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Systematic reviews of bladder training and


voiding programmes in adults: a synopsis of
findings from data analysis and outcomes using
metastudy techniques

ARTICLE in JOURNAL OF ADVANCED NURSING FEBRUARY 2007


Impact Factor: 1.69 DOI: 10.1111/j.1365-2648.2006.04097.x Source: PubMed

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JAN REVIEW PAPER

Systematic reviews of bladder training and voiding programmes in


adults: a synopsis of findings from data analysis and outcomes using
metastudy techniques
Brenda Roe1, Joan Ostaszkiewicz2, Jill Milne3 & Sheila Wallace4

Accepted for publication 31 July 2006

1
Brenda Roe PhD RN RHV FRSH R O E B . , O S T A S Z K I E W I C Z J . , M I L N E J . & W A L L A C E S . ( 2 0 0 7 ) Systematic
Professor of Health Sciences reviews of bladder training and voiding programmes in adults: a synopsis of findings
Faculty of Health and Applied Social from data analysis and outcomes using metastudy techniques. Journal of Advanced
Sciences,
Nursing 57(1), 1531
Liverpool John Moores University,
doi: 10.1111/j.1365-2648.2006.04097.x
Liverpool, UK

2
Joan Ostaszkiewicz MSN RN Abstract
Coordinator Aged Care and Rehabilitation Title. Systematic reviews of bladder training and voiding programmes in adults: a
Nursing Research synopsis of findings from data analysis and outcomes using metastudy techniques
The Peter James Centre, Aim. This paper reports a comparison of the data analysis and outcomes from
Deakin University, four Cochrane systematic reviews on bladder training and voiding programmes
Melbourne, Australia
for the management of urinary incontinence using metastudy descriptive tech-
3 niques to inform clinical practice, generate new ideas and identify future research
Jill Milne PhD RN
Postdoctoral Fellow directions.
School of Nursing, Background. Bladder training is used for cognitively and physically able adults to
University of Alberta, regain continence by increasing the time interval between voids. Prompted void-
Edmonton, Canada ing, habit retraining and timed voiding, collectively known as voiding pro-
grammes, are generally used for people with cognitive and physical impairments
4
Sheila Wallace BSc MSc in institutional settings. Bladder training and voiding programmes feature as
Search Coordinator
common clinical practice for the management of urinary incontinence.
Cochrane Incontinence Reviews Group,
Health Services Research Unit,
Methods. A synopsis of four Cochrane systematic reviews that included rand-
University of Aberdeen, omized controlled trials on bladder training, prompted voiding, habit retraining
Aberdeen, UK and timed voiding was undertaken using metastudy techniques for the synthesis of
qualitative research, and has provided a discursive comparison and contrast of the
Correspondence to Brenda Roe: meta-data analysis and outcomes of these reviews.
e-mail: b.h.roe@ljmu.ac.uk Results. Frequency of incontinence was the most common and constant outcome
measure of effectiveness in the reviews. Limited data were available on other
health outcomes, change in dependency status, quality of life and cost-effective-
ness. The systematic review on bladder training included different types of urinary
incontinence, whereas those on voiding programmes did not differentiate the type
of incontinence. There is evidence on the effectiveness of bladder training but
long-term follow up studies are needed. Evidence on the effectiveness of voiding
programmes is limited and not available for many outcomes.
Conclusion. Future research needs to consider the theory underpinning interven-
tions for bladder training and voiding programmes for urinary incontinence and
should incorporate recognized quality research designs, established outcomes and
long-term follow up. It is unclear whether health outcomes for people with

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 15


B. Roe et al.

comorbidities, cognitive and physical impairments will improve if extensive


diagnostic and assessment investigations are undertaken.

Keywords: bladder training, metastudy, nursing, systematic review, urinary


incontinence, voiding programmes

for bladder training, prompted voiding, habit retraining and


Introduction
timed voiding are available in the reviews themselves, and an
In this paper we present the findings on data analysis and accompanying paper (Roe et al. 2007), which also provides a
outcomes from four Cochrane systematic reviews on bladder synopsis based on meta study techniques for selection and
training, prompted voiding, habit retraining and timed appraisal of primary research, and findings for meta-theory
voiding. Metastudy techniques developed for the synthesis and the meta-methods for the four systematic reviews.
of qualitative research comprise selection and appraisal of Synopses are particularly useful in summarizing research
primary research, meta theory, meta methods and meta data for clinicians, which they would not do for themselves by
analysis (Paterson et al. 2001) and provide a useful method reading directly the Cochrane Reviews, which can each be up
for the synopsis, descriptive comparison and contrast of to 78 pages long (for example, Wallace et al. 2004). This
systematic reviews of randomized controlled trials (RCTs). synopsis using metastudy techniques and the accompanying
These techniques are useful for revisiting the theory under- paper (Roe et al. 2007) has allowed discursive comparison,
pinning interventions, their design, methods and outcomes contrast and summary of the four Cochrane systematic
with a view to generating new ideas for research and future reviews and provides an accessible source for clinicians and
directions for empirical study. The metastudy and findings for researchers. It is a requirement that clinical practice is based
selection and appraisal of primary research, meta theory and upon sound evidence, and these interventions are the main
meta methods of these systematic reviews have been reported behavioural practices used internationally by nurses, as the
in an accompanying paper (Roe et al. 2007). The metastudy basis of every day care for the management of urinary
technique for meta data analysis and the related findings on incontinence.
outcomes are reported in this paper.

The study
Background
Aim
Systematic reviews of RCTs that have investigated the value
of bladder training, prompted voiding, habit retraining and The aim of the study was to provide a synopsis of the findings
timed voiding for the management of urinary incontinence in from meta-data analysis and outcomes from the metastudy of
adults are available in the Cochrane Library (Eustice et al. four Cochrane systematic reviews on behavioural interven-
2002, Ostaszkiewicz et al. 2004a, 2004b, Wallace et al. tions which include, bladder training, prompted voiding,
2004). These behavioural interventions commonly form habit retraining and timed voiding. The purpose was to
bladder re-education strategies and voiding programmes compare and contrast outcomes in relation to the interven-
frequently used by nurses for the management of urinary tions and study designs to inform clinical practice, generate
incontinence in community, clinic and institutional settings new ideas and future directions for research.
(Hadley 1986, Kennedy 1992). The development of these
interventions dates back to the mid to late 1970s with
Methodology
bladder training being the earliest and aimed at people who
are physically and cognitively able (Willington 1975, Frewen Methods for the synthesis of qualitative research are
1978). Habit retraining evolved at a similar time and aimed evolving (Thorne et al. 2004) and a useful framework and
to be delivered by motivated staff to people with cognitive techniques have been developed for metastudy, which allow
and physical disabilities (Clay 1978). Timed voiding (Castl- discursive comparison and contrast (Paterson et al. 2001).
eden & Duffin 1981) and prompted voiding (Hu 1989) are While the four systematic reviews in this paper are
also used for people with cognitive and physical disabilities quantitative research, RCTs in particular, such metastudy
by care staff, and are common in institutional settings techniques allow a useful synopsis to be undertaken. In this
(Hadley 1986, Kennedy 1992). Definitions of the terms used paper, the references to each of the trials and their related

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JAN: REVIEW PAPER Systematic reviews of bladder training and voiding programmes in adults

publications adhere to the Cochrane Library convention of Bladder training


giving a single name and year. Findings on meta-data Of the 10 eligible trials on bladder training, statistically sig-
analysis and outcomes are the focus of this paper. Selection nificant benefits were associated with the intervention on four
and appraisal of primary research, meta-theory and meta- reported outcomes:
method of interventions have been presented elsewhere (Roe number of individuals improved immediately after blad-
et al. 2007). der training for other incontinence (Fantl 1991) with
bladder training compared with no bladder training (45/60
vs. 15/65; Relative Risks (RR) 315; 85% confidence
Meta-data analysis methods
interval (CI),
The meta-data analysis strategy adhered to that developed by number of incontinence episodes for individuals with stress
Paterson et al. (2001) and involved identifying the analysis incontinence immediately after treatment with bladder
methods of the 22 trials that were eligible for inclusion in the training combined with pelvic floor muscle exercises and
four systematic reviews, the development of a filing and biofeedback (n = 42; mean 92; SD 115) compared with
coding system, tabulation, categorization of the data and a pelvic floor muscle exercises and biofeedback alone
discussion and interpretation of the findings. Data were (n = 46, mean 87; SD 100) (pairwise comparison
categorized according to the comparisons that were P = 0003, as reported by trialists) (Wyman 1998),
addressed in the four systematic reviews and the associated number of incontinent episodes for individuals with other
outcomes. Outcomes were grouped as follows: incontinence immediately after treatment with bladder
Frequency of incontinence. training combined with pelvic floor muscle exercises and
Severity of incontinence. biofeedback (n = 16; mean 58; SD 95) compared with
Other objective outcomes. pelvic floor muscle exercises and biofeedback alone
Subjective outcomes. (n = 18; mean 119; SD 127) (pairwise comparison
In addition to examining the reported results within each P = 0003, as reported by trialists) (Wyman 1998),
systematic review, we examined the specific units of measure number of individuals cured of other incontinence
that were used to evaluate outcomes. We report data for immediately after treatment with bladder training com-
those outcomes wherein trialists reported statistically signi- bined with pelvic floor muscle exercises and biofeedback
ficant differences and/or where this was demonstrated in the compared with pelvic floor muscle exercises and biofeed-
relevant systematic review metaview, as well areas where back alone [Weighted Mean Difference (WMD) 249; 95%
there is insufficient data. Where possible, data were com- CI 118 to 526) (Wyman 1998).
bined.
Prompted voiding
Of the six trials included in the systematic review on
Findings
prompted voiding, two reported statistically significant
reductions in the mean number of episodes of incontinence
Frequency of incontinence
per individual for those receiving prompted voiding com-
Methods employed by trialists to calculate the effectiveness of pared with those who did not receive prompted voiding
the intervention on the frequency of incontinence varied (WMD 025; 95% CI 075 to 025) and (WMD 200;
between trials and included measures of: 95% CI 263 to 137) (Hu 1989, Schnelle 1989). These
Number of episodes of incontinence within a defined per- data were pooled to provide a total sample of 257
iod of time (i.e. usually 24-hour duration) measured at participants (Gp 1: 127 Gp 2: 130) which demonstrated
variable point estimates (i.e. at the end of treatment and statistical significance favouring prompted voiding (WMD
3 months later). 093; CI 95% 132 to 053), however it was noted that this
Number of individuals with reductions in the incidence of was largely due to the relatively large estimated effect in the
daytime or night-time incontinence. trial conducted by Schnelle (1989).
Number of individuals with no improvement of wet epi-
sodes. Habit retraining
Number of individuals improved or cured immediately Of the three trials that comprised the systematic review on
after treatment, 3 months later and at a mean of 32 years habit retraining, each reported reductions in the incidence of
follow-up. incontinence from baseline to outcome for individuals in the
Individual and group rates of incontinence (Table 1). treatment groups. Where comparable data were available, no

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 17


B. Roe et al.

Table 1 The frequency of incontinence

Relevant comparison Unit of measure Relevant trial Results Analysis

BT vs. no BT Number of individuals improved Fantl Gp 1: (60) 45 RR 315;


immediately after treatment for (1991) Gp 2: (65) 15 95% CI 198 to 502
other incontinence Statistical significance
favouring BT
Number of individuals cured Gp 1: (60) 7 RR 368;
immediately after treatment Gp 2: (63) 2 95% CI 079 to 1699
for other incontinence
Number of incontinent episodes Gp 1: (45)
per week for stress incontinence mean = 1000 (SD 1200)
at the end of treatment Gp 2: (43)
mean = 1900 (SD 1900)
Number of incontinent episodes Gp 1: (7)
per week for urge incontinence mean = 500 (SD 600)
at the end of treatment Gp 2: (7)
mean = 1800 (SD 1400)
Number of incontinent episodes Gp 1: (8)
per week for mixed incontinence mean = 700 (SD 800)
at the end of treatment Gp 2: (12)
mean = 2000 (SD 1200)
BT vs. other treatment Number of incontinent episodes for Wyman Gp 1: (46)
(i.e. behavioural, stress incontinence immediately after (1998) mean = 125 (SD 83)
physical or treatment ended Gp 2: (48)
psychological) mean = 87 (SD 1000)
Number of incontinent episodes for Gp 1: (19)
other incontinence immediately after mean = 62 (SD 91)
treatment ended Gp 2: (18)
mean = 119 (SD 127)
Number of incontinent episodes for Gp 1: (62)
other incontinence 3 months after mean = 100 (SD 120)
the end of treatment Gp 2: (65)
mean = 94 (SD 140)
Number of individuals cured of other Gp 1: (68) 12 RR 141
incontinence immediately after Gp 2: (64) 8 95% CI 062 to 323
treatment
Number of individuals cured of other Gp 1: (62) 10 RR 081
incontinence at 3 months Gp 2: (65) 13 95% CI 038 to 170
Number of individuals cured of other Gp 1: (45) 4 RR 462
incontinence at a mean 32 years Gp 2: (52) 1 95% CI 054 to 3987
follow-up
BT another treatment Number of incontinent episodes Wyman Gp 1: (42) The authors reported
(i.e. PFMT biofeedback) for stress incontinence immediately (1998) mean = 92 (SD 115) statistical significance
vs. that other treatment after treatment ended Gp 2: (46) favouring BT PFMT
alone mean = 87 (SD 100) biofeedback (P = 0003)
Number of incontinent episodes Gp 1: (16) The authors reported
for other incontinence immediately mean = 58 (SD 95) statistical significance
after treatment ended Gp 2: (18) favouring BT PFMT
mean = 119 (SD 127) biofeedback (P = 0003)
Number of incontinent episodes Gp 1: missing data This data could not be
for other incontinence 3 months Gp 2: (65) used in the standard
after the end of treatment mean = 94 (SD 140) metaview analysis due to
missing data

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JAN: REVIEW PAPER Systematic reviews of bladder training and voiding programmes in adults

Table 1 (Continued)

Relevant comparison Unit of measure Relevant trial Results Analysis

Number of individuals cured Gp 1: (19) 61 WMD 249;


of other incontinence Gp 2: (8) 64 95% CI 118 to 526
immediately after treatment Statistical significance
favouring BT
PFMT biofeedback
Number of individuals cured Gp 1: (60) 16 RR 133;
of other incontinence Gp 2: (65) 13 95% CI 070 to 253
at 3 months
Number of individuals cured Gp 1: (48) 8 RR 867;
at a mean 32 years follow-up Gp 2: (52) 1 95% CI 113 to 6675
PV vs. no PV Mean number of episodes Hu (1989) Gp 1: (64) Pooled data
of incontinence per mean = 165 (SD 161) WMD 093;
individual per 24 hours Gp 2: (67) CI 95% 132 to 053
mean = 190 (SD 129) Total sample
WMD 025; 95% Gp 1: 127
CI 075 to 025 Gp 2: 130
Schnelle (1989) Gp 1: (63) Statistical significance
mean = 210 (SD 160) favouring PV
Gp 2: (63)
mean = 410 (SD 200)
WMD 200; 95%
CI 263 to 137
Number of individuals Hu (1989) Gp 1: (65) 17 Pooled data
with no improvement Gp 2: (68) 24 OR 059; 95%
of wet episodes OR 065: 95% CI 031 to 114
CI 031 to 136 Total sample
Schnelle (1983) Gp 1: (11) 2 Gp 1: (82)
Gp 2: (10) 3 Gp 2: (84)
OR 054; 95% Favouring PV
CI 008 to 383 but not statistically
Surdy (1992) Gp 1: (6) 1 significant
Gp 2: (6) 3
OR 025; 95%
CI 003 to 252
PV other vs. Mean number of Ouslander Treatment mean = This data could not be
PV alone episodes of incontinence (1995) 66 (SD 37) vs. 77 used in the standard
(i.e. oxybutynin) (SD 37) metaview tables as it was
reported at the end of the
study period and not given
separately for the first phase
Number of wet checks Treatment This data could not be used
percentage = in the standard metaview
20% (SD 11) vs. tables as it was reported
24% (SD 11) at the end of the study
period and not given
separately for the first phase
HT other vs. usual care Mean number episodes Colling Gp 1: (51) This data could not be
of incontinence (1992) mean = 45 used in the standard
(SD missing data) metaview tables due to
Gp 2: (37) missing data
mean = 55
(SD missing data)

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 19


B. Roe et al.

Table 1 (Continued)

Relevant comparison Unit of measure Relevant trial Results Analysis

Mean number of episodes Colling (2003) Gp 1: (32) WMD 022;


of incontinence mean = 400 (SD 263) 95% CI 032 to 075
Gp 2: (24)
mean = 343 (SD 259)
Jirovec & Templin Treatment Gps 1 & 2: (44) WMD 038;
(2001) mean = 037 (SD 028) 95% CI 085 to 009
Control Gp: (30)
mean = 049 (SD 036)
TV other vs. Number of individuals with Tobin & Gp 1: (102) 40 RR 134;
usual care reductions in the frequency Brocklehurst (1986) Gp 2: (89) 26 95% CI 090 to 201
of daytime incontinence
Number of individuals with Gp 1: (95) 39 RR 180;
reductions in the frequency Gp 2: (79) 18 95% CI 112 to 289
of night-time incontinence
Individual rates of Smith (1992) End of phase 3 This data could not be
incontinence Gp 1: (Gp size not stated) used in the standard
38% metaview analysis
Gp 2: (Gp size not stated) due to missing data
missing data
Group rates of incontinence End of phase 3 This data could not be
Gp 1: (Gp size not stated) used in the standard
21% metaview analysis
Gp 2: (Gp size not stated) due to missing data
85%

PFMT, pelvic floor muscle exercise training; BT, bladder training; PV, prompted voiding; TV, timed voiding.

statistically significant between group differences were noted treatment group compared with the control group (RR 180;
on this outcome. 95% CI 112 to 289) (Tobin & Brocklehurst 1986).

Timed voiding
Severity of incontinence
Outcome data that could be used in a meta-view were
available for one of the two trials included in the systematic Severity of incontinence was calculated as an outcome
review on timed voiding. There was a statistically significant measure by three trials (Colling et al. 1992, 2003, Tobin &
increase in the number of individuals with reductions in the Brocklehurst 1986) (Table 2). Two of these trials described a
frequency of night-time incontinence for individuals in the habit retraining protocol (Colling et al. 1992, 2003) whilst the

Table 2 The severity of incontinence

Relevant comparisons Unit of measure Relevant trial Results Analysis

HT other vs. Mean volume of incontinence Colling (1992) Gp 1: (51) This data could not be
usual care per individual per 24 hours mean = 600 cc (SD missing data) used in the standard
based on pad weighing Gp 2: (37) metaview analysis
mean = 650 cc (SD missing data) due to missing data
Colling (2003) Gp 1: (32) WMD 045;
mean = 292 cc (SD 202 cc) 95% CI 008 to 099
Gp 2: (24)
mean = 193 cc (SD 233 cc)
TV other vs. Number of individuals with Tobin & Gp 1: (65) 16 RR 101;
usual care improvement in volume of Brocklehurst Gp 2: (45) 11 95% CI 052 to 196
incontinence based on pad (1986)
weighing

TV, timed voiding; cc, cubic centimetres.

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JAN: REVIEW PAPER Systematic reviews of bladder training and voiding programmes in adults

other focused on timed voiding (Tobin & Brocklehurst 1986).


Health measures
Outcome data were based on the mean volume of incon-
tinence per individual and/or the number of individuals with Adverse drug effects
reductions in the volume of incontinence. Where comparable Data were available on this outcome from two of the 10 trials
data were available, no statistically significant between group on bladder training (Jarvis 1981, Colombo et al. 1995), and
differences were noted on this outcome (Table 2). from one trial on prompted voiding (Ouslander et al.
1995)(Table 3). Colombo et al. (1995) reported a statistically
significant number of participants who experienced adverse
Other objective outcomes
events as a consequence of oxybutynin compared with
Other objective outcomes that were reported included, self- bladder training alone (RR 003; 95% CI 000 to 044). Jarvis
initiated requests for toileting, the frequency of voiding, (1981) also reported a higher number of patients experien-
health measures (adverse drug effects, altered skin integrity, cing adverse events in the group receiving medication (i.e.
urinary tract infection) and health economic measures (cost flavoxate hydrochloride 200 mg, three times a day
of implementation and cost savings) (Table 3). (TDS) imipramine 25 mg TDS) compared with bladder
training alone, however this difference did not reach statis-
tical significance (RR 003; 95% CI 000 to 055) (Table 3).
Self-initiated request for toileting
In the single trial on the effects of oxybutynin in prompted
Whilst this outcome was evaluated for each eligible trial on voiding, the top three side effects noted were dry mouth
prompted voiding (Schnelle 1983, Hu 1989, Schnelle 1989, (n = 22 active and n = 19 placebo), constipation (n = 16
Surdy 1992, Ouslander et al. 1995), outcome data were active and n = 13 placebo) and incomplete bladder emptying
limited to one trial (Schnelle 1989). This reported a statis- (n = 14 active and n = 16 placebo) (Ouslander et al. 1995).
tically significantly higher number of self-initiated requests Two participants dropped out due to urinary retention. The
for toileting for the group exposed to prompted voiding trialists concluded that oxybutynin does not add to the
compared with the group that did not receive prompted clinical effectiveness of prompted voiding in the majority of
voiding (OR 190: 95% CI 151 to 229) (Table 3). nursing home residents with urge type urinary incontinence
although some individuals may be more responsive to
prompted voiding whilst on this drug (Ouslander et al.
Frequency of voiding
1995) (Table 3).
Evaluation of the frequency of voiding was limited to three
trials that focused on bladder training (Jarvis 1981, Fantl Altered skin integrity
1991, Colombo et al. 1995). Measures used to determine the The incidence of skin rash and skin breakdown was evaluated
effectiveness of the intervention included (a) the number of by one trial of habit retraining (Colling et al. 2003) (Table 3).
day-time and night-time micturitions per week for stress Research staff conducted tests using the Oregon Health Sci-
incontinence, and for other incontinence immediately ences University skin breakdown and rashes evaluation tool
following treatment and (b) the number of individuals cured at weeks 3, 6, 9 and 12. The trialists reported significant
of daytime and night-time urinary frequency. Data were within group decreases in incidence of skin rash and skin
based on self-completed urinary diaries in two of the three breakdown associated with treatment. No further analysis
trials. Between-group data were available for eight outcomes could be applied to the data presented (Table 3).
and three of these supported a statistically significant differ-
ence in favour of bladder training: Urinary tract infection
An increase in the number of individuals cured of daytime Baseline screening for and treatment of urinary tract infection
frequency with bladder training compared with oxybuty- were consistent features of trials within each of the reviews.
nin (RR 123 95% CI 083 to 181) (Colombo et al. 1995). One trial on habit retraining further evaluated the incidence
An increase in the number of individuals cured of night-time of urinary tract infection as an outcome (Colling et al. 2003)
frequency with bladder training compared with oxybutynin (Table 3). Research staff collected clean-catch specimens of
(RR 224 95% CI 080 to 630) (Colombo et al. 1995). urine at weeks 3, 6, 9 and 12, and sent them for culture and
An increase in the number of individuals cured of daytime sensitivity if positive on dipstick. The trialist reported that
frequency with bladder training combined with flavoxate there were no statistically significant differences. No further
hydrochloride 200 mg TDS imipramine 25 mg TDS analysis could be applied to the type of data presented
(RR 256; 95% CI 128 to 513) (Jarvis 1981) (Table 3). (Table 3).

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 21


B. Roe et al.

Table 3 Other objective outcomes

Objective outcomes Relevant comparisons Unit of measure Relevant trial Results Analysis

Self-initiated PV vs. no PV Number of Hu (1989, 1990) Gp 1: (65) This data could not
requests for self-initiated mean = 265 be used in the standard
toileting requests for (SD missing data) metaview analysis due
toileting vs. Gp 2: (68) to missing data
caregiver mean = 112
initiated toileting (SD missing data)
Schnelle (1983) Gp 1: (11) This data could not
mean = 200 be used in the standard
(SD missing data) metaview analysis due
Gp 2: (10) to missing data
mean = 023
(SD missing data)
Schnelle (1989, Gp 1: (63) Statistical
1990) mean = 270 significance
(SD 120) favouring PV
Gp 2: (63) OR 190: 95% CI 151
mean = 080 to 229
(SD 100)
Percentage of Surdy (1992) F (1, 7) = 1026, This data could not
independent P = 001 be used in the standard
requests for metaview analysis due
toileting to missing data
PV other vs. Number of Ouslander Treatment This data could not be
PV alone self-initiated (1995) mean = 06 used in the standard
(i.e. oxybutynin) requests for (SD 15) vs. metaview tables as it
toileting vs. 05 (SD 10) was reported at the end
caregiver initiated of the study period and
toileting not given separately for
the first phase
The frequency of BT vs. no BT Number of daytime Fantl (1991) Gp 1: (45) WMD 500; 95% CI
voiding micturitions per mean = 51 1179 to 179
week immediately (SD 1100)
after treatment for Gp 2: (43)
stress incontinence mean = 56
(SD 2000)
Number of Gp 1: (45) WMD 300; 95% CI
night-time mean = 500 514 to 086
micturitions per (SD 400)
week immediately Gp 2: (43)
after treatment for mean = 800
stress incontinence (SD 600)
Number of day-time Gp 1: (15) WMD 400; 95% CI
micturitions per mean = 5600 2238 to 1438
week immediately (SD 2000)
after treatment for Gp 2: (20)
other incontinence mean = 6000
(SD 3500)
Number of Gp 1: (15) WMD 100; 95% CI
night-time mean = 800 569 to 369
micturitions per (SD 700)
week immediately Gp 2: (20)
after treatment for mean = 900
other incontinence (SD 700)

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Table 3 (Continued)

Objective outcomes Relevant comparisons Unit of measure Relevant trial Results Analysis

BT vs. other Number of individuals Colombo Gp 1: (29) 20 RR 123 95% CI


treatment cured of daytime (1995) Gp 2: (32) 18 083 to 181
(i.e. oxybutynin) frequency
Number of individuals Gp 1: (18) 11 RR 224 95% CI
cured of night-time Gp 2: (11) 3 080 to 630
frequency
BT vs. other Number of individuals Jarvis (1981) Gp 1: (21) 17 RR 256; 95% CI
treatment (i.e. cured of daytime Gp 2: (19) 6 128 to 513
Flavoxate frequency Statistical
hydrochloride significance
200 mg TDS favouring BT
Imipramine
25 mg TDS)
Number of individuals Gp 1 (25) 19 RR 146; 95% CI
cured of night-time Gp 2: (25) 15 094 to 226
frequency
Health measures: BT vs. other Number of Colombo (1995) Gp 1: (37) 0 RR 003; 95% CI
adverse drug effects treatment individuals Gp 2: (39) 18 000 to 044
(i.e. oxybutynin) experiencing side Statistically
effects significance
favouring BT
BT vs. other treatment Jarvis (1981) Gp 1: (25) 0 RR 003; 95% CI
(i.e. Flavoxate Gp 2: (25) 14 000 to 055
Hydrochloride
200 mg
TDS Imipramine
25 mg TDS)
PV other vs. PV Ouslander (1995) Treatment with drug No further analysis
alone dry mouth n = could be applied to
(i.e. oxybutynin) 22 vs. 19, constipation this data
n = 16 vs. 13,
incomplete bladder
emptying n = 14 vs. 16
Skin integrity HT other vs. Incidence of skin Colling (2003) Author reported No further analysis
usual care rash & skin significant within could be applied to
breakdown group decrease in inci- this data
dence of skin rash and
skin breakdown asso-
ciated with treatment
Urinary tract HT other vs. Incidence of urinary Colling (2003) No significant No further analysis
infections usual care tract infections difference reported. could be applied to
this data
Health economic PV vs. no PV Average dollar cost Surdy (1992) $US 851 per patient No further analysis
measures: cost of implementing and reductions in other could be applied to
implementation/ intervention costs to value of $US this data
cost saving 2357
Average reduction in Hu (1989) Equal to one hour of
dollars per person time per patient per
based on 1 episode day
of incontinence
HT other vs. Average dollar cost Colling (2003) $US 23000 per
usual care savings based on a person per year
reduction of one incon-
tinent episode per day

BT, bladder training; PV, prompted voiding.

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 23


B. Roe et al.

used to assess subjective outcomes in the review on bladder


Health economic measures
training were designed for self-completion whilst the instru-
Cost of implementation/cost savings ments used in the trial on habit retraining were targeted to
The costs of implementing and/or the cost savings associated community-based home caregivers.
with interventions were reported by two trials for prompted Fantl (1991) reported statistically significant improve-
voiding (Hu 1989, Surdy 1992) and one trial for habit ments in the QOL score for participants with other
retraining (Colling et al. 2003) (Table 3). Both Hu (1989) and incontinence in the bladder training group compared with
Surdy (1992) included labour and supply costs. Hu (1989) controls. The only other trial that demonstrated a statisti-
additionally undertook time and motion recordings of care cally significant result on subjective outcomes related to
and training activities. This was supported further by inter- satisfaction immediately after treatment (Wyman 1998).
rater reliability testing. On this basis Hu (1989) reported that Data favoured the control group which received pelvic floor
prompted voiding was reported to be equal to the cost of muscle exercises and biofeedback compared with bladder
1 hour of staff time per patient per day. Surdy (1992) esti- training alone (RR 082; 95% CI 069 to 097). The
mated the cost at $US 851 per patient however this was reviewer noted that this difference was not sustained at
offset by a cost saving of $US 2357 per patient. Based on a 3 months (Table 4).
single trial (Colling et al. 2003), the average cost savings Data reported on caregiver perception of burden/stress and
associated with habit retraining in a community based home preparedness for caregiving were suggestive of an improve-
environment, were $US 23000 per person per year. Factors ment for participants in the intervention phase however no
that were considered in this calculation were confined to the further analyses could be applied to these data (Colling et al.
cost of supplies. Because of the nature of the data presented 2003). Similarly, further analysis on the level of behavioural
on this outcome, no further analyses could be undertaken capability was unable to be performed on the type of data
(Table 3). presented (Table 4).

Subjective outcomes Discussion


Subjective outcomes that were evaluated were: (a) partici- As reported in each of the relevant systematic reviews, the
pants perception of improvement or cure of urge incontin- analysis of results from each systematic review was limited by
ence, (b) participants perception of improvement of other a lack of comparable data and by variability in the quality of
incontinence, (c) quality of life (QOL) of participants with available data. Similarly, the diversity of protocols and
genuine stress incontinence, (d) quality of life of participants methods (Roe et al. 2007) meant that combining data of
with other incontinence, (e) number of individuals with similar outcomes was not undertaken. Comparison across
other incontinence who were satisfied, (e) caregivers reviews is cautioned on the basis of differences between
perception of burden/stress and (f) level of behavioural population groups in terms of their age, residential status and
capability (Table 4). Data collection instruments were: health status and continence status. The limited data that
The Incontinence Impact Questionnaire (Fantl 1991, were available, however, highlight a number of pertinent
Wyman 1998). issues for further consideration.
The Urogenital Distress Inventory (Wyman 1998). It is noteworthy that the review on bladder training
The Center for Epidemiological Studies Depression Scale differed from those on systematic voiding programmes in
(Wyman 1998). that data were stratified for the four main diagnostic
Visual Analogue Scales (Fantl 1991, Wyman 1998). groupings of urge incontinence, genuine stress incontinence,
An Economic Burden Scale (Colling et al. 2003). mixed urinary incontinence and other incontinence. This
A Global Role Strain Scale (Colling et al. 2003). differentiation was not evident in trials on prompted voiding,
A Preparedness for Caregiving Scale (Colling et al. 2003). habit retraining and timed voiding with the exception of
The Hadley, Wood, McCracken (HWM) Behavioral timed voiding for individuals with urge incontinence (Tobin
Capabilities Scale for Older Adults (Colling et al. 2003). & Brocklehurst 1986). Whilst arguably, choice of appro-
Data on the perceptions of participants and QOL param- priate management is limited in the absence of an appropriate
eters were available in five trials on bladder training (Jarvis diagnosis, experts debate the extent to which intensive
1981, Fantl 1991, Colombo et al. 1995, Lagro-Janssen 1992, assessment and diagnostic investigations will improve the
Wyman 1998) and in one trial on habit retraining (Colling health outcomes and QOL of individuals with comorbidities
et al. 2003) (Table 4). Data collection instruments that were and impairments, and urodynamic investigations are not

24  2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd


JAN: REVIEW PAPER Systematic reviews of bladder training and voiding programmes in adults

Table 4 Subjective measures

Relevant comparisons Unit of measure Relevant trial Results Analysis

BT vs. no BT Participants perception of Lagro-Janssen Gp 1: (9) 8 RR 1700; 95% CI


improvement of urge incontin- (1992) Gp 2: (9) 0 113 to 25656
ence at 2 months
Participants perception of cure of Lagro-Janssen Gp 1: (9) 1 RR 300; 95% CI
urge incontinence at 2 months (1992) Gp 2: (9) 0 014 to 6516
QOL for participants with other Fantl, 1991 Gp 1: (39) mean = 025 Authors reported a
incontinence (SD 029) significant difference
Gp 2: (39) mean = 050 in QOL favouring
(SD 059) BT group
BT vs. other treatment Participants perception of cure of Colombo (1995) Gp 1: (37) 27 RR 099; 95% CI
(i.e. oxybutynin) urge incontinence at the end of Gp 2: (38) 28 075 to 130
treatment
Participants perception of cure of Gp 1: (27) 26 RR 160; 95% CI
urge incontinence 6 months after Gp 2: (28) 16 121 to 234
treatment ended
Participants perception of Gp 1: (37) 34 RR 113; 95% CI
improvement at the end of treat- Gp 2: (38) 31 094 to 135
ment
BT vs. other treatment Participants perception of cure of Jarvis (1981) Gp 1: (25) 21 RR 150; 95% CI
(i.e. flavoxate hydro- urge incontinence at the end of Gp 2 (25) 14) 102 to 221
chloride 200 mg treatment phase
TDS Imipramine Participants perception of cure of Gp 1: (25) 21 RR 150 95% CI
25 mg TDS) urge incontinence 2 months after Gp 2: (25) 14 102 to 221
treatment ended
BT vs. other treatment QOL of participants with GSI at Wyman (1998) Gp 1: (47) WMD 1800; 95%
(i.e. behavioural, the end of treatment Gp 2: (45) CI 138 to 3737
physical or Participants perception of Gp 1: (66) 43 RR 086; 95% CI
psychological) improvement of other incontin- Gp 2: (63) 48 068 to 107
ence at the end of treatment
Participants perception of Gp 1: (60) 37 RR 088; 95% CI
improvement of other incontin- Gp 2: (64) 45 068 to 113
ence 3 months after treatment
ended
QOL of participants with other Gp 1: (20) WMD -2800;
incontinence at the end of Gp 2: (18) 95% CI 6839 to
treatment 1239
QOL of participants with other Gp 1: (60) WMD 680; 95% CI
incontinence 3 months after the Gp 2: (64) 1223 to 2563
end of treatment
Number of individuals satisfied Gp 1: (66) 48 RR 082; 95% CI
immediately after treatment Gp 2: (63) 56 069 to 097 Statisti-
ended for other incontinence cally signifi-
cance  favouring
PFMT biofeed-
back
Number of individuals satisfied Gp 1: (60) 47 RR 095; 95% CI
2 months after treatment ended Gp 2: (64) 53 080 to 113
for other incontinence
BT another treatment QOL of participants with GSI at Wyman (1998) Gp 1: (44) mean WMD 1800; 95%
(i.e. PFMT biofeed- the end of treatment score = 6320 (SD 4920) CI 3658058
back) vs. that other Gp 2: (45)
treatment alone mean = 8120 (SD
3960)

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 25


B. Roe et al.

Table 4 (Continued)

Relevant comparisons Unit of measure Relevant trial Results Analysis

Participants perception of Gp 1: (61) 55 RR 118; 95% CI


improvement of other incontin- Gp 2: (63) 43 101 to 139
ence at the end of treatment
Participants perception Gp 1: (58) 44 RR 108; 95% CI
of improvement of other incon- Gp 2: (64) 45 087 to 134
tinence 3 months after treatment
ended
QOL of participants Gp 1: (17) WMD 4720; 95%
with other incontinence at the mean = 6760 (SD CI 8703 to 737
end of treatment 4850)
Gp 2: (18)
mean = 11480 (SD
7030)
QOL of participants Gp 1: (58) WMD 1220; 95%
with other incontinence mean = 7280 (SD CI 3045 to 605
3 months after the end of treat- 5040)
ment Gp 2: (64)
mean = 8500
(SD = 5240)
Number of individuals Gp 1: (61) 57 RR 105; 95% CI
satisfied immediately after treat- Gp 2: (63) 56 094 to 117
ment for other incontinence
Number of individuals Gp 1: (58) 51 RR 106; 95% CI
satisfied 2 months after treatment Gp 2: (64) 53 092 to 123
for other incontinence
HT other vs. usual Caregivers perception of burden/ Colling (2003) Caregivers involved in No further analysis
care stress HT reported less stress could be applied to
at outcome this data
Level of behavioural capability No significant changes No further analysis
reported could be applied to
this data

PFMT, pelvic floor muscle exercise training; QOL, quality of life; GSI, genuine stress incontinence; BT, bladder training.

recommended for the frail elderly (Fonda et al. 2005). Tobin offered increased opportunity for toileting assistance and
and Brocklehurst (1986) reported that in a sample of 278 favourable reinforcement for continence (Schnelle 1990). If
older adults, 78% of whom had cognitive impairment, only the value of systematic voiding programmes pertains to the
three individuals were recommended for urodynamic proce- fact that they provide individuals with otherwise limited
dures and this was determined on the basis that the result was toileting opportunities, then clearly, there is little need for
likely to affect management and thus, be of direct benefit to intensive assessment procedures to identify the aetiological
that individual. type of incontinence.
At this stage, on the basis of the limited data, it is unclear if The most common and consistent measure of effectiveness
certain types of incontinence are more responsive to system- was the frequency of incontinence. Although there were four
atic voiding programmes or if the value of these programmes statistically significant measures that favoured bladder train-
lies in none other than the fact that they provide dependent ing compared with two trials with statistically significant
individuals with regular voiding opportunities. This propo- results in favour of prompted voiding, none on habit
sition is not without precedence as other research has retraining and one on timed voiding, it would be simplistic
identified immediate improvements associated with the at the very least to suggest that bladder training is more
introduction of a prompted voiding protocol (Schnelle effective than systematic voiding programmes. At the same
1990). This observation led Schnelle to hypothesize that time, based on the sample of 1366 participants from 10
responders were not developing new skills related to contin- trials, the body of evidence on bladder training is greater
ence, instead they were responding to an environment that than that on prompted voiding (n = 479, 6 trials), habit

26  2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd


JAN: REVIEW PAPER Systematic reviews of bladder training and voiding programmes in adults

retraining (n = 337, 3 trials) and timed voiding (n = 298, 2 these types of outcomes are related to supportive contact
trials). from researchers compared with the intervention itself.
Another measure of effectiveness was the frequency of An important comparison that has not been addressed to
voiding; however, this was limited to the review on bladder date is that of prompted voiding compared with either habit
training. This is consistent with the aim of bladder training, retraining or timed voiding or both. In the absence of this
which is targeted to individuals with an overactive bladder, research it remains unclear which, if any, of the various types
urgency and/or urge incontinence and urinary frequency. of systematic voiding programmes are most effective and how
In terms of health outcomes, data were confined to the clinicians should choose between the three types. A lack of
incidence of adverse drug effects, skin breakdown and rash outcome data also means that there is a lack of clarity about
and/or urinary tract infection although no further analysis the optimal methods for assessment, implementation and
could be applied to these data. Other health factors that evaluation. As noted previously, prompted voiding assess-
could be considered in future trials could include; changes in ment and evaluation procedures represent a function of the
bladder capacity and post void residual volume. The first of intervention itself. These procedures involve intensive and
these two conditions is particularly relevant for individuals arguably, intrusive contact with individuals. Two trials on
undergoing bladder training. Assessment of a post void habit retraining described the concurrent use of an electronic
residual is particularly relevant for individuals with poor data logger to obtain accurate data on individuals voiding
mobility and for those who often rely on another person for patterns thus mitigating some of the resource and privacy
toileting assistance. issues associated with hourly or two hourly wet checks
The review on prompted voiding reported on three trials conducted by other individuals.
(Schnelle 1983, 1989, Hu 1989) that evaluated the number More trials were included in the bladder training system-
of self initiated requests for toileting. This is consistent with atic review and there was an attempt to establish its
the aim of prompted voiding which uses positive reinforce- effectiveness for specific types of incontinence, while the
ment in an effort to increase individuals ability to discrim- other systematic reviews lumped all urinary incontinence
inate their continence status and initiate toileting. Whilst together and did not differentiate between conditions. It is of
individuals enrolled in the reviews on habit retraining and note that the more recent trials on bladder training, since the
timed voiding were similarly dependent, there was no 1990s have more complex RCT designs (Fantl 1991, Wyman
strategic effort made to alter this dependence. Instead, 1998 compared with Jarvis 1981). Such trials involve a
efforts were directed toward accommodating this depend- number of arms or interventions that have a cross over
ence by identifying and mimicking the individuals unique element over time. They also combine a number of therapies
voiding pattern (habit retraining) or providing regular and which reflects custom and clinical practice, but can ulti-
systematic voiding opportunities at times that are based on mately tease out the effectiveness of an individual therapy
the notion of a rhythmic bladder storage/voiding cycle under test, in this case bladder training. Based on the findings
(timed voiding). and outcomes of Wyman (1998) combining therapies of
Cost data were evaluated by two trials on prompted voiding bladder training, pelvic floor muscle exercise training and
(Hu 1989, Surdy 1992) and one trial on habit retraining biofeedback was statistically significantly more effective
(Colling et al. 2003). It is noteworthy that the cost data on compared with PFMT and biofeedback alone, for stress
prompted voiding are now more than 10 years old. No cost incontinence and other incontinence at the end of the
data were available for bladder training or for timed voiding. intervention. Trial designs and methods are evolving and are
Evaluations of individuals perception of cure or improve- becoming more complex combining therapies for both urge
ment were limited to the review on bladder training. Again, and stress incontinence. These developments in design and
this may relate to the higher cognitive status of individuals methods need to be considered when designing future studies.
involved in trials on bladder training compared to those who A further observation from this metastudy was that none of
were enrolled in trials on systematic voiding programmes. the trials in the systematic reviews undertook long-term
Nevertheless, given the necessity for caregivers (i.e. either follow up of patients included in the studies to establish
informal or formal) to implement voiding programmes, their benefits over time which again requires more complex study
perceptions, morale and QOL are of paramount importance. designs, methods and incurs considerable expenses. However,
The one trial that evaluated this outcome in caregivers of such long-term follow up of cohorts are required if we want
community-dwelling and cognitively impaired older adults to not only explore the effectiveness of current and future
stated that caregivers were less stressed at outcome (Colling interventions and treatments but also to study prevention of
et al. 2003). It is also important to know the extent to which incontinence over the life course.

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 27


B. Roe et al.

complex designs than those from the 1970s and 1980s, with
What is already known about this topic greater emphasis on quality, power calculations, sample size,
Systematic reviews on bladder training, prompted blinding and intention-to-treat analysis (MRC 1998). Meth-
voiding, habit retraining and timed voiding are avail- ods for the systematic review of research evidence are also
able in the Cochrane Library. evolving with synthesis and meta-analysis of quantitative
There is evidence that bladder training is effective for research, notably RCTs (Egger et al. 2005), being electron-
the management of urinary incontinence in adults and ically disseminated via the Cochrane Library. Systematic
suggestive evidence for the use of prompted voiding. review, metastudy, metasynthesis or integration of qualitative
There is insufficient evidence to support habit retraining research evidence are also evolving and methods being
or timed voiding, despite timed voiding, in particular, developed (Thorne et al. 2004, Whittemore & Knafl 2005),
being common custom and practice for the management although there is not a specific electronic library for their
of urinary incontinence in people with cognitive and dissemination. The challenge is now to systematically review
physical impairments. and integrate evidence from quantitative and qualitative
research, which The Joanna Briggs Foundation (2005) is
pioneering. Synopses of systematic reviews across related
What this paper adds subjects, diagnostic categories and groups of patients, such as
It is unclear whether diagnostic and assessment inves- those with long-term conditions, for example, of quantitative
tigations for urinary incontinence will improve health evidence, qualitative evidence or those integrating both
outcomes for people with comorbidities, cognitive and quantitative and qualitative evidence are warranted. This
physical impairments. study has provided a synopsis of systematic reviews of four
Frequency of urinary incontinence is the most com- main behavioural interventions used by nurses for the
monly cited outcome measure in randomized controlled management of urinary incontinence. The individual reviews
trials on bladder training and voiding programmes, but took nearly 10 years to be completed and published and are
limited or no data are available on other health out- in the process of being added to and updated, which is a
comes, change in dependency status, quality of life or requirement of the Cochrane Collaboration and Library.
cost effectiveness. None of these reviews received external funding, which is an
The theory under-pinning bladder training and voiding important consideration for future systematic reviews irres-
programmes for the management of urinary incontin- pective of the types of evidence being synthesized and
ence, the research design and interventions, outcomes integrated. The metastudy framework and techniques while
and long-term follow up need to be considered in future developed for review of qualitative studies, provides a useful
research. methodology for the descriptive comparison and contrast of
systematic reviews of quantitative evidence.

It is a requirement that nurses, along with other healthcare


Conclusion
professionals base their clinical practice on established
evidence of effectiveness (Closs & Cheater 1999, Roe & The number of trials included in the systematic reviews and
Moore 2000). This synopsis using metastudy techniques has evidence on the effectiveness of voiding programmes, in
synthesized the current evidence on theory, methods, analysis particular, is very limited. There is evidence that bladder
and outcomes of the four main behavioural interventions, training is effective for the management of urinary incontin-
bladder training, prompted voiding, habit retraining and ence in adults and is recommended for clinical practice,
timed voiding, used by nurses for the management of urinary although long-term follow up studies are required. Bladder
incontinence which is easily accessible to inform their clinical training has also been combined with pelvic floor muscle
practice, as well as identifying gaps where future research exercises and other cognitive and lifestyle modification
endeavours should be targeted to advance clinical practice. techniques and so combination interventions need to be
This synopsis also contributes to the dissemination of studied in future research for the management of urinary
evidence to its target audience of international nurses who incontinence. There is limited evidence on the effectiveness of
may not have access to or the time to read individual prompted voiding for adults reliant on carers to avoid
Cochrane systematic reviews. incontinence and studies, which include follow up are
As discussed above, trial designs and methods are evolving required. The systematic review on bladder training included
with more recent trials combining therapies and having more different types of urinary incontinence that were stratified

28  2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd


JAN: REVIEW PAPER Systematic reviews of bladder training and voiding programmes in adults

whereas those on voiding programmes made no attempt to subsequent papers and publications arising from the original
accurately diagnose the type of incontinence and may reflect trial included under that author and date.
that patients had limited cognitive and physical abilities as
Castleden C.M. & Duffin H.M. (1981) Guidelines for controlling
well as clinical custom and practice. It is unknown whether urinary incontinence without drugs or catheters. Age and Ageing
intensive diagnostic and assessment investigations will 10, 186190.
improve health outcomes or people with comorbidities and Clay E.C. (1978) Incontinence of urine: a regimen for retraining.
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programmes are more effective for different types of urinary Closs S.J. & Cheater F.M. (1999) Evidence for nursing practice:
A clarification of the issues. Journal of Advanced Nursing 30,
incontinence and whether the more dependent individuals
1017.
they are targeted at might benefit equally from regular Colling J., Ouslander J., Hadley B.J., Eisch J. & Campbell E. (1992)
voiding opportunities. The theories underpinning bladder The effects of patterned urge-response toileting (PURT) on urinary
training and voiding programmes, their future classification incontinence among nursing home residents. Journal of the
and interventions studies are warranted (Ostaszkiewicz et al. American Geriatrics Society 40(2), 135141.
Colling J., Owen T.R., McCreedy M. & Newman D. (2003) The
2005, Roe et al. 2007). The most common and constant
effects of a continence program on frail community dwelling
measure of effectiveness was the frequency of incontinence. elderly persons. Urology Nursing 23(2), 117122.
The body of evidence on this was greatest for bladder Colombo M., Zanetta G., Scalambrino S. & Milani R. (1995)
training, and more limited for prompted voiding, habit Oxybutinin and bladder training in the management of female
retraining and timed voiding. There were insufficient studies urinary urge incontinence. A randomised study. International
undertaken and therefore included in the latter two system- Urogynecology Journal and Pelvic Floor Dysfunction 6, 6367.
Egger M., Davey, Smith G. & Altman D.G. (2005) Systematic Re-
atic reviews to make definitive recommendations for clinical
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in future research and need to adhere standards for good
practice so that evidence on effectiveness of interventions is Fantl 1991
obtained and future meta-analyses can be performed. Meta-
Fantl A., Wyman J.F., McCLish D.K., Harkins S.W., Elswick R.K.,
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Fantl J.A., Wyman J.F., Harkins S.W. & Taylor J.R. (1988) Bladder
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We would like to thank Margarete Sandelowski and Sally
McLish D.K., Fantl J.A., Wyman J.F., Pisani G. & Bump R.C. (1991)
Thorne for their support and encouragement in pursuing this Bladder training in older women with urinary incontinence:
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