Abstract
Background
Habit retraining is a form of toileting assistance given by a caregiver to adults with urinary incontinence. It involves the identification of an incontinent person's natural voiding pattern and the development of an individualised toileting schedule, which pre‐empts involuntary bladder emptying.
Objectives
To assess the effects of habit retraining for the management of urinary incontinence in adults.
Search methods
We searched the Cochrane Incontinence Group Specialised Register (2 April 2009), MEDLINE (January 1966 to February 2004), EMBASE (1980 to May 2002), CINAHL (January 1982‐February 2001), PsycINFO (January 1972‐July 2002), Biological Abstracts, Current Contents and the reference lists of relevant articles. We also contacted experts in the field, searched relevant websites and handsearched journals and conference proceedings.
Selection criteria
Selection criteria include all randomised or quasi‐randomised controlled trials comparing habit retraining delivered either alone or in conjunction with another intervention for urinary incontinence in adults.
Data collection and analysis
At least two people, working independently, undertook data extraction and quality assessment. We resolved any differences by discussion.
Main results
Four trials with a total of 378 participants meet the inclusion criteria. Three of these (n = 337) test habit retraining combined with other approaches against usual care (Colling 1992; Colling 2003; Jirovec 2001). Participants in these trials were mainly women, with an average age of 80 years, who were physically and/or cognitively impaired, dependent on caregivers and residing in either a nursing home or in their own home. The included trials are considered too heterogeneous for meta‐analysis. Each trial is therefore considered individually. Primary outcomes are the incidence and/or severity of urinary incontinence. Other outcomes include the incidence of urinary‐tract infection, skin rash and skin breakdown, as well as measures of cost, caregiver preparedness, role strain and burden.
There are no statistically significant differences detailed in incontinence rates. However, the trials are characterised by limited data, difficulties maintaining compliance with the retraining regimes, and high rates of loss to follow up. The fourth trial compares habit retraining alone with habit retraining plus an electronic monitoring device, aiming to identify episodes of incontinence more reliably. The 41 participants (25 women and 16 men; mean age 83 years) were from acute care rehabilitation wards. The data are too limited to provide reliable treatment after estimates. However, there is some evidence of less severe incontinence in the monitoring group.
A consistent finding from descriptive data suggest that caregivers involved in maintaining voiding records and implementing habit retraining find it difficult to adhere to the protocol.
Authors' conclusions
The features of habit retraining programmes vary. Adherence to the protocol appears to be problematic for carers. The evidence from the four reviewed trials is too limited to judge whether or not there are improvements in continence that would make investment in habit‐retraining programmes worthwhile.
Plain language summary
Habit retraining for the management of urinary incontinence in adults
Urinary incontinence (inability to control the release of urine) is common in older people, especially those with physical or cognitive impairment. There is a variety of ways of curing or improving incontinence. Habit retraining involves identifying an incontinent person's toileting pattern and developing an individualised toileting schedule to pre‐empt involuntary bladder emptying. It can be labour intensive for the carers. This updated review found that there is not enough evidence from trials on which to judge whether or not there is sufficient improvement in continence to make a habit‐retraining programme worthwhile.
Background
Urinary incontinence is common amongst older people, especially those with cognitive or physical impairment. Over 50% of elderly residents of long‐term care facilities suffer from urinary incontinence. Toileting‐assistance programmes and use of pads and briefs are the most common forms of management for this condition (Brandeis 1997; Ouslander 1985). In the nursing home setting, as in the community, incontinence is costly (Borrie 1992; Cummings 1995; Hu 1986; Ouslander 1984; Schnelle 1998) and negatively impacts the psychosocial wellbeing of both residents (DuBeau 1999; Robinson 2000) and caregivers (Yu 1987; Yu 1991).
Urinary incontinence can often be improved or cured with treatment (Fantl 1996). Current guidelines recommend an evaluation of urinary incontinence for diagnosis to detect transient causes and to guide appropriate management (Button 1998; Fantl 1996; Thuroff 1999). Behavioural therapies are promoted as reasonable first steps in management for selected groups (Button 1998; Fantl 1996; Thuroff 1999). Behavioural therapies include: pelvic‐floor muscle training, bladder training and toileting assistance. Three types of toileting assistance programs are promoted: habit retraining, prompted voiding and timed voiding (otherwise known as scheduled toileting or routine toileting). This review addresses habit retraining in terms of impact on frequency and severity of incontinence, cost and quality of life. Other Cochrane reviews are available, including those covering prompted voiding (Eustice 2000), timed voiding (Ostaszkiewicz 2004), pelvic‐floor muscle training (Hay‐Smith 2006), bladder training (Wallace 2004) and absorbent products (Fader 2007; Fader 2008).
The Agency for Healthcare Research and Quality guidelines on urinary incontinence in adults classifies habit retraining as a caregiver‐dependent behavioural toileting intervention (Fantl 1996). It is usually initiated and maintained by the active involvement of a caregiver or caregivers. Habit retraining is promoted for use amongst incontinent nursing‐home residents, particularly when cognitive and/or motor deficits limit the application of more active behavioural programmes such as bladder training. Although the literature on habit retraining primarily refers to its application to the nursing‐home setting, habit retraining may also apply to other settings. In particular, it may assist caregivers of homebound incontinent older adults (Fantl 1996).
Habit retraining was first described in 1978 in relation to institutionalised geriatric patients (Clay 1978). It involves identification of an incontinent person's toileting pattern and development of an individualised toileting schedule, which pre‐empts involuntary bladder emptying by either decreasing or increasing the voiding intervals, while aiming to keep intervals as long as possible without incontinence. The voiding pattern may be identified either before a schedule is developed or after implementation of a schedule.
The literature on habit retraining is characterised by a lack of consensus about the conceptual and operational definition of the term. The definition used in this review is that proposed by Hadley 1986 and by The Agency for Healthcare Quality and Research guidelines on the management of urinary incontinence in adults (Fantl 1996). The essential features involve recognising and mimicking the patient's usual voiding pattern. Attempts are made to pre‐empt voiding, rather than to alter the voiding pattern.
Objectives
To assess the effects of habit retraining for the management of urinary incontinence in adults, we have made the following comparisons:
habit retraining compared with no habit retraining for the management of urinary incontinence;
habit retraining compared with another intervention for the management of urinary incontinence;
habit retraining in combination with another intervention compared with that intervention alone;
habit retraining in combination with another intervention compared with habit retraining alone;
habit retraining in combination with another intervention compared with usual care.
Methods
Criteria for considering studies for this review
Types of studies
Types of studies include all randomised or quasi‐randomised trials of habit retraining for the management of urinary incontinence in adult men and women. Urinary incontinence could be diagnosed either by symptom classification or by urodynamic study. Outcomes of interest are categorised as clinical outcomes, health status measures, health economic measures, adherence to the research protocol and other outcomes.
Types of participants
Types of participants include all adult men and women with or without cognitive impairment who are diagnosed either by symptom classification or by urodynamic study as having urinary incontinence.
Types of interventions
We have included studies if at least one trial group is managed with habit retraining.
Types of outcome measures
Patient symptoms
Perception of improvement or cure (as reported by patient or caregiver)
Clinical outcomes
Number of incontinent episodes in 24 hours (as indicated from completed bladder charts, total number and mean)
Pad changes due to incontinence over 24 hours (i.e. as reported by patient or caregiver ‐ total number and mean)
Pad weight
Voided volume
Maintenance of skin integrity
Urinary‐tract infection
Health status measures e.g. Short Form 36 (Ware 1993) Health economic measures Adherence to research protocol
Other outcomes * Measures of carer assessment (e.g. satisfaction and/or compliance) and non‐specified outcomes judged relevant when performing the review
Search methods for identification of studies
We did not impose any language or other limits on any of the searches detailed below.
Electronic searches
This review draws on the search strategy developed for the Incontinence Review Group. Relevant trials have been identified from the Group's Specialised Register of controlled trials (For more details please see the ‘Specialized Register’ section of the Group’s module in The Cochrane Library). The register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, and handsearching of journals and conference proceedings. The date of the most recent search of the trials register for this review is 2 April 2009. The terms used to search the Incontinence Group trials register are given below:
({TOPIC.URINE.INCON*} AND ({DESIGN.CCT*} OR (DESIGN.RCT*}) AND {INTVENT.PSYCH*}) Key: * = wildcard. (All searches were of the keywords field of Reference Manager 9.5 N, ISI ResearchSoft).
For this review, we performed the following additional, specific searches. These are given in more detail, including the search strategies used, in Appendix 1.
We searched the following electronic bibliographic databases:
MEDLINE (on OVID) (January 1966 to February 2004)(date of last search 15 February 2004)
EMBASE (on OVID) from 1980 to 2002 Week 18. We performed the search on 9 May 2002
CINAHL (January 1982‐February 2001) in March 2001
PsycINFO (January 1972‐July 2002) in August 2002
Current Contents (January 1993‐2001)
We also searched 11 evidence based nursing and medicine related websites for relevant studies.
Searching other resources
Handsearching
We handsearched 12 journals and the conference proceedings of six relevant associations, details of which are given in Appendix 1.
Contacting experts in the field
We contacted trialists and other experts in the field as deemed necessary.
Reference Lists of Relevant Articles
We searched the reference lists of relevant articles for other possible relevant trials.
Data collection and analysis
Two review authors checked all abstracts and references identified from the search strategy. We selected all randomised and quasi‐randomised studies which met the inclusion criteria. We appraised these for methodological quality using the Cochrane Incontinence Review Group's criteria. These criteria are based on the assumption that the avoidance of bias is best achieved by secure concealment of random allocation prior to formal entry; few and identifiable withdrawals and dropouts; and analysis based on an intention to treat. Two review authors, working independently, extracted data from trials that met the inclusion criteria. We resolved any discrepancies by discussion. We analysed raw data using the statistical analysis package, Review Manager (RevMan 4.2), developed by The Cochrane Collaboration. Ideally, the relative risk for dichotomous data and weighted mean differences for continuous data should be calculated with 95% confidence intervals (CI), using a fixed‐effect model, and when quantitative analysis is impossible or inappropriate, a narrative overview should be undertaken.
Results
Description of studies
The searches identified 61 potentially eligible studies. On detailed examination of the reports, however, we found 57 to be ineligible, as detailed in the table, 'Characteristics of excluded studies'. The most common reasons for exclusion were that studies were not RCTs, or were RCTs testing forms of management other than habit retraining. There are, thus, four eligible studies on which this review is based (Colling 1992; Colling 2003; Jirovec 2001; Nikoletti 2004).
Participants
The four eligible trials were reported as randomised controlled trials. One describes habit retraining in a nursing home setting with 113 residents in which the caregivers were indigenous nursing staff (Colling 1992). Two trials with a sample size of 224, involve home‐based community‐dwelling care recipients and their home‐based caregivers (Colling 2003; Jirovec 2001). The fourth trial describes a sample of 41 patients in acute‐care rehabilitation wards in a hospital setting (Nikoletti 2004). Participants of the first three trials were primarily elderly women (average age 80.3 years) who had cognitive and/or physical impairments and who were dependent on a caregiver. Participants in the trial conducted by Nikoletti were also elderly (mean age 83 years) and include 25 women and 16 men.
Terminology
Terms used to describe the intervention differ. In two trials, the intervention is called "Patterned Urge‐Response Toileting" (PURT) (Colling 1992; Colling 2003); in one trial it is referred to as "Individualised Scheduled Toileting" (Jirovec 2001); and in the trial by Nikoletti (Nikoletti 2004), it is called "habit training". A consistent feature of each trial is the identification of an individual participant's voiding pattern and an attempt to replicate it.
Duration and intensity of monitoring
The duration and intensity of monitoring an individual's voiding episodes and episodes of incontinence are important issues for clinicians, as they can provide valuable information that can be used to plan and evaluate care. In each trial, the duration and intensity of monitoring differ, as do the requirements regarding the specificity of information collected. For example, in one trial, usual care staff were asked to observe and document each participant's voiding and toileting needs/behaviours, incontinence checks, episodes of incontinence, volume, time of fluid intake and output, bowel function, and use and soakage of incontinence pads (Nikoletti 2004). In another trial, home‐based caregivers were asked to monitor participants for up to one week at baseline and for another week six months later (Jirovec 2001). The number of hours per day of data collection is not stated. In a trial involving a similar population, caregivers were asked to conduct two‐hourly observations of the care recipients' continence status for three consecutive days at baseline and again six weeks later (Colling 2003). In the trial conducted in a nursing‐home setting, research staff were required to monitor participants on an hourly basis for three days at baseline, and on a further 14 occasions at three‐week intervals, each occasion consisting of hourly observations for 24 hours (Colling 1992). Finally, in the trial conducted in acute‐care rehabilitation wards, usual care staff in the control group were asked to observe and document participants' voiding episodes (including incontinent episodes) over a 72‐hour period. The intensity of observations is not reported. Participants in the experimental group also had their incontinence monitored for 72 hours. However, this was done using electronic monitoring devices rather than by personnel (Nikoletti 2004).
Electronic monitoring devices
Electronic monitoring devices feature in three trials (Colling 1992; Colling 2003; Nikoletti 2004). These devices consist of a small moisture‐sensitive plate (sensor), which is placed inside the patient's incontinence pad and is linked with a monitoring device that is either positioned at the nurses' work bench or carried by the nurse. Electronic monitoring devices work by emitting an alarm to alert the nurse when a patient is incontinent.
In the two trials conducted by Colling and colleagues (Colling 1992; Colling 2003), electronic devices were used as an adjunct to continence checks conducted by caregivers or staff. Information from both sources was used to construct highly individualised toileting schedules for each participant. Although the sensitivity and specificity of the electronic monitoring device is not described as a predefined outcome of interest in either trial, one trial describes a validation study prior to its use, in which data from the device and from the research assistants is reported as consistent in 98% of cases (Colling 1992). The trial by Nikoletti and colleagues (Nikoletti 2004) is based on the assumption that the electronic monitoring device is accurate. Specifically, it is hypothesised that patients' actual voids and their recorded voids would be more accurate with the electronic monitoring device than with person‐dependent continence checks; that staff in acute‐care rehabilitation wards would subsequently implement toileting programmes that would be consistent with identified individualised voiding schedules for each participant; and that this would translate into reductions in incontinence.
Features of the intervention
Three trials describe habit retraining combined with other treatment, compared with usual care (Colling 1992; Colling 2003; Jirovec 2001). One trial describes habit retraining combined with other treatment compared with habit retraining alone (Nikoletti 2004). Other aspects combined with habit retraining include education to staff or caregivers, toileting prompts, contingent reinforcement, support, environmental modifications, fluid manipulation, and an electronic monitoring device. For example, Colling (Colling 1992) describes a four‐hour education programme for nursing‐home staff on the topic of urinary incontinence and on the protocol. Education and training of some form was also provided to caregivers of homebound older adults and to usual care staff on acute‐care rehabilitation wards (Colling 2003; Jirovec 2001; Nikoletti 2004). The content and mode of delivery of this education and training is not described.
Other features of habit retraining identified in the trials include the involving of caregivers in the process of developing individualised toileting schedules (Colling 2003; Jirovec 2001), manipulating the care recipients' fluid intake, altering the environment to make toileting easier, and providing support phone calls and/or home visits (Jirovec 2001).
Trials differ considerably in terms of the duration of habit retraining, ranging from six weeks (Colling 2003) to 12 weeks (Colling 1992), and even up to six months (Jirovec 2001). In one trial, the duration of the intervention depended on how long the participant was in hospital (Nikoletti 2004). During the six‐ and 12‐week intervention periods in two trials, staff and caregivers were advised to implement the protocol both during the day and at night (Colling 1992; Colling 2003).
Outcome measures
The incidence of incontinent episodes is the primary outcome of interest in all four trials. Two trials additionally examine the volume of incontinent and continent voids (Colling 1992; Colling 2003), and one of these trials additionally evaluates the cost of the intervention as well as the prevalence of skin rashes, skin breakdown and urinary‐tract infections (Colling 2003). Other outcomes examined in this trial include caregiver preparedness, burden and role strain. Nikoletti (Nikoletti 2004) further evaluated patients' and caregivers' perspectives of the frequency of urinary incontinence and severity of urinary incontinence.
Rates of adherence to the intervention and/or to providing evaluation data were reported in each trial. However, this measure is not predefined by the trialists. Similarly, mobility status and cognitive status are described, but are not predefined in the protocol.
Risk of bias in included studies
Overview One trial is a cluster randomised controlled trial (Colling 1992) and three are parallel group randomised controlled trials (Colling 2003; Jirovec 2001; Nikoletti 2004), two with deferred treatment groups (Colling 2003; Jirovec 2001). All trials report random allocation, and three describe using a table of random numbers to assign participants to either group. In the trial that employed a cluster randomisation method, units were designated as either experimental or control units, with no adjustment in the analysis for the effect of this clustering.
None of the trials describes blinding as a feature of the intervention. Blinding associated with assessing outcomes may have occurred, however, in one trial in which research staff collected all data and usual care nursing staff delivered the intervention (Colling 2003).
Power calculations are reported in three of the four trials (Colling 1992; Colling 2003, Nikoletti 2004), albeit with limited description. A key limitation is that, even when planned sample sizes are achieved, high rates of attrition and incomplete outcome data greatly reduce the statistical power. None of the trials included in this review meet the full criteria of an intention‐to‐treat analysis because of incomplete outcome data. Reasons for incomplete outcome data are due in part to high attrition rates, and in part to low rates of engagement by usual care staff or home‐based caregivers in monitoring and documenting participants' voiding and incontinent episodes. Attrition rates are 22% (Colling 1992), 26% (Colling 2003), 37% (Jirovec 2001) and 31% (Nikoletti 2004). One trial describes a sensitivity analysis to establish the potential bias due to incomplete records, and reports no significant differences (Colling 2003).
Effects of interventions
1. Habit retraining versus no habit retraining
We identified no trials that address this comparison.
2. Habit retraining versus other treatment
We identified no trials that address this comparison.
3. Habit retraining plus other treatment versus other treatment
We identified no trials that address this comparison.
4. Habit retraining plus other treatment versus habit retraining alone
One trial with a total of 41 participants compared habit retraining combined with other treatment to habit retraining alone (Nikoletti 2004). Habit retraining was combined with the use of an electronic monitoring device and staff training. The outcomes of interest are a) the frequency of incontinence (i.e. a clinical outcome); b) participants' perceptions of the frequency of incontinence; and c) participants' perceptions of the severity of incontinence.
Clinical outcomes
Number of incontinent episodes Objective data on frequency of incontinence are limited to six complete cases and therefore are not able to be further analysed.
Pad weight
No data reported for this outcome.
Voided volume and incontinent volume
No data reported for this outcome.
Prevalence of skin rash
No data reported for this outcome.
Prevalence of skin breakdown
No data reported for this outcome.
Prevalence of urinary‐tract infection
No data reported for this outcome.
Health economic measures
No data reported for this outcome.
Adherence to the research protocol
No data reported for this outcome.
Other outcomes
Other outcomes include participants' perceptions of their frequency of incontinent episodes in 24 hours.
The trialists (Nikoletti 2004) report that participants' self‐rated frequency of incontinent episodes in 24 hours is 3.5 episodes at baseline and 2.5 episodes at one‐month follow up for the experimental group (SD = 1.7, 2.2 respectively), compared with 3.5 episodes at baseline and 2.6 at one‐month follow up (SD = 1.5 at both time periods) in the control group. These differences are reported as not statistically significant within the experimental group (p = .21, n = 11). Between‐group data was analysed using a Mann‐Whittney U test. The trialists report no significant differences at either baseline or follow up (p = .74, n = 24). We chose not to analyse the follow‐up data in the Cochrane Collaboration's RevMan statistical package (RevMan 4.2) because of the skewed data and the number of participants with no data.
Participants' perceptions of their severity of incontinent episodes in 24 hours The severity of incontinence was assessed in four categories: damp pad/underwear; wet pad/underwear; wet outer clothing; and wet furniture. Participants with damp pad/underwear were compared with those who had wet pad/underwear, wet outer clothing or wet furniture (see other data table[10]]. Amongst the 26 with data (13 in each group) there is some evidence of a trend towards less severe incontinence in the group with electronic monitoring, but this is difficult to interpret because no data are available for 15 participants.
5. Habit retraining plus other treatment versus usual care
Three trials with a total of 337 participants compared habit retraining combined with other treatment to usual care (Colling 1992; Colling 2003; Jirovec 2001). Other aspects combined with habit retraining included: education to staff/caregivers; toileting prompts; contingent reinforcement; support; environmental modification;, fluid manipulation; and an electronic monitoring device. We could not apply analyses to the data from one trial (Colling 1992) because no standard deviations are reported (see table 'Characteristics of included studies'). We chose not to combine data from the other two trials (Colling 2003; Jirovec 2001) because of the differences between the trials in the other treatments, combined with habit retraining and the presence of statistical heterogeneity (chi squared = 2.69, df = 1, p = 0.1). We have therefore analysed between‐group raw outcome data for each trial independently.
Clinical outcomes
Number of incontinent episodes Between‐group outcome data from one of the trials conducted by Colling and colleagues (Colling 1992) are primarily expressed as the ratio difference (i.e. the number of incontinent voids per participant divided by the total number of voids per participant per 24‐hour period). These data are reported in narrative and graphic illustration. Reference is made to a table with data on means and standard deviation. However, as this is missing from the report, no further analysis could be applied to these data. A within‐group reduction from a urinary‐incontinence frequency ratio of 0.70 at baseline to an average of 0.57 during the treatment period is reported to be statistically significant. An analysis of data from the other trial conducted by Colling and colleagues (2003) reports within‐group decreases in the incidence of incontinence (standardised mean difference 0.22; 95% CI ‐0.32 to 0.75), but there are no statistically significant differences between groups. It is unclear if the outcome data reported in this trial are derived from week nine or week 15 of the intervention. In Jirovec 2001, the data favour the intervention group, but they are not statistically significant (standardised mean difference ‐0.38; 95% CI ‐0.85 to 0.09).
Pad changes
No data reported for this outcome.
Pad weight
No data reported for this outcome.
Voided volume and incontinent volume
Both trials conducted by Colling and colleagues (Colling 1992; Colling 2003) include baseline assessment procedures that involve measuring both continent and incontinent volumes. Data on the continent volume were not reported at outcome. Data on the mean incontinent volume in the first trial conducted by Colling and colleagues (Colling 1992) are illustrated with associated standard deviations. However, the data could not be further analysed, as the estimate points on the graph are poorly defined and incompletely reported in the text. Modest between‐group differences were reported at outcome. The other trial by Colling and colleagues (Colling 2003) includes raw data, which show no statistically significant differences between groups in the volume of incontinence associated with the intervention (standardised mean difference 0.45; 95% CI ‐0.08 to 0.99).
Prevalence of skin rash
Colling 2003 reported a significant within‐group decrease in the prevalence of skin rashes for the intervention group, from 17.7% at baseline to 9.4% following the intervention. The control group is reported, by contrast, to have had a non‐significant increase in the prevalence of skin rash over the same period. As there are no further data on this outcome, between‐group analysis could not be performed.
Prevalence of skin breakdown
The prevalence of skin breakdown was reported to have decreased from 11.6% at baseline to 2.3% (p = .05) for participants in the intervention group in Colling 2003. In the control group, which had only two participants with skin breakdown at baseline, skin breakdown had resolved by the end of the study. As there are no further data on this outcome, between‐group analysis could not be performed.
Prevalence of urinary‐tract infection
Absence of urinary‐tract infections is a trial‐entry requirement in Colling 2003. Escherichia coli (E. coli) was newly identified in five intervention‐group participants and two control‐group participants after three weeks in the trial, and in one to two participants per data point for the remainder of the trial. It was not possible to conduct any further analysis of these data.
Health economic measures
Data on the cost associated with managing incontinence was collected for both groups three days before and after the intervention in Colling 2003. These data were aggregated for both groups and expressed as an average daily cost of US$3.03 per person, regardless of group allocation. It is difficult to determine the extent to which the intervention alters the cost of managing incontinence. However, it was reported that, based on an average reduction of one episode of urinary incontinence per day per participant, estimated savings were calculated at US$230.00 per person per year.
Adherence to the research protocol
Adherence to the research protocol was not predefined as an outcome in any of the included trials. At the same time, each trialist reported that this is problematic. Jirovec reported, for example, that "caregivers in the treatment group did not normally keep a record of incontinent episodes" (Jirovec 2001). It was also noted that caregivers found a week‐long voiding record too burdensome, and the number of days of data varied from three to seven days, with most providing three to four days of complete data (Jirovec 2001). Colling 2003 also expresses doubts about home‐based caregivers' adherence to the protocol, and these doubts are confirmed by objective data provided by the electronic data logger. "It is possible," suggests Colling, "that the prescriptions were only carried out as caregivers had the time and energy to add this new care routine into their life as a caregiver" (Colling 2003). Data from Colling 1992 indicate that protocol adherence was also problematic for nursing staff working amongst elderly people living in residential aged‐care facilities. Despite four hours of training, in‐house nursing staff adhered to the protocol only about 61% of the time.
Other outcomes
Impact on caregivers Colling 2003 evaluated caregiver outcomes. These include caregiver preparedness, burden and role strain. The management of urinary incontinence was subjectively reported by caregivers to be less stressful at the completion of the intervention than at baseline, and more caregivers reported feeling more prepared to care for their care recipients' incontinence. Overall, there were no significant changes during the trial period. No further statistical analyses could be applied to these data.
Discussion
Trials of habit retraining are typically characterised by different terminology to describe the intervention, small sample sizes, limited description of the intervention, high attrition rates and limited outcome data. Data for the trials included in this review were too limited to be combined for statistical analysis. All four trials have some methodological weaknesses, according to criteria set out in the Cochrane Handbook (Higgins 2005). This means that one or more quality criteria have not been met and hence, the potential for overestimating or underestimating the effects of the interventions must be considered.
Three trials evaluate habit retraining combined with other strategies and compare this with usual care. One trial evaluates habit retraining combined with other strategies and compares this to habit retraining alone. The interventions are poorly described, and thus we are challenged to identify the essential and defining features of habit retraining. Some trials report that education was provided to staff or caregivers. Others refer to the use of positive reinforcement strategies, social support, advice regarding fluid manipulation or use of an electronic monitoring device. We interpreted these activities as additional features to habit retraining. Ideally, the relative contribution of each of these aspects should be considered so that clinicians are better informed about the optimal methods for implementing habit retraining.
Aspects of concern in trials on habit retraining include the difficulties experienced by the trialists in a) retaining participants in the trials and b) in obtaining complete outcome data. It would also seem that habit retraining is a resource‐intense approach for the management of incontinence. We speculate that this is largely due to the requirements for usual care staff or caregivers to conduct frequent checks of each person's continence status to identify individual voiding patterns. We found no research to indicate the optimum frequency with which continence checks should be conducted, or the duration. Intuitively, it would seem that continence checks that are conducted more frequently have a greater likelihood of providing more accurate information, which could in turn provide for a more targeted toileting‐assistance programme. At the same time, in a clinical context, the frequency and duration of continence checks need to be conducted in a way that promotes personal autonomy and dignity. The ethical issues associated with conducting continence checks in frail older adults have received scant attention in the literature on assessment of incontinence. This is particularly important given that many of the people for whom habit retraining has been targeted have cognitive impairment.
Whilst electronic monitoring devices may mitigate some of the concerns about the labour‐intense nature of assessment procedures associated with habit retraining, the qualitative data from usual care staff involved in these procedures, the Nikoletti study (Nikoletti 2004) suggests that further testing is required before the full benefit of electronic monitoring devices can be realised. Device problems include continuous and intermittent alarming for no apparent reason, a transmission range considerably less than that which is reported in the specifications, the need to frequently recharge the devices from the main power source, the bulkiness of the devices, and sensors being discarded with pads.
Another factor that requires further consideration is that, whilst electronic monitoring devices can potentially provide more accurate information on patients' voiding patterns than would otherwise be obtained, there is no guarantee that staff or caregivers necessarily adhere to the toileting schedule. To this end, it is important that usual care staff or caregivers are supported with strategies that promote adherence and, at the same time, reduce the burden of care.
Limitations
In interpreting the results of this review, the reader is cautioned to consider that, whilst the search is designed to be as comprehensive and inclusive as possible, the potential nevertheless exists for studies to have been overlooked by virtue of publication bias. The review is primarily drawn from publications in English‐language journals, although we searched one major database of non‐English‐language journals. As with any review, the quality of the data is determined by the quality of the trials that contribute to the review. As noted in the critique of the quality of included trials, many trials are characterised by missing or incomplete data.
Authors' conclusions
Implications for practice.
The four trials reviewed describe a range of approaches used to promote continence in selective groups of older adults with incontinence. The intervention can be labour intensive for usual care staff and caregivers, and hence, lead to reduced adherence. This issue raises the question of the trade‐off between treatment benefit and associated resources and costs. There is also a question about the most ethical way to obtain information on voiding patterns in this vulnerable group of individuals. At the same time, toileting‐assistance programs are central to the management of incontinence in people who are otherwise unable to independently toilet themselves. Clearly, for those individuals who are dependent on a carer for toileting assistance to maintain continence, any form of toileting assistance is better than no toileting assistance. The critical issues for practice include a) whether or not individuals with incontinence have predictable patterns of continence and incontinence; b) if they do, what are the best methods to attain information on this pattern; c) what strategies and resources are required to implement a toileting‐assistance program that is based on this pattern; and d) how this program can be sustained. The review findings of inadequate evidence to support habit retraining as a specific type of toileting‐assistance intervention should not be interpreted as evidence of no effect, or lead to its dismissal. The findings do, however, highlight the need for usual care staff or caregivers to be supported to provide continence care to individuals who are unable to toilet themselves independently, and for further research on the factors that either enable or hinder habit retraining being applied to an everyday clinical context. Given the labour‐intense assessment procedures involved in delivering habit retraining, an alternative, safe and pragmatic approach to continence care in vulnerable individuals with cognitive and physical impairments may be to ensure regular opportunities for them to go to the toilet based on a fixed voiding schedule (i.e. timed voiding), and to modify the schedule to accommodate individual differences. However, it should be noted that this approach remains untested.
Implications for research.
Key issues associated with evaluating the effectiveness of habit retraining for the management of urinary incontinence are the challenges associated with recruiting and retaining participants, as well as the challenges involved in obtaining evaluative data and in introducing and describing methods for minimising bias. These are not uncommon challenges for trials involving vulnerable populations, particularly for those trials that address behavioural interventions. Based on the findings of this systematic review, there is a need for further research:
a) to test the assumption that the target population has predictable patterns of continence and incontinence; b) to identify the optimum frequency and duration for conducting continence checks to establish the predictability of an individual's continence and incontinence episodes; c) to explore the ethical issues associated with conducting continence assessments in vulnerable populations; d) to explore the underlying reasons for usual care staff and caregivers' low levels of adherence to research recommendations on habit retraining; e) to evaluate the effectiveness of different approaches to supporting usual care staff or caregivers to adhere to research recommendations to minimise incontinence; f) to identify which patients would benefit most from habit retraining compared with other management options; and g) to enhance the sensitivity and specificity of electronic monitoring devices so that they can augment evaluation procedures associated with habit retraining.
Another area for further research pertains to the finding of various terms that describe an intervention in which patients' voiding patterns are identified and toileting assistance is offered on the basis of this pattern. The lack of consensus and overlap with other terms such as timed voiding/scheduled voiding and prompted voiding indicates the need for a review of terminology for these approaches to the management of urinary incontinence.
What's new
| Date | Event | Description |
|---|---|---|
| 16 July 2009 | New search has been performed | new search, no new studies |
History
Protocol first published: Issue 4, 2000 Review first published: Issue 2, 2004
| Date | Event | Description |
|---|---|---|
| 9 October 2008 | Amended | Converted to new review format. |
| 14 November 2007 | New search has been performed | minor update |
| 24 February 2004 | New citation required and conclusions have changed | Substantive amendment |
Appendices
Appendix 1. Extra search methods and strategies used for this review
For this review, the review authors performed additional, specific searches. These are detailed below.
Electronic Databases We searched the following electronic bibliographic databases: Search strategy for MEDLINE (on OVID) (January 1966 to February 2004)(date of last search 15 February 2004):
1 exp behavior therapy 2 (behav$ adj25 therapy).mp. [mp=title, abstract, registry number word, mesh subject heading] 3 exp cognitive therapy/ 4 (cognit$ adj25 therapy).mp. [mp=title, abstract, registry number word, mesh subject heading] 5 (conservat$ adj25 intervention$).mp. [mp=title, abstract, registry number word, mesh subject heading] 6 toilet training.mp. [mp=title, abstract, registry number word, mesh subject heading] 7 (habit training or habit retraining).mp. [mp=title, abstract, registry number word, mesh subject heading 8 timed void$.mp. [mp=title, abstract, registry number word, mesh subject heading] 9 prompted void$.mp. [mp=title, abstract, registry number word, mesh subject heading] 10 (nursing homes and urinary incontinence).mp. [mp=title, abstract, registry number word, mesh subject heading] 11 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 12 exp Urinary Incontinence/ or urinary incontinence.mp. [mp=title, abstract, registry number word, mesh subject heading] 13 11 and 12 14 13 not child.mp. [mp=title, abstract, registry number word, mesh subject heading] 15 exp randomized controlled trials/ 16 randomized controlled trial.pt. 17 exp random allocation/ 18 exp double blind method/ 19 exp single blind method/ 20 exp clinical trials/ 21 clinical trial.pt. 22 (clin$ adj25 trial$).ti,ab. 23 ((singl$ or doubl$ or treb$ or tripl$) adj25 (blind$ or mask$)).ti,ab. 24 placebo$.ti,ab. (62844) 25 random$.ti,ab. 26 research design/ 27 placebos.mp. [mp=title, abstract, registry number word, mesh subject heading] 28 or/15‐27 29 14 and 28
We searched EMBASE (on OVID) from 1980 to 2002 Week 18. We performed the search on 9 May 2002, using the following search terms:
1 Randomized Controlled Trial/ 2 controlled study/ 3 clinical study/ 4 major clinical study/ 5 prospective study/ 6 meta analysis/ 7 exp clinical trial/ 8 randomization/ 9 crossover procedure/ or double blind procedure/ or parallel design/ or single blind procedure/ 10 Placebo/ 11 latin square design/ 12 exp comparative study/ 13 follow up/ 14 pilot study/ 15 family study/ or feasibility study/ or pilot study/ or study/ 16 placebo$.tw. 17 random$.tw. 18 (clin$ adj25 trial$).tw. 19 ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).tw. 20 factorial.tw. 21 crossover.tw. 22 latin square.tw. 23 (balance$ adj2 block$).tw. 24 or/1‐23 25 (nonhuman not human).sh. 26 24 not 25 27 behavior modification/ or behavior therapy/ 28 (conservat$ adj25 (intervention$ or therap$)).tw. 29 conservative treatment/ 30 (behav$ adj25 (therap$ or train$ or treatment$ or intervention$)).tw. 31 (habit adj2 (train$ or retrain$)).tw. 32 (void$ adj2 (time$ or prompt$ or schedul$)).tw. 33 toilet$.tw. 34 or/27‐33 35 bladder disease/ or bladder dysfunction/ or detrusor dyssynergia/ or neurogenic bladder/ 36 (continen$ or incontinen$).tw. 37 exp Incontinence/ 38 37 or 35 or 36 39 26 and 34 and 38 40 limit 39 to (embryo <first trimester> or infant <to one year> or child <unspecified age> or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>) 41 limit 39 to (adult <18 to 64 years> or aged <65+ years>) 42 40 not 41 43 39 not 42
We searched CINAHL (January 1982‐February 2001) in March 2001 using the following search terms:
1 behavio?r$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 2 (behav$ adj25 therapy).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 3 cognitive therapy.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 4 (cognit$ adj25 intervention$).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 5 (conservat$ adj25 intervention$).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 6 (timed void$ or schedule$ void$).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 7 (habit retraining or habit training).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 8 toilet training.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 9 (nurs$ adj25 care).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 10 nurs$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 11 nurs$ home$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 12 dementia$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 13 or/1‐12 14 urinary incontinence or Urinary Incontinence).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 15 13 and 14 16 random$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 17 randomized controlled trial$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 18 random allocation$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 19 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).mp. [mp=title, cinahl subject heading, abstract, instrumentation] 20 placebo$ control$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] 21 or/16‐20 22 15 and 21 23 22 not child$.mp. [mp=title, cinahl subject heading, abstract, instrumentation] Search strategy for Biological Abstracts (January 1980‐December 2000). The search was performed in March 2001 using the following search terms: 1 behavio?r$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 2 (behav$ adj25 therapy).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 3 cognitive therapy.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 4 (cognit$ adj25 intervention$).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 5 (conservat$ adj25 intervention$).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 6 (timed void$ or schedule$ void$).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 7 (habit training or habit retraining).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 8 toilet training.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 9 (nurs$ adj care).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 10 nurs$ home$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 11 nurs$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 12 dementia$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 13 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 14 (urinary incontinence or Urinary Incontinence).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 15 13 and 14 16 random$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 17 randomized controlled trial$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 18 random allocation$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 19 (clin$ adj25 trial$).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 20 ((singl$ or doubl$ or trebl$ or tripl) adj (blind$ or mask$)).mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 21 placebo$ control$.mp. [mp=title, keywords, heading words, registry words, abstract, biosystematic codes/super taxa, book title, original language book title, subject headings] 22 or/16‐21 23 15 and 22
We searched PsycINFO (January 1972‐July 2002) in August 2002 using the following search terms:
1 urinary incontinence 2 Behavio* 3 1 and 2
We searched Current Contents (January 1993‐2001) using the following search terms: 1 behavio?r$.mp. [mp=abstract, title, author keywords, keywords plus] 2 (behav$ adj25 therapy).mp. [mp=abstract, title, author keywords, keywords plus] 3 cognitive therapy.mp. [mp=abstract, title, author keywords, keywords plus] 4 cognitive therapy.mp. [mp=abstract, title, author keywords, keywords plus] 5 (cognit$ adj25 intervention$).mp. [mp=abstract, title, author keywords, keywords plus] 6 (conservat$ adj25 intervention$).mp. [mp=abstract, title, author keywords, keywords plus] 7 (timed void$ or schedule$ void$).mp. [mp=abstract, title, author keywords, keywords plus] 8 (habit retraining or habit training).mp. [mp=abstract, title, author keywords, keywords plus] 9 toilet training.mp. [mp=abstract, title, author keywords, keywords plus] 10 (nurs$ adj25 care).mp. [mp=abstract, title, author keywords, keywords plus] 11 nurs$.mp. [mp=abstract, title, author keywords, keywords plus] 12 nurs$ home$.mp. [mp=abstract, title, author keywords, keywords plus] 13 dementia$.mp. [mp=abstract, title, author keywords, keywords plus] 14 or/1‐13 15 (urinary incontinence or Urinary Incontinence).mp. [mp=abstract, title, author words, keywords plus] 16 14 and 15 17 random$.mp. [mp=abstract, title, author keywords, keywords plus] (188244) 18 randomized controlled trial$.mp. [mp=abstract, title, author keywords, keywords plus] 19 random allocation$.mp. [mp=abstract, title, author keywords, keywords plus] 20 (clin$ adj25 trial$).mp. [mp=abstract, title, author keywords, keywords plus] 21 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).mp. [mp=abstract, title, author keywords, keywords plus] 22 placebo$ control$.mp. [mp=abstract, title, author keywords, keywords plus] 23 or/17‐22 24 not child$.mp. [mp=abstract, title, author keywords, keywords plus]
We searched Current Contents (January 1993‐2001) using the following search terms: using the following search terms:
1. (urinary incontinence not child).mp. [mp=title, abstract, full text, keywords, caption text] Search for: from 1 [urinary incontinence.mp. [mp=title, short title, abstract, full text] urinary incontinence.mp. [mp=ti, ot, ab, tx, kw, ct] Key: $ = wildcard; tw = textword; / = MeSH term or emtree term or other controlled language term with all subheadings; exp = explode; adj25 = within 25 words either side of this word.
Websites We searched the following websites for relevant studies: Agency for Healthcare Quality and Research (AHRQ) Australian Institute of Health and Welfare (AIHW) Centers for Disease Control and Prevention (CDC) Centre for Evidence‐Based Medicine, Oxford University Centre for Evidence‐based Nursing ‐ based at University of York Database of Abstracts of Reviews of Effectiveness (DARE) National Guidelines Clearing House National Health and Medical Research Council (Aust)(NHMRC) The NHS Centre for Reviews and Dissemination Netting the Evidence (ScHARR) World Health Organization (WHO)
Handsearching We hansearched the following sources for this review.
Journals American College of Physicians (ACP) Journal Club Bandolier Clinical Effectiveness in Nursing Controlled Clinical Trials Effective Health Care Effectiveness Matters Evidence‐Based Medicine Evidence‐Based Nursing Journal of Clinical Effectiveness Journal of Evidence‐Based‐Healthcare Policy and Management Journal of Health Services Research and Policy Journal of Quality in Clinical Practice
Conference proceedings The Association for Continence Advice (UK) British Association of Urological Surgeons The Continence Foundation of Australia (AUST) The International Continence Society The Society of Urologic Nurses and Associates (USA) The Wound, Ostomy and Continence Nurses Society (USA)
Contacting experts in the field We contacted trialists and other experts in the field as deemed necessary.
Reference Lists of Relevant Articles We searched the reference lists of relevant articles for other possible relevant trials.
Data and analyses
Comparison 1. Habit retraining versus no habit retraining.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
|---|---|---|---|---|
| 1 Number of patients cured | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2 Number of patients improved | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 3 Number of incontinence episodes | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4 Pad weights | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5 Voided volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6 Incontinent volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7 Health status measures | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.1 Number of patients with skin breakdown | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.2 Number of patients with rashes | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 Number of patients with UTI | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8 Health economic measures | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.1 Cost | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Compliance | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
Comparison 2. Habit retraining compared with other treatment.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
|---|---|---|---|---|
| 1 Number of patients cured | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2 Number of patients improved | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 3 Number of incontinence episodes | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4 Pad weights | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5 Voided volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6 Incontinent volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7 Health status measures | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.1 Number of patients with skin breakdown | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.2 Number of patients with rashes | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 Number of patients with UTI | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8 Health economic measures | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Compliance | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
Comparison 3. Habit retraining + other versus other treatment.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
|---|---|---|---|---|
| 1 Number of patients cured | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.1 At reassessment | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 At follow‐up | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 2 Number of patients with no change in frequency of incontinence at follow‐up | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 4 Pad weights | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5 Voided volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6 Incontinent volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7 Health status measures | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.1 Number of patients with skin breakdown | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.2 Number of patients with rashes | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 Number of patients with UTI | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8 Health economic measures | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.1 Cost | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Compliance | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
Comparison 4. Habit retraining + other versus habit retraining alone.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
|---|---|---|---|---|
| 1 Number of patients cured | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2 Number of patients improved | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 3 Number of incontinence episodes | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 4 Pad weights | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5 Volume voided | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6 Incontinent volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7 Health status measures | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.1 Number of patients with skin breakdown | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.2 Number of patients with rashes | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 Number of patients with UTI | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8 Health economic measures | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Compliance | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10 Participants' perceptions of their severity of incontinent episodes in 24 hours | Other data | No numeric data |
4.10. Analysis.
Comparison 4 Habit retraining + other versus habit retraining alone, Outcome 10 Participants' perceptions of their severity of incontinent episodes in 24 hours.
| Participants' perceptions of their severity of incontinent episodes in 24 hours | |||
|---|---|---|---|
| Study | Group 1 Experimental | Group 2 Control | |
| Nikoletti 2004 | Damp pad/underwear = 5 wet/pad underwear/outer/furniture = 8 | Damp pad/underwear = 0 wet/pad underwear/outer/furniture = 13 | |
| Nikoletti 2004 | |||
Comparison 5. Habit retraining + other versus usual care.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
|---|---|---|---|---|
| 1 Number of patients cured | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 2 Number of patients improved | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 3 Number of incontinent episodes | 2 | Std. Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 4 Pad weights | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 5 Voided volume | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 6 Incontinent volume | 1 | Std. Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 7 Health status measures | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.1 Number of patients with skin breakdown | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.2 Number of patients with rashes | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 7.3 Number of patients with UTI | 0 | 0 | Peto Odds Ratio (Peto, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8 Health economic measures | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Compliance | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
5.3. Analysis.
Comparison 5 Habit retraining + other versus usual care, Outcome 3 Number of incontinent episodes.
5.6. Analysis.
Comparison 5 Habit retraining + other versus usual care, Outcome 6 Incontinent volume.
Characteristics of studies
Characteristics of included studies [ordered by study ID]
Colling 1992.
| Methods | Cluster randomised controlled trial. No data on allocation concealment. Groups comparable at baseline. No data on concealment associated with outcome assessment. 12 week follow up. Drop outs accounted for. Complete case analysis. | |
| Participants | 113 long‐stay cognitively or physically impaired elderly nursing home residents with either urge or urge/stress UI, mean age 85, mainly female. Recruited from four nursing homes. | |
| Interventions | 12 weeks of baseline assessment. Group I: (63) 12 weeks of individualised toileting called Patterned Urge‐Response Toileting (PURT) + staff education, feedback and encouragement delivered by indigenous staff 24 hrs per day followed by 12 weeks of maintenance follow up. Group 2:(50) nature of intervention not stated. | |
| Outcomes | Incontinence frequency in 24 hour periods @ 36 weeks Group I: (51) mean = 4.5 (SD missing data) Group 2: (37) mean = 5.5 (SD missing data). Incontinence volume in 24 hour periods @ 36 weeks: Group 1: (51) mean = 600 cc (SD missing data ) Gp 2: (37) mean = 650 cc (SD missing data) | |
| Notes | Not included in meta‐analysis as cluster randomisation with data analysed on individual patient basis. Outcome data expressed as UI frequency and volume ratios. Authors contacted for additional data. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Allocation concealment? | Unclear risk | B ‐ Unclear |
Colling 2003.
| Methods | Randomised controlled trial with concealed allocation. Groups not comparable at baseline. No data on concealment associated with outcome data. Follow up data ‐ unclear. Drop outs accounted for. Outcome data based on between group data on frequency and volume of UI. Complete case analysis. | |
| Participants | 106 home based family caregivers (CG) and their care‐recipient (CR) recruited from a network of community agencies/brochures and community newspapers. CR: mean age 76.3, white, predominantly female with urge or stress/urge UI, married and living in own home/apartment. CG: usually spouses or daughters. | |
| Interventions | 3 weeks of baseline assessment. Group 1: (number not stated) 6 weeks of habit training called Patterned Urge‐Response Toileting (PURT) based on identified individualised toileting times instructed by research staff and delivered by caregivers followed by 6 weeks post‐intervention treatment (nature of this treatment unclear). Group 2: (number not stated) same as Group 1 but delayed treatment. | |
| Outcomes | Change in UI frequency in 24 hour periods Group 1: (32) mean = 4.0 (SD 2.63). Group 2: (24) mean = 3.43 (SD 2.59). UI volume in 24 hour periods. Group 1: (32) mean = 292 (SD 202) Gp 2: (24) mean = 193 (SD 233) Other outcomes: cost, UTI, caregiver burden, preparedness and role strain, skin rash and skin breakdown. | |
| Notes | Baseline differences between groups: experimental gp were more mentally and physically impaired and control group had significantly lower levels of UI frequency and volume. Family caregiving group and group with no caregiver were combined for data analysis as no differences were detected between groups. Authors contacted for additional data. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Allocation concealment? | Unclear risk | B ‐ Unclear |
Jirovec 2001.
| Methods | Randomised controlled trial. No data on allocation concealment. Groups comparable at baseline. No data on concealment associated with outcome data. Follow up ‐ no data. Drop‐outs accounted for. Outcome data based on between‐group data. Complete case analysis. | |
| Participants | 118 memory‐impaired care‐recipients (CR) & their caregivers (CG). Mainly female volunteers recruited from advertisements. CR ‐ mean age 80 (SD 7.93), duration of memory impairment ‐ 43 months (SD 35), duration of UI ‐ 29 months (SD 32). | |
| Interventions | Group 1: (38) 6 months of individualised scheduled toileting + education re fluid intake + environmental assessment + monthly phone calls + bimonthly visits. Group 2: (39) same as Group 1 but 6 monthly visit instead of bi‐monthly. Group 3: (41) control group ‐ payment + monthly social phone call. | |
| Outcomes | Change in UI frequency in 24 hour periods @ 6 months. Groups 1 & 2: (44) mean UI freq = 0.37, (SD 0.28) Group 3: (30) mean UI freq = 0.49 (0.36). Other outcomes: mobility & mental status. | |
| Notes | Groups 1 & 2 combined @ 6 months for data analysis. Outcome data were based on CG subjective report & on one week of voiding records completed by CG. Poor compliance with outcome data noted. Most CG implemented a 2 hourly regimen. No sensitivity analysis of 2 hourly vs individualised scheduled toileting. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Allocation concealment? | Unclear risk | B ‐ Unclear |
Nikoletti 2004.
| Methods | Randomised controlled trial with concealed allocation. Groups comparable at baseline. One month follow up post discharge. Drop outs accounted for. Complete case analysis. | |
| Participants | 41 rehabilitation patients in 2 acute‐care hospitals. Gp 1: (22) mean age: 82. Gp 2: (19) mean age 85 | |
| Interventions | 72 hour baseline assessment
Gp 1: electronic monitoring device Gp 2: electronic monitoring device + habit retraining until discharge, with one month follow up |
|
| Outcomes | Frequency of incontinence ‐ 6 complete cases. Self rated frequency of incontinence @ 1month Gp 1: (12) 2.5 (SD = 2.2). Gp 2: (11) 2.6 (SD = 1.5) Self rated severity of incontinence @ 1 month a) Damp underwear/pad Gp 1: (13) 5 Gp 2: (13) 0 b) Wet underwear/pad Gp 1: (13) 6 Gp 2: (13) 4 c) Wet outer clothing Gp 1: (13) 2 Gp 2: (13) 7 d) Wet furniture Gp 1: (13) 0 Gp 2: (13) 2 |
|
| Notes | High attrition rate. Poor compliance with outcome data noted. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Allocation concealment? | Unclear risk | B ‐ Unclear |
SD = Standard deviation: UI = Urinary Incontinence: CG = Caregiver: CR = Care recipient: PURT = Patterned Urge‐Response Toileting: UTI = Urinary Tract Infection:
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
|---|---|
| Baigis‐Smith 1989 | Non RCT ‐ observational study involving 54 volunteers aged 60 or over who received Kegel exercises with biofeedback augmented by habit retraining & relaxation (no data on habit retraining). |
| Borrie 2002 | Non RCT ‐ 421 patients aged 26 years or over who received behavioural and lifestyle modification sessions every 4 weeks for 25 weeks (no data on habit retraining). |
| Burgio 1985 | Non RCT ‐ 48 volunteers aged 60‐86 years who received biofeedback assisted exercises plus relaxation training plus an intervention that was termed 'habit retraining'. Participants were instructed to void 2‐hourly for 4‐week baseline period as well as during treatment however those with detrusor motor instability were taught deferment techniques. Pre‐ and post‐ evaluation. |
| Burgio 1989 | Non RCT ‐ 20 men with persistent post‐prostatectomy incontinence purposively selected for 2 weeks of 2‐hourly voiding followed by biofeedback. |
| Burgio 1994 | Non RCT ‐ 41 incontinent residents of a skilled nursing care facility who were purposively selected for one of four groups with exposure to varying schedules or prompted voiding. |
| Burgio 1998 | RCT ‐ 91 women aged 55‐92 with urge incontinence or mixed symptoms randomised to biofeedback assisted pelvic floor muscle exercises with bladder training or dry treatment. |
| Carpenter 1960 | Non RCT ‐ 94 hospitalised patients with longstanding psychiatric disorders divided into 4 groups purposively selected for an intervention which is referred to as habit training and which is combined with various levels of reinforcement and compared against each other and a control group. Description of intervention is consistent with timed voiding. |
| Castleden 1986 | Double‐blind placebo controlled trial of imipramine. All participants were exposed to habit retraining; however, the description was consistent with review definition of bladder training (ie involved a progressive increase in intervoiding intervals) |
| Chanfreau‐Rona 1984 | Non RCT ‐ 24 elderly female residents of a psychogeriatric ward purposively assigned to either usual care or to habit retraining combined with environmental modifications, pad and pant system and verbal and material reinforcement. |
| Chanfreau‐Rona 1986 | Non RCT ‐ 30 elderly residents of a psychogeriatric ward purposively assigned to either usual care or to habit retraining combined with environmental modifications, pad and pant system and verbal and material reinforcement. |
| Colombo 1995 | RCT ‐ 81 women with detrusor instability randomised to 6 weeks of either bladder training or medication. |
| Engberg 1997 | RCT ‐ 124 homebound older adults ‐ cognitively intact patients received 8 weeks of bladder training with biofeedback assisted pelvic floor muscle exercises and deferment techniques. Cognitively impaired patients received 8 weeks of either prompted voiding or usual care. |
| Engberg 2002 | RCT ‐ 29 cognitively impaired and homebound older adults randomised to either prompted voiding or delayed prompted voiding. |
| Engel 1990 | Non RCT ‐ 62 elderly men and women admitted to a Geriatric Continence Research Unit ‐ purposively allocated to prompted voiding followed by different forms of feedback from staff. |
| Fantl 1991 | RCT ‐ 123 non institutionalised women 55 years or older ‐ randomised to either 6 weeks of bladder training or deferred bladder training. |
| Fonda 1994 | RCT ‐ 78 community dwelling older adults attending an outpatient continence clinic ‐ randomised to either immediate or deferred conservative management. |
| Gaitsgori 1998 | Non RCT ‐ 35 'demented patients from 2 nursing homes'. Pre‐ and post‐evaluation of the intervention which was referred to as 'timed voiding'. Description of intervention is consistent however with review definition of habit retraining. |
| Goode 2002 | RCT ‐ 105 community dwelling women aged 55 years and over randomised to either four sessions of biofeedback‐assisted behavioural training with drug treatment or a placebo. |
| Grosicki 1968 | Non RCT ‐ 17 'geriatric' patients of a neuropsychiatric hospital purposively selected for an intervention that was based on principles of operant conditioning. |
| Hu 1988 | RCT ‐ 133 women with urinary incontinence from 7 nursing homes. Intervention consisted of prompted voiding with hourly checks and prompts, verbal reinforcement, and additional attention contingent upon success and encouragement. |
| Jarvis 1980 | RCT ‐ 60 women with detrusor instability treated with "bladder drill". |
| Jarvis 1981 | RCT ‐ 50 women with detrusor instability treated with in‐patient "bladder drill" compared to out‐patient bladder drug therapy. |
| Jarvis 1982 | Non RCT ‐ 33 women with primary vesical sensory urgency treated with "bladder drill". |
| Jilek 1993 | Non RCT ‐ 28 residents of a nursing home purposively selected for 8 weeks of 2‐hourly toileting followed by 8 weeks of 4‐hourly toileting. |
| Jirovec 1991 | Non RCT ‐ 14 incontinent nursing home residents in a pre‐ and post‐evaluation of a program involving hourly wet/dry checks to enable the development of an individualised and flexible toileting program ‐ referred to by author as prompted voiding, but reinforcement is not reported as an integral feature (ie nurse aids were instructed to toilet residents at the identified times) hence is consistent with review definition of habit retraining. Excluded as not RCT. |
| Johnson 2005 | Non RCT ‐ 197 women aged over 55 years with incontinence and urodynamic evidence of bladder dysfunction, who received 4 sessions of biofeedback‐assisted pelvic floor muscle exercises with either drug treatment or placebo. |
| King 1980 | Non RCT ‐ 15 women with urinary and/or faecal incontinence ‐ residing in psychogeriatric and long‐stay wards ‐ purposively selected for habit retraining. |
| Kirkpatrick 1987 | Non RCT ‐ 6 women with urinary incontinence from an intermediate‐care unit of a long‐term care facility ‐ purposively selected for habit retraining. |
| Lagro‐Janssen 1992 | RCT ‐ 110 women attending their GP for incontinence. Women with stress incontinence allocated to either pelvic floor muscle exercises or deferred treatment. Women with urge incontinence allocated to either bladder training or deferred treatment. |
| Lekan‐Rutledge 1992 | Non RCT ‐ 9 nursing home residents with urinary incontinence ‐ pre‐ and post‐evaluation of prompted voiding. |
| McCormick 1992 | Non RCT ‐ 11 residents with urinary incontinence from a long‐term care facility ‐ purposively selected for a pre‐ and post‐ evaluation of prompted voiding and compared with prompted voiding combined with buzzer which sounded in response to wetness in between 2 hourly prompts. |
| McCormick 1990 | Non RCT ‐ 10 women with urinary incontinence from a 'Geriatric Continence Research Unit" ‐ purposively selected for pre‐ and post‐evaluation of prompted voiding. This consisted of 2‐hourly toileting prompts followed by staff assisted toileting using a mechanical lift combined with contingent reinforcement. |
| McDowell 1992 | Non RCT ‐ 7 individuals with Alzheimer's dementia and their caregivers in a pilot study with pre‐ and post‐evaluation of habit retraining. |
| O'Brien 1991 | RCT ‐ 378 adults involved in a prevalence study on urinary incontinence allocated to 4 sessions of pelvic floor muscle exercises and bladder training or deferred treatment delivered by a nurse. |
| Ouslander 1988 | Double blind placebo controlled trial ‐ 15 purposively selected nursing home residents. Intervention referred to as habit retraining but involved fixed every 2‐hour toileting schedule, staff education, recording form, reinforcement, and adjustment to schedule if possible compared with medication. Included in review on timed voiding. |
| Ouslander 1995 | A randomised placebo controlled, double‐blinded dose‐adjusted, crossover trial of oxybutynin with prompted voiding to 75 nursing home residents who had failed a prompted voiding alone program. |
| Palmer 1994 | Non RCT ‐16 residents of nursing homes served as their own controls in a pre‐ and post‐assessment of a 2‐hourly prompted voiding program. |
| Proctor 1999 | RCT ‐ 120 nursing home residents with behavioural problems allocated to either a behavioural training programme and education or control. A change in continence status was not an outcome. |
| Ramsay 1996 | RCT ‐ 74 women with mixed symptoms allocated to either inpatient or outpatient bladder training, physiotherapy, fluid manipulation, dietary advice and general support and advice. |
| Saltmarche 1991 | RCT ‐ 40 elderly men residing in a long‐term care facility allocated to a 10‐week program of either habit retraining or usual care. Excluded as outcome data insufficient for analysis. |
| Schnelle 1983 | Non RCT ‐ 21 residents from two nursing homes, randomly assigned to intervention or control groups. Intervention involved 1‐hourly wet/dry checks and prompted toileting with contingent reinforcement. |
| Schnelle 1988 | Non RCT ‐ 92 residents from 3 nursing homes purposively selected for pre‐ and post‐evaluation of cost of hourly wet/dry checks with prompted voiding and contingent reinforcement. 36 participants who were responsive were changed to a 2‐ hourly protocol. |
| Schnelle 1989,1990a | Non RCT ‐ 126 residents from 6 nursing homes purposively selected and then randomly assigned to intervention or delayed intervention groups for hourly wet/dry checks, prompted voiding and contingent reinforcement. |
| Schnelle 1990b | Follow‐up of 91 responsive individuals out of 126 participants who had been involved in a one hour prompted voiding intervention or delayed intervention were moved to a 2‐hour prompted voiding protocol. |
| Schnelle 1991 | Descriptive analysis of the implementation of a set of procedures for a 2‐hourly prompted voiding program and a 2 hourly changing schedule ‐ based on 81 purposively selected residents from 4 nursing homes. |
| Schnelle 1993 | A descriptive analysis of the 6 month outcomes of 76 out of 198 nursing home residents who were responsive to a 2‐hourly prompted voiding protocol. |
| Schnelle 1995 | RCT ‐ 76 nursing home residents allocated to either 2‐hourly prompted voiding or 2‐hourly prompted voiding combined with an exercise program. |
| Smith 1992 | RCT ‐ 20 nursing home residents assigned to intervention or control. The intervention which was referred to as prompted voiding was characterized by 4 phases involving the development of a schedule to enhance staff compliance with set toileting times (ie 5 times per day). The intervention is consistent with review definition of timed voiding. |
| Snape 1989 | Follow‐up study of a pre and post evaluation of treatment for detrusor instability. Treatment consisted of pelvic floor exercises, drugs as appropropriate and an intervention which was referred to as habit retraining. Examination of the intervention details indicates that it is consistent with the review definition of bladder training. |
| Sogbein 1982 | Non RCT ‐ 161 men in a geriatric hospital ‐ assigned treatment on basis of clinical symptoms. 20 men with detrusor hyperreflexia received 4 weeks of 2‐hourly voiding followed by 4 weeks of medication. |
| Sowell 1987 | Non RCT ‐ 24 purposively selected residents from a nursing home who had reverted to incontinence at the completion of a prompted voiding program. Pre‐ and post‐evaluation of the cost of 5 different methods of continence management. Allocated to either one of two different disposable products, one of two different washable products or a toileting procedure. No data on the nature of the toileting program. |
| Spangler 1984 | Non RCT ‐ Multiphase cross‐over study of 16 purposively selected non ambulant nursing home residents, matched according to levels of incontinence and dehydration and assigned to either regular receipt of offers of fluid and toileting assistance or random offers. |
| Subak 2002 | RCT involving 152 community‐dwelling women randomized to treatment or deferred treatment. Treatment involved bladder training which followed individualised voiding schedules which were based on each participant's baseline daytime voiding frequency. Examination of the intervention indicated that it is consistent with the review definition of bladder training (ie involved patient education, pelvic floor muscle exercises and progressive increases in intervoiding intervals). |
| Surdy 1992 | RCT ‐ 12 nursing home residents randomised to either control or prompted voiding. Prompted voiding involved 2‐hourly wet/dry checks, prompted toileting and contingent reinforcement. |
| Szonyi 1995 | RCT ‐ 57 elderly adults with detrusor instability randomised to either bladder training or medication. |
| Tobin 1986 | Quasi‐randomised controlled trial ‐ 278 residents from 30 residential homes for the elderly allocated on basis of clinical symptoms to an individualised medical management program combined with 2‐hourly toileting for those with urge incontinence. |
| Wilder 1997 | Case study involving 1 male adult with profound "mental retardation" ‐ received 30 minute toileting plus contingent reinforcement (ie prompted voiding). |
| Williams 2005 | RCT ‐ with 3 and 6 month follow‐up 3746 adults aged 40 years and over living in the community randomised to 8 week intervention package including diet advice, bladder training, pelvic floor awareness and lifestyle advice or standard care including GP and continence advisory services in the area. |
| Wiseman 1991 | RCT ‐ 37 frail adults with detrusor instability randomised to either bladder training with medication or bladder training with placebo. |
| Wyman 1997 | RCT ‐ 123 older community dwelling women randomised to 6 weeks of either bladder training or control. |
| Wyman 1998 | RCT ‐ 204 women with genuine stress incontinence and/or detrusor instability randomised to 12 weeks of bladder training, pelvic floor muscle exercises with biofeedback or combination therapy. |
Contributions of authors
The review protocol was written by one reviewer (J. Ostaszkiewicz). For the first published review two reviewers (J. Ostaszkiewicz, L. Johnston) independently screened all retrieved publications and selected those which met the inclusion criteria. Data extraction and critical appraisal of selected trials were undertaken by external colleagues working independently of each other. One reviewer (J. Ostaszkiewicz) wrote the review and both co‐reviewers contributed to the writing of the review.
Issue 1, 2008 The update of the review was written by two reviewers (J. Ostaszkiewicz & B. Roe). Two reviewers (J. Ostaszkiewicz, & T. Chestney) independently screened all retrieved publications, selected those, which met the inclusion criteria, extracted data and conducted the critical appraisal of selected trials.
Sources of support
Internal sources
Victorian Centre for Nursing Practice Research, Australia.
External sources
No sources of support supplied
Declarations of interest
None known.
New search for studies and content updated (no change to conclusions)
References
References to studies included in this review
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