Committee 10 B

Conservative Management in Men

Chairman A. KONDO (JAPAN)

Members TL. LIN (TAIWAN, CHINA), J. NORDLING (DENMARK), M. SIROKY (USA), T. TAMMELA (FINLAND),

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CONTENTS Chapter 10B

VI. PHARMACOTHERAPY FOR STORAGE SYMPTOMS AND NOCTURIA

I. INTRODUCTION II. LIFESTYLE INTERVENTIONS IN MALE ADULTS

1. BACKGROUND 2. DRUG THERAPY

FOR DTORAGE DYMPTOMS

IN MEN

1. BACKGROUND

3. DRUGS FOR NOCTURIA 4. SUMMARY

2. REDUCTION IN BODY WEIGHT 3. REDUCTION IN CIGARETTE SMOKING 4. REDUCTION IN CAFFEINE INTAKE

VII. BEHAVIORAL THERAPY FOR MALE ADULTS

5. REDUCTION IN FLUID INTAKE 6. REDUCTION IN ALCOHOL

1. BACKGROUND 2. BLADDER TRAINING 3. TIMED (SCHEDULED) VOIDING 4. PROMPTED VOIDING 5. SUMMARY

7. SUMMARY III. NOCTURNAL ENURESIS IN MALE ADULTS 1. BACKGROUND

VIII. PELVIC FLOOR MUSCLE TRAINING AND ELECTROSTIMULATION

2. PRIMARY NOCTURNAL ENURESIS 3. SECONDARY NOCTURNAL ENURESIS 4. SUMMARY

1. URGE INCONTINENCE 2. STRESS INCONTINENCE 3. CHRONIC PELVIC PAIN SYNDROME 4. GERIATRIC PATIENTS 5. SUMMARY

IV. POST- PROSTATECTOMY INCONTINENCE 1. BACKGROUND 2. QUALITY OF STUDIES 3. NON-SURGICAL INCONTINENCE

IX. DEVICES FOR CONTAINMENT OF URINARY INCONTINENCE

4. MECHANISMS OF POST-PROSTATECTOMY INCONTINENCE

1. BACKGROUND 2. ABSORBENT PRODUCTS 3. COLLECTING DEVICES 4. OCCLUDING DEVICES 5. SUMMARY

5. RISK FACTORS FOR POST-PROSTATECTOMY INCONTINENCE

6. TREATMENTS OF POST-PROSTATECTOMY INCONTINENCE 7. SUMMARY

X. GENERAL CONCLUSIONS

V. POST-MICTURITION DRIBBLING

XI. FUTURE RESEARCH AND RECOMMENDATIONS

1. MECHANISM AND INCIDENCE 2. TREATMENTS

REFERENCES

3. SUMMARY

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Conservative Management in Men A. KONDO TL. LIN, J. NORDLING, M. SIROKY, T. TAMMELA

I. INTRODUCTION

II. LIFESTYLE INTERVENTIONS IN MALE ADULTS

Urinary incontinence jeopardizes the dignity and health of patients. In addition to consuming considerable resources, it is associated with embarrassment, stigmatization, isolation, depression, loss of morale, and/or increased risk of institutionalization. Furthermore, it constitutes a considerable burden to families and caregivers [1-3] 1-3 and predisposes the patient to perineal rashes, pressure ulcers, urinary tract infection, falls and bone fractures. The prevalence of urinary incontinence is about 10% among men who reside in the community and are otherwise healthy and about 30% among women [4]. 4

1. BACKGROUND There are no prospective, randomized studies on the effect of life style interventions on urinary incontinence in males. Most of our information comes from epidemiological studies that have investigated associations between life style and urinary incontinence.

2. REDUCTION IN BODY WEIGHT In women a significant correlation between body mass index and urinary incontinence has been reported [5] 5 but no similar study has been reported in males. In a cross-sectional study in male patients, body weight and body mass index did not correlate with lower urinary 6 tract symptoms (LUTS) (C) [6].

Male incontinence may result from inappropriate life styles, disturbances in bladder or sphincter function, distorted environmental parameters, and/or a combination of these disorders. The major causes of male incontinence are nocturnal enuresis, post-prostatectomy incontinence and post-micturition dribbling. These vesicourethral dysfunctions may be caused by detrusor overactivity, chronic infection, irradiation, bladder outlet obstruction, bladder malignancy or neurologic lesions. Unlike the female, in men sphincteric incompetence occurs rarely but may be due to trauma, surgery to the prostate or neurologic disorders. We herewith discuss incidence, risk factors, and management of urinary incontinence in adult males by means of conservative treatment modalities. Since the elderly population has been increasing rapidly especially in the developed countries, there is increasing need for devices for containment of urinary incontinence. These devices must be evaluated from the therapeutic and economical point of view.

3. REDUCTION IN CIGARETTE SMOKING In animal models, nicotine has been demonstrated to produce phasic contractions of the urinary bladder [7, 7 8]. 8 Although an association between cigarette smoking and incontinence in adult women has been described [9, 9 10], 10 not until quite recently have there been reports on the association of cigarette smoking and LUTS in males. KoskimŠki et al. [11] 11 reported an association between smoking and LUTS as measured by the Danish Prostatic Symptom ScoreÐ1, especially bothersomeness including urgency and urge incontinence. Compared with individuals who had never smoked, age-adjusted odds ratios of LUTS were 1.47 (95% CI 1.09-1.98) for current smokers and 1.38 (1.08-1.78) for former smokers. The association of cigarette smoking with 6 who LUTS was confirmed by Haidinger et al. [6] observed a highly significant positive correlation between the numbers of cigarettes smoked per day and the

When we looked for references, we have been cautious not to be much involved in urinary incontinence among frail, elderly people wherever possible, since that is discussed in other committees.

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irritative score of the International Prostatic Symptom Score (IPSS). In addition, in a population of 528 men aged 60-89 the odds ratio of urgency for current smokers was 2.55 (95% CI 1.13-5.73) and for former smokers 1.28 (0.68-2.41) compared with those who had 12 These findings support the suggesnever smoked [12]. tion that smoking may cause urge incontinence and that the adverse effects of smoking are to some extent reversible once smoking ceases. These facts imply that smoking should be discouraged.

alcohol consumption have been identified to be significantly correlated with urgency and urge urinary incontinence (B). It is suggested that smoking should be discouraged (D). On the other hand there are conflicting reports of caffeine intake and fluid intake on urinary incontinence (C). Body mass index does not correlate with LUTS in male adults (C).

III. NOCTURNAL ENURESIS IN MALE ADULTS

4. REDUCTION IN CAFFEINE INTAKE It has been demonstrated that, following administration of caffeine, a statistically significant increase in detrusor pressure occurs during bladder filling in patients with detrusor instability whereas in normal patients no cystometric abnormality is noted [13]. 13 However, there are conflicting data on the clinical significance of coffee or tea drinking in urinary incontinence. Some studies have not found any relation between caffeine inta14 15] 15 whereas 5 12 ke and urinary incontinence [5, 12, 14, others have reported an association between high caffeine intake and detrusor overactivity [16]. 16 Although decreased caffeine intake has often been advocated for 17 the evidenthe treatment of urinary incontinence [17], ce for that is weak (C).

1. BACKGROUND Nocturnal enuresis in adults may not only lead to embarrassment and discomfort but also affect careers, social life and personal relationships. Enuresis can be defined as any involuntary loss of urine; it may be nocturnal, both nocturnal and diurnal, or diurnal alone. Primary nocturnal enuresis refers to the patient who has never been dry at night, and secondary or acquired nocturnal enuresis refers to the patient who has been dry for at least a year before the onset of present enuresis. High pressure chronic retention is an uncommon but important cause of leakage at night (nocturnal enuresis) in old men. Other pathologic conditions such as detrusor overactivity, low compliance and chronic retention, will lead to upper urinary tract dilation and impair renal function. Reasons for secondary enuresis include psychosomatic factors such as dysfunctional voiding 22 [2224], 24 sleep disorders, organic factors such as tethered cord syndrome [25], diabetes mellitus, constipation 25 [26], 26 abnormal diurnal rhythm of plasma vasopressin [27], 27 and certain abnormalities manifested by abnormal 28 29]. 29 ECG patterns [28,

5. REDUCTION IN FLUID INTAKE Urine loss has been shown to be significantly related to fluid intake in geriatric patients [18, 19 (B). Overhy18 19] dration was found in the majority of the elderly who complained of pollakisuria when frequency-volume charts were utilized [20] 20 (C). Although reduction in fluid intake has been recommended in the treatment of urinary incontinence [17], 17 no relation was found between reduction in fluid intake and outcome in treating urinary incontinence in frail, elderly people [14] 14 or older women living at home [15]. 15 In fact, completely opposite findings recommending increased fluid intake 21 There is no strong evihave also been reported [21]. dence to recommend reduction in fluid intake for the treatment of urinary incontinence (C).

2. PRIMARY NOCTURNAL ENURESIS

7. SUMMARY

Although it is believed that the majority of enuretics will easily and spontaneously cure as they grow older, a large-scale survey of bedwetting in the Netherlands found that 0.6% of male adults still suffered from noc30 In a large Finnish study of 11220 turnal enuresis [30]. subjects aged 33-60 years, the corresponding number was 0.3% [31]. 31 The latter study involved twins and confirmed the central role of genetic liability in adult enuresis. Treatment modalities for primary enuresis include an alarm bell [32], 32 desmopressin (DDAVP) at bedtime [33] 33 and antimuscarinic agents such as oxybutynin [34]. 34 Secondary enuresis should be treated according to the causative factors involved. Strategies for this pathology will be covered in more detail by the childrenÕs committee.

Several studies have reported the effects of life style on urinary incontinence. Cigarette smoking and regular

30 studied a random sample of 4527 Hirasing et al. [30] non-institutionalized Dutch male adults (18-64 years

6. REDUCTION IN ALCOHOL In a cross-sectional study, regular alcohol consumption resulted both in higher total IPSS (p=0.01) and irritative scores (p=0.02) (B) [6]. 6 However, in a population based survey involving 1059 people aged 60-89, alcohol use did not predict urgency [12]. 12

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old) in 1997 and found that 0.6% of them had nocturnal enuresis at least once in the past 4 weeks. Fifty percent of the enuretic patients had primary enuresis nocturna and never consulted a care provider. Previously, Forsythe and Redmond [35] 35 observed that 33 (3%) of 1129 former patients who attended the Enuretic Clinic were still wetting after 20 years. Torrens and Collins [36] 36 studied 54 adults having enuresis with the largest number of them being in their 20Õs. Seventy percent (70%) demonstrated either detrusor overactivity or low blad37 urodynamider compliance. Whiteside and Arnold [37] cally investigated 50 patients with persistent primary enuresis 25 of whom were >20 years old. They found that nocturnal enuresis was associated mainly with normal detrusor function while nocturnal plus diurnal enuresis was mainly associated with detrusor overactivity McGuire and Savastano [38] 38 studied 55 adults with enuresis, 13 of whom (24%) were adults. They observed detrusor overactivity was the predominant clinical finding in these patients. Fidas et al. [39] 39 studied 25 primary adult enuretics with a mean age of 28 years by means of urodynamic assessment and neurophysiological measurements of static EMG and sacral reflex latencies (SRL). Detrusor overactivity was present in 15 patients (60%) and abnormal neurophysiological measurements were found in 88% of them. Hunsballe [40] 40 found increased delta activity in electroencephalography among adult primary enuretics compared to normal controls indicating increased depth of sleep.

time incontinence, nocturnal enuresis was due to severe bladder outlet obstruction and resolved after treatment of obstruction. In a group of patients with delayed presentation of posterior urethral valves the most common presenting symptom was diurnal enuresis in 60% 46 [46].

c) Endocrine disease 47 studied 30 consecutive patients with Goswami et al [47] active GravesÕ disease (thyrotoxicosis) whose age averaged 31 years. Of the patients 12 (40%) had some bladder symptoms and 4 (13%) had nocturnal enuresis. These pathologies resolved after euthyroidism was achieved.

d) Sleep apnea In the elderly obstructive sleep apnoea might be a cause 48 Treatment with nasal contiof nocturnal enuresis [48]. nuous positive airway pressure was more effective than conservative treatment (B).

e) Drug induced enuresis It has been known for some time that some patients suffer from drug-induced enuresis and/or retention for a certain period of time. Since resolution of this pathology is directly associated with cessation of taking the drug(s), it is essential to identify medications such as 49 thioridazine for psychiatric patients [49], risperidone 50 and prazosin for hypertension for schizophrenia [50], 51 [51].

3. SECONDARY NOCTURNAL ENURESIS 4. SUMMARY

a) Diabetic cystopathy

The incidence of nocturnal enuresis in the male adultpopulation is 0.3-0.6% (B). The majority of those with primary enuresis suffered from detrusor overactivity (50-70%) (C). Etiologies of secondary enuresis include bladder outlet obstruction, diabetic cystopathy, obstructive sleep apnea, GravesÕ disease, anti-psychotic medication, alpha-antagonists for hypertension, and so on (C). If one finds causative factors of underlying diseases or medications, the treatment should be directed to these pathologies (C). Strategies for managing this condition will be covered in more detail by the childrenÕs committee.

Diabetic cystopathy refers to the spectrum of voiding dysfunction in patients with diabetes mellitus. This is marked by insidious onset and progression with minimal symptomatology. Although the common urodynamic findings are impairment of bladder sensation, increased post-void residual volume and decreased detrusor contractility, involuntary contractions are fre41 Kitami [42] 42 stuquently observed in these patients [41]. died 173 diabetic patients. Of the patients, 32 (18%) suffered from urinary incontinence and detrusor overactivity was observed in 13 of the 32 patients (41 %). 43 observed an even higher rate of Starer & Libow [43] urinary incontinence in elderly patients. Of 23 patients with mean age of 80, 17 (74%) suffered from urinary incontinence and detrusor instability was found in 13 (76%) of them. In experimental animals Andersson et al. [44] 44 observed in a cystometric study of diabetic rats, that there was an increased compliance, a higher threshold volume for initiating a micturition reflex without residue and spontaneous rhythmic contractions.

IV. POST- PROSTATECTOMY INCONTINENCE 1. BACKGROUND We are here concerned with conservative treatment of post-prostatectomy incontinence, defined as any treatment strategy not involving surgical intervention. Prostatectomy, especially when performed for control of

b) Outlet obstruction Sakamoto et al [45] 45 found that in 8 males without day-

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be associated with neurogenic detrusor overactivity [65]. 65

cancer, continues to be an important cause of incontinence in the male. Incontinence rates following radical prostatectomy vary widely among different series due to disparities in patient selection and in the definition of incontinence (some degree of incontinence versus total incontinence). Greater understanding of the anatomy of the prostatic apex and the perineal floor, as well as attention to details of surgical technique, have all contributed to improvements in continence rates. If further improvement is to be achieved, we shall have to increase our understanding of the mechanisms, risk factors and preventive strategies related to post-prostatectomy incontinence.

c) Diminished bladder compliance and capacity These findings seem to accompany the aging process 56 Severe diminution of bladder capacity may follow (56]. 66 Ischemic changes of the detrupelvic irradiation [66]. sor muscle may play a role in the loss of bladder compliance [67]. 67

4. MECHANISMS OF POST-PROSTATECTOMY INCONTINENCE

The table analyzes 573 patients described in 8 articles [68-75] 68-75 who suffered urinary incontinence after undergoing surgery for benign prostatic hyperplasia or prostatic cancer. Urodynamic studies identified 34% of patients as having sphincter incompetence, 26% as having detrusor overactivity and 33% of mixed incontinence. Other factors such as low compliance were responsible for the remaining 7%. Figure 1 schematically illustrates the proportion of these findings.

2. QUALITY OF STUDIES There are 4 recent randomized controlled trials of pelvic floor training dealing with urinary incontinence following radical prostatectomy [52-55] 52-55 in a total of 318 patients. In this section, evidence for the efficacy of various conservative approaches to this distressing problem is reviewed.

a) Transurethral (TURP) and open prostatectomy

3. NON-SURGICAL INCONTINENCE

The incidence of incontinence following transurethral prostatectomy continues to be low, approximately 1% (76]. Patient continence following TURP depends on a normal bladder filling and an intact distal striated muscle sphincter. The pelvic floor muscles normally provide additional closure during periods of increased abdominal pressure such as during coughing or laughing as well as during periods of detrusor overactivity. Kahn et al. reported [71] 71 that sphincteric incompetence alone accounted for approximately 25% of incontinence patients following TURP. The remaining 6075% of patients had detrusor overactivity, either alone or in combination with sphincteric incompetence. Although it is well known that detrusor overactivity fol-

In men without a prior history of surgery, pelvic surgery or trauma, incontinence is almost always due to abnormalities of bladder function. Sphincteric incompetence in men who have not had surgery is usually due to a neurological deficit (cauda equina or lower cord injury, myelomeningocele). Continuous or unconscious incontinence may mimic stress incontinence and may occur secondary to bladder outlet obstruction, impaired contractility or a combination of the two. Loss of storage function may be due to detrusor overactivity, neurogenic detrusor overactivity, and diminished bladder compliance.

a) Detrusor overactivity This pathology increases with aging in both men and women [56]. 56 In males bladder outlet obstruction is an additional etiologic factor. Relief of obstruction reverses detrusor overactivity in 50-60% of cases, although reversal is less common in the elderly [57]. 57 The mechanism of detrusor overactivity is incompletely understood at present. Increased electrical coupling between muscle fibers [58] 58 as well as denervation supersensitivity [59] may play a role. Detrusor overac59 tivity has been produced in an animal model of pelvic 60 ischemia [60].

b) Neurogenic detrusor overactivity This is caused by neurological conditions, most commonly stroke [61], dementia [62] 61 62 and ParkinsonÕs disease or multiple system atrophy [63, 64]. Even mild hypoperfusion of the cerebral cortex has been shown to

Figure 1 : A pie chart represents 4 major etiologies of postprostatectomy incontinence.

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Table 1 : Etiologies of post-prostatectomy incontinence are analyzed based on 573 patients reported in 8 articles [9-76]. Authors

Sphincter incompetence

Detrusor overactivity

Mixed incontinence

Others

Andersen (68) (n=34, 1978)

24%

44%

26%

6%

Fitzpatrick (69) (n=68, 1979)

26%

16%

38%

19%

Leach (70) (n=38, 1987)

40%

19%

42%

0

Kahn (71) (n=63, 1991)

22%

49%

25%

3%

Goluboff (72) (n=56, 1995)

5%

61%

34%

0

Chao (73) (n=74, 1995)

57%

4%

39%

0

Leach (74) (n=201, 1996)

41%

10%

25%

24%

Desautel (75) (n=39, 1997)

59%

3%

35%

3%

Mean

34%

26%

33%

7%

lowing TURP is common, it is unclear why postoperative detrusor overactivity causes incontinence in some patients but not in others.

detrusor hyperreflexia are at increased risk of incontinence following all types of prostatectomy. Such disorders include cerebrovascular disease, multiple sclerosis and ParkinsonÕs disease. Staskin et al noted that patients with ParkinsonÕs disease who had poor voluntary sphincter control suffered a significantly higher post-prostatectomy incontinence rate than did those 84 Recent stuwho had preserved voluntary control [84]. dies have confirmed this and pointed out that many severely debilitated patients with parkinsonism actually suffer from multiple system atrophy. Chandiramani et al stated that these patients should not undergo prostatectomy because urinary incontinence is unavoidable postoperatively [63]. 63 Peripheral neuropathy affecting the external sphincter is often mentioned as a risk factor [71] 71 but good studies are difficult to find.

b) Radical prostatectomy In comparison to TURP, incontinence is much more common after radical prostatectomy, whether performed by the retropubic or the perineal route. In patients who have had radical prostatectomy, the striated urinary sphincter may play a more important role (Table 1). In physician reported studies, the incidence of total incontinence is 0-5% and the incidence of stress incontinence requiring some degree of protection is 5-15% [77-79]. 77-79 In studies based on patient self-report, the incidence of any degree of incontinence is 66% and the incidence of pad use is 33% [80]. Many studies have indicated - somewhat surprisingly - that urethral incompetence alone is present in only about one third of cases 74 Detrusor overactivity alone accounts for 20% [72, 72 74]. and the remainder are due to a combination of these two factors. In contrast, more recent studies have found that sphincteric incompetence rather than bladder overactivity is the predominant factor causing post-radical pros73 75, 75 81]. 81 Patients who tatectomy incontinence [73, undergo a nerve-sparing radical prostatectomy appear to have a better chance of achieving continence than those undergoing standard radical prostatectomy [82]. 82 Recent enhancements to the nerve-sparing prostatectomy may preserve external sphincter function and shor83 ten the time to achieve post-operative continence [83].

5. RISK

b) Age Whenever it is specifically mentioned, increased age appears to be correlated with increased risk after radical prostatectomy incontinence. For example, in the study by Steiner et al, patients in the fifth decade had an incontinence rate of 2% in comparison to 14% for 82 patients in the eighth decade [82].

c) Radiation therapy Radical prostatectomy following radiation therapy to the prostates is rarely performed and is associated with 85 markedly higher incontinence rates [85].

d) Prior TURP

FACTORS FOR POST-PROSTATECTOMY

Although prior prostatectomy was reported to be associated with higher rates of incontinence in the past, modern series appear to show that prior TURP does not affect incontinence rates following radical prostatecto65 my [65].

INCONTINENCE

a) Neurological Disease Patients with neurological disorders associated with

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6. TREATMENTS OF POST-PROSTATECTOMY

cant after 4 weeks suggesting recovery of the muscle was substantial in patients of the control group. Since the exercise is simple and easy to perform, this should be recommended to all patients who undergo TURP. Van Kampen et al [53] 53 compared effects of PFMT and sham stimulation of placebo electrotherapy in those with radical prostatectomy. One hundred and two men following radical prostatectomy were randomized after catheter removal into two equal sized groups. A trained physiotherapist instructed PFMT in combination with initial ES and biofeedback in 50 men. Urinary continence was achieved after 3 months in 88% of the treatment group and 56% in the control group. At 1 year, continence rate was 95% and 81%, respectively, reducing the difference in proportion between treatment and control group being 14 % (95 % CI 2-27). In the treatment group, improvement in both duration and degree of incontinence was significantly better without side effects or risks from therapy than in the control group during the first 4 months. Moore et al. [52] 52 randomized 58 patients after radical prostatectomy to 3 groups: control group (short instructions on PFMT before surgery), intensive pelvic floor muscle training, and PFMT and electrostimulation. Although the patients were recruited 8 weeks after surgery, their urine loss averaged 463g/24 hours and was much more than that reported by van Kampen et al [53]. 53 The authors found no effects of either PFMT alone or in combination with ES compared with control treatment. The inconsistent conclusion may be explained by the degree of incontinence being very severe in their patients, the small number of patients in each group and the initial rapid spontaneous improvement of the sphincter component (463g at baseline to 115g 12 weeks after treatments) that masked any treatment benefits. 54 randomly allocated 100 men who were Bales et al. [54] scheduled to undergo radical prostatectomy to a group of intensive pelvic floor muscle trainings with biofeedback and to a control group that received only brief explanations of pelvic floor muscle trainings. Continence rates were not significantly different between the two group at 1, 2, 3, 4, and 6 months after surgery. There were some shortcomings in the study design compared to that of van Kampen et al. For instance, those assigned to PFMT had only one 45-min session of muscle training prior to surgery in BaleÕs patients compared to regular, frequent attendance to training programme in Van KampenÕs patients. It is quite likely that it is not PFMT itself but insufficient exposure to adequate and meaningful PFMT that led to treatment failure. Although sphincter muscle function recovers spontaneously after TURP in one month, PFMT enhances recovery of continence during the first few weeks. In patients who undergo radical prostatectomy, after an

INCONTINENCE

a) Patient selection Detrusor overactivity is an important contributing factor to postoperative incontinence. In patients with symptoms of urge incontinence, pre-operative urodynamics may be used to identify patients with severe overactivity or loss of bladder compliance who may do poorly in terms of regaining continence. Patients with severe parkinsonism or multiple system atrophy may be at particular risk and should be managed non-operatively if possible [71, 71 84]. 84

b) Modification of surgical technique During radical prostatectomy, careful anatomic dissection of the apex to preserve urethral length and fixation are important factors in reducing post-operative incontinence. Preservation of the anterior attachments of the urethra, including the puboprostatic ligaments, seems to aid in rapid achievement of post-operative continen86 This result may be due to preservation of the ce [86]. external sphincter complex.

c) Peri-operative pelvic floor training In males the effects of pelvic floor muscle training (PFMT) and electrical stimulation (ES) have been evaluated in patients suffering from post-prostatectomy incontinence. PFMT has been the mainstay of therapy and improvement has been reported in men who follow an intensive exercise regimen in nurse-run or physiotherapy clinics [87, 88]. Some have proposed that 87 88 continence is regained more rapidly when PFMT is 89 90], 90 biofeedback [91, augmented with ES [89, 91 92] 92 or transcutaneous electrical stimulation [93]. 93 Most studies suggest that these treatments are successful but control groups are missing, sample sizes are small, objective measures of incontinence are not included and longterm follow-up is lacking. Moreover, the uncontrolled nature of the studies does not account for a placebo effect that was reported to be as high as 25 % in women 94 95] 95 or for spontaneous improvewith incontinence [94, 96 ment that may occur up to 12 months after surgery [96, 97 Subjective improvement rates have varied between 97]. 60 and 82 %. So far four randomized controlled trials evaluating 55 ranPFMT and ES have been reported. Porru et al [55] domly assigned a total of 58 patients about to undergo TURP into a control group or an investigational group. The latter was instructed to contract the perineal muscles 45 times a day after the removal of the urethral catheter. Urge incontinence, terminal dribbling and voiding interval in those with PFMT significantly improved up to 3 weeks after surgery compared to the control. However this difference ceased to be signifi-

560

initial period of rapid improvement, incontinence continues to improve even beyond three months following surgery. Only a small minority of men had incontinence by 6 to 12 months. Therefore, there is an argument for delaying formal conservative management for at least three months and focusing intensive therapy on those with persistent incontinence. The data available suggest that PFMT and ES are beneficial in the management of post-prostatectomy urinary incontinence but the correct timing remains unclear.

petence, 26% suffered detrusor overactivity, and 33% suffered mixed incontinence (B). Pelvic floor muscle training is beneficial in the treatment of post-prostatectomy incontinence (B), although different study designs arrived at conflicting conclusions. Research on detrusor overactivity in association with prostatic surgery is strongly needed.

V. POST-MICTURITION DRIBBLING

d) Pharmacotherapy for post-prostatectomy incontinence

1. MECHANISM AND INCIDENCE

Urinary incontinence following transurethral or open prostatectomy for benign prostatic obstruction may be due to sphincter incompetence, detrusor overactivity, or combination of both factors [74, 74 75]. 75 Stewart et al. [98] 98 used phenylpropanolamine, a sympathomimetic agent, in patients with stress incontinence after prostatectomy. They found this agent to have low efficacy, particularly for severe incontinence. Khanna used ephedrine, phenylephrine or propranolol in patients with post-prostatectomy incontinence and achieved cure or improvement in 73% patients. However, KhannaÕs paper did not describe the type of incontinence and the study was not placebo-controlled [99]. The true effect of sympatho99 mimetics in treating post-prostatectomy stress incontinence is questionable (C). Detrusor overactivity following prostatectomy can be managed pharmacologically. Theodorou et al used oxybutynin on post-prostatectomy detrusor overactivity and found that 8 of 13(61.5%) patients either were cured or significantly improved [100]. Leach et al 100 found that 59% of incontinent patients following prostatectomy for benign prostatic obstruction were mainly due to Òhigh-pressure bladder dysfunction,Ó which included detrusor overactivity and/or low compliance. They treated bladder dysfunction with oxybutynin or propantheline initially followed by adding imipramine if initial medication failed. Although they reported an improvement in pad scores, which decreased from 2.69 to 1.69, there was no information on the efficacy of 74 Iselin et al reported an interesting individual drugs [74]. paper on managing early detrusor overactivity after TURP. They used oxybutynin 2 days after TURP and discovered that, compared with placebo, oxybutynin significantly decreased frequency, urgency and detrusor pressure at first sensation of filling (C) [101]. 101

Post-micturition dribbling is characteristic of male patients and is usually unrelated to either urethral stricture or urethral obstruction [102-104]. 102-104 This pathology is due to pooling of urine in the bulbous urethra after micturition, which later drains by gravity or body movement. In rare cases a urethral diverticulum may be the cause. Since this symptom itself is minor and does not threaten oneÕs life, not many patients visit urologists for treatments. Furuya et al. [105] 105 reported their study on incidence, frequency, and severity by sending questionnaires to 3034 healthy male subjects. Of the patients 2839 (94%) sent replies. The incidence of this condition was found to be 17%, which increased from 12% in those in their 20Õs to 27% in those in their 50Õs. One third of the patients experienced the dribbling once a week or more. Although 94% of them noted spotting or slight wetting of their underwear, 22% noticed their pants got considerably wet. Sommer et al. [106] 106 found in 572 men from 20 to 79 years of age a similar incidence but no increase with age. Peterson et al. [107] 107 evaluated the incidence of post-micturition dribbling in 1251 men with lower urinary tract symptoms (LUTS) by questionnaires in the ICS ÇBPHÈ study. They found that post-micturition dribbling was present in 67% of 1250 men but did not increase with age (69% in those < 60 years, 69% in those of their 60Õs and 65% in those > 70 years) and that post-micturition dribble bothered men the most among 19 subjective symptoms.

2. TREATMENTS Furuya and his associates [105] 105 mentioned that younger men prefer fashionable trunks which lack a front exit and inevitably compress the bulbous urethra from below during micturition. If this is the reason for this symptom, one should abandon this type of the underwear and put on a conventional one instead. Paterson et 107 compared treatment with counselling, urethral al. [107] milking and pelvic muscle exercise in a prospective, randomised study. They found counselling without effect, while both urethral milking and pelvic floor exercise were effective with pelvic floor exercise being the most effective.

7. SUMMARY Detrusor overactivity is a major contributing factor in post-prostatectomy incontinence. It is, however, not possible to predict whether this pathology will subside after TURP or radical prostatectomy. Urodynamically, 34% of incontinent patients suffered sphincter incom-

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In any case, it is advisable to recommend those who wet their underwear after voiding to thoroughly milk the anterior urethra, which is illustrated in figure 2, and/or to shake their pelvis rhythmically. If a wetting episode persists, urinary flowmetry and cystourethrography are suggested to rule out possible lower urinary tract pathology.

detrusor overactivity associated with bladder outlet obstruction. About 60% of symptomatic older men have bladder storage symptoms, including urgency, frequency and urge incontinence [108]. 108 Investigators have proposed several mechanisms explaining bladder outlet obstruction-induced overactivity. Steers et al. demonstrated an increased incidence of short latency spinal reflex in obstructed rats [109]. 109 Sibley et al. showed a partial denervation with resulting supersensitivity to cholinergic stimulation in obstructed pig bladders [110]. 110 Both findings indicated a neurogenic origin of obstruction-induced overactivity. Another proposed mechanism is increased alpha-adrenergic responses in the obstructed detrusor, as reported by Perlberg et al. [111]. 111 Theoretically, drugs aiming at reducing bladder outlet obstruction may concurrently improve storage LUTS. However, reports on pharmacotherapy of BOO usually compare the effects by a total symptom score, instead of emptying and storage symptoms, respectively. It is difficult to identify or compare the effects of these drugs on damaged storage functions, particularly for urge incontinence. Although storage LUTS associated with BOO can be improved by drugs targeting outlet obstruction, the improvement in symptoms is often not enough to satisfy the patient. An addition of an anticholinergic agent may improve storage LUTS, but at the same time may compromise bladder emptying, particularly in the presence of severe outlet obstruction or weak detrusor contractility. A recent study, however, describing the use of tolterodine in men with BOO showed no increase in voiding dysfunction [112]. 112 Dahm et al. [113] 113 used flavoxate and placebo to treat storage symptoms of patients with Òbenign prostatic hyperplasiaÓ. They found that flavoxate was not more effective than placebo for relieving symptoms. Chapple et al. have proposed a combination of alpha-1 adrenergic antagonist and anticholinergics to further ameliorate storage LUTS of patients with suspected BPO [114]. 114 Well-controlled studies are necessary to demonstrate the value of this combination therapy.

Figure 2 : This shows how to milk the bulbous urethra of those with post-voiding dribbling.

3. SUMMARY Post-micturition dribbling is a minor condition which does not hamper health but is a nuisance and causes discomfort and embarrassment (B). This symptom is present in 17% of healthy adults and 67% of those with LUTS (B). Since this condition is usually due to urine pooled in the bulbous urethra, it is advisable to thoroughly milk the urethra (B) and/or to rhythmically shake oneÕs pelvis prior to putting back the penis (D). Pelvic floor training might be even better treatment (B).

VI. PHARMACOTHERAPY FOR STORAGE SYMPTOMS AND NOCTURIA

3. DRUGS FOR NOCTURIA Urinary frequency (nocturia) and even urge incontinence at nighttime is one of the more debilitating urinary symptoms in males, greatly affecting sleep and quality of life, particularly for the elderly. Nocturia can be caused by nocturnal polyuria and/or decreased functional bladder capacity. Nocturnal polyuria may be due to aging-associated loss of renal concentrating ability, increased sodium excretion, decreased nocturnal production of anti-diuretic hormone or disturbance of renin-angiotensin-aldosterone axis. Decreased nocturnal functional capacity may be due to idiopathic or obstruction-induced detrusor overactivity, or due to increased residual urine. Sleep disorders may also contribute 115 to nocturia [115].

1. BACKGROUND Drugs managing lower urinary tract dysfunction have been applied on both the female and the male. There is no evidence of different effects of these drugs depending on sex. As for drugs for detrusor overactivity, the reader is referred to a chapter on the pharmacologic treatment prepared by other committee.

2. DRUG THERAPY FOR STORAGE SYMPTOMS IN MEN

Overactive detrusor symptoms in men are usually due to

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Pharmacotherapy of nocturia is based on the etiology. Theoretically, if nocturia is due to BPH-induced outlet obstruction, alpha-adrenergic antagonists and/or 5 alpha reductase inhibitors may decrease outlet obstruction and reduce nocturnal urinary frequency. However, there are no available data specifically addressing the effects of these drugs on nocturia. Encouraging urine excretion before sleep or decreasing urine production at nighttime are other techniques to manage nocturnal polyuria. In a double blind placebo-controlled study, Reynard et al. used the diuretic frusemide 6 hours before bedtime to reduce urine excretion at nighttime. Nocturnal voiding frequency and urinary production were 116 (B). significantly reduced [116]

VII. BEHAVIORAL THERAPY FOR MALE ADULTS 1. BACKGROUND Behavioral therapy refers to several techniques that modify patientsÕ voiding behavior to achieve urinary continence. These techniques include bladder training, timed voiding and prompted voiding. They are frequently combined to achieve maximum benefits.

2. BLADDER TRAINING In bladder retraining, the focus of treatment is on changing the patientÕs bladder habits. The goal is to reduce urinary incontinence by increasing bladder capacity and restore normal bladder function. This is accomplished by providing the patient with a voiding schedule and by gradually increasing the intervals between voids. In women 124 there is some evidence for the efficacy of bladder [124], training in the treatment of urge incontinence but in men that information is missing. Oxybutynin with bladder training was superior to bladder training alone in reducing frequency due to detrusor overactivity in very elderly people (mostly women) living at home [125]. 125 Bladder training may be helpful for the treatment of urge incontinence in males, but at this time there is insufficient evidence to come to any conclusion (D).

Several reports have demonstrated that desmopressin (DDAVP) before bedtime may decrease nocturnal urinary production with a reduction of nocturnal urinary frequency, particularly for patients with higher noctur118 (B). Since desmopressin 117 118] nal urinary volume [117, increases urine concentration and reduces total urine output, it has been shown to be effective and well tolerated in the treatment of nocturia in male adults [119]. 119 However, the optimal dosage is not determined yet. 120 Some investigators suggested 0.1mg is enough [120], while others advised 0.4mg [121]. Side effects of 121 DDAVP should be balanced with the benefits. With fluid retention induced by DDAVP, hyponatremia, 122 and care edema, or even heart failure may occur [122] should be exercised when used in the older men. The serum sodium should be checked 3 days after starting the treatment or changing the dose.

3. TIMED (SCHEDULED) VOIDING The patients are scheduled to void at a fixed interval, usually 2 to 4 hours. This technique allows the bladder to remain at a lower volume and thus avoid provoking involuntary detrusor contractions, particularly in the elderly patient with impaired mobility. The number of reports on using this technique specifically in male patients is limited. Sogbein et al. applied timed voiding in incontinent men in a geriatric hospital with an 85% improvement rate [126]. 126 Timed voiding may also help stress incontinence in men. Burgio et al. instructed timed voiding with 2-hour interval on 20 men with 127 which initially post-prostatectomy incontinence [127] resulted in 33.1% increase in urge incontinence and 28.5% decrease in stress incontinence. When biofeedback was subsequently taught to control the sphincter muscle and to inhibit the detrusor overactivity, urge and stress incontinence decreased 80.7% and 78.3%, respectively. Since this technique is simple and harmless, it can be recommended as an initial management for urinary incontinence in men (C).

In young adult enuretics, bedtime imipramine may decrease nocturnal urinary output curing nocturnal enuresis. The antidiuretic effect of imipramine may come from its alpha-adrenergic actions on proximal renal tubules with increased urea and water reabsorption more distally in the nephron [123]. 123 Whether imipramine also has similar effects in older individuals with nocturnal polyuria deserves further clinical investigation.

4. SUMMARY Drugs for storage symptoms are to be chosen depending on etiology of the condition. Anti-cholinergics in addition to drugs targeting outlet obstruction may be beneficial for those with outlet obstruction, urgency and urge incontinence (A). Nocturia due to nocturnal polyuria was favorably treated with frusemide or desmospressin (DDAVP) (B).

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4. PROMPTED VOIDING

PFMT supplemented with EMG biofeedback plus bladder training to 19 male patients with chronic pelvic pain syndrome. AUA symptom score and urgency score were significantly reduced by the therapy. However, only 10 patients completed full treatment sessions and the follow-up period was short (5.8 months). Whether the therapeutic benefits come from PFMT remains unclear (C).

This technique gives positive social reinforcement when patients, who are checked by caregivers at regular intervals, request toileting assistance. In contrast to timed voiding, the toileting is not scheduled in advance. This technique is mainly for the elderly with impaired cognitive function [128,129]. 128 129 There are no articles reporting this method specifically in men. Although published studies generally concluded the technique had a favorable effect, these studies are usually not adequately controlled. Other disadvantages of this method are that it requires considerable manpower and compliance from nursing staff [130] 130 (C).

4. GERIATRIC PATIENTS In geriatric patients PFMT and ES have been used as part of a combination of several therapies and interventions which makes it difficult to evaluate their roles in the treatment. In a randomized control study, McDowell et al. randomized 105 subjects comprising 95 females and 10 males aged 60 and older to either biofeedback-assisted PFMT or the control group. They observed that subjects treated with active treatments resulted in a clinically significant reduction in urinary incontinence in homebound older adults despite high levels of co-morbidity and functional impairment [137]. 137 This suggests that PFMT may be beneficial in the treatment of urinary incontinence in geriatric patients (B).

5. SUMMARY Bladder training, timed voiding and prompted voiding have been studied in male adults suffering from urinary incontinence. Due to lack of well-controlled studies, clinical effects are not convincing (C or D).

VIII. PELVIC FLOOR MUSCLE TRAINING AND ELECTROSTIMULATION

5. SUMMARY PFMT or ES can be offered as a first-line treatment for those with urge incontinence (C) and stress incontinence (B).

1. URGE INCONTINENCE The rationale behind the use of pelvic floor muscle training (PFMT) or electrical stimulation (ES) to treat urge incontinence is the observation that ES of the pelvic floor muscle inhibits detrusor contraction [131]. 131 The aim of therapy is to inhibit detrusor muscle contraction by voluntary contraction of the PFMs when urgency is present and to prevent sudden falls in urethral pressure [132]. 132 Several randomized, controlled studies have demonstrated that PFMT is more effective 133 134] 134 and more effective than than no treatment [133, other conservative methods in treating genuine stress 134 135] 135 (A). In PFMT with incontinence in women [134, biofeedback, the biofeedback is intended to increase the patientÕs motivation by demonstrating positive effects of their efforts. Hence the combination of biofeedback with PFMT may increase the effectiveness of the training and improve the outcome of treatment (C).

IX. DEVICES FOR CONTAINMENT OF URINARY INCONTINENCE 1. BACKGROUND For patients with intractable urinary incontinence, the goals of management should be 1) protection of skin, 2) protection of clothing and bedding, and 3) control of odor. The methods available may be divided into absorbent products, collecting devices and occluding devices. Figure 3 illustrates various kinds of absorbent products, collecting devices and occlusive devices available in the market.

2. ABSORBENT PRODUCTS

2. STRESS INCONTINENCE

Absorbent products are of three general types: 1. products designed to be worn inside underwear (pads, liners, shields, inserts), 2. diapers, both disposable and reusable, and 3. underpads for bedding.

This pathology in adult males is rare and mostly caused by surgery or trauma. PFMT following TURP or radical prostatectomy is effective and was discussed in the section on post-prostatectomy incontinence.

a) Pads and liners are worn inside conventional underwear or inside a built-in pouch. Their construction is 138 similar to that of diapers [138].

3. CHRONIC PELVIC PAIN SYNDROME In a descriptive study, Clemens et al [136] 136 applied

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4. OCCLUDING DEVICES The most common device in this category is the Cunningham clamp. Another version of the penile clamp is the C3 clamp made by Timm Medical. The Cunningham clamp consists of an adjustable clamp lined with soft foam-like material as a cushion. The C3 device is a Styrofoam urethral cushion held in place with a Velcro strap. The Cunningham clamp has the advantage of low cost, simplicity of use and effectiveness. However, it is unsightly and for many patients it is uncomfortable to wear. The C3 device is smaller and lighter than the Cunningham but is somewhat less effective as an occluding device. The Cunningham clamp should be put around the penis and closed only tight enough to occlude the urinary leak. Problems arise when the clamp is worn too long or closed too tightly, leading to skin necrosis, urethral erosion or peri-urethral abscess.

Figure 3 : Absorbent and collecting devices available on the market.

b) Disposable diapers are convenient and popular but expensive [139]. 139 They are generally constructed of a soft inner lining, an absorbent middle layer and a waterproof outer layer [140]. 140 The absorbent middle layer is made of cellulose fibers with or without the addition of polymers that gel with urine. The waterproof outer layer is made of rayon, polyester, polypropylene or polyethylene. Skin sensitization from rosin allergens in diapers has been described [141]. 141

5. SUMMARY Disposable pads and diapers are effective but costly to purchase. This cost difference is ameliorated by savings in labor costs and better skin protection in incontinent patients. Though level of evidence is low, it is common knowledge that the condom catheter is by far the most commonly used external collecting device in males. Careful attention to its use should be paid to enhance its effectiveness and reduce complications. Our society where the elderly have been rapidly increasing depends heavily on these products to deal with urinary and fecal incontinence. Consequently it is important that these products have to be prepared and evaluated from the therapeutic and economic point of view.

c) Since wet bed sheets have a markedly increased coefficient of friction, increasing the risk of skin abrasion, the use of effective bedding underpads is important in protecting the skin of incontinent patients [142]. 142 The polymer underpad seems to be the most effective in containing urine [143-145]. 143-145 d) Failure of absorbent products occurs when the absorbing material is saturated beyond its capacity. Improper fitting at the legs is also a common reason for failure. Skin irritation or reaction (diaper rash) remains a major 146 problem [146].

X. GENERAL CONCLUSIONS ¥ Urinary incontinence in male adults cab be satisfactorily cured or managed provided pathologies and etiologies are clearly identified. ¥ Smoking habits increase the prevalence of lower urinary tract symptoms 1.5 times compared to non-smokers and stopping smoking decreases odds ratios (B). Accordingly, it is advised that cigarette smoking should be discouraged (D). Reductions in body weight, in caffeine intake, in fluid intake or in alcohol consumption are not known to significantly improve urinary incontinence (C). ¥ The prevalence of nocturnal enuresis is 0.3 to 0.6% in large randomly sampled population studies and 2.9% in former enuretics. Although the cause of nocturnal enuresis is multifactorial, a majority of patients suffer from detrusor overactivity (C). Secondary nocturnal enuresis should be treated by looking for underlining causative factors.

3. COLLECTING DEVICES Urine collecting devices are used by 10-15% of all nursing home residents and by about 50% of those who are bedridden [147]. 147 A variety of devices are available, including the condom sheath, the McGuire urinal and the drip collector. The condom sheath is the most widely used because of convenience, low cost and disposability. However, there are risk factors associated with 148 penile ischethese devices, including dermatitis [148], mia/necrosis, urethral erosion and increased incidence 149 Guarding against excessive of urinary infection [149]. pressure on the penis is especially important in patients with impaired sensation. Limiting factors may include small penile size and redundant foreskin. It may be necessary to perform a circumcision or penile implant 150 to facilitate placement of a condom sheath [150].

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¥ Risk factors related to post-prostatectomy incontinence have to be investigated prior to surgery (C). Urodynamic studies of patients with post-prostatectomy incontinence show this to have several causes, including sphincter incompetence, detrusor overactivity, or mixed incontinence (B). Pelvic floor muscle training (PFMT) is beneficial in the treatment of post-prostatectomy incontinence (B), although different study designs arrived at conflicting conclusions. ¥ Post-micturition dribbling is present in 17 to 51% of male adults. The etiology is pooling of urine in the bulbous urethra. Clinical managements include pelvic floor muscle training and milking the bulbous urethra immediately after micturition, (B). ¥ Storage LUTS with BOO was shown to be successfully treated by anti-cholinergics (A). Desmopressin and frusemide (B) were of effect for the treatment of urinary frequency and nocturia. ¥ The effects of behavioral treatments such as bladder training, timed voiding and prompted voiding are not supported by strong evidence (C). ¥ Pelvic floor muscle training and electro-stimulation are effective for those suffering from stress incontinence (B) or urge incontinence (C). ¥ Devices for containment of incontinence are effective but lack well-controlled studies.

4. Kondo A, Saito M, Yamada Y, Kato T, Hasegawa S, Kato K. Prevalence of hand-washing urinary incontinence in healthy subjects in relation to stress and urge incontinence. Neurourol Urodyn 11: 519-23, 1992. 5. Burgio KL, Matthews KA, Engel BT. Prevalence, incidence and correlates of urinary incontinence in healthy, middle aged women. J Urol 146:1255-9, 1991. 6. Hadinger G, Temml C, Schatzl G, Brossner M, Schmidbauer CP, Madersbacher S. Risk factors for lower urinary tract symptoms in elderly men. Eur Urol 37: 413-20, 2000. 7. Koley B, Koley J, Saha Jk. The effects of nicotine on spontaneous contractions of cat urinary bladder in situ. Br J Pharmacol 83: 347-55, 1984. 8. Hisayama T, Shinkai M, Takayanagi I, Toyoda T. Mechanism of action of nicotine in isolated bladder of guinea-pig. Br J Pharmacol 95: 465-72, 1988. 9. Bump & Mcclish DM.Cigarette smoking and pure genuine stress incontinence of urine: a comparison of risk factors and terminants between smokers and non-smokers. Am J Obstet Gynecol 170: 579-82, 1994. 10. Tampakoudis P, Tantanassis T, Grimbitzis G, Papaletsos M, Mantalenakis S. Cigarette smoking and urinary incontinence in women: a new calculative method of estimating the exposure to smoke. Eur J Obstet & Gynecol and Reprod Biol 63: 27-30, 1995. 11. KoskimŠki J, Hakama M, Huhtala H, Tammela TLJ. Association of smoking with lower urinary tract symptoms. J Urol 159: 1580-2, 1998. 12. Nuotio M, JylhŠ M, Koivisto A-M, TammelaTLJ. Association of smoking in urgency in older people. Eur Urol, in press (2001). 13. Creighton Sm, Stanton SL. Caffeine: does it affect your bladder? Br J Urol 66: 613-4, 1990. 14. Fried GW, Goetz G, Potts-Nulty S, Cioschi Hm, Staas WE, JR. A behavioral approach to the treatment of urinary incontinence in a disabled population. Arch Phys Med Rehabil 76: 1120-4, 1995.

XI. FUTURE RESEARCH AND RECOMMENDATIONS

15. Tomlinson BU, Dougherty Mc, Pendergast JF, Boyington AR, Coffman MA, Pickens SM. Dietary caffeine, fluid intake and urinary incontinence in older rural women. Int Urogynecol J Pelvic Floor Dysfunct 10: 22-8, 1999.

Randomized controlled trials (RCTs) are necessary to assess the effectiveness of lifestyle interventions. Further studies on the pathophysiology of detrusor overactivity especially associated with bladder outlet obstruction are needed. RCTs of pelvic floor muscle training (PFMT) for those having post-prostatectomy incontinence are necessary in large randomized samples in order to identify its real value and to assess the correct time to initiate PFMT. Pharmacological research is needed to satisfactorily treat nocturia caused by nocturnal polyuria. Devices for the containment of urinary incontinence should be produced and evaluated from the therapeutic and economic point of view.

16. Arya LA, Myers DL, Jackson ND. Dietary caffeine intake and the risk for detrusor instability: a case-control study. Obstet Gynecol 96: 85-9, 2000. 17. Iqbal P, Castleden CM. Management of urinary incontinence in the elderly. Gerontology 43: 151-7, 1997. 18. Griffiths DJ, Mccracken PN, Harrison GM, Gormley EA. Relationship of fluid intake to voluntary micturition and urinary incontinence in geriatric patients. Neurourol Urodyn 12: 1-7, 1993. 19. Griffiths DJ, Mccracken PN, Harrison GM, Moore KN. Urge incontinence in elderly people: factors predicting the severity of urine loss before and after pharmacological treatment. Neurourol Urodyn 15: 53-7, 1996. 20. Saito M, Kondo A, Kato T, Yamada Y. Frequency-volume charts: Comparison of frequency between elderly and adult patients. Br J Urol 72: 38-41, 1993. 21. Dowd TT, Campbell JM, Jones JA. Fluid intake and urinary incontinence in older community-dwelling women. J Community Health Nurs 13: 179-86, 1996. 22. Hinman F, Baumann FW. Vesical and ureteral damage from voiding dysfunction in boys without neurologic or obstructive disease. J Urol 109:727-732, 1973. 23. Baumann FW, Hinman F. Treatment of incontinent boys with non-obstructive disease. J Urol 111:114-116,1974.

REFERENCES 1. Resnick NM. Geriatric incontinence. Urol Clin North Am 23: 5574, 1996. 2. Herzog AR, Diokno AC, Fultz NH. Urinary incontinence: Medical and psychological aspects. Ann Rev Gerontol Geriatr 9: 74119, 1989. 3. Wyman JF, Harkins SW, Fantl JA. Psychological impact of urinary incontinence in the community-dwelling population. J Am Geriat Soc 38: 282-8, 1990.

24. Hinman F, Jr. Nonneurogenic neurogenic bladder (the Hinman syndrome): 15 years later. J Urol 136:769-777, 1986.

566

25. Kondo A, Kato K, Kanai S, Sakakibara T. Bladder dysfunction secondary to tethered cord syndrome in adults: is it curable? J Urol 135:313-316, 1986.

49. Berrios GE. Temporary urinary incontinence in the acute psychiatric patient without delirium or dementia. Br J Psychiatry 149: 224-7, 1986.

26. OÕRegan S, Yazbeck S, Hamberger B, Schick E. Constipation a commonly unrecognized cause of enuresis. Am J Dis Child 140:260-261, 1986.

50. Poyurovsky M, Weizman A. Risperidone-induced nocturnal enuresis. Isr J Psychiatry Relat Sci 34:247-8, 1997. 51. Mathew TH, McEwen J, Rohan A. Urinary incontinence secondary to prazosin. Med J Aust 148:305-6, 1988.

27. Ritting S, Knudsen UB, Norgaard JP, Pedersen EB, Djurhuus JC. Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. Am J Physiol 256:F664-71, 1989.

52. Moore KN, Griffiths D, Hughton A. Urinary incontinence after radical prostatectomy: a randomized controlled trial comparing pelvic muscle exercises with or without electrical stimulation. Brit J Urol 83: 57-65, 1999.

28. Campbell EW, Jr., Young JD, Jr. Enuresis and its relationship to electroencephalographic disturbances. J Urol 96:947-9, 1966.

53. Van Kampen M, Deweerdt W, Van Poppel H, De RidderD, Feys H, Baert L. Effect of pelvic-floor re-education on duration and degree of incontinence after radical prostatectomy: a randomised controlled study. Lancet 355: 98-102, 2000.

29. Watanabe H, Kawauchi A, Kitamori T, Azuma T, Azuma Y. Treatment system for nocturnal enuresis according to an original classification system. Eur Urol 25:43-50, 1994.

54. Bales GT, Gerber GS, Minor TX, Mhoon DA, McFarland JM, Kim HL, Brendler CB. Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy. Urology 56: 627-30, 2000.

30. Hirasing RA, Van Leedam FJ, Bolk-Bennink L, Janknegt RA. Enuresis nocturna in adults. Scand J Urol Nephrol 31:533-536, 1997. 31. Hublin C, Kaprio J, Partinen M, Koskenvuo M. Nocturnal enuresis in a nationwide twin cohort. Sleep 21:579-585, 1998.

55. Porru D, Campus G, Caria A, Madeddu G, Cucci A, Rovereto B, Scarpa RM, Pili P, Usai E. Impact of early pelvic floor rehabilitation after transurethral resection of the prostate. Neurourol Urodyn 20: 53-9, 2001.

32. Elinder G, Soback S. Effect of Uristop on primary nocturnal enuresis. A prospective randomized double-blind study. Acta Paediatr Scand 74:574-578, 1985.

56. Madersbacher S, Pycha A, Schatzi G, Mian C, Klingler CH, Marberger M.The aging lower urinary tract: A comparative urodynamic study of men and women. Urology 51:206-12, 1998.

33. Vandersteen DR, Husmann DA. Treatment of primary nocturnal enuresis persisting into adulthood. J Urol 161:90-2, 1999. 34. Hjalmas K. Pathophysiology and impact of nocturnal enuresis. Acta Paediatr 86: 919-22,1997.

57. Gormley EA, Griffiths DJ, McCracken PN, Harrison GM, McPhee MS. Effect of transurethral resection of the prostate on detrusor instability and urge incontinence in elderly men. Neurourol Urodyn 12:445-453, 1993.

35. Forsythe WI, Redmond A. Enuresis and spontaneous cure rate. Study of 1129 enuretics. Arch Dis Child 49:259-63, 1974. 36

Torrens MJ, Collins CD. The urodynamic assessment of adult enuresis. Br J Urol 47: 433-40, 1975.

58. Elbadawi A, Yalla SV, Resnick N. Structural basis of geriatric voiding function. III. Detrusor overactivity. J Urol 150: 166880, 1993.

37. Whiteside CG, Arnold EP. Persistent primary enuresis: a urodynamic assessment. Br Med J 1:364-367, 1975. 38.

59. Speakman MJ, Brading AF, Gilpin CJ, Dixon JS, Gilpin SA, Gosling JA. Bladder outflow obstruction: a cause of denervation supersensitivity. J Urol 138:1461-6, 1987.

Mc Guire EJ, Sabastano JA. Urodynamic studies in enuresis and the nonneurogenic neurogenic bladder. J Urol 132:299-302, 1984.

60. Azadzoi KM, Tarcan T, Kozlowski R, Krane RJ, Siroky MB. Overactivity and structural changes in the chronically ischemic bladder. J Urol 162:1768-78, 1999

39. Fidas A, Galloway NT, Mcinnes A, Chisholm GD. Neurophysiological measurements in primary adult enuretics. Br J Urol 57:635-640,1985.

61. Marinkovic S, Badlani G. Voiding and sexual dysfunction after cerebrovascular accidents. J Urol 165: 359-70, 2001.

40. Hunsballe JM. Increased delta component in computerized sleep electroencephalographic analysis suggests abnormally deep sleep in primary monosymptomatic nocturnal enuresis. Scand J Urol Nephrol 34:294-302, 2000.

62. Griffiths DJ, Mccracken PN, Harrison GM, Gormley EA, Moore K, Hooper R, McEwan AJ, Triscott J. Cerebral aetiology of urinary urge incontinence in the elderly people. Age Ageing 23:246-250, 1994.

41. Kaplan SA, Blaivas JG. Diabetic cystopathy. J Diabet Complications 2: 133-39, 1988. 42. Kitami K. [Vesicourethral dysfunction of diabetic patients]. Nippon Hinyokika Gakkai Zasshi 82:1074-83, 1991. 43. Starer P, Libow L. Cystometric evaluation of bladder dysfunction in elderly diabetic patients. Arch Intern Med 150:810-813, 1990. 44. Andersson PO, Malmgren A, Uvelius B. Cystometrical and in vitro evaluation of urinary bladder function in rats with streptozotocin-induced diabetes. J Urol 139: 1359-62, 1988. 45. Goswami R, Seth A, Goswami AK, Kochupillai N. Prevalence of enuresis and other bladder symptoms in patients with active GravesÕ disease. Br J Urol 80:563-6, 1997 46. Sakamoto K, Blaivas JG. Adult onset nocturnal enuresis. J Urol 165: 1914-7, 2001. 47. Bomalaski MD, Anema JG, Coplen DE, KooHP, Rozanski T, Bloom DA. Delayed presentation of posterior urethral valves: a not so benign condition. J Urol 162: 2130-2132, 1999.

63. Chandiramani VA, Palace J, Fowler CJ. How to recognize patients with parkinsonism who should not have urological surgery. Br J Urol 80:100-104, 1997. 64. Singer C. Urinary dysfunction in ParkinsonÕs disease. Clin Neurosci 5:78-86, 1998. 65. Griffiths D. Clinical studies of cerebral and urinary tract function in elderly people with urinary incontinence. Behav Brain Res 92:151-155, 1998. 66. Schultheiss TE, Lee WR, Hunt MA, Hanlon AL, Peter RS, Hanks GE. Late GI and GU complications in the treatment of prostate cancer. Int J Radiat Oncol Biol Phys 37:3-11, 1997. 67. Azadzoi KM, Tarcan T, Siroky MB, Krane RJ. Atherosclerosisinduced chronic ischemia causes bladder fibrosis and non-compliance in the rabbit. J Urol 161: 1626-1635, 1999. 68. Andersen JT, Nordling J. Urinary incontinence after transvesical prostatectomy. Urol Int 33: 191-8, 1978. 69. Fitzpatrick JM, Gardina RA, Worth PHL. The evaluation of 68 patients with post-prostatectomy incontinence. Br J Urol 51: 552-5, 1979.

48. Kiely JL, Murphy M, Mcnicholas WT. Subjective efficacy of nasal CPAP therapy in obstructive sleep apnoea syndrome: a prospective controlled study. Eur Respir J 13: 1086-90, 1999.

567

70.

Leach GE, Yip CM, Donovan BJ. Post-prostatectomy incontinence: the influence of bladder dysfunction. J Urol 138: 574-8, 1987.

93. Krauss DJ, Lilien OM. Transcutaneous electrical nerve stimulator for stress incontinence. J Urol 125: 790-3, 1981. 94. Laycock J, Jerwood D. Does pre-modulated interferential therapy cure genuine stress incontinence? Physiotherapy 78: 553-60, 1993.

71. Khan Z, Mieza M, Starer P, Singh VK. Post-prostatectomy incontinence. Urology 38: 483-488, 1991. 72. Goluboff ET, Chang DT, Olsson CA, Kaplan SA. Urodynamics and postprostatectomy urinary incontinence: The initial Columbia experience. J Urol 153: 1034-7, 1995.

95. Sand PK, Richardson DA, Staskin DR, Swift SE, Appell RA, Whitmore KE. Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebocontrolled trial. Am J Obstet Gynecol 173: 72-9, 1995. 96. Jonler M, Madsen FA, Rhodes PR, Sall M, Messing EM, Bruskewitz RC. A prospective study of quantification of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy. Urology 48: 433-40, 1996. 97. Donnellan SM, Duncan HJ, Macgregor A, Russell JM. Prospective assessment of incontinence after radical prostatectomy: objective and subjective analysis. J Urol 49: 225-30, 1996. 98. Stewart BH, Banowsky LH, Montague DK. Stress incontinence: conservative therapy with sympathomimetic drugs. J Urol 115:558-559, 1976. 99. Khanna OP. Disorders of micturition: neuropharmacologic basis and results of drug therapy. Urology 8: 316-28, 1976. 100. Theodorou C, Moutzouris G, Floratos D, Plastiras D, Katsifotis C, Mertziotis N. Incontinence after surgery for benign prostatic hypertrophy: the case for complex approach and treatment. Eur Urol 33: 370-375, 1998. 101. Iselin CE, Schmidlin F, Borst F, Rohner S, Graber P. Oxybutynin in the treatment of early detrusor instability after transurethral resection of the prostate. Br J Urol 79:915-919, 1997. 102.Stephenson TP, Farrar DJ. Urodynamic study of 15 patients with postmicturition dribble. Urology 9: 404-406, 1977. 103. Furuya S, Yokoyama E. [Urodynamic studies on postmicturition dribble] Hinyokika Kiyo 29:395-400, 1983. 104. Corcoran M, Smith G, Chisholm GD. Indications for investigation of post-micturition dribble in young adults. Br J Urol 59:222-223, 1987. 105. Furuya S, Ogura H, Tanaka M, Masumori N, Tsukamoto T. [Incidence of postmicturition dribble in adult males in their twenties through fifties]. Hinyokika Kiyo 43 :407-410, 1997.

73. Chao R, Mayo ME. Incontinence after radical prostatectomy: detrusor or sphincter causes. J Urol 154:16-18, 1995. 74.

Leach GE, Trockman B, Wong A, et al: Post-prostatectomy incontinence: urodynamic findings and treatment outcomes. J Urol 155:1256-1259, 1996.

75. Desautel MG, Kapoor R, Badlani GH. Sphincteric incontinence: the primary cause of post-prostatectomy incontinence in patients with prostate cancer. Neurourol Urodyn 1997;16:15360, 1997. 76. Mebust WK, Holtgrewe HL. Current status of transurethral prostatectomy: a review of the AUA National Cooperative Study. World J Urol 6:194, 1989. 77. Catalona WJ, Basler WJ. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J. Urol 150:905-907, 1993. 78. Geary ES, Dendlinger TE, Freiha FS, Stamey TA. Incontinence and vesical neck strictures following radical perineal prostatectomy. Urology 45:1000, 1995. 79. Krane RJ. Urinary incontinence after treatment for localized prostate cancer. Mol Urol 4:279-286, 2000. 80. Kao TC, Cruess DF, Garmer D, et al: Multicenter patient selfreporting questionnaire on impotence, incontinence and stricture after radical prostatectomy. J Urol 163:858-864, 2000. 81. Gudziak MR, McGuire EJ, Gormley EA. Urodynamic assessment of urethral sphincter function in post-prostatectomy incontinence. J Urol 156: 1131-1134, 1996. 82. Steiner MS, Morton RA, Walsh PC. Impact of anatomical radical prostatectomy on urinary incontinence. J Urol 145: 512-515, 1991.

106. Sommer P, Nielsen KK, Bauer T, Kristensen ES, Hermann GG, Steven K, Nordling J. Voiding patterns in men evaluated by a questionnaire survey 2. Br J Urol 1990: 65(2):155-160. 107. Paterson J, Pinnnock CB, Marshall VR. Pelvic floor exercises as a treatment for post-micturition dribble 1. Br J Urol 79:892-7, 1997. 108. Abrams PH, Farrar DJ, Turner-Warwick RT, Whiteside CG, Feneley RC. The results of prostatectomy: a symptomatic and urodynamic analysis of 152 patients. J Urol 121:640-642, 1979. 109. Steers WD, De Groat WC. Effect of bladder outlet obstruction on micturition reflex pathways in the rat. J Urol 140:864-871, 1988. 110. Sibley GN. The physiological response of the detrusor muscle to experimental bladder outflow obstruction in the pig. Brit J Urol 60:332-336, 1987. 111. Perlberg S, Caine M. Adrenergic response of bladder muscle in prostatic obstruction. Its relation to detrusor instability. Urology 20:524-527, 1982. 112. Abrams P, Kaplan S, Millard R. Tolterodine treatment is safe in men with bladder outlet obstruction (BOO) and symptomatic detrusor overactivity (DO). Neurourol Urodyn 20: 547, 2001. 113. Dahm TL, Ostri P, Kristensen JK, Walter S, Frimodt-Moller C, Rasmussen RB, Nohr M, Alexander N. Flavoxate treatment of micturition disorders accompanying benign prostatic hypertrophy: a double-blind placebo-controlled multicenter investigation. Urol Int 55:205-208, 1995. 114. Chapple CR, Smith D. The pathophysiological changes in the bladder obstructed by benign prostatic hyperplasia. Br J Urol 73:117-123, 1994.

83. Steiner MS. Anatomic basis for the continence-preserving radical retropubic prostatectomy. Semin Urol Oncol 18:9-18, 2000. 84. Staskin DS, Vardi Y, Siroky MB. Post-prostatectomy continence in the Parkinsonian patient: The significance of poor voluntary sphincter control. J Urol 140:117-8, 1988. 85. Rainwater LM, Zincke H. Radical prostatectomy after radiation therapy for cancer of the prostate: feasibility and prognosis. J Urol 140:1455-9, 1988. 86. Lowe BA. Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study. J Urol 158: 2137-2141, 1997. 87. Joseph AC, Chang MK. A bladder behavior clinic for post prostectomy patients. Urol Nursing 9: 15-9, 1989. 88. Meaglia JP, Joseph AC, Chang M, Schmidt JD. Post-prostatectomy urinary incontinence: response to behavioural training. J Urol 144: 674-6, 1990. 89. Hirakawa S, Hassouna M, Deleon R. ElHilali M. The role of combined pelvic floor stimulation and biofeedback in post-prostatectomy urinary incontinence. J Urol 149: 235A, 1993. 90. Salinas CJ, Virseda CM, Salomon MS, Bravo Derueda C, Aristizabal JM, Resel EL. Results of electrical stimulation in the treatment of post-prostatectomy urinary incontinence. Actas Urolog Espanol 20: 544-50, 1996. 91. Burgio K, Stutzman RE, Engel BT. Behavioral training for postprostatectomy urinary incontinence. J Urol 141: 303-6, 1989. 92. Jackson J, Emerson L, Johnson B, Wilson J, Morales A. Biofeedback: a non-invasive treatment for incontinence after radical prostatectomy. Urol Nursing 16: 50-4, 1996.

568

115. Pressman MR, Figueroa WG, Kendrick-Mohamed J, Greenspon LW, Peterson DD. Nocturia. A rarely recognized symptom of sleep apnea and other occult sleep disorders. Arch Intern Med 156:545-550, 1996.

134. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones and no treatment in management of genuine stress incontinence in women. BMJ 318: 487-493, 1999.

116. Reynard JM, Cannon A, Yang Q, Abrams P. A novel therapy for nocturnal polyuria: a double-blind randomized trial of frusemide against placebo. Br J Urol 81:215-218, 1998.

135. Henalla S, Hutchins C, Robinson. Non-operative methods in the treatment of female stress incontinence of urine. J Obstet Gynecol 9: 222-5, 1989.

117. Asplund R, Sundberg B, Bengtsson P. Oral desmopressin for nocturnal polyuria in elderly subjects: a double-blind, placebocontrolled randomized exploratory study. BJU Int 83:591-595, 1999.

136. Clemens JQ, Nadler RB, Schaeffer AJ, Belani J, Albaugh J, Bushman W. Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome. Urology 56: 951-955, 2000.

118. Miller M. Nocturnal polyuria in older people: pathophysiology and clinical implications. JAGS 48: 1321-9, 2000.

137. McDowell BJ, Engberg S, Sereika S, Donovan N, Jubeck ME, Weber E, Engberg R. Effectiveness of behavioural therapy to treat incontinence in homebound older adults. J Am Geriatr Soc 47: 309-18, 1999.

119. Weiss J, Blaivas JG, Abrams P, Mattiasson A, Robertson G, Van Kerrebroeck P, Walter S. Oral desmopressin (Minirin, DDAVP) in the treatment of nocturia in men. J Urol 165: Suppl 250, 2001.

138. Cottenden AM: Incontinence pads: clinical performance, design and technical properties. J Biomed Eng 10:506-514, 1988.

120. Asplund R, Sundberg B, Bengtsson P. Desmopressin for the treatment of nocturnal polyuria in the elderly: a dose titration study. Br J Urol 82:642-646, 1998.

139. Kozakov S, Shats V. Cost-effectiveness of disposable diapers versus catheters in dependent patients. Harefuah 124:258-261, 1993.

121. Cannon A, Carter PG, Mcconnell AA, Abrams P. Desmopressin in the treatment of nocturnal polyuria in the male. Br J Urol Int 84:20-24, 1999.

140. Biesecker JE, Edlich JE, Thomas HL, Steers WD. Recent advances in absorbent products for the incontinent patient with burns. J Burn Care Rehabil 16:146-153, 1995.

122. Bernstein SA, Williford SL. Intranasal desmopressin-associated hyponatremia: a case report and literature review. J Fam Pract 44:203-208, 1997.

141. Karlberg AT, Magnusson K. Rosin components identified in diapers. Contact Dermatitis 34:176-180, 1996.

123. Hunsballe JM, Rittig S, Pedersen EB, Olesen OV, Djurhuus JC. Single dose imipramine reduces nocturnal urine output in patients with nocturnal enuresis and nocturnal polyuria. J Urol 158:830-836, 1997.

142. Biesecker JE, Thomas HL, Thacker JG, Blackwood HS, Edlich RF. Innovations in the design and performance of underpads for patients with burns. J Burn Care Rehabil 16:66-73, 1995. 143. Rbown DS. Diapers and underpads, Part 1: Skin integrity outcomes. Ostomy Wound Manage 40:20-22, 24-26, 28, 1994.

124. Fantl JA, Wyman JF, McClish DK, Harkins SW, Elswick RK, Taylor JR, Hadley EC. Efficacy of bladder training in older women with urinary incontinence. JAMA 265: 609-13, 1991.

144. Brown DS: Diapers and underpads, Part 2: Cost outcomes. Ostomy Wound Manage 40:34-36, 38, 40, 1994.

125. Cazzulani P, Panzarasa R, Luca C, Oliva D, Graziani G. Pharmacological studies on the mode of action of flavoxate. Arch Int Pharmacodyn Ther 268:301-312, 1984.

145. Leiby DM, Shanahan N. Clinical study: assessing the performance and skin environments of two reusable underpads. Ostomy Wound Manage 40:30-32, 34-37, 1994.

126. Sogbein SK, Awad SA. Behavioural treatment of urinary incontinence in geriatric patients. Can Med Assoc J 127:863-864, 1982.

146. Boiko S. Diapers and diaper rashes. Dermatol Nurs 9:33-39, 4346, 1997. 147. Hebel JR, Warren JW. The use of urethral, condom, and suprapubic catheters in aged nursing home patients. J Am Geriatr Soc 38:777-784, 1990.

127. Burgio KL, Stutzman RE, Engel BT. Behavioral training for post-prostatectomy urinary incontinence. J Urol 141: 303-306, 1989.

148. Harmon CB, Connolly SM, Larson TR. Condom-related allergic contact dermatitis. J Urol 153:1227-1228, 1995.

128. Schnelle JF, Traughber B, Sowell VA, Newman DR, Petrilli CO, Ory M. Prompted voiding treatment of urinary incontinence in nursing home patients. A behavior management approach for nursing home staff. J Am Geriatr Soc 37:1051-1057, 1989.

149. Johnson ET. The condom catheter: Urinary tract infection and other complications. South Med J 76:579-582, 1983. 150. Perkash I, Kabalin JN, Lennon S, Wolfe V. Use of penile prostheses to maintain external condom catheter drainage in spinal cord injury patients. Paraplegia 30:327-332, 1992.

129. OÕDonnell PD. Behavioral modification for institutionalized individuals with urinary incontinence. Urology 51: 40-42, 1998. 130. Remsburg RE, Palmer MH, Langford AM, Mendelson GF. Staff compliance with and ratings of effectiveness of a prompted voiding program in a long-term care facility. J Wound Ostomy Continence Nurs 26:261-269, 1999. 131. Godec C, Cass A, Ayala G. Bladder inhibition with functional electrical stimulation. Urology 6: 663-6, 1975. 132. Bo K, Berghams LCM. Nonpharmacologic treatments for overactive bladder Ð pelvic floor exercises. Urology 55 (Suppl 5A): 7-11, 2000. 133. Largo-Janssen TLM, Debruyne FMJ, Smits AJ, VanWeel C. Controlled trial of pelvic exercises in the treatment of urinary stress incontinence in general practice. Br J Gen Pract 41: 44459, 1991.

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