Nonpharmacologic Treatment

At the primary care level, nonpharmacologic treatment of UI constitutes the chief approach to UI management. In patients in whom pharmacologic or surgical management is inappropriate or undesirable or refused, nonsurgical nonpharmacologic treatment is the only option. Examples of patients fitting this scenario include:

• Those not medically fit for surgery

• Those who plan future pregnancies (as pregnancy/childbirth can compromise the long-term results of certain types of continence surgery)

• Those with OUI whose condition is not amenable to surgical or drug treatment

• Those with comorbidities which place them at high-risk for significant side effects to drug therapy

• Those who wish to delay or avoid surgery

• Those with mild to moderate symptoms who do not wish to undergo surgery or take medication

Nonpharmacologic approaches include lifestyle modifications, scheduled voiding regimens, pelvic floor muscle rehabilitation (PFMR), anti-incontinence devices, and supportive interventions.4,6 Many of these are best utilized through attendance at multidisciplinary UI clinics staffed by specialist nurses and/or physical therapists in addition to physicians. Behavioral interventions are among the first-line treatment approaches for SUI, UUI, and mixed UI. However, these lifestyle modifications, scheduling regimens, and PFMR methods require a motivated patient and/or caregiver who can play an active role in developing the treatment plan. Anything that interferes with active participation (including cognitive dysfunction) will render these approaches suboptimal. Patients/caregivers also must attend regular follow-up visits to monitor outcomes. Of interest, nonpharmacologic treatment may even be superior to pharmacologic treatment in select cases. For example, the short-term (6 months) and long-term (21 months) results of a combination of PFMR plus behavioral training produced statistically superior results compared to anticholinergic therapy in women

with UUI. ' Even if the results of nonpharmacologic treatment have not fully achieved the desired outcomes, if it has provided at least some improvement in UI

signs and symptoms, it should be continued during pharmacologic treatment. Nonpharmacologic treatment can allow the use of lower drug doses. The combination of both therapies may have at least an additive effect on UI signs and symptoms.

In the recent systematic review of nonsurgical treatments for UI by Shamliyan et al., the only nonpharmacologic treatment for which true objective evidence of benefit exists is the combination of PFMR plus behavioral training (restored continence with an effect size of 0.13 (95% CI, 0.07-0.20) but improvement in continence was not consistent between trials). Although PFMR alone or combined with biofeedback restored and improved continence, the effect size was not consistent between trials.9 Weight loss of 5% to 10% in overweight or obese women has an efficacy similar to that of other nonpharmacologic treatments.

Surgery is rarely a first-line treatment for UI. Surgery is generally considered only when the degree of bother or lifestyle compromise is sufficient and other nonoperative therapies are either undesired or have been ineffective. Surgery can be used to manage urethral overactivity due to benign prostatic enlargement and bladder outlet obstruction (via endoscopic incision using a cystoscope). Bladder underactivity cannot be managed surgically and rarely is surgery considered for UUI. Surgery is most effective in the management of SUI. Surgery for SUI is directed toward stabilizing the urethra and bladder neck and/or augmenting urethral resistance using periurethral collagen and other injectables. In males, SUI is best treated by implanting an artificial urinary sphincter.4

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