in the Elderly

Urinary IncontinenceReviewBiofeedback and other Therapiesfor the Treatment of Urinary Incontinencein the ElderlyE. Paul Cherniack, MDAbstractAlternative therapies hold potential promisefor the treatment of urinary incontinence inthe elderly. Assessment and comparisons ofthe efficacies of such therapies have beenhindered by a lack of standardized definitionsof urinary incontinence in the study populations,lack of standardization of treatment protocols,inadequate sample sizes, and lack of blindingand appropriate controls. Biofeedback hasbeen the most extensively studied therapy andmay provide appropriate adjunctive or primarytherapy for select individuals. Other potentialtherapies, such as acupuncture, hypnosis, andherbal therapies, have not been sufficientlyexamined to make definitive recommendations.{Altern Med Rev 2006;11 (3):224-231)thalamus - and receive afferent impulses from blad-der receptors, the frontal lobes, and basal ganglia toprevent leakage. The pons synthesizes afferent sig-nals and provides efferent regulation of the detrusorand sphincter muscles.'Classification of Urinary IncontinenceUI has been classified into three subtypesbased on symptoms and pathologic mechanisms -urge incontinence (UR), stress incontinence (SI), andoverfiow incontinence (01). Mixed incontinence canoccur when a patient exhibits features of two differ-ent forms simultaneously; the combination of SI andUR has been reported.^Urge IncontinenceThe most common form of incontinence isUR, characterized by a sudden urge and loss of urinewith polyuria.' UR usually occurs when the detrusormuscle becomes disinhibited as the result of centralnervous system disease, such as Alzheimer's demen-tia, stroke, or Parkinson's disease.' Denervation ofbladder smooth wall muscle from increased intrave-sicular pressure with bladder outlet obstruction canalso result in UR.^ Two other theories explaining URinclude increased sensitivity to the neurotransmitteracetylcholine by bladder smooth muscle receptorsand abnormal leakage of neurotransmitter by efferentfibers that innervate bladder smooth muscle.^IntroductionThe treatment of urinary incontinence (UI)in elderly individuals is a significant challenge. UI isa multifactorial syndrome caused by normal age-re-lated changes and pathology in the urinary tract. Ap-proximately 15-30 percent of adults over age 65 areaffected, experiencing loss of health and quality oflife. Women are twice as frequently affected as menuntil age 80, after which the prevalence is equal.'Pathophysiology of UINormal continence is maintained by nervoussystem control of the detrusor muscle surroundingthe bladder, the muscles surrounding the urethralsphincter, and the muscles of the lower abdomen andpelvic floor.' ^ Urination occurs when parasympathet-ic nerves from the sacral spine S2 to S4 contract thedetrusor muscle, while sympathetic nerves from TUto L2 relax the urethral sphincter.' The spinal neuronsare under the control of the brain - parietal lobes andPage 224E. Paul Chemiack, MD - Division of Geriatrics and Gerontology, LeonardM. Miller School of Medicine, University of Miami and the Miami VAHealth Care System.Correspondence address: Room 1D200, Miami VA Medical Center, 1201NW 16 St, Miami, FL 33125Email: evan.chemiack@med.va.govAlternative Medicine Review • Volume 11, Number 3 • 2006ReviewUrinary IncontinenceStress IncontinenceConventional Treatments for StressSI is the second-most frequent form of in-continence in women.' SI results when laxity in theIncontinencemuscles of the pelvic floor, loss of urinary sphinc-Conventional treatments for SI include pel-ter function, or urethral closure fails to prevent urinevic floor muscle exercises and reparative surgery. Infrom leaking from the bladder.' Childbirth-relatedtwo studies, the combination of exercise and educa-trauma is a common cause of pelvic muscle injurytion about the function and anatomy of the urinarythat ultimately predisposes to SI.^ SI can also occurtract decreased incontinence by 88* and 94'' percent,in men who have had prostate surgery.\"* The incidencerespectively. However, two other studies found no ad-of SI following prostate surgery varies widely fromditional benefit from the combination after surgery.*'0.3-65.6 percent, possibly due to differences in surgi-Success rates of surgical treatments for in-cal technique.'continence following prostatectomy vary widely. Ina series of small studies - less than 50 patients perOverflow Incontinencestudy - continence was restored in 36-95 percent ofsubjects.'\"'\"01 is the second-most common form of in-continence in men.' It usually results when the out-flow from the bladder is blocked by structures distalConventional Treatments for Overflowto the bladder (in men usually an enlarged prostate).'IncontinenceUrinary pressure builds in the bladder until it exceeds01 is typically treated with medication or sur-the ability of the musculature surrounding the bladdergery.' In published trials of the treatments for symp-to maintain continence, causing leakage.'tomatic relief of benign prostatic hypertrophy, theincidence of 01 has been rather low - less than oneConventional Treatmentevent per patient per year - making evaluation of suchtreatments difficult. In these trials, neither surgery norConventional treatments consist of behav-medication decreased the incidence of OI.'*'^ioral therapy, exercises to strengthen the pelvic floormuscles, medications, or surgery.'Alternative TreatmentsConventional Treatments for UrgeSince no conventional therapy is completelyIncontinenceefficacious and older individuals may be unwillingor unable to undergo surgical treatment, alternativeUR is treated either by behavioral therapytreatments may potentially be used as primary or ad-or medication. Behavioral therapies, although notjunctive therapy to reduce the number of episodes ofa cure, can decrease the incidence of incontinence.UI. While conventional non-surgical treatments canTherapies may include habit training consisting of ei-be efficacious, the cure rate is less than 50 percent.'*ther scheduled voiding based on a person's usual toi-Assessment and comparison of the efficaciesleting schedule (which can result in at least a 25-per-of alternative therapies in different studies have beencent decrease in episodes of incontinence) or specifichindered by lack of a standardized definition of UIinterval toileting schedules every 2-3 hours (whichin the subject populations, lack of standardization ofcan reduce episodes by as much as 80 percent).'treatments and treatment protocols, inadequate sam-The most effective medications, includingple sizes, and lack of blinding and appropriate con-oxybutinin and tolterodine, inhibit bladder muscletrols.contractions, reduce episodes of incontinence by ap-proximately 70 percent, and have a cure rate of about20 percent.'Alternative Medicine Review • Volume 11, Number 3 • 2006Page 225Urinary IncontinenceReviewBiofeedback and Pelvic Exercise forBiofeedback for Stress ImcomtineinceUrinary IncontinenceBiofeedback has also been used alone or inBiofeedback is the most extensively studiedcombination with conventional therapy to treat stressunconventional therapy for UI. In the application ofincontinence. Although the pelvic muscle exercisesbiofeedback to treat UI, surface or internal electrodesthat are the mainstay of conventional therapy for SIcreate visual or auditory signals when pelvic musclesbear the name of Dr. Arnold Kegel (Kegel exercises),'^are contracted. Using these signals, subjects can learnKegel did not develop these exercises, but invented ato augment or reduce muscle contractions voluntarilybiofeedback device to use with the exercises.\" Usingthrough muscle exercises to maintain continence. Thehis device, he reported to have eradicated symptomstechniques used in the various studies differ in regardin 93 percent of incontinent individuals.'^to location of the electrodes (intravesicular, anal, orPages et al performed a randomized, con-urethral sphincter), type of signal, (auditory or visu-trolled, four-week trial on 40 women (ages not re-al), and duration of training.''^ported) with SI. They compared biofeedback andphysical therapy followed by two weeks of home ex-Biofeedback/Pelvic Floor Exercises for Urgeercises. The physical therapy group received 20 one-Incontinencehour sessions of practice in pelvic muscle exercisesBoth controlled and uncontrolled trials havewith education on the anatomy and function of thecompared pelvic exercises with and without biofeed-bladder. Subjects who received biofeedback expe-back in limited numbers of subjects with UR; norienced decreased urinary frequency and subjectiveresults of placebo-controlled trials have been pub-improvement on symptom scores.^'lished.In a controlled investigation, 130 womenIn a small study, biofeedback reduced urinary(mean age 60) were randomized to receive biofeed-incontinence symptom scores and improved bladderback, pelvic floor muscle exercises, or no treatmentmuscle pressure in 10 subjects, ages 24-53.^\" In a sec-for six months. Compared to the control group, bothond study, women (ages 16-65 years; mean age 41)interventional arms experienced equal statisticallywere administered biofeedback for an average of fivesignificant reductions in episodes of incontinence.^*sessions with an 87-percent cure rate.^'-^^Thirty-five women (ages 31-69 years; meanWang et al compared biofeedback-assistedage 50) were randomized to utilize pelvic floor mus-pelvic floor muscle exercises to either pelvic floorcle exercises with or without home biofeedback. Aftermuscle exercise alone or exercise aided by electrical12 weeks, the biofeedback group obtained significantstimulation of the pelvic floor musculature via an in-improvement on a self-reported questionnaire scaletravaginal electrode in 103 women (ages 15-71 years)of urinary leakage.^^for 12 weeks.^^ There was a significant improvementIn several small, uncontrolled studies involv-in symptom score in biofeedback-assisted pelvic flooring 28-60 women, subjects observed both symptomexercises above that achieved by pelvic floor musclereduction and improved contractility of pelvic floorexercises alone; however, the cure rate was not sig-nificantly different among the three groups. AlthoughNot all studies have noted positive results. Inindividuals in the electrical-stimulation group expe-a randomized study, 103 women (ages 30-70; meanrienced the most improvement, the subjects in thisage 46.6) received pelvic floor muscle training withgroup were significantly younger than women in theor without biofeedback.^' No differences were notedother two groups.between groups in any of the measures studied.In a second study, 30 of 70 women who failedIn another study, 44 subjects were random-medication as therapy for UR were offered either bio-ized to receive six treatments of pelvic floor exercisesfeedback or pelvic floor muscle exercises.^'* Biofeed-with or without biofeedback. Both groups improved,back recipients exhibited greater bladder detrusorbut no statistically significant differences were notedmuscle pressures, although there was no differencebetween the groups at the end of the trial.^^in cure rate.Page 226Alternative Medicine Review • Volume 11, Number 3 • 2006ReviewUrinary IncontinenceAlthough a systematic review concludedto utilize biofeedback-assisted pelvic fioor musclethere is no benefit to adding biofeedback to pelvicexercises, medication, or a placebo.*-^' Subjects whofloor muscle exercises,-'-' a meta-analysis of the sameperformed the pelvic floor muscle exercises had twodata noted a \"trend\" in favor of adding biofeedback tosessions to learn how to perform them. Biofeedbackexercise; the pooled results almost reached statisticalwas added to the protocol for those subjects who ex-significance.^''hibited less than 50-percent reduction in frequencyBiofeedback has been evaluated as a treatmentof incontinence with exercise alone. Those subjectsfor patients who develop post-surgical SI. Studiestrained in combination exercise and biofeedback re-adding biofeedback to pelvic floor muscle exercisesduced episodes of incontinence from 15 to two epi-have reached different conclusions as to whether bio-sodes a week, medication-treated subjects decreasedfeedback confers an additional advantage.'•^'''^ In oneincontinent episodes from 15 to three episodes ainvestigation, 50 post-prostatectomy subjects (meanweek, and placebo recipients lowered episodes fromage 65) were randomized to receive biofeedback-as-15 to 10 episodes a week after two months.'\" Bio-sisted pelvic floor muscle exercises and educationfeedback-treated subjects also reduced episodes offor three months or to a control group who receivednocturia from 1.9 to 1.4 episodes a night, which wasno post-surgical intervention.'^ Biofeedback-trainedstatistically significant and not matched in the othersubjects experienced a 26-percent greater continencegroups.\"rate at three months and 14 percent at one year.^^In two studies, individuals who utilized bio-Biofeedback Conclusionsfeedback regained continence sooner after prosta-A number of problems exist in the quality oftectomy, although the overall rate of continence wasthe evidence on the use of biofeedback as a treatmentunchanged.'\"^-'^ Biofeedback yielded continence ratesfor incontinence: (1) there is no standardization ofof close to 80 percent in two other uncontrolled trialsbiofeedback devices or subject training used in dif-after prostatectomy.^'*--'^ Two investigations, however,ferent investigations; (2) the nature of the treatmentdid not find added benefit to the use of biofeedbackmakes blinding difficult, if not impossible; (3) manyafter prostate surgery.'*\"-'\" Differences in biofeedbackof the studies include a small number of subjects; (4)training techniques, devices, and subject populationsvarying inclusion criteria are used to define inconti-might have accounted for the variation in results.nence; and (5) different instruments are used to assessOverall, two comprehensive reviews con-the efficacy of treatment on outcomes.cluded the preponderance of evidence suggests thereOther important issues must be considered inmight be benefit to the addition of biofeedback to pel-a feasibility assessment of biofeedback for the elder-vic fioor muscle exercises for SI.^''^ In one, the com-ly. Although many studies include older subjects, fewbined relative risk of SI in biofeedback-assisted ex-trials have been performed exclusively on the elderly.ercise was 0.74 (95% confidence interval 0.60-0.93)It is not clear how easily elderly patients, many whocompared to no treatment.''^might have sensory or cognitive impairment, can betrained to use a biofeedback device. Other concernsBiofeedback for Mixed UIinclude determining the optimal biofeedback deviceBiofeedback has been utilized for individu-or training method and assessing the cost of such aals who exhibit features of both SI and UR - termeddevice.mixed UI. In several small, uncontrolled trials, last-ing from six weeks to 26 months and involving pri-marily middle-aged or elderly women, improvementMiscellaneous Therapies: Hypnosis,in symptom scores of episodes of incontinence andAcupuncture, and Botanical Medicineurgency ranged from 36-75 percent.''^\"'*^Hypnosis was the subject of one uncontrolledOne investigation added biofeedback to oth-trial to treat UR.'^ The subjects had 12 sessions overer treatments to reduce urge or mixed incontinence inone month, followed by audio-taped sessions at homea primarily elderly population. One hundred ninety-for six months. Fifty-eight percent of 50 subjects whoseven patients (ages 55-92) were randomly assignedreceived hypnosis experienced symptom improve-Alternative Medicine Review • Volume 11, Number 3 • 2006Page 227Urinary IncontinenceTable 1. Potential Application of Alternative Therapies in the Treatmentof Urinary IncontinenceReviewTherapyPotential Uses in UIMixed RCTs*BiofeedbackAcupunctureHypnosisChinese herbsSerenoa repensPygeum africanumHerbal combinationsSt. John's WortCuban Royal PalmYoga*Randomized controlled trialspuncture between four and12 times. Nine subjects expe-rienced complete resolutionof incontinent episodes.'^ Inanother uncontrolled series,20 individuals were given in-dividualized therapy accord-ing to the principles of tra-ditional Chinese medicine;'^77 percent had resolution ofincontinence.In an uncontrolledtrial, 23 subjects were given7.5 g three times daily of aChinese herbal formula {bu-zhongyiqitang) consisting ofginseng. Astragalus, Atrac-tylodis albae, Codonopsis,Glycyrrhiza, Angelica, Cit-rus reticulatae, Cimicifuga,Bupleurum, Zingiberis re-cens, and Ziziphus jujuba.Eighteen subjects (78%)experienced decreased fre-quency of incontinent epi-ment, and incontinence resolved in 41 percent of sub-jects. Six of the symptom-free patients relapsed, andfive had complete resolution of incontinent episodesafter additional treatment.Acupuncture has been studied as a treatmentfor SI or UR in several small trials.\"\"^^ In one study,13 subjects with UI due to chronic spinal cord inju-ries received four acupuncture treatments. Inconti-nence was completely eliminated in two patients andreduced to 50 percent or less compared to baseline inanother six patients.^^In a placebo-controlled, one-month trial of85 elderly women, 14-percent more subjects in theacupuncture-treated group experienced reduction inurinary incontinence compared to those in the place-bo group, who received acupuncture at sham points.'*In one small uncontrolled investigation, 11 subjects(mean age 71) had individualized treatments of acu-Page 228Several herbal thera-pies have been tested to de-termine if they amelioratethe symptoms of benignprostatic hypertrophy, the most common cause of 01,although none has been specifically tested as a treat-ment for OI.^** ™ Botanicals studied for BPH includeSerenoa repens (saw palmetto),*'-*^**'^*'^^'^^ Pygeum' and Urtica dioica (stinging nettle).^ConclusionsAlternative medicine holds promise for thetreatment of UI. Biofeedback has been the mostfrequently utilized and integrated into experimen-tal regimens. Biofeedback might be an appropriatetherapy for middle-aged or elderly women with stressincontinence wishing to avoid surgery and for whompelvic-floor muscle exercise alone does not providecomplete relief. Biofeedback should also be consid-ered after prostate surgery in men who experience in-continence, despite exercise, and who wish to avoidAlternative Medicine Review • Volume 11, Number 3 • 2006ReviewUrinary Incontinence10. Moore KN, Griffiths D, Hughton A. Urinaryadditional surgery. Other potential treatments, suchas acupuncture, hypnosis, and botanical medicine re-quire further research to determine effectiveness forUI.Further research may identify other alterna-11. tive treatments that alleviate symptoms of UI. Forexample, St. John's wort has been found in rats toinhibit contraction of the bladder, implying a possiblerole in treatment of UR;™ a fruit extract of the Cuban12. royal palm, Roystonea regia, inhibited testosterone-induced prostate enlargement in rodents;^\" and yogahas been suggested as a means to improve pelvic floor13. musculature to alleviate SI, although no clinical trialshave been published.*'Table 1 provides a summary of potential al-ternative therapies. More methodologically rigorous14. studies are indicated in order to determine safety andefficacy of these treatments for UI, particularly in the15. elderly population.References16. 1. DeBeau CE. Urinary incontinence. In: Pompei P,Murphy JB, eds. Geriatric Review Syllabus. 6th ed.Oxford, UK: Blackweli; 2006:184-195.2. Norton P, Brubaker L. Urinary incontinence in17. women. Lancer 2006;367:57-67.3. Wein AJ, Rackley RR. Overactive bladder: a betterunderstanding of pathophysiology, diagnosis, andmanagement. 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