Effectiveness and cost-effectiveness randomised controlled trial of basic versus biofeedback-mediated intensive pelvic floor muscle training for female stress or mixed urinary incontinence: protocol for the OPAL (optimising pelvic floor exercises to achieve long-term benefits) trial mixed methods longitudinal qualitative case study and process evaluation.

INTRODUCTION: Female urinary incontinence (UI) is common affecting up to 45% of women. Pelvic floor muscle training (PFMT) is the first-line treatment but there is uncertainty whether intensive PFMT is better than basic PFMT for long-term symptomatic improvement. It is also unclear which factors influence women's ability to perform PFMT long term and whether this has impacts on long-term outcomes. OPAL (optimising PFMT to achieve long-term benefits) trial examines the effectiveness and cost-effectiveness of basic PFMT versus biofeedback-mediated PFMT and this evaluation explores women's experiences of treatment and the factors which influence effectiveness. This will provide data aiding interpretation of the trial findings; make recommendations for optimising the treatment protocol; support implementation in practice; and address gaps in the literature around long-term adherence to PFMT for women with stress or mixed UI. METHODS AND ANALYSIS: This evaluation comprises a longitudinal qualitative case study and process evaluation (PE). The case study aims to explore women's experiences of treatment and adherence and the PE will explore factors influencing intervention effectiveness. The case study has a two-tailed design and will recruit 40 women, 20 from each trial group; they will be interviewed four times over 2 years. Process data will be collected from women through questionnaires at four time-points, from health professionals through checklists and interviews and by sampling 100 audio recordings of appointments. Qualitative analysis will use case study methodology (qualitative study) and the framework technique (PE) and will interrogate for similarities and differences between the trial groups regarding barriers and facilitators to adherence. Process data analyses will examine fidelity, engagement and mediating factors using descriptive and interpretative statistics. ETHICS AND DISSEMINATION: Approval from West of Scotland Research Ethics Committee 4 (16/LO/0990). Findings will be published in journals, disseminated at conferences and through the final report. TRIAL REGISTRATION NUMBER: ISRCTN57746448.

Effectiveness and cost-effectiveness of basic versus biofeedback-mediated intensive pelvic floor muscle training for female stress or mixed urinary incontinence: protocol for the OPAL randomised trial.

INTRODUCTION: Accidental urine leakage is a distressing problem that affects around one in three women. The main types of urinary incontinence (UI) are stress, urgency and mixed, with stress being most common. Current UK guidelines recommend that women with UI are offered at least 3 months of pelvic floor muscle training (PFMT). There is evidence that PFMT is effective in treating UI, however it is not clear how intensively women have to exercise to give the maximum sustained improvement in symptoms, and how we enable women to achieve this. Biofeedback is an adjunct to PFMT that may help women exercise more intensively for longer, and thus may improve continence outcomes when compared with PFMT alone. A Cochrane review was inconclusive about the benefit of biofeedback, indicating the need for further evidence. METHODS AND ANALYSIS: This multicentre randomised controlled trial will compare the effectiveness and cost-effectiveness of PFMT versus biofeedback-mediated PFMT for women with stress UI or mixed UI. The primary outcome is UI severity at 24 months after randomisation. The primary economic outcome measure is incremental cost per quality-adjusted life-year at 24 months. Six hundred women from UK community, outpatient and primary care settings will be randomised and followed up via questionnaires, diaries and pelvic floor assessment. All participants are offered six PFMT appointments over 16 weeks. The use of clinic and home biofeedback is added to PFMT for participants in the biofeedback group. Group allocation could not be masked from participants and healthcare staff. An intention-to-treat analysis of the primary outcome will estimate the mean difference between the trial groups at 24 months using a general linear mixed model adjusting for minimisation covariates and other important prognostic covariates, including the baseline score. ETHICS AND DISSEMINATION: Approval granted by the West of Scotland Research Ethics Committee 4 (16/LO/0990). Written informed consent will be obtained from participants by the local research team. Serious adverse events will be reported to the data monitoring and ethics committee, the ethics committee and trial centres as required. A Standard Protocol Items: Recommendations for Interventional Trials checklist and figure are available for this protocol. The results will be published in international journals and included in the relevant Cochrane review. TRIAL REGISTRATION NUMBER: ISRCTN57746448; Pre-results.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a cochrane systematic review abridged republication.

BACKGROUND: Pelvic floor muscle training is the most commonly used physical therapy treatment for women with urinary incontinence. OBJECTIVES: To assess the effects of Pelvic floor muscle training for women with urinary incontinence in comparison to a control treatment and to summarize relevant economic findings. METHODS: Cochrane Incontinence Group Specialized Register (February 12, 2018). SELECTION CRITERIA: Randomized or quasi-randomized trials in women with stress, urgency or mixed urinary incontinence (symptoms, signs, or urodynamic). DATA COLLECTION AND ANALYSIS: Trials were independently assessed by at least two reviewers authors and subgrouped by urinary incontinence type. Quality of evidence was assessed by adopting the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS: The review included thirty-one trials involving 1817 women from 14 countries. Overall, trials were small to moderate size, and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration. Based on data available, we can be confident that Pelvic floor muscle training can cure or improve symptoms of stress and all other types of urinary incontinence. It may reduce the number of leakage episodes and the quantity of leakage, while improving reported symptoms and quality of life. Women were more satisfied with Pelvic floor muscle training, while those in control groups were more likely to seek further treatment. Long-term effectiveness and cost-effectiveness of Pelvic floor muscle training needs to be further researched. CONCLUSIONS: The addition of ten new trials did not change the essential findings of the earlier review, suggesting that Pelvic floor muscle training could be included in first-line conservative management of women with urinary incontinence.

Effects on urinary outcome of patients and caregivers' burden of pelvic floor muscle exercises based on the health belief model done at home by post-stroke patients.

OBJECTIVE: The purpose of this study is to investigate the effects of pelvic floor muscle exercises (PFMEs) done by stroke patients at home in line with the health belief model (HBM) on patient care outcomes and caregivers' burdens. METHOD: In the study, a quasi-experimental design with a pre- and post-test control group was used. The study was conducted with 20 patients in the experimental group and 18 patients in the control group. The patients and caregivers were evaluated at baseline and after the 12-week PFME intervention performed at home. The data were analyzed with the chi-square, Mann-Whitney U, Wilcoxon signed rank test and multiple regression analysis. RESULTS: A statistically significant difference was found between the two groups in terms of the mean scores they obtained from the ICIQ-SF and I-QOL, the number of urinary incontinence episodes, pad test after interventions and quality of life scores (p < 0.05), while no statistically significant difference was found between the groups in terms of the mean scores for the Burden Interview (p > 0.05). An increase was determined in the self-efficacy of the patients in the experimental group after the PFMEs (p < 0.05). CONCLUSIONS: Given the results of the present study, it is recommended that in the management of post-stroke urinary incontinence, post-stroke patients should be encouraged to do PFME at home in line with the HBM, and they should be monitored periodically.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.

BACKGROUND: Pelvic floor muscle training (PFMT) is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed urinary incontinence (MUI) and, less commonly, urgency urinary incontinence (UUI).This is an update of a Cochrane Review first published in 2001 and last updated in 2014. OBJECTIVES: To assess the effects of PFMT for women with urinary incontinence (UI) in comparison to no treatment, placebo or sham treatments, or other inactive control treatments; and summarise the findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register (searched 12 February 2018), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings, and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials in women with SUI, UUI or MUI (based on symptoms, signs or urodynamics). One arm of the trial included PFMT. Another arm was a no treatment, placebo, sham or other inactive control treatment arm. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trials for eligibility and risk of bias. We extracted and cross-checked data. A third review author resolved disagreements. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We subgrouped trials by diagnosis of UI. We undertook formal meta-analysis when appropriate. MAIN RESULTS: The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. Overall, trials were of small-to-moderate size, with follow-ups generally less than 12 months and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration, study populations and outcome measures. There was only one study of women with MUI and only one study with UUI alone, with no data on cure, cure or improvement, or number of episodes of UI for these subgroups.Symptomatic cure of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were eight times more likely to report cure (56% versus 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68 to 19.07; 4 trials, 165 women; high-quality evidence). For women with any type of UI, PFMT groups were five times more likely to report cure (35% versus 6%; RR 5.34, 95% CI 2.78 to 10.26; 3 trials, 290 women; moderate-quality evidence).Symptomatic cure or improvement of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were six times more likely to report cure or improvement (74% versus 11%; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women; moderate-quality evidence). For women with any type of UI, PFMT groups were two times more likely to report cure or improvement than women in the control groups (67% versus 29%; RR 2.39, 95% CI 1.64 to 3.47; 2 trials, 166 women; moderate-quality evidence).UI-specific symptoms and quality of life (QoL) at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT group were more likely to report significant improvement in UI symptoms (7 trials, 376 women; moderate-quality evidence), and to report significant improvement in UI QoL (6 trials, 348 women; low-quality evidence). For any type of UI, women in the PFMT group were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate-quality evidence) and to report significant improvement in UI QoL (4 trials, 258 women; moderate-quality evidence). Finally, for women with mixed UI treated with PFMT, there was one small trial (12 women) reporting better QoL.Leakage episodes in 24 hours at the end of treatment: PFMT reduced leakage episodes by one in women with SUI (mean difference (MD) 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women; moderate-quality evidence) and in women with all types of UI (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women; moderate-quality evidence).Leakage on short clinic-based pad tests at the end of treatment: women with SUI in the PFMT groups lost significantly less urine in short (up to one hour) pad tests. The comparison showed considerable heterogeneity but the findings still favoured PFMT when using a random-effects model (MD 9.71 g lower, 95% CI 18.92 lower to 0.50 lower; 4 trials, 185 women; moderate-quality evidence). For women with all types of UI, PFMT groups also reported less urine loss on short pad tests than controls (MD 3.72 g lower, 95% CI 5.46 lower to 1.98 lower; 2 trials, 146 women; moderate-quality evidence).Women in the PFMT group were also more satisfied with treatment and their sexual outcomes were better. Adverse events were rare and, in the two trials that did report any, they were minor. The findings of the review were largely supported by the 'Summary of findings' tables, but most of the evidence was downgraded to moderate on methodological grounds. The exception was 'participant-perceived cure' in women with SUI, which was rated as high quality. AUTHORS' CONCLUSIONS: Based on the data available, we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-specific symptom questionnaires. The authors of the one economic evaluation identified for the Brief Economic Commentary reported that the cost-effectiveness of PFMT looks promising. The findings of the review suggest that PFMT could be included in first-line conservative management programmes for women with UI. The long-term effectiveness and cost-effectiveness of PFMT needs to be further researched.

[Management of urinary incontinence in a geriatric rehabilitation department : Global urinary incontinence assessment incorporating the International Consultation on Incontinence Questionnare - Urinary Incontinence Short Form (ICIQ-UI SF)]. / Management der Harninkontinenz in einer geriatrischen Rehabilitationsklinik : Globales Harninkontinenz-Assessment unter Einbeziehung des International Consultation on Incontinence Questionnare ­ Urinary Incontinence Short Form (ICIQ-UI SF).

Although it is generally agree that older people have a high prevalence of urinary incontinence with a significant influence on health and quality of life, there is no standardized generally accepted assessment. The pathophysiology of urinary incontinence in frail elderly people requires a broad medical and functional scope to address the multifactorial nature of urinary incontinence, especially to identify treatable, potentially reversible conditions. To incorporate the multiple aspects into the daily routine, we developed a global urinary incontinence assessment at the Clinic for Geriatric Rehabilitation of the Robert Bosch Hospital including the validated International Consultation on Incontinence Questionnare - Urinary Incontinence Short Form (ICIQ-UI SF), a symptom score and results of a comprehensive geriatric assessment for mobility and cognition. In the years 2013-2015 this strategy was pursued for 728 geriatric patients and individually adapted interventions were initiated depending on the triggering cause. The experiences are presented.

Impact of pelvic floor muscle training on sexual function of women with urinary incontinence and a comparison of electrical stimulation versus standard treatment (IPSU trial): a randomised controlled trial.

AIMS: To evaluate the clinical and cost-effectiveness of electric stimulation plus standard pelvic floor muscle training compared to standard pelvic floor muscle training alone in women with urinary incontinence and sexual dysfunction. METHODS: Single centre two arm parallel group randomised controlled trial conducted in a Teaching hospital in England. Participants were women presenting with urinary incontinence and sexual dysfunction. The interventions compared were electric stimulation versus standard pelvic floor muscle training. OUTCOME MEASURES: included Prolapse and Incontinence Sexual function Questionnaire (PISQ) physical function dimension at post-treatment (primary); other dimensions of PISQ, SF-36; EQ-5D, EPAQ, resource use, adverse events and cost-effectiveness (secondary outcomes). RESULTS: 114 women were randomised (Intervention n=57; Control group n=57). 64/114 (56%). PARTICIPANTS: had valid primary outcome data at follow-up (Intervention 30; Control 34). The mean PISQ-PF dimension scores at follow-up were 33.1 (SD 5.5) and 32.3 (SD 5.2) for the Intervention and Control groups respectively; with the Control group having a higher (better) score. After adjusting for baseline score, BMI, menopausal status, time from randomisation and baseline oxford scale score the mean difference was -1.0 (95% CI: -4.0 to 1.9; P=0.474). There was no differences between the groups in any of the secondary outcomes at follow-up. Within this study, the use of electrical stimulation was cost-effective with very small incremental costs and quality adjusted life years (QALYs). CONCLUSIONS: In women presenting with urinary incontinence in conjunction with sexual dysfunction, physiotherapy is beneficial to improve overall sexual function. However no specific form of physiotherapy is beneficial over another. Trial registration ISRCTN09586238.

Impact of urinary incontinence on medical rehabilitation inpatients.

AIMS: To determine the prevalence of urinary incontinence (UI) and its association with rehabilitation outcomes in patients receiving inpatient medical rehabilitation in the United States. METHODS: A retrospective, cohort study of 425,547 Medicare patients discharged from inpatient rehabilitation facilities (IRFs) in 2005. We examined prevalence of UI at admission and discharge for 5 impairment groups. We examined the impact of demographics, health, and functional status on the primary outcome, change in continence status, and secondary outcomes of discharge location and 6-month mortality. RESULTS: Approximately one-quarter (26.6%) of men were incontinent at admission compared to 22.2% of women. In all diagnostic groups, continence status remains largely unchanged from admission to discharge. Patients who are older, have cognitive difficulties, less functional improvement, and longer lengths of stay (LOS), are more likely to remain incontinent, compared to those who improved, after controlling for patient factors and clinical variables. UI was significantly associated with discharge to another post-acute setting (PAC). For orthopedic patients, UI was associated with a 71% increase in the likelihood of discharge to an institutional setting after controlling for patient factors and clinical variables. UI was not associated with death at 6 months post-discharge. CONCLUSIONS: UI is highly prevalent in IRF patients and is associated with increased likelihood of discharge to institutional care, particularly for orthopedic patients. Greater attention to identifying and treating UI in IRF patients may reduce medical expenditures and improve other outcomes. Neurourol. Urodynam. 36:176-183, 2017. © 2015 Wiley Periodicals, Inc.

Cost-effectiveness of a behavioral intervention for persistent urinary incontinence in prostate cancer patients.

OBJECTIVE: The aim of this study was to evaluate the cost-effectiveness of a behavioral intervention for urinary incontinence of prostate cancer patients. Study subjects were either participating in or eligible but declined (i.e., nonparticipating) the active intervention study. METHODS: The intervention-participating subjects were randomized into three groups, including two intervention groups (support and telephone groups) and a usual care reference group. Intervention-nonparticipating subjects were concurrently enrolled. Intervention effectiveness was assessed on the EQ-5D measure. The costs included direct healthcare cost from medical billing data, patient out-of-pocket expense, caregiver expense, patient loss-of-work cost, and intervention cost. We calculated incremental cost-effectiveness ratios (ICERs) from societal, provider, and patient perspectives. RESULTS: Two hundred and sixty-seven intervention-participating and 69 intervention-nonparticipating post-cancer treatment patients were included. The support and telephone groups, but not the usual care group, had significantly higher EQ-5D index scores (0.054, p = 0.033, and 0.057, p = 0.026, respectively) than the intervention-nonparticipating group at month 6. Within 6 months, intervention cost per subject was $252 and $484, respectively, for providers, and $564 and $203, respectively, for the support and phone group subjects. The final ICERs were $16,759 per quality-adjusted life year (QALY) and $12,561/QALY for support and telephone groups, compared with those of the intervention-nonparticipating group. These ICERs are much smaller than $50,000/QALY, the consensus threshold to determine cost-effectiveness for society. CONCLUSIONS: The study interventions are cost-effective in consideration of eligible patients who declined the interventions. The interventions can provide meaningful outcome improvement on urinary continence at a low cost. This evidence provides critical information for future health policy decision-making of healthcare providers and payers.

Incontinência urinária e fecal: estudo sobre o uso de fraldas e insumos auxiliares / Fecal and urinary incontinence: study on the use of diapers and auxiliary products / Incontinencia fecal y incontinencia urinaria: estudio acerca de la utilización de pañales y productos auxiliares

TECNOLOGIA: Fraldas geriátricas e insumos auxiliares. INDICAÇÃO: Incontinência urinária e fecal. CARACTERIZAÇÃO DAS TECNOLOGIAS: Fralda geriátrica é um produto de higiene íntima usado por adultos, principalmente idosos, que não têm (ou perderam) o controle de suas necessidades fisiológicas. Insumos auxiliares são preparações utilizadas para prevenção e/ou tratamento de problemas decorrentes do uso das fraldas. PERGUNTA: Quais as indicações de uso de fraldas geriátricas e insumos auxiliares, quais são as alternativas terapêuticas a esses produtos e qual é o custo estimado da sua utilização crônica em comparação com alternativas terapêuticas disponibilizadas no SUS? Métodos: As indicações de uso das fraldas geriátricas, bem como de outras alternativas para o controle/tratamento das incontinências foram encontradas em busca na literatura científica e em guias de tratamento nacionais e estrangeiros. Para se ter uma noção do gasto público atual com fraldas geriátricas os preços desses produtos foram levantados de acordo com dados do Banco de preços em Saúde. Também foram pesquisados os preços de fraldas em 57 sítios eletrônicos de farmácias e drogarias, além de sites de compras coletivas e o Sistema de Atendimento ao Consumidor (SAC) dos fabricantes. Os tipos e preços dos insumos auxiliares foram pesquisados em três grandes redes de drogarias privadas, das quais uma está presente apenas no Estado de Minas Gerais. Além disso, como forma de contemplar aqueles produtos mais judicializados foram pesquisados os principais insumos auxiliares solicitados no JusBrasil. RESULTADOS: O gasto do SUS com procedimentos cirúrgicos e fisioterápicos é bem menor que o próprio subsídio dado à compra de fraldas geriátricas no programa "Aqui tem Farmácia Popular" e, portanto, deveriam ser recomendados com maior frequência, dependendo da condição de incontinência de cada indivíduo. Nesse parecer, constatou-se a necessidade do uso de produtos de barreira e hidratantes na prevenção e cuidado de dermatites e úlceras associadas à condição de incontinência, evidenciando a necessidade de maior financiamento por parte do SUS para garantir acesso a cremes, pomadas e loções (preventivas e/ou curativas), os quais, pela análise aqui conduzida, são bastante onerosos para o paciente. De acordo com os dados levantados nesse parecer, os valores estimados de gasto individual anual com fraldas geriátricas foram de R$1.674,04; R$1.827,81; R$1.439,31; e R$1.123,72, respectivamente para as fraldas tamanho extragrande, grande, médio e pequeno. Os produtos considerados auxiliares foram cremes, loções, pomadas, óleos e pastas, com propriedades oclusivas, hidratantes e de restauração da pele afetada por assaduras, decorrentes do uso de fraldas geriátricas. O gasto médio anual com insumos auxiliares foi estimado em R$2.255,78. Como alternativas terapêuticas foram consideradas a terapia medicamentosa, fisioterapia e procedimentos cirúrgicos, de acordo com levantamento bibliográfico e guias de tratamento da incontinência nacionais e estrangeiros. Os principais medicamentos foram a oxibutinina, tolterodina, darifenacina e toxina botulínica, os quais apresentaram valores estimados de custo anual médio de R$988,20; R$4.355,05; R$4.322,40; e R$3.979,14, respectivamente. Os procedimentos cirúrgicos ofertados pelo Sistema Único de Saúde foram pesquisados no SIGTAP (Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS) e apresentaram valores de ressarcimento que variaram de R$372,54 a R$457,67. De acordo com o SIGTAP o preço da sessão de fisioterapia para fins de controle da incontinência é R$4,67, sendo recomendadas 20 sessões por semana. CONSIDERAÇÕES FINAIS: Observou-se que a estimativa de gasto médio de pacientes com uso de fraldas e insumos auxiliares para o cuidado e tratamento das incontinências é elevado, podendo atingir R$2.255,78 por ano. O uso de fralda será necessário em caso de incontinência fecal e condicional no caso de incontinência urinária (IU). Na IU, o uso de fralda irá depender do tipo e gravidade da incontinência, estado físico e funcional da pessoa e se foram utilizadas opções de tratamento (reeducação, ingestão controlada de líquidos, fisioterapia, terapia ocupacional, medicamentos e cirurgias). De acordo com as evidências levantadas por esse PTC, parece haver uma subutilização de terapia medicamentosa, da fisioterapia e de procedimentos cirúrgicos e uma superutilização de fraldas geriátricas, as quais podem, em caso de uso desnecessário, contribuir para manter ou instituir a incontinência. De toda forma o SUS ainda não dispensa medicamentos recomendados para IU, insumos auxiliares ao tratamento e o valor do subsídio econômico fornecido aos pacientes é insuficiente para cobrir os gastos com as incontinências, nas situações onde o uso da fralda está adequadamente recomendado.(AU)

TECHNOLOGY: Adult diapers and auxiliary inputs. INDICATION: Urinary and fecal incontinence. TECHNOLOGY CHARACTERIZATION: Geriatric diaper is a hygiene product used by adults, especially the elderly, who do not have (or lost) control of your physiological needs. Auxiliary products are preparations and equipment used for prevention and / or treatment of problems emerging from the use of diapers. MAIN QUESTION: What are the indications for use of geriatric diapers and auxiliary products, which are therapeutic alternatives to these products and what is the estimated cost of its chronic use in comparison with therapeutic alternatives available through the Unified Health System (SUS ­ Sistema Único de Saúde)? METHODS: Indications for use of adult diapers, as well as other alternatives for the control / treatment of incontinence were found after search of scientific literature and national and international treatment guidelines. To get a sense of current public spending on adult diapers the prices of these products were raised in accordance with the Health price Bank. Also diaper prices were surveyed in 57 electronic sites of pharmacies and sites of collective shopping and the System of Customer Service of the manufacturers. The types and prices of auxiliary products were surveyed in three major networks of private drugstores, one of which is present only in the state of Minas Gerais. Furthermore, most solicited auxiliary products where searched in JusBrasil website. RESULTS: SUS spends with surgical and physical therapy procedures is much less than own subsidy given to the purchase of diapers in the program "Aqui tem farmácia popular" and therefore should be recommended more often, depending of each individual incontinence condition. Thus, there is the need for the use of barrier products and moisturizers in the prevention and care of dermatitis and ulcers associated with incontinence condition, highlighting the need for greater financial effort by the SUS in ensuring access to creams, ointments and lotions (preventive and / or curative), which, by the analysis undertaken here, are quite costly to the patient. According to our data, the estimated annual individual expenditure values with adult diapers were R$ 1674.04 ± 722.89; R$ 1827.81 ± 1179.24; R$ 1439.31 ± 724.88; and 1123.72 ± 521.21 respectively for the extra-large, large, medium and small size diapers. Auxiliary products are creams, lotions, ointments, oils and pastes, with occlusive properties, moisturizing and restoring the skin affected by diaper rash. Antifungal creams such as nystatin, were also classified as an auxiliary product. The estimated average annual expenditure on auxiliary products was R$ 2255.78 ± 3096.36. According to literature, national and foreign incontinence guides, drug therapy, physical therapy and surgical procedures were considered therapeutic alternatives. The main drugs are oxybutynin, tolterodine, darifenacin and botulinum toxin, which showed estimated annual average cost of R$ 988.20; R$ 4,355.05; R$ 4,322.40; and 3979.14, respectively. Surgical procedures offered by the Brazilian Public Health system were surveyed in SIGTAP (Management System of SUS Procedures) and had compensation values ranging from R$ 372.54 to R$ 457.67. According to the SIGTAP, the price of a single physiotherapy procedure for incontinence control purposes is R$ 4.67; the recommended are 20 sessions per week. CONCLUSIONS: We observed that the average spending estimation patients using diapers and auxiliary inputs for the care and treatment of incontinence is high, reaching R $ 2255.78 per year. The diaper use will be necessary in case of fecal incontinence and conditional in the case of urinary incontinence (UI). UI, use diaper will depend on the type and severity of incontinence, physical and functional condition of the person and were used treatment options (reeducation, controlled fluid intake, physical therapy, occupational therapy, medication and surgery). According to the evidence raised by this PTC, there seems to be an underspend of drug therapy, physical therapy and surgical procedures and overuse of adult diapers, which can, in case of unnecessary use, contribute to maintain or establish incontinence. Anyway SUS does not dispense drugs recommended for UI and auxiliary products to the treatment; moreover the value of the subsidy provided to patients is insufficient to cover the costs of the incontinences, in situations where the use of the diaper is properly recommended. (AU)

TECNOLOGÍA: Pañales geriátricos y entradas auxiliares. INDICACIÓN: Incontinencia urinaria y fecal. CARACTERIZACIÓN DEL TECNOLOGÍA: Pañal geriátrica es un producto de higiene íntima utilizado por adultos, especialmente los ancianos, que no tienen (o han perdido) el control de sus necesidades fisiológicas. Productos auxiliares son preparaciones utilizadas para la prevención y / o tratamiento de los problemas derivados del uso de los pañales. PREGUNTA: ¿Cuáles son las indicaciones para el uso de los pañales geriátricos y de los productos auxiliares, que son las alternativas terapéuticas para estos productos y cuál es el costo estimado de su uso crónico en comparación con las alternativas terapéuticas disponibles en el Sistema Único de Salud (SUS ­ Sistema Único de Saúde)? MÉTODOS: Las indicaciones de uso de pañales para adultos, así como otras alternativas para el control / tratamiento de la incontinencia se encontraron en la búsqueda de la literatura científica y directrices nacionales e internacionales de tratamiento. Los precios de pañales se buscaron en el Banco de los Precios en Salud de Brasil, para tener una idea del actual gasto público en pañales para adultos. Además, los precios de pañales fueron encuestados en 57 sitios electrónicos de las farmacias y droguerías, así como los sitios de compra en grupo y el Servicio de Atención al Consumidor (SAC) de los fabricantes. Los tipos y precios de productos auxiliares fueron encuestados en tres grandes redes de farmacias privadas, en el que uno se encuentra sólo en el Estado de Minas Gerais. Además, a fin de contemplar aquellos principales productos demandados en los tribunales, los productos auxiliares se buscaran en sitio electrónico JusBrasil. RESULTADOS: El gasto del SUS con procedimientos quirúrgicos y de terapia física es mucho menos que la propia subvención dada a la compra de pañales en el programa "Aqui tem Farmácia Popular" y por lo tanto se debe recomendar más veces, dependiendo de la condición de incontinencia individual. En este estudio, se constató la necesidad de la utilización de productos de barrera y humectantes en la prevención y cuidado de la dermatitis y úlceras asociadas con la condición de pañales, destacando la necesidad de mayor esfuerzo financiero por el SUS en garantizar el acceso a cremas, ungüentos y lociones (preventivo y / o curativo), que, por la análisis hecha aquí, son bastante costosos para el paciente. De acuerdo con los datos recogidos, los valores estimados anuales de gastos individuales con pañales para adultos fueron de R$ 1.674,04 ± 722,89; R$ 1827,81 ± 1179,24; R$ 1.439,31 ± 724,88; y R$ 1.123,72 ± 521,21, respectivamente, para los pañales extra grandes, grandes, medianas y pequeños. Productos considerados auxiliares son cremas, lociones, ungüentos, aceites y pastas, con propiedades oclusivas, hidratante y de restauración de la piel afectada por la utilización del pañal. El gasto estimado medio anual con productos auxiliares fue de R$ 2.255,78 ± 3.096,36. Se consideraron alternativas terapéuticas la terapia con medicamentos, fisioterapia y procedimientos quirúrgicos, de acuerdo con la literatura y las guías nacionales y extranjeras para la incontinencia. Los principales fármacos son oxibutinina, tolterodina, darifenacina y la toxina botulínica, que mostraron coste estimado medio anual de R$ 988,20; R$ 4,355.05; R$ 4,322.40; y R$ 3.979,14, respectivamente. Los procedimientos quirúrgicos ofrecidos por el Sistema Único de Salud fueron buscados en SIGTAP (tabla de Procedimientos del SUS) y tenían valores de compensación que van desde R$ 372,54 a R $ 457,67. Según el SIGTAP, el precio de la sesión de fisioterapia para el control de la incontinencia es de R $ 4,67; son recomendadas 20 sesiones por semana. CONSIDERACIONES FINALES: Se observó que el gasto promedio estimado de los pacientes utilizando pañales y productos auxiliares para el cuidado y tratamiento de la incontinencia es alta, alcanzando R $ 2.255,78 por año. El uso del pañal será necesario en el caso de la incontinencia fecal y condicional en el caso de la incontinencia urinaria (UI). En la UI, el uso de pañales dependerá del tipo y la gravedad de la incontinencia y de la condición física y funcional de la persona y se fueron utilizadas opciones de tratamiento (reeducación, la ingestión controlada de líquidos, fisioterapia, terapia ocupacional, medicamentos y cirugía). De acuerdo con las evidencias de este PTC, parece que hay una infrautilización del tratamiento farmacológico, fisioterapia y los procedimientos quirúrgicos y el uso excesivo de pañales para adultos, que pueden, en caso de uso innecesario, contribuir a mantener o establecer la incontinencia. De todos modos SUS no dispensa fármacos recomendados para UI y productos auxiliares para el tratamiento, además el valor del subsidio económico prestado a los pacientes es insuficiente para cubrir los costos de las incontinencias, en situaciones donde se recomienda adecuadamente el uso del pañal.(AU)

Conservative treatment for urinary incontinence in Men After Prostate Surgery (MAPS): two parallel randomised controlled trials.

OBJECTIVE: To determine the clinical effectiveness and cost-effectiveness of active conservative treatment, compared with standard management, in regaining urinary continence at 12 months in men with urinary incontinence at 6 weeks after a radical prostatectomy or a transurethral resection of the prostate (TURP). BACKGROUND: Urinary incontinence after radical prostate surgery is common immediately after surgery, although the chance of incontinence is less after TURP than following radical prostatectomy. DESIGN: Two multicentre, UK, parallel randomised controlled trials (RCTs) comparing active conservative treatment [pelvic floor muscle training (PFMT) delivered by a specialist continence physiotherapist or a specialist continence nurse] with standard management in men after radial prostatectomy and TURP. SETTING: Men having prostate surgery were identified in 34 centres across the UK. If they had urinary incontinence, they were invited to enroll in the RCT. PARTICIPANTS: Men with urinary incontinence at 6 weeks after prostate surgery were eligible to be randomised if they consented and were able to comply with the intervention. INTERVENTIONS: Eligible men were randomised to attend four sessions with a therapist over a 3-month period. The therapists provided standardised PFMT and bladder training for male urinary incontinence and erectile dysfunction. The control group continued with standard management. MAIN OUTCOME MEASURES: The primary outcome of clinical effectiveness was urinary incontinence at 12 months after randomisation, and the primary measure of cost-effectiveness was incremental cost per quality-adjusted life-year (QALY). Outcome data were collected by postal questionnaires at 3, 6, 9 and 12 months. RESULTS: Within the radical group (n = 411), 92% of the men in the intervention group attended at least one therapy visit and were more likely than those in the control group to be carrying out any PFMT at 12 months {adjusted risk ratio (RR) 1.30 [95% confidence interval (CI) 1.09 to 1.53]}. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (75.5%) and control (77.4%) groups was -1.9% (95% CI -10% to 6%). NHS costs were higher in the intervention group [£ 181.02 (95% CI £ 107 to £ 255)] but there was no evidence of a difference in societal costs, and QALYs were virtually identical for both groups. Within the TURP group (n = 442), over 85% of men in the intervention group attended at least one therapy visit and were more likely to be carrying out any PFMT at 12 months after randomisation [adjusted RR 3.20 (95% CI 2.37 to 4.32)]. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (64.9%) and control (61.5%) groups for the unadjusted intention-to-treat analysis was 3.4% (95% CI -6% to 13%). NHS costs [£ 209 (95% CI £ 147 to £ 271)] and societal costs [£ 420 (95% CI £ 54 to £ 785)] were statistically significantly higher in the intervention group but QALYs were virtually identical. CONCLUSIONS: The provision of one-to-one conservative physical therapy for men with urinary incontinence after prostate surgery is unlikely to be effective or cost-effective compared with standard care that includes the provision of information about conducting PFMT. Future work should include research into the value of different surgical options in controlling urinary incontinence.

Barriers to pelvic floor physical therapy utilization for treatment of female urinary incontinence.

OBJECTIVE: The purpose of this study was to estimate the effect of insurance status on pelvic floor physical therapy (PFPT) nonparticipation for the treatment of urinary incontinence. STUDY DESIGN: A cross-sectional study of women referred to PFPT for urinary incontinence between January 2009 and June 2010 was conducted. A telephone questionnaire was administered. Multiple logistic regression was used to identify risk factors for nonparticipation. RESULTS: Thirty-three percent of women with private insurance and 17% with other insurance were PFPT nonparticipants. On multiple logistic regression, women with Medicare were more likely to participate in PFPT (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.01-0.72). Risk factors for nonparticipation included insurance noncoverage (OR, 103.85; 95% CI, 6.21-infinity) and a negative perception regarding the benefit of PFPT (OR, 5.07; 95% CI, 2.16-12.49). CONCLUSION: Among women who were referred to PFPT for urinary incontinence, insurance noncoverage and negative patient perception of efficacy were risk factors for nonparticipation, although having Medicare was protective. Improving patient education and insurance coverage for PFPT may increase usage.

Assessment-guided therapy of urinary incontinence after stroke.

Urinary incontinence (UI) frequently occurs after stroke and often remains an extensive problem for these patients and their relatives even after discharge from the hospital. Therapeutic interventions, such as behavioral training, can help manage UI. Recently, a multimodal application of nursing interventions was recommended (Wilbert-Herr, Hürlimann, Imhof & Wilbert, 2006). The primary goals of the study discussed in this article were to introduce therapeutic interventions of UI management into clinical rehabilitation practice based on a structured process of interdisciplinary caregiving and test the treatment effect. Forty-four patients who had suffered a cerebrovascular accident (CVA) were included in the study. Nursing interventions included distinction of stress or urge UI and the assessment of different forms of UI. The latter intervention was based on the functional independence measure (FIM Item G-bladder management), the protocol of micturition, urine dipstick, and ultrasound measurement of post-void residual urine (PVR). Interventions were applied according to the recommendations of the 3rd International Consultation on Incontinence. An algorithm of the interdisciplinary process was implemented, and the nursing staff received specific education regarding the interventions. Twenty-one (47%) of the patients in the study were diagnosed with UI; 67% of these patients achieved the targeted level of continence by individually tailored interventions, which consisted of a systematic nursing assessment and standards for prompted voiding, timed voiding, and habit training. Planned processes, including screening procedures, assessment, profile of continence, intervention, and education and evaluation, increase the likelihood of positive results of rehabilitation of patients after CVA. Additional intervention studies are suggested to investigate the effectiveness of the algorithm used in this study.

Urinary dysfunction: assessment and management in stroke patients.

Continence care is a high priority during the rehabilitative process following stroke. Effective continence care can significantly improve the quality of life of patients and carers. A lack of knowledge and understanding of the likely causes of incontinence can lead to a failure to adopt the correct care strategies, which may in turn cause incontinence. Nurses are given little training and support in continence care, yet a basic level of training and the ability to assess potential problems may improve rehabilitation progress and outcomes.

Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence.

BACKGROUND: The aim was to compare effectiveness of group versus individual sessions of physiotherapy in terms of symptoms, quality of life, and costs, and to investigate the effect of patient preference on uptake and outcome of treatment. METHODS: A pragmatic, multi-centre randomised controlled trial in five British National Health Service physiotherapy departments. 174 women with stress and/or urge incontinence were randomised to receive treatment from a physiotherapist delivered in a group or individual setting over three weekly sessions. Outcome were measured as Symptom Severity Index; Incontinence-related Quality of Life questionnaire; National Health Service costs, and out of pocket expenses. RESULTS: The majority of women expressed no preference (55%) or preference for individual treatment (36%). Treatment attendance was good, with similar attendance with both service delivery models. Overall, there were no statistically significant differences in symptom severity or quality of life outcomes between the models. Over 85% of women reported a subjective benefit of treatment, with a slightly higher rating in the individual compared with the group setting. When all health care costs were considered, average cost per patient was lower for group sessions (Mean cost difference 52.91 pounds 95%, confidence interval ( 25.82 pounds- 80.00 pounds)). CONCLUSION: Indications are that whilst some women may have an initial preference for individual treatment, there are no substantial differences in the symptom, quality of life outcomes or non-attendance. Because of the significant difference in mean cost, group treatment is recommended. TRIAL REGISTRATION NUMBER: ISRCTN 16772662.

Rehabilitation nurses practices in relation to urinary incontinence following stroke: a cross-cultural comparison.

AIM: To explore nurses' practices and influences in relation to urinary incontinence following stroke, in the UK, Sweden and China. BACKGROUND: Urinary incontinence following stroke is common, under-recognised and poorly researched. Before appropriate rehabilitation interventions can be developed, an understanding of nurses' current management approaches and cultural influences is required. DESIGN: Qualitative. METHODS: Semi-structured interviews were undertaken with ten registered nurses from at least four different stroke units in three countries (n = 30). Interviews were carried out in the participants' first language, using an agreed interview guide. Following translation, thematic analysis focusing on manifest meaning was undertaken, using an iterative approach involving electronic and face-to-face discussions. RESULTS: The consequence of only superficial assessment was no systematic identification of types or causes of urinary incontinence and no individualised plans developed. A process model of practice, common to all three countries, was identified for stroke survivors with urinary incontinence. Routine core activities were followed by the palliative pathway (most frequently), where urinary incontinence was contained to protect the stroke survivors' safety and ensure social continence; or the rehabilitative route (more rarely), where simple continence promoting activities were implemented with the purpose of facilitating recovery of bladder function. CONCLUSIONS: Nurses' reactively manage urinary incontinence following stroke, adopting a routinised approach based on local custom and practice. Promotion of urinary continence is not a priority area of stroke rehabilitation for nurses in western or eastern countries. RELEVANCE TO CLINICAL PRACTICE: The dearth of evidence-based interventions available to rehabilitate bladder function following stroke means that stroke nursing practice is an experience-based endeavour. This study explains the nurses' focus on containment and social continence and highlights the need to systematically assess stroke survivors' bladder rehabilitation needs, identify types of urinary incontinence and adopt appropriate urinary continence promoting practices.

Evaluation of a urinary incontinence unit for community-dwelling older adults in Barcelona: implementation and improvement of the perceived impact on daily life, frequency and severity of urinary incontinence.

BACKGROUND: Urinary incontinence >(UI) is one of the most important and frequent geriatric syndromes. It is considered a silent but great social problem. Conservative management of UI, in a multidisciplinary and comprehensive approach, has been successful in previous studies, leading to a partial or total remission of the syndrome. AIMS: To investigate the acceptance of a geriatric incontinence unit and the effect of a multidimensional intervention on the improvement of UI regarding frequency, severity and perceived impact on daily life of community-dwelling older adults. METHODOLOGY: Prospective study with a multifactorial intervention with pre-post analyses. 92 patients aged 60 years and over were assessed for UI at an outpatient geriatric unit. They received an individualized conservative treatment and were followed up for 3 months. The International Consultation on Incontinence modular Questionnaire-Short Form (ICIQ-SF) was translated into Catalan. The difference of the perceived impact on the daily life before and 3 months after treatment was used as a primary outcome. The global score and the subscores on frequency and severity were used as secondary outcomes. RESULTS: 77.2% patients had an improvement in their perceived impact of UI on daily life. Concerning the ICIQ-SF global score, 82.6% improved. There was a significant improvement of about 30% in all dimensions measured. Many patients pointed out that being able to talk about the problem with a healthcare professional, in some cases for the first time, was very important to them. CONCLUSIONS: A conservative and multidisciplinary management of UI improved the impact of UI on daily life among comorbid geriatric patients. The Catalan ICIQ-SF was successfully implemented. Outpatient geriatric incontinence units seem to be effective and should be implemented to improve detection and management of this important geriatric syndrome.

Incontinence pads: recommending the best product-based wetback performance and price.

Incontinence pads are available in the USA without a prescription and are commonly the first treatment option a patient with incontinence uses. The goal of this study was to examine the difference in the performance and cost of commercially available incontinence pads with the intention of providing recommendations to women. Ten different urinary incontinence products were selected. A modified wetback test was used to test product performance. For the small volume leaks, the Walgreen's Extra pad generally performed worse on the wetback test than the three other pads tested (p = 0.001-0.012), but four tests were not statistically significant. At larger leak volumes, the Walgreen's underwear generally performed worse than other products (p < or = 0.001-0.046), with some exceptions. Brand name products generally performed better than generic products, but cost more. Undergarments and underwear do the worst job of keeping moisture inside the pad.