TITLE: Randomized, Placebo-Controlled Trial of the Cognitive Effect, Safety, and Tolerability of Oral Extended-Release Oxybutynin in Cognitively Impaired Nursing Home Residents With Urge Urinary Incontinence
AUTHORS: Lackner TE, Wyman JF, McCarthy TC, Monigold M, Davey C
SOURCE:Journal of the American Geriatrics Society 2008; 56(5):862-870
ARTICLE TYPE: Research Report; Randomized Controlled Trial
DESCRIPTION/RESULTS:
* The study investigated whether cognitive impairment in older people with urinary incontinence would worsen if they are treated with an antimuscarinic agent. Subjects (N = 50) were aged 65 and all had cognitive impairment. Subjects received daily oral extended release oxybutynin 5 mg or placebo for 4 weeks. Outcome measures were MMSE (normal score is 23-30), Confusion Assessment Method short (CAM) (normal score 0/4), and self or caregiver report.
* MMSE mean score was 14.5 (4.3) at baseline and CAM score was 2 or lower indicating cognitive impairment, but this difference was not different between groups at any of the time points or at the conclusion of the study at 4 weeks.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* The judicious use of antimuscarinic medications such as oxybutynin at a low dose may improve symptoms and is not likely to worsen cognitive impairment. Evaluation strategies should be included in all treatment protocols for older people to ensure satisfactory benefit without adverse effects.
TITLE: Treatment Interventions in Nursing Home Residents With Urinary Incontinence: A Systematic Review of Randomized Trials
AUTHORS: Fink HA, Taylor BC, Tacklind JW, Rutks IR, Wilt TJ
SOURCE:Mayo Clinic Proceedings 2008; 83(12): 1332-1343
ARTICLE TYPE: Systematic Literature Review
DESCRIPTION/RESULTS:
* The authors reviewed randomized controlled trials on management of incontinence in nursing home residents. Interventions included antimuscarinic medications, hormone replacement therapy, and prompted voiding, exercise, or other behavioral interventions. Fourteen trials were identified that enrolled a total of 1161 patients.
* Prompted voiding plus oxybutynin was effective in slightly reducing incontinence episodes. Adding oral hormone replacement therapy did not improve outcomes.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* Systematic reviews of the literature are one method of obtaining summary information on intervention studies. In this review, the authors note that there is benefit from simple procedures such as prompted voiding for people in long-term care and nursing home settings to improve continence status. Nurses may need to consider strategies to improve the use of prompted voiding.
TITLE: Behavioral Therapy to Enable Women With Urge Incontinence to Discontinue Drug Treatment: A Randomized Trial
AUTHORS: Burgio KL, Kraus SR, Menefee S, Borello-France D, Corton M, Johnson HW, Mallett V, Norton P, FitzGerald MP, Dandreo KJ, Richter HE, Rozanski T, Albo M, Zyczynski HM, Lemack GE, Chai TC, Khandwala S, Baker J, Brubaker L, Stoddard AM, Goode PS, Nielsen-Omeis B, Nager CW, Kenton K, Tennstedt SL, Kusek JW, Chang TD, Nyberg LM, Steers W; Urinary Incontinence Treatment Network
SOURCE:Annals of Internal Medicine 2008; 149(3): 161-169
ARTICLE TYPE: Research Report; Randomized Controlled Trial
DESCRIPTION/RESULTS:
* The authors investigated whether a combination of antimuscarinic medication and behavioral training (bladder diary and fluid management) would improve symptoms of urge incontinence when compared to medication therapy alone. Three hundred seven subjects with urge incontinence participated in the trial.
* People receiving information on behavioral training reported more satisfaction and reported reduction of other bladder symptoms but did not significantly improve symptoms once medication therapy was discontinued. It appears that on-going combination therapy is required for at least 8 months. Behavioral training included pelvic floor muscle training, urge suppression strategies, fluid management, and written material. People in the behavior plus drug arm reported more satisfaction with care than those in the drug arm.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* Urge symptoms are typically gradual in intensity and bother to the individual and it may be years before they seek assistance. Thus relief of symptoms and lifestyle changes are likely to take a significant time to integrate and people require support and encouragement to adhere to lifestyle/behavioral changes that will improve urgency symptoms.
LIMITATIONS:
* Both arms received drug therapy so we do not know if behavioral strategies alone could achieve similar benefits; adding a third arm of behavior strategies alone may have helped answer that question.
TITLE: Does the Mode of Delivery Predispose Women to Anal Incontinence in the First Year Postpartum? A Comparative Systematic Review
AUTHORS: Pretlove SJ, Thompson PJ, Toozs-Hobson PM, Radley S, Khan KS
SOURCE:British Journal of Obstetrics and Gynecology 2008; 115(4):421-434
ARTICLE TYPE: Systematic Literature Review/ Meta-analysis
DESCRIPTION/RESULTS:
* A systematic literature review was undertaken to determine whether anal incontinence is related to vaginal delivery and whether caesarean section reduces the risk of anal incontinence in the first postpartum year. Eighteen studies were found that compared the two methods in 12,237 women. Women experiencing any type of vaginal delivery have an increased risk of anal incontinence compared with a caesarean section. Forceps delivery has a doubled risk but ventouse deliveries did not increase risk.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* When assessing a woman with fecal or urinary continence symptoms, questions should include delivery mode and explore any problems immediately postdelivery.
TITLE: Does Cesarean Section Reduce Postpartum Urinary Incontinence?
AUTHORS: Press JZ, Klein MC, Kaczorowski J, Liston RM, von Dadelszen P
SOURCE:Birth 2007; 34(3):228-237
ARTICLE TYPE: Systematic Literature Review/Meta-analysis
DESCRIPTION/RESULTS:
* The authors systematically reviewed the literature to determine whether urinary incontinence is related to vaginal delivery and whether Caesarean section protects against urinary incontinence. Eighteen studies, 12 comparison cohort and 6 cross sectional studies that met inclusion criteria. Analysis of pooled data from these studies revealed that, in the short term, caesarean section reduced the risk of urinary incontinence between 6% and 10%. However, over time neither stress nor urge incontinence were clearly related to delivery method.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* It is likely that other factors are equally important in the onset of urinary incontinence in women over time-weight gain, exercise, smoking. In primary care, nurses need to consider ways to ensure that healthy lifestyle changes are incorporated into pre- and postpartum care.
TITLE: Pelvic Floor Muscle Training for Prevention and Treatment of Urinary and Faecal Incontinence in Antenatal and Postnatal Women
AUTHORS: Hay-Smith J, Morkved S, Fairbrother KA, Herbison GP
SOURCE:Cochrane Database of Systematic Reviews 2008; (4):CD007471
ARTICLE TYPE: Systematic Literature
Review/Meta-analysis
DESCRIPTION/RESULTS:
* The authors systematically reviewed the literature and analyzed pooled data to determine whether pelvic floor muscle training (PFMT) is effective for the treatment of UI and FI in women. Sixteen studies that enrolled a total of 6181 women met inclusion criteria. Women randomized to active PFMT under direct care of a clinician or therapist during pregnancy were less likely to have UI in late pregnancy and postpartum than those who were not. Fecal incontinence was also less in the treatment groups.
WHAT DOES THIS MEAN TO ME AND MY PRACTICE?
* The review provides good support for the benefit of active PFMT for pregnant women and this should be incorporated as part of any antenatal program.
TITLE: Risk Factors for Fecal Incontinence After Rectal Cancer Treatment
AUTHORS: Lange MM, den Dulk M, Bossema ER, Maas CP, Peeters KC, Rutten HJ, Klein Kranenbarg E, Marijnen CA, van de Velde CJ; Cooperative Clinical Investigators of the Dutch Total Mesorectal Excision Trial
SOURCE:British Journal of Surgery 2007; 94(10): 1278-1284
ARTICLE TYPE: Research Report, Randomized Controlled Trial
DESCRIPTION/RESULTS:
* The researchers investigated whether preoperative radiotherapy increases the risk for long-term fecal incontinence in patients with rectal cancer. Nine hundred twenty-four subjects were randomized but only 460 provided data due to disease progression or other factors. Those who did participate completed questionnaires at several intervals up to 2 years and then again at 5 years.
* At 5 years, 62% of those who had undergone preop radiotherapy had fecal incontinence as compared to 39% of those who did not receive radiation therapy.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* People undergoing treatment for rectal cancer are at high risk for fecal incontinence. Questions about fecal incontinence should be included in any assessment of a patient who has undergone treatment for rectal cancer, even if the primary purpose of their visit is not about incontinence. Moreover, discussion may include the option of an ostomy rather than rectal preservation.
TITLE: Moderate Weight Loss in Obese Women With Urinary Incontinence: A Prospective Longitudinal Study
AUTHORS: Auwad W, Steggles P, Bombieri L, Waterfield M, Wilkin T, Freeman R
SOURCE:International Urogynecology Journal and Pelvic Floor Dysfunction 2008; 19(9):1251-1259
ARTICLE TYPE: Research Report; Prospective Longitudinal Study
DESCRIPTION/RESULTS:
* The authors investigated whether women with urinary incontinence who follow a weight loss program have a reduction in urinary incontinence. Sixty-four women followed an exercise and low calorie diet; some also received Orlistat. Sixty-five percent achieved their weight loss target.
RESULTS:
* Loss of 5% of body weight resulted in a significant reduction in urine loss on pad testing and improved health related quality of life.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* Obesity in an increasingly prevalent condition; weight loss is associated with multiple positive benefits including improvement in urinary incontinence. The findings of this study are encouraging because they infer that loss of a comparatively small proportion of body weight (5%) results in a clinically relevant improvement in urinary incontinence. Nevertheless, many patients may need support and encouragement to adhere to a weight loss and exercise program, and the WOC nurse can be instrumental in referring people and assisting them in making major lifestyle changes.
TITLE: Fibre Supplementation in Addition to Loperamide for Fecal Incontinence in Adults: A Randomized Trial
AUTHORS: Lauti M, Scott D, Thompson-Fawcett MW
SOURCE:Colorectal Disease 2008; 10(6):553-562
ARTICLE TYPE: Research Report; Randomized Controlled Trial
DESCRIPTION/RESULTS:
* The authors compared loperamide plus a fiber dietary supplement to loperamide plus a placebo fiber supplement in patients with fecal incontinence. Sixty-three subjects with fecal incontinence of differing etiologies completed the trial; 59 completed the trial. The low residue diet or fiber supplement (psyllium) along with loperamide resulted in a decrease in fecal incontinence Severity Index scores for both groups but the difference was not significant between groups. Some subjects reported that fiber supplements were very beneficial while others did not find them useful. All subjects received loperamide, which may have affected the results; therefore, we do not know if fiber alone would have assisted in improving some of the subjects.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* This study illustrated that some patients benefit from fiber supplements while other do not. Individual protocols are important in finding the best combination of treatment strategies for patients with fecal incontinence.
TITLE: Current Evidence on Intermittent Catheterization: Sterile Single-Use Catheters or Clean Reused Catheters and the Incidence of UTI
AUTHORS: Getliffe K, Fader M, Allen C, Pinar K, Moore KN
SOURCE:Journal of Wound, Ostomy and Continence Nursing 2007; 34(3):289-296
ARTICLE TYPE: Systematic Literature Review
DESCRIPTION/RESULTS:
* The authors systematically reviewed the literature to determine whether various types of sterile single-use catheters reduce the incidence of urinary tract infections when compared to reused catheters. Fourteen randomized controlled studies met inclusion criteria, including some of which were more than 10 years old. Definitions of urinary tract infection varied, sample sizes were small, and follow-up was typically short.
* No strong evidence to support one method of catheterization method over another was found. However, the current research evidence is limited and further well-designed studies are recommended, considering the current focus on infection control and antibiotic resistance.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* There is insufficient evidence to definitively determine whether single catheter use or reuse of intermittent catheters reduces the incidence of urinary tract infections. The Centers for Medicare & Medicaid Services provides reimbursement for single-use, sterile catheters for patients who experience recurring urinary tract infections. WOC nurses should remain aware of current regulations concerning options for intermittent catheterization and closely consult with a pediatric urologist or specialist when determining the optimal catheter type and technique for individual patients.
TITLE: Relationship Between Catheter Care and Catheter-Associated Urinary Tract Infection at Japanese General Hospitals: A Prospective Observational Study
AUTHORS: Tsuchida T, Makimoto K, Ohsako S, Fujino M, Kaneda M, Miyazaki T, Fujiwara F, Sugimoto T
SOURCE:International Journal of Nursing Studies 2008; 45(3):352-361
ARTICLE TYPE: Research Report; Case Series
DESCRIPTION/RESULTS:
* The authors sought to determine patterns of catheter care and identify risk factors for catheter associated urinary tract infection (CAUTI) associated with routine catheter care. Five hundred fifty-five adult inpatients catheterized for 3 days or more in 5 general hospitals in Japan comprised the sample population. The overall incidence was 3.9 days of urinary tract infection per 1000 days catheterized; 94% of patients experiencing CAUTI had fecal incontinence.
* Use of a pre-connected closed and daily perineal cleansing also reduced the risk of CAUTI. Regular use of these 2 interventions reduced CAUTI risk by 50%.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* Multiple aspects of catheter care have the potential to influence the risk of CAUTI, including regular cleansing of the urethral meatus and selection of a pre-connected, closed urinary drainage system. The association between CAUTI incidence and fecal incontinence is also significant and suggests that prevention, transient or adequate containment of fecal incontinence is needed in patients managed by indwelling urinary catheters in the acute care setting.
TITLE: A Randomized, Multicenter, Placebo-Controlled Trial of Polyethylene Glycol Laxative for Chronic Treatment of Chronic Constipation
AUTHORS: Dipalma JA, Cleveland MV, McGowan J, Herrera JL
SOURCE:The American Journal of Gastroenterology 2007; 102(7):1436-1441
ARTICLE TYPE: Research Report; Randomized Clinical Trial
DESCRIPTION/RESULTS:
* The researchers compared the safety and efficacy of PEG laxative versus placebo in adults with chronic constipation. Three hundred four adults from 50 facilities participated in the trial. Subjects randomized to the treatment group received PEG 17G daily PO. The main outcome measure was a change in ROME scores for constipation. Fifty-two percent of subjects randomized to the PEG laxative vs 11% of placebo subjects improved ROME scores. No differences in diarrhea or flatulence were found when PEG was compared with placebo.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* Constipation is a significant problem among elder patients, especially in long-term care and homebound patients. This study provides evidence that daily treatment with PEG is both safe and effective in adults with chronic constipation. This treatment option is even more accessible since Miralax is now available as an over-the-counter product.
See also Thomson MA, Jenkins HR, Bisset WM, Heuschkel R, Kalra DS, Green MR, Wilson DC, Geraint M. Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double blind, placebo controlled, crossover study. Archives of Disease in Children 2007; 92(11):996-1000
(RCT with 51 children found PEG safe and effective in children with chronic constipation.)
TITLE: Understanding Recent Regulatory Guidelines for Hospital-Acquired Catheter-Related Urinary Tract Infections and Pressure Ulcers
AUTHORS: Hess CT, Rook LJ
SOURCE:Ostomy Wound Management 2007; 53(12):34-42
ARTICLE TYPE: Announcement of Regulatory Change
DESCRIPTION/RESULTS:
* Hospital-acquired urinary tract infection is the most common nosocomial infection, accounting for 40% of all such adverse events. Recent changes in the Centers for Medicare & Medicaid Services (CMS) concerning denial of additional payments for treatment of specific hospital acquired infections including hospital acquired pressure ulcers are well known to WOC nurses practicing in the United States. However, this article reminds us that this changes also applies to hospital-acquired UTI. The authors report that the majority of these infections (66% to 86%) are associated with urinary tract instrumentation, principally the use of indwelling urinary catheters.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* This article serves as a reminder that WOC nurses are an invaluable resource as acute care facilities revise existing policies and implement novel strategies to prevent CAUTI. The January/February and March/ April issues of the Journal of Wound, Ostomy and Continence Nursing include a 2-part Evidence-Based Report Card outlining nursing interventions to reduce CAUTI risk and a CAUTI Fact Sheet from the Society's Continence Care Subcommittee.
TITLE: Outcomes of Urinary and Bowel Function in Myelomeningocele Patients With Augmentation Enterocystoplasty
AUTHORS: Mitsui T, Tanaka H, Moriya K, Matsuda M, Nonomura K
SOURCE:Spinal Cord 2008; 46(6):432-437
ARTICLE TYPE: Research Report; Pre and Post Test Study
DESCRIPTION/RESULTS:
* The study described bowel elimination and voiding function before and 15 months following augmentation enterocystoplasty in a group of 22 subjects with myelomeningocele and neurogenic bladder dysfunction. All subjects underwent ileocystoplasty; 4 also underwent suburethral sling, 4 underwent cecostomy and 2 had ureteral reimplantation. Responses to the International Consultation on Incontinence Questionnaire-Short Form and a bowel function questionnaire demonstrated that 80% of subjects achieved urinary continence, but slightly more than half had persistent or de novo rectal urgency and fecal incontinence. Despite deterioration of bowel function in more than half of subjects, more than 80% reported satisfaction with augmentation enterocystoplasty surgery with respect to overall health related quality of life.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* Patients with myelomeningocele undergoing augmentation enterocystoplasty are at increased risk for persistent or de novo rectal urgency or fecal incontinence. Although the majority of these patients reported satisfaction with surgery despite these outcomes, preoperative teaching and postoperative nursing management should acknowledge this increased risk and provide patients and families with strategies for managing these clinically relevant bowel elimination symptoms.
TITLE: Efficacy, Safety and Tolerability of Fesoterodine for Overactive Bladder Syndrome
AUTHORS: Nitti VW, Dmochowski R, Sand PK, Forst HT, Haag-Molkenteller C, Massow U, Wang J, Brodsky M, Bavendam T
SOURCE:Journal of Urology 2007; 178(6):2488-2494
ARTICLE TYPE: Research Report; Randomized Controlled Trial
DESCRIPTION/RESULTS:
* Fesoterodine is available in the United States as an antimuscarinic agent for the treatment of overactive bladder. The drug acts as a prodrug; it is rapidly metabolized by non-specific esterases to 5HMT (hydroxymethyl tolterodine), which is also the active metabolite for tolterodine. Distinctive from tolterodine, conversion of fesoterodine to its active metabolite bypasses the hepatic CYP pathway. Eight hundred thirty-six subjects with urinary frequency, urgency or urge urinary incontinence were randomized to receive placebo (n = 274), 4 mg of fesoterodine (n = 283) or 8 mg of fesoterodine (n = 279) once daily for a period of 12 weeks. Subjects randomized to 4 or 8 mg of fesoterodine daily had significantly greater reductions in daytime voiding frequency, episodes of urge incontinence and episodes of urgency than subjects randomized to the placebo. The incidence and character of adverse side effects were comparable to other antimuscarinic agents, especially tolterodine.
WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?
* Fesoterodine (Toviaz, Pfizer, New York, NY) offers an additional option of the pharmacologic management of overactive bladder dysfunction in adults. Pharmacotherapy should be combined with behavioral interventions to achieve maximal relief from the lower urinary tract symptoms associated with overactive bladder dysfunction.