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The purpose of this study was to compare the effect of three conservative interventions: pelvic floor muscle training, bladder training, or both, on urodynamic parameters in women with urinary incontinence. Two hundred four women with genuine stress incontinence (GSI) or detrusor instability with or without GSI (DI +/- GSI) participated in a two-site trial comparing pelvic floor muscle training, bladder training, or both. Patients were stratified based on severity of urinary incontinence, urodynamic diagnosis, and treatment site, then randomized to a treatment group. All women underwent a comprehensive standardized evaluation including multi-channel urodynamics at the initial assessment and at the end of 12 weeks of therapy. Analysis of covariance was used to detect differences among treatment groups on urodynamic parameters. Post-treatment evaluations were available for 181 women. No differences were found among treatments on the following measurements: maximum urethral closure pressure, mean urethral closure pressure, maximum Kegel urethral closure pressure, mean Kegel urethral closure pressure, functional urethral length, pressure transmission ratios, straining urethral axis, first sensation to void, maximum cystometric capacity, and the MCC minus FSV. The effect of treatment did not differ by urodynamic diagnosis. Behavioral therapy had no effect on commonly measured urodynamic parameters. The mechanism by which clinical improvement occurs remains unknown. Neurourol. Urodynam. 18:427-436, 1999.

Objectives . To review the use of behavioral modification as a treatment for urinary incontinence (UI) among individuals in the community. Methods. The implementation of pelvic floor rehabilitation and bladder training is discussed. "Cure rates" reported in studies of community-dwelling women with UI are presented, and possible mechanisms of the treatment effect are described. Results. Clinical trials of behavioral modification for UI have incorporated different therapeutic regimens and outcome measurements. On average, however, pelvic muscle rehabilitation has produced complete resolution in approximately 20% of patients and a 50% to 75% reduction in most individuals. Bladder training has produced complete resolution in fewer than 15% of patients and a 50% to 75% reduction in more than 50% of subjects. Although the mechanism of the treatment effect remains undetermined, it may involve modification of voluntary striated muscle contractility, reflex striated muscle contractility, cortical inhibition, and cortical facilitation. The structure and implementation of the technique, rather than the specific technique itself, may be responsible for the treatment effect. Conclusions. Behavioral interventions have a definite place in the management of UI. Most such therapies will reduce, rather than abolish, UI. However, the reduction in symptoms may improve the quality of life.

Behavioral interventions, bladder training, and pelvic muscle exercises are recommended as a first line of treatment in the management of stress and urge incontinence in outpatient female populations.1-11 Traditionally, these two interventions have been used to treat different types of incontinence on the basis of their proposed mechanism of action. Bladder training is hypothesized to improve cortical inhibition over lower urinary tract functioning and has been primarily used in the treatment of urge incontinence.2 Pelvic muscle exercise is hypothesized to enhance urethral resistance by increasing the strength and endurance of the periurethral and perivaginal muscles and by improving the anatomic support to the bladder neck and proximal urethra. These exercises are considered the preferred treatment for female stress incontinence but have recently been recommended for urge incontinence because of reflex bladder inhibition associated with pelvic muscle contraction.1, 11 Biofeedback-assisted instruction is typically used as an adjunct technique to teach correct pelvic muscle contraction and/or bladder inhibition, depending on the instrumentation used to monitor physiologic responses. Although many studies have documented the effectiveness of a particular behavioral intervention, few have compared specific treatments or examined their effects in different physiologic subtypes of urinary incontinence. This study examined the relative efficacy From the Departments of Adult Health Nursing,a Obstetrics and Gynecology,b and Biostatistics,c Virginia Commonwealth University/ Medical College of Virginia, the Department of Obstetrics and Gynecology, Duke University Medical Center,d and The Continence Program for Women Research Group.e A complete list of group members and their affiliations appears at the end of the article. Supported by the National Institute of Aging/National Institutes of Health, Bethesda, Maryland, grant No. UO1 AG05170. Received for publication July 9, 1997; revised March 6, 1998, accepted March 31, 1998. Reprint requests: Jean F. Wyman, PhD, RN, School of Nursing, University of Minnesota, 6-101 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455. Copyright © 1998 by Mosby, Inc. 0002-9378/98 $5.00 + 0 6/1/90643 Comparative efficacy of behavioral interventions in the management of female urinary incontinence

Urinary incontinence (UI) is a relatively common condition in middle-aged and older women. Traditional measures of symptoms do not adequately capture the impact that UI has on individuals' lives. Further, severe morbidity and mortality are not associated with this condition. Rather, Ul's impact is primarily on the health status and health-related quality of life (HRQOL) of women. Generic measures of HRQOL inadequately address the impact of the condition on the day-to-day lives of women with UI. The current paper presents data on two new condition-specific instruments designed to assess the HRQOL of UI in women: the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionaire (IIQ). Used in conjunction with one another, these two measures provide detailed information on how UI affects the lives of women. The measures provide data on the more traditional view of HRQOL by assessing the impact of UI on various activities, roles and emotional states (IIQ), as well as data on the less traditional but critical issue of the degree to which symptoms associated with UI are troubling to women (UDI). Data on the reliability, validity and sensitivity to change of these measures demonstrate that they are psychometrically strong. Further, they have been developed for simple, self-administration.