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Educational interventions to raise men's awareness of bladder and bowel health.

Recommendations

* Pelvic floor muscle exercises (PFME) with or without additional interventions such as biofeedback could be used to reduce the incidence of urinary incontinence in men who have had a prostatectomy (Grade B).

* Education on lifestyle and behavioural modifications may be more effective in reducing lower urinary tract symptoms than doing nothing (Grade B).

* Pelvic floor muscle exercises may be effective in treating post-micturition dribble in men with or without erectile dysfunction (Grade B).

Information Source

This Best Practice Information Sheet has been derived from a systematic review (2) conducted by ACEBCC, Queensland Australia. The full text of the systematic review report is available from the Joanna Briggs Institute Library of Systematic Reviews(www.joannabriggs.org).

Background

Urinary incontinence (UI) is an objectively demonstrable condition in which the involuntary loss of urine is a social or hygienic problem. Urinary incontinence is a common health problem that carries with it significant medical, psychosocial and economic burdens.(2) Faecal incontinence has been defined as the involuntary or inappropriate passing of liquid or solid stool and can also include the incontinence of flatus. Studies suggest that twice as many men suffer from faecal incontinence compared to urinary incontinence whilst more than three times as many women suffer from urinary incontinence compared to faecal incontinence.(2) The general consensus in the literature is that barriers exist for seeking help for those with incontinence, especially men.

Objectives

The purpose of this Best Practice Information Sheet is to present the best available evidence identified from a review assessing the effectiveness of educational interventions at raising men's awareness of bladder and bowel health, with the idea that raising awareness will lead to an increase in help-seeking behaviour.

Types of Intervention

The review considered any intervention, program or action that provided information, or attempted to raise awareness of men's bladder and bowel health. None of the included studies evaluated interventions to improve men's knowledge or management of bowel health, or to improve men's attendance at promotional events.

Quality of the research

The review identified 12 randomized and two quasi experimental studies and overall the quality of the included studies was moderate. Only two RCTs described their method of randomization and no trials reported using blinding. Two studies did not provide the measures of dispersion (no standard deviation), one study provided graphical data only and one presented no data whatsoever.

Results

Pelvic floor muscle exercises (PFME) for prostatic cancer

Nine randomized controlled trials (RCTs) and two controlled trials examined the effectiveness of pelvic PFME on improving urinary incontinence in males ([greater than or equal to] 65 years) who have undergone prostatectomy. For participants with stress urinary incontinence, PFME may train the person to exert a well-timed, fast and strong voluntary pelvic floor muscle contraction just prior to an exertion. This contraction may clamp the urethra to increase intraurethral pressure and prevent urine leakage. For participants with urge urinary incontinence, it has been suggested PFME, conditions a reflex inhibition of detrusor contraction, thus preventing involuntary contractions and urine leakage.

Random effects meta analysis was performed with two RCTs with similar populations (men after prostatectomy), interventions (pelvic floor muscle training) and outcomes (urinary continence at 1, 3, 6 and 12 months). This analysis revealed that treatment with PFME resulted in statistically significant reductions in the number of incontinent participants at 3 months (RR= 0.35, 95%CI 0.25, 0.49), 6 months (RR= 0.313, 95%CI 0.06, 0.25), and 12 months (RR= 0.15, 95%CI 0.05, 0.42), of PFME when compared with controls who did not practice PFME.

These findings were echoed in a RCT of older males ([greater than] 66 years, N= 58). The PFME group showed significantly more participants attaining continence compared with the no PFME group at week 1, 2 and 3 of treatment, but not at 4 weeks.

Two RCTs examined the effectiveness of PFME in combination with biofeedback in men who had undergone radical prostatectomy and neither study reported any significant improvement in the number of incontinent episodes per 24 hours, or at reducing the number of grams of urine loss in a 24 hour period, when compared with the control groups. One RCT (n=24) randomised the subjects to either a biofeedback with pelvic floor muscle exercises group (45 minute sessions at 6, 7, 9, 11, and 16 weeks post-op) or a "no instruction" control group. PFME plus biofeedback was no more effective than the control in these patients for reducing the number of incontinent episodes per 24 hours, or at reducing the number of grams of urine loss in a 24 hour period. In the second RCT, (n=42) males after radical retropubic prostatectomy for localised prostate cancer were randomized to receive either pelvic floor muscle exercises with biofeedback or to PFME with verbal feedback only. Results showed that although urine loss (measured by 1 hour pad tests) reduced significantly from baseline to 1, 2, 3 and 6 months for both groups, there was no significant difference between the two groups.

In a RCT, 63 males four or more weeks after radical retropubic prostatectomy (mean age [greater than] 65 years) were randomised to either pelvic floor muscle exercises with intensive physiotherapy, PFME with electrical stimulation (ES), or PFME only provided by simple written and verbal instruction. While all groups showed significant reductions in urine loss (using the 24 hour pad test) at 12, 16 and 24 weeks compared to baseline, no significant differences were found between any group at any time point.

In a similar RCT, 139 older males (mean age 65 years) who had undergone radical prostatectomy were randomized to one of three treatment groups:

1 Pelvic floor muscle exercises plus intensive physiotherapy

2 PFME plus electrical stimulation

3 PFME plus ES plus biofeedback

Again, significant improvements in the number of continent participants were seen at each time point for each treatment group, however, no significant differences were found between any of the treatment groups at any time point.

In a RCT of 36 males with urinary incontinence after radical prostatectomy (mean age [greater than] 66 years) were randomized to treatment consisting of PFME or functional pelvic floor electrical stimulation (FES), or extracorporeal magnetic stimulation (ExMI) and followed up for 6 months. Using a 24 hour pad leakage test, there was little difference in the comparative effectiveness between the three treatment arms. There was significant reduction in the amount of urine leakage over time compared to the baseline (catheter removal) beginning at one month post-removal of the catheter. By 6 months urinary leakage was less than 10 grams in a 24 hour period compared with [greater than] 660grams 24 hours after catheter removal.

Finally, in a quasi experimental study of 24 male prostatectomy patients (mean age 70.2 years) introduction of PFME resulted in 16 of 24 (67%) participants exhibiting at least a 50% improvement in the number of incontinence episodes. At 1 to 17 months follow-up, 11 participants who had initially shown improvement reported no change to their condition or further improvement.

Post-micturition dribble

Two RCTs attempted to address the use of educational interventions at reducing the symptoms of post-micturition dribble. In the first RCT, 44 men were randomized to receive either:

a) counselling,

b) training on urethral milking, or

c) training in performing PFME.

The authors found that both milking and pelvic muscle exercises were significantly more effective at reducing the amount of urine lost post-micturition than counselling.

In the second RCT, 55 men with erectile dysfunction and post-micturition dribble were randomized to receive either advice on lifestyle changes (control) or PFME combined with biofeedback and lifestyle change advice (treatment). The results showed that after 3 months nearly all treatment recipients were free of post-micturition dribble (19 of 21) while only one third of control subjects were free (5 of 15) with a risk of having post-micturition dribble less than 20% of that of the control group (RR 0.14, 95% CI 0.04, 0.56). At 6 months however, both treatments were equally successful with no-one in the treatment and only 2 men in the control group still suffering post-micturition dribble.

Lower urinary tract symptoms

An RCT evaluated the effectiveness of lifestyle and behavioural education sessions on men suffering from uncomplicated lower urinary tract symptoms (LUTS). The primary outcome was the number of treatment failures defined as evidence of urinary retention, a rise of 3 points or more on the international prostate symptom score, the need for drugs or a surgical intervention to control LUTS. When compared with a standard care control group, participants provided with education had significantly fewer treatment failures at every time point (3, 6 and 12 months) with a reduced risk of failure of over 60% (RR 0.38, 95%CI 0.24, 0.58 at 12 months). A decrease in the number of treatment failures were reported over time for each group.

Evidence based guidelines for management of urinary and/or faecal incontinence

One quasi experimental study examined the effectiveness of consensus guidelines designed for the management of continence by primary health care teams placed in an urban general practice. A random sample of patients of this general practice were mailed a questionnaire to determine their continence status (N=1503). Those that were identified as incontinent and agreed to follow-up (174 patients, 42 males) were encouraged to attend the practice where GP's could institute best practice treatment according to the guidelines. Only 4 males actually sought help and 3 or 4 (number unclear from the text) still considered their incontinence to be a problem after the intervention. Therefore, a conclusion as to the effectiveness of these guidelines in males cannot be ascertained, due to lack of detail in the study report.

[ILLUSTRATION OMITTED]

Conclusions

The review highlighted that with the exception of PFME after prostatectomy, few controlled trials have examined the effectiveness of any interventions at raising awareness of bladder and bowel health in males aged 12 years and over. Specifically, no trials examined effectiveness of education interventions on faecal incontinence and no controlled trials were identified that looked exclusively at interventions to improve men's knowledge or management of bowel health, and no trials were identified that attempted to improve men's attendance at promotional events. Further, the majority of trials that evaluated interventions to manage bladder and bowel health presented both male and female data combined, making it impossible to estimate the effect of the intervention(s) on male participants only. In some cases, where the male data were presented separately, the population was too small to provide adequate power, and therefore most comparisons between treatment groups were found to have statistically insignificant differences in effectiveness. The majority of male only trials were examining the effectiveness of pelvic floor muscle exercises with and without other co-interventions in older men suffering urinary incontinence after prostatectomy.

From these trials there is some evidence to suggest an effective use of PFME. Eight randomized controlled trials RCT showed a benefit of PFME however, the timing and extent of that benefit was variable. In one trial of four weeks duration, PFME was more effective than control for the first three weeks of the intervention but not by the 4th week. Conversely, meta-analysis of two RCT showed that while PFME was not statistically significantly more effective than control at four weeks (though favoured), PFME was significantly more effective at reducing urinary incontinence symptoms over the longer term (at 3, 6, and 12 months) when compared with control participants.

An interesting finding was that neither of two RCTs found any benefit of biofeedback compared with verbal feedback when providing training in PFME. Similarly, in three RCTs, other interventions were added to PFME, such as intensive physiotherapy, or electrical stimulation. However, while significant improvements were seen in all PFME treated groups at follow-up compared with baseline, no significant differences were seen between the treatment arms at any time point. In other words, PFME alone would seem to be adequate as an effective strategy to reduce urinary incontinence in men after prostatectomy negating the need for more extensive and possibly expensive and time consuming therapy.

With the exception of instruction of pelvic floor muscle exercises for men after prostatectomy, no quantitative research has been performed that establishes the effectiveness of an intervention on men's awareness of bladder and bowel health. While numerous interventions have been trialled on mixed gender populations, and these trials suggest that the interventions would be effective, their effectiveness on the male component cannot be definitively established. Therefore, well designed controlled trials using male sample populations only are needed to confirm these suppositions.

Acknowledgments

This Best Practice information sheet was developed by the Joanna Briggs Institute.

Grades of Recommendation

These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness (1)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported

Evidence-based Practice evidence, context, client preference judgement

This Best Practice information sheet presents the best available evidence on this topic. Implications for practice are made with an expectation that health professionals will utilise this evidence with consideration of their context, their client's preference and their clinical judgement. (3)

References

(1.) The Joanna Briggs Institute. Levels of evidence and Grades of Recommendations. http://www.joannabriggs.edu.au/About%20Us/JBI%20Approach

(2.) Hodgkinson B, Tuckett A, Hegney D, Paterson J, Kralik D. Effectiveness of educational interventions to raise men's awareness of bladder and bowel health: a systematic review. The Joanna Briggs Library of Systematic Reviews 2010; 8(30):1202-1241

(3.) Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare. Int J of Evid Based Healthc 2005; 3(8):207-215.
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Publication:Best Practice
Date:Mar 15, 2011
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