000;14:91–103.
    1. Hannestad YS, Rortveit G, Hunskaar S. Help-seeking and associated factors in female urinary incontinence. The Norwegian EPINCONT Study. Epidemiology of Incontinence in the County of Nord-Trondelag. Scand J Prim Health Care. 2002;20:102–107.
    1. MacKay K, Hemmett L. Needs assessment of women with urinary incontinence in a district health authority. Br J Gen Pract. 2001;51:801–804.
    1. Teunissen D, van den Bosch W, van Weel C, Lagro-Janssen T. Urinary incontinence in the elderly: attitudes and experiences of general practitioners. A focus group study. Scand J Prim Health Care. 2006;24:56–61.
    1. Hay-Smith EJ, Herderschee R, Dumoulin C, Herbison GP. Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011;(12):CD009508.
    1. Goode PS, Burgio KL, Locher JL, et al. Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA. 2003;290:345–352.
    1. WHO. WHO e-Health. [Internet] 2012 [cited 2012 June 13]. Available at: . Accessed December 2012.
    1. Andersson G, Ljotsson B, Weise C. Internet-delivered treatment to promote health. Curr Opin Psychiatry. 2011;24:168–172.
    1. Statistics Sweden. Use of computers and the Internet by private persons [Internet]. Stockholm Sweden, 2012 [cited 2012 June 11]; IT01BR1201. Available at: . Accessed October 2012.
    1. Umefjord G, Petersson G, Hamberg K. Reasons for consulting a doctor on the Internet: web survey of users of an Ask the Doctor service. J Med Internet Res. 2003;5:e26.
    1. Sandvik H, Seim A, Vanvik A, Hunskaar S. A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests. Neurourol Urodyn. 2000;19:137–145.
    1. Herrmann C. International experiences with the Hospital Anxiety and Depression Scale – a review of validation data and clinical results. J Psychosom Res. 1997;42:17–41.
    1. Dallal GE. [Internet] [updated 2008 July 16; cited 2012 June 12]. Available at: . Accessed October 2012.
    1. Cuijpers P, van Straten A, Andersson G. Internet-administered cognitive behavior therapy for health problems: a systematic review. J Behav Med. 2008;31:169–177.
    1. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn. 2004;23:322–330.
    1. Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol. 1997;104:1374–1379.
    1. Sjostrom M, Stenlund H, Johansson S, Umefjord G, Samuelsson E. Stress urinary incontinence and quality of life: a reliability study of a condition-specific instrument in paper and web-based versions. Neurourol Urodyn. 2012;31:1242–1246.
    1. Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol. 2003;189:98–101.
    1. Brooks R. EuroQol: the current state of play. Health Policy. 1996;37:53–72.
    1. Albers-Heitner P, Berghmans B, Joore M, et al. The effects of involving a nurse practitioner in primary care for adult patients with urinary incontinence: the PromoCon study (Promoting Continence) BMC Health Serv Res. 2008;8:84.
    1. Ghoniem GM, Van Leeuwen JS, Elser DM, et al. A randomized controlled trial of duloxetine alone, pelvic floor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. J Urol. 2005;173:1647–1653.
    1. Klovning A, Avery K, Sandvik H, Hunskaar S. Comparison of two questionnaires for assessing the severity of urinary incontinence: the ICIQ-UI SF versus the incontinence severity index. Neurourol Urodyn. 2009;28:411–415.
    1. Higgins JPT, Deeks JJ, Altman DG, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration; Chapter 16: special topics in statistics. [updated 2011 March; cited 2012 June 12]. Available at: . Accessed October 2012.
    1. Samuelsson E, Victor A, Tibblin G. A population study of urinary incontinence and nocturia among women aged 20–59 years. Prevalence, well-being and wish for treatment. Acta Obstet Gynecol Scand. 1997;76:74–80.
    1. Statistics Sweden. Educational attainment of the population 2011 [Internet]. Stockholm Statistics Sweden; 2012 [updated 2012 April 18; cited 2012 June 13]. Available at: . Accessed October 2012.
    1. Albers-Heitner CP, Lagro-Janssen AL, Joore MA, et al. Effectiveness of involving a nurse specialist for patients with urinary incontinence in primary care: results of a pragmatic multicentre randomised controlled trial. Int J Clin Pract. 2011;65:705–712.
    1. Sherburn M, Bird M, Carey M, Bo K, Galea MP. Incontinence improves in older women after intensive pelvic floor muscle training: an assessor-blinded randomized controlled trial. Neurourol Urodyn. 2011;30:317–324.
    1. Castro-Diaz D, Palma PC, Bouchard C, et al. Effect of dose escalation on the tolerability and efficacy of duloxetine in the treatment of women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:919–929.
    1. Samuelsson EC, Victor FT, Svardsudd KF. Five-year incidence and remission rates of female urinary incontinence in a Swedish population less than 65 years old. Am J Obstet Gynecol. 2000;183:568–574.
    1. Tate DF, Finkelstein EA, Khavjou O, Gustafson A. Cost effectiveness of internet interventions: review and recommendations. Ann Behav Med. 2009;38:40–45.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren