Integrated care for older people (ICOPE)

Guidelines on community-level interventions

to manage declines in intrinsic capacity

Evidence profile:
urinary incontinence
Scoping question:
Do non-pharmacological interventions
(prompted voiding, timed voiding, toilet
training, habit retraining, pelvic floor muscle
training) produce any benefit and/or harm
for older people with urinary incontinence?
The full ICOPE guidelines and complete
set of evidence profiles are available at
who.int/ageing/publications/guidelines-icope

Painting: “Wet in Wet” by Gusta van der Meer. At 75 years of age, Gusta
has an artistic style that is fresh, distinctive and vibrant. A long-time lover
of art, she finds that dementia is no barrier to her artistic expression.
Appreciated not just for her art but also for the support and
encouragement she gives to other artists with dementia, Gusta
participates in a weekly art class. Copyright by Gusta van der Meer. All
rights reserved
 Evidence profile: urinary incontinence

Contents
Background ........................................................................................................................................................................................................ 1
Part 1: Evidence review ..................................................................................................................................................................................... 2
Scoping question in PICO format (population, intervention, comparison, outcome) .............................................................................................. 2
Search strategy .................................................................................................................................................................................................... 3
List of systematic reviews identified by the search process .................................................................................................................................. 3
PICO table ........................................................................................................................................................................................................... 4
Narrative description of the systematic reviews included in the analysis .............................................................................................................. 5
Brief descriptions of the included non-pharmacological interventions ................................................................................................................... 6
GRADE table 1: Prompted voiding versus no prompted voiding for adults with urinary incontinence ................................................................... 8
GRADE table 2: Pelvic floor muscle training (PFMT) with or without biofeedback plus other interventions versus no active control for older
people with urinary incontinence ........................................................................................................................................................................ 10
GRADE table 3: Habit retraining plus others compared with usual care for older people (men and women) with urinary incontinence .............. 12
GRADE table 4: Pelvic floor muscle training (PFMT) compared with no treatment for older women with urinary incontinence ........................... 13
GRADE table 5: Bladder training versus no treatment for older people with urinary incontinence ...................................................................... 15
GRADE table 5.1: Bladder training versus other behavioural interventions for older people with other incontinence .......................................... 16
GRADE table 6: Timed voiding plus other versus usual care for older people with urinary incontinence ............................................................ 17
Part 2: From evidence to recommendations .................................................................................................................................................. 18
Summary of evidence ........................................................................................................................................................................................ 18
Evidence-to-recommendations table .................................................................................................................................................................. 20
Guideline development group recommendation and remarks ..................................................................................................................... 24
References ....................................................................................................................................................................................................... 26
Annex 1: Search strategy ................................................................................................................................................................................ 28
Annex 2: PRISMA 2009 flow diagram for non-pharmacological intervention for managing urinary incontinence .................................. 30

© World Health Organization 2017

Some rights reserved. This work is available under the Creative Commons Attribution-
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ICOPE guidelines – World Health Organization

 1 Evidence profile: urinary incontinence
Background
Urinary incontinence, the involuntary loss of urine, is a highly
prevalent condition in older people aged 60 years and over (1).
The common types of urinary incontinence in older people are
stress incontinence and urge incontinence. Stress incontinence is
the involuntary leaking of urine during efforts or exertion, or while
sneezing or coughing. Urge incontinence, or overactive bladder
syndrome, involves a constellation of symptoms including
frequency, urgency and leakage immediately preceded by urgency.
The prevalence of urinary incontinence reported in population-
based studies ranges from 9.9% to 36.1% (2–4), and is twice as
high in older women as in older men. Urinary incontinence has a
profound impact on the quality of life of older people, their
subjective health status (5, 6), levels of depression (7) and need
for care (8).
Several chronic conditions and environmental factors increase
the risk of urinary incontinence in older people. Chronic diseases
that are associated with urinary incontinence include diabetes
mellitus, Parkinson’s disease, dementia, stroke, prostatic cancer,
chronic obstructive pulmonary disease (COPD) and arthritis.
Environmental factors such as inaccessible or unsafe toilet
facilities, and the absence of caregivers for toileting assistance
are also associated with urinary incontinence. Non-
pharmacological interventions are mostly preferred and remain
the mainstay of urinary incontinence management for patients
with mild urinary incontinence. The primary goal of urinary
incontinence interventions is to improve continence by reducing
the frequency of urinary incontinence episodes. The non-
pharmacological interventions addressed in this guideline include
pelvic floor muscle training (PFMT), bladder training and habit
retraining, and timed or prompted voiding.
ICOPE guidelines – World Health Organization
 2 Evidence profile: urinary incontinence

Part 1: Evidence review

Scoping question in PICO format (population,
intervention, comparison, outcome)

Population
• Older people with urgency or stress or mixed urinary incontinence

Interventions
• Prompted voiding
• Timed voiding
• Bladder training
• Habit retraining
• Pelvic floor muscle training (PFMT)

Comparison
• No intervention/usual care

Outcomes
• Critical: Proportion of mean change in frequency of urinary
incontinence, change in mean proportion of hourly checks that are
wet, number of patients with reductions in incidence of daytime
incontinence, number of patients with reductions in incidence of
night-time incontinence, incontinent episodes in 24 hours, mean
urinary incontinence incidence per 24 hours, urinary incontinence
symptoms
• Important: Perceived cure, self-initiated toileting, median percentage
of checks wet, number of incontinent episodes, urinary incontinence
urgency, urinary incontinence frequency, nocturia, quality of life

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 3 Evidence profile: urinary incontinence
Search strategy
A systematic literature search for reviews was conducted in Ovid
MEDLINE, Embase, PsycINFO and Cochrane databases. The
details of the search terms used for retrieving studies are provided
in Annex 1. The search retrieved 188 reviews and 798 randomized
controlled trials (RCTs). After initial screening for eligibility, 111
reviews and 161 RCTs were considered for full-text review.
Ultimately, five systematic reviews that included 25 RCTs and two
additional studies investigating the benefits of non-pharmacological
interventions were included in this review (see Annex 2).
List of systematic reviews identified by the search
process
Included in GRADE1 tables
— Wallace SA, Roe B, Williams K, Palmer M. Bladder training for
urinary incontinence in adults. Cochrane Database Syst Rev.
2004;(1):CD001308. Updated in 2009. [Systematic review was
updated by WHO in 2015] (9)
_______________________________
1GRADE: Grading of Recommendations Assessment, Development
and Evaluation. More information: http://gradeworkinggroup.org
— Ostaszkiewicz J, Johnston L, Roe B. Habit retraining for the
management of urinary incontinence in adults. Cochrane Database
Syst Rev. 2004;(2):CD002801. Updated in 2009. [Systematic
review was updated by WHO in 2015] (10)
— Eustice S, Roe B, Paterson J. Prompted voiding for the
management of urinary incontinence in adults. Cochrane Database
Syst Rev. 2000;(2):CD002113. Updated in 2006. [Systematic
review was updated by WHO in 2015] (11)
— Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the
management of urinary incontinence in adults. Cochrane Database
Syst Rev. 2004;(1):CD002802. Updated in 2009. [Systematic
review was updated by WHO in 2015] (12)
— Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor
muscle training versus no treatment, or inactive control treatments,
for urinary incontinence in women. Cochrane Database Syst Rev.
2014;(5):CD005654 (13)
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 4 Evidence profile: urinary incontinence

PICO table

Intervention/ Outcomes Studies used for GRADE

comparison

1 Timed voiding plus others
vs usual care
• Number of patients with reductions in incidence of
daytime urinary incontinence
• Number of patients with reductions in incidence of
night-time incontinence
• Number of patients whose pad test indicates
reduction in the volume of incontinence
Ostaszkiewicz J, Johnston L, Roe B. Timed
voiding for the management of urinary
incontinence in adults. Cochrane Database
Syst Rev. 2004;(1):CD002802. Updated in
2009. (12)

2 Prompted voiding vs no
prompted voiding
• Number of patients with no improvement in urinary
incontinence episodes
• Change in mean proportion of hourly checks that are
wet
• urinary incontinence episodes in 24 hours
• Self-initiated toileting
Eustice S, Roe B, Paterson J. Prompted
voiding for the management of urinary
incontinence in adults. Cochrane Database
Syst Rev. 2000;(2):CD002113. Updated in
2006. (11)

3 Habit retraining plus
others vs usual care
• Number of incontinent episodes Ostaszkiewicz J, Johnston L, Roe B. Habit
• Incontinent volume retraining for the management of urinary
incontinence in adults. Cochrane Database
Syst Rev. 2004;(2):CD002801. Updated in
2009. (10)

4 Bladder training vs no • Cure rate Wallace SA, Roe B, Williams K, Palmer M.

treatment or active • Number of micturition episodes Bladder training for urinary incontinence in
treatment controls adults. Cochrane Database Syst Rev.
2004;(1):CD001308. Updated in 2009. (9)
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 5 Evidence profile: urinary incontinence

5 Pelvic floor muscle
training plus bladder
retraining vs control
• Mean urinary incontinence incidence per 24 hours
• Urinary incontinence urgency
• Urinary incontinence frequency
• Nocturia
Dumoulin C, Hay-Smith EJC, Mac Habée-
Séguin G. Pelvic floor muscle training versus
no treatment, or inactive control treatments,
for urinary incontinence in women. Cochrane
Database Syst Rev. 2014;(5):CD005654. (13)

Narrative description of the systematic reviews CINAHL, PsycINFO, Biological Abstracts, Current Contents and the
reference lists of relevant articles. Experts in the field were also
included in the analysis
contacted for potential papers. The search included relevant
websites and hand searches of journals and conference
The Cochrane systematic review by Wallace et al. (updated in
proceedings. Four trials with a total of 378 participants met the
2009) aimed to synthesise evidence for effectiveness of bladder
inclusion criteria. Participants in these trials (mean age 80 years)
training for urinary incontinence in adults (9). Relevant trials were
were mainly women and they were physically and/or cognitively
identified from the Cochrane Incontinence Review Group’s
impaired, dependent on caregivers and residing either in nursing
specialized register of controlled trials, which contains trials
homes or in their own homes. Three trials tested habit retraining
identified from MEDLINE, the Cumulative Index to Nursing and
combined with other treatment, compared with usual care (14–16)
Allied Health Literature (CINAHL) and the Cochrane Central
and another trial compared the combination treatment with habit
Register of Controlled Trials (CENTRAL). The specialized register
retraining alone (17).
was searched using the Review Group’s own keywords and
medical search terms. The review included 12 RCTs (total of 1473
The Cochrane systematic review by Eustice et al. (updated in 2006)
participants). The participants were predominantly female (75%).
aimed mainly to examine the effectiveness of prompted voiding in
Eight included trials had useable data but only four of them included
the management of urinary incontinence in adults (11). The search
older people aged over 60 years. Three of the trials were conducted
for trials was conducted in the Cochrane Incontinence Review
in the United States of America and another study is a multicentre
Group’s specialized register of controlled trials (31 January 2006)
trial that included participants from Denmark, Norway and Sweden.
as well as the reference lists of relevant articles. Investigators in the
field were also contacted for additional studies. As a result, nine
The Cochrane systematic review by Ostaszkiewicz et al aimed to
trials with a total 674 participants (mean age 84 years) were
investigate the benefit of habit retraining in the management of
included in the review. The majority of participants included in the
urinary incontinence in adults (10). Trials were identified from the
trials were older women. Prompted voiding was compared with no
search conducted in the Cochrane Incontinence Review Group’s
specialized register of controlled trials, MEDLINE, Embase, (continued next page)

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 6 Evidence profile: urinary incontinence
prompted voiding in nine trials. One trial was excluded as the ages
of the trial participants were not reported (18).
Ostaszkiewicz et al. (updated in 2009) is a Cochrane systematic
review on timed voiding for the management of urinary incontinence
in adults (12). The search for trials was conducted in Cochrane
Incontinence Review Group’s specialized register of controlled trials
(searched 2 April 2009), MEDLINE (January 1966 to November
2003), Embase (January 1980 to Week 18 2002), CINAHL (January
1982 to February 2001), PsycINFO (January 1972 to August 2002),
Biological Abstracts (January 1980 to December 2000), Current
Contents (January 1993 to December 2001) and the reference lists
of relevant articles. Experts in the field were contacted for potential
studies. The search included relevant websites and conference
proceedings. Hand searches were also conducted in relevant
journals. Two trials with a total of 298 participants met the inclusion
criteria (19, 20). Both compared timed voiding plus additional
intervention with usual care. Most of the participants from the two
selected trials were cognitively impaired elderly women (mean age
86.7 years) and all resided in facilities that provided nursing care.
The majority of participants (82%) in one study were older
women (19) while the other study did not report the sex of
participants (20).
Dumoulin et al. is a Cochrane systematic review of pelvic floor
muscle training (PFMT) versus no treatment, or inactive control
treatments, for urinary incontinence in women (13). The search for
relevant trials was conducted in the Cochrane Incontinence Review
Group’s specialized register of controlled trials, which contains trials
identified from CENTRAL (1999 onwards), MEDLINE (1966
onwards) and MEDLINE In-Process (2001 onwards). Conference
proceedings were searched (15 April 2013), and hand searches
were done in the journals and reference lists of relevant articles to
identify potential studies. Twenty-one trials involving 1281 women
(665 PFMT, 616 controls) met the inclusion criteria. Seven of them
recruited older people aged over 60 years or had mean participant
age of more than 60 years (21–27).
Two additional RCTs, not listed in the above-mentioned Cochrane
systematic reviews, were identified in an independent literature
search and were also included (28, 29).
Brief descriptions of the included non-
pharmacological interventions
Prompted voiding is administered for older people with or without
cognitive impairment to initiate their own toileting through requests
for help, and includes the use of positive reinforcement from carers
when they do this. This is distinct from some other therapies
because of the participation of the individual in the process. In
contrast, habit retraining attempts to determine the micturition
pattern for an individual, which can be used to achieve continence
but does not necessarily rely on the individual’s participation.
Timed voiding is fixed by time or event, and is carer led and is not
an individualized intervention. Bladder training actively includes the
individual in attempting to increase the interval between the desire
to void and the actual void, and hence would not be suitable for
those who are cognitively impaired. It comprises three components:
(a) patient education – information about the bladder and how
continence is usually maintained; (b) scheduled voiding – a
“timetable for voiding” which may be fixed or flexible to suit the
participant’s rate of increase in the interval between voids (the aim
is usually to achieve an interval of 3–4 hours between voids); and
(c) positive reinforcement – psychological support and
(continued next page)
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 7 Evidence profile: urinary incontinence
encouragement is generally considered important and is usually
provided by a health care professional. Pelvic floor muscle training
(PFMT) is an exercise programme of repeated pelvic floor muscle
contractions taught and supervised by a health care professional, at
times combined with bladder training for individuals with mixed
urinary incontinence.
Other physical exercise interventions – such as
functional incidental training, mobility and toileting training – focus
on improving the ability of older people to reach the toilet or
developing related skills (e.g. getting up from bed or a chair,
walking 5 metres, undoing clothing hooks, zippers and buttons,
letting down the garment, sitting down on the toilet, rising up from
the toilet seat and adjusting the garment) to improve toilet timing.
Functional incidental training combines prompted voiding with
functionally oriented, low-intensity endurance exercises (e.g. timed
sit-to-stands, walking or wheelchair mobility) and strengthening
exercises (e.g. bicep curls, straight-arm raises, knee extensions
and hip abductions and flexions).
Treatment adherence. There is limited evidence on adherence to
non-pharmacological treatments. Adherence reported in four
included RCTs ranges from 72% to 89% (30–33).
Adverse events. The included trials neither performed explicit
assessment for adverse events nor reported any major risks.
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 8 Evidence profile: urinary incontinence

GRADE table 1: Prompted voiding versus no prompted voiding for

adults with urinary incontinence

Author: WHO systematic review team

Date: 11 November 2015
Question: Is prompted voiding more effective than no prompted voiding when
used for adults with urinary incontinence (urge, stress, mixed)?
Settings: Community
Bibliography: (11) Eustice S, Roe B, Paterson J. Prompted voiding for the
management of urinary incontinence in adults. Cochrane Database
Syst Rev. 2000;(2):CD002113. Updated in 2006

Quality assessment Number of patients Effect

Quality Importance

Number of Risk of Other Prompted No prompted Relative

Design Inconsistency Indirectness Imprecision Absolute
studies bias considerations voiding voiding (95% CI)

Mean proportion of hourly checks that are wet (follow-up 32 weeks; measured with diary and report; lower score = better performance)

1 randomized serious a not serious serious b serious c none 73 74 – MD -12.00  CRITICAL
trials lower (-18.79 VERY LOW
to -5.21
lower)

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next page)

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 9 Evidence profile: urinary incontinence

Change in mean proportion of hourly checks that are wet (follow-up 8 weeks; measured with diary and self-report; lower score = better performance)

1 randomized serious d no serious no serious very serious e none 9 10 – MD 17.60  CRITICAL
trials imprecision indirectness higher (-14.58 VERY LOW
lower to 49.78
higher)

Number of incontinent episodes in 24 hours (follow-up 3–13 weeks; measured with diary and self-report; lower score = better performance)

2 randomized serious f serious g serious h no serious none 127 130 – MD –0.92  CRITICAL
trials imprecision lower (-1.32- VERY LOW
to –0.53
lower)

Self-initiated toileting (follow-up 3 weeks; measured with self-report; lower score = better performance)

1 randomized serious i no serious serious j serious k none 63 63 – MD –1.90  IMPORTANT

trials imprecision lower (-2.29 LOW
to -1.51
lower)

CI: confidence interval; MD: mean difference

a. Risk of bias: Downgraded once as allocation concealment was unclear in one trial.
b. Indirectness: Downgraded once as trial was conducted in nursing home setting, and generalizing the evidence to other settings is doubtful.
c. Imprecision: Downgraded once as sample size was small (smaller than 200).
d. Risk of bias: Downgraded once as method applied for allocation concealment was unclear.
e. Imprecision: Downgraded twice as sample size was very small (smaller than 50).
f. Risk of bias: Downgraded once as allocation concealment method was unclear in two trials.
g. Inconsistency: Downgraded once as considerable heterogeneity was observed: Chi 2 = 18.07, df = 1 (P = 0.00002); I2 = 94%.
h. Indirectness: Downgraded once as included trials were conducted in nursing home settings and generalizing the interventions to other settings is doubtful.
i. Risk of bias: Downgraded once as allocation concealment was unclear.
j. Indirectness: Downgraded once as trial was conducted in nursing home setting and generalizing the interventions to other settings is doubtful.
k. Imprecision: Downgraded once as sample size was small (smaller than 200).

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 10 Evidence profile: urinary incontinence

GRADE table 2: Pelvic floor muscle training (PFMT) with or without biofeedback plus
other interventions versus no active control for older people with
urinary incontinence

Author: WHO systematic review team

Date: 11 November 2015
Question: Is multicomponent behavioural interventions (PFMT with or without biofeedback, bladder
control strategy, education and self-monitoring) more effective than no active control when
used for older people (women and men) with urinary incontinence?
Setting: Community
Bibliography: (34) McFall SL, Yerkes AM, Cowan LD. Outcomes of a small group educational
intervention for urinary incontinence: episodes of incontinence and other urinary
symptoms. J Aging Health. 2000;12(2):250–67.
(21) Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M et al.
Behavioral vs drug treatment for urge urinary incontinence in older women: a
randomized controlled trial. JAMA. 1998;280(23):1995–2000.
(35) Goode PS, Burgio KL, Locher JL, Umlauf MG, Lloyd LK, Roth DL. Urodynamic
changes associated with behavioral and drug treatment of urge incontinence in older
women. J Am Geriatr Soc. 2002;50(5):808–16.
(36) Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of
behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet
Gynecol. 2002;100(1):72–8.
(37) Dougherty MC, Dwyer JW, Pendergast JF, Boyington AR, Tomlinson BU, Coward
RT et al. A randomized trial of behavioral management for continence with older rural
women. Res Nurs Health. 2002;25(1):3–13.
(38) Johnson TM, Burgio KL, Redden DT, Wright KC, Goode PS. Effects of behavioral
and drug therapy on nocturia in older incontinent women. J Am Geriatr Soc.
2005;53(5):846–50.
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 11 Evidence profile: urinary incontinence

Quality assessment Number of patients Effect

Multicomponent
behavioural Quality Importance
Number interventions (PFMT
No active Relative
of Design Risk of Other with or without Absolute
Inconsistency Indirectness Imprecision control (95% CI)
studies bias considerations biofeedback plus
bladder control
strategy and self-
monitoring)

Total number of incontinent episodes per week (post treatment) (follow-up 6–24 weeks; assessed with bladder diary; lower score = better performance)

a
5 randomized serious no serious no serious no serious none 382 327 – WMD -3.63  CRITICAL
trials inconsistency indirectness imprecision lower (-5.19 MODERATE
to -0.99
lower)

Patients’ perception of improvement in urinary incontinence (follow-up 6–8 weeks; assessed with self-report and bladder diary; improvement was
defined as self-reported improvement or no restriction in daily activities)

3 randomized serious b no serious no serious no serious none 165/234 65/174 RR 4.15 339 more per  IMPORTANT
trials inconsistency indirectness imprecision (70.5%) (37.4%) (2.70 to 6.37) 1000 (from MODERATE
243 more to
418 more)

CI: confidence interval; RR: relative risk; WMD: weighted mean difference
a. Risk of bias: Downgraded once as method applied for allocation concealment was unclear in all five included trials
b. Risk of bias: Downgraded once as method applied for allocation concealment was not clear in all three included trials.

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 12 Evidence profile: urinary incontinence

GRADE table 3: Habit retraining plus others compared with usual care for older
people (men and women) with urinary incontinence

Author: WHO systematic review team

Date: 11 November 2015
Question: Is habit retraining plus others more effective than usual care when used for older
people (men and women) with urinary incontinence?
Setting: Community
Bibliography: (10) Ostaszkiewicz J, Johnston L, Roe B. Habit retraining for the management of
urinary incontinence in adults. Cochrane Database Syst Rev. 2004;(2):
CD002801. Updated in 2009. [Systematic review was updated by WHO in 2015].

Quality assessment Number of patients Effect

Quality Importance
Number
Risk of Other Habit retraining Usual Relative
of Design Inconsistency Indirectness Imprecision Absolute
bias considerations plus other care (95% CI)
studies

Number of incontinent episodes (follow-up 6–36 weeks; assessed with bladder diary; lower score = better performance)

2 randomized serious a no serious no serious serious b none 76 54 – SMD 0.12  CRITICAL
trials inconsistency indirectness lower (0.47 LOW
lower to 0.23
higher)

CI: confidence interval; MD: mean difference

a. Risk of bias: Downgraded once as allocation concealment was unclear in one of the included trial.
b. Imprecision: Downgraded once as sample size was small (smaller than 200).

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 13 Evidence profile: urinary incontinence

GRADE table 4: Pelvic floor muscle training (PFMT) compared with no treatment for
older women with urinary incontinence

Author: WHO systematic review team

Date: 11 November 2015
Question: Is PFMT more effective than no treatment or placebo when used for older women with
urinary incontinence?
Settings: Primary care or community
Bibliography: (13) Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training
versus no treatment, or inactive control treatments, for urinary incontinence in women.
Cochrane Database Syst Rev. 2014;(5):CD005654.

Quality assessment Number of patients Effect

Quality Importance
Pelvic floor
Number of Risk of Other No treatment Relative
Design Inconsistency Indirectness Imprecision muscle Absolute
studies bias considerations or education (95% CI)
training

Participant perceived cure (all types of urinary incontinence) (follow-up 12 weeks; assessed with self-reported information)

3 randomized serious a serious b no serious no serious none 50/144 9/146 RR 5.34 (2.78 268 more per  IMPORTANT
trials indirectness imprecision (34.7%) (6.2%) to 10.26) 1000 (from 110 LOW
more to 571
more)

Quality of life (follow-up 6 weeks; measured with King’s Health Questionnaire (KHQ)/severity measure after treatment; lower score = better performance)

1 randomized serious c not serious no serious very serious d none 30 15 – MD -24.92  IMPORTANT
trials applicable indirectness lower (-39.06 VERY LOW
lower to -10.78
lower)

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 14 Evidence profile: urinary incontinence

Urinary incontinence symptoms (follow-up 6 weeks; measured with: King’s health questionnaire; Better indicated by lower values)

2 randomized serious e not serious no serious very serious d none 30 30 – MD -34.16  CRITICAL
trials indirectness lower VERY LOW
(-47.45 lower
to -20.88 lower)

CI: confidence interval; MD: mean difference; RR: relative risk.

a. Risk of bias: Downgraded once as allocation concealment method and procedure for masking outcome assessor was unclear in one trial.
b. Inconsistency: Downgraded once as moderate heterogeneity was observed: Chi2 = 7.56, df = 2 (P = 0.02); I2 = 74%.
c. Risk of bias: Downgraded once as outcome assessor was not masked and method applied for allocation concealment was unclear.
d. Imprecision: Downgraded twice as sample size was very small (smaller than 100).
e. Risk of bias: Downgraded once as allocation concealment method was unclear in one trial.

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 15 Evidence profile: urinary incontinence

GRADE table 5: Bladder training versus no treatment for older people with
urinary incontinence

Author: WHO systematic review team

Date: 11 November 2015
Question: Is bladder training more effective than no treatment, placebo or control when
used for older people (male and female) with urinary incontinence?
Settings: Community
Bibliography: (9) Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary
incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD001308.
Updated in 2009. [Systematic review was updated by WHO in 2015]

Quality assessment Number of patients Effect

Quality Importance

Number of Risk of Other Bladder No treatment Relative

Design Inconsistency Indirectness Imprecision Absolute
studies bias considerations training control (95% CI)

Cure of incontinent episodes (follow-up 6 weeks; assessed with diary, number of participants cured, immediately after treatment)

not serious no serious serious b none 7/60 2/63 RR 3.68 85 more per  CRITICAL
1 randomized serious a
trials indirectness (11.7%) (3.2%) (0.79 to 1000 (from 7 LOW
16.99) fewer to 508
more)

Number of micturition episodes per week (daytime) (follow-up 6 weeks; assessed with diary immediately after the treatment phase; lower score = better performance)

not serious no serious very serious d none 45 43 – MD -0.31  IMPORTANT

1 randomized serious c
trials indirectness lower (-0.73 VERY
lower to 0.11 LOW
higher)

CI: confidence interval; MD: mean difference; RR: relative risk.

a. Risk of bias: Downgraded once as method applied for allocation concealment was unclear.
b. Imprecision: Downgraded once as sample size was small (smaller than 200).
c. Risk of bias: Downgraded once as information on incomplete data not described adequately.
d. Imprecision: Downgraded twice as sample size was very small (smaller than 100).

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 16 Evidence profile: urinary incontinence

GRADE table 5.1: Bladder training versus other behavioural interventions for
older people with other incontinence

Author: WHO systematic review team

Date: 11 November 2015
Question: Is bladder training more effective than other behavioural, physical,
psychological treatments when used for older people with other incontinence?
Settings: Primary care or community
Bibliography: (9) Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary
incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD001308.
Updated in 2009. [Systematic review was updated by WHO in 2015]

Quality assessment Number of patients Effect

Quality Importance
Other behavioural,
Number of Other Bladder physical, Relative
Design Risk of bias Inconsistency Indirectness Imprecision Absolute
studies considerations training psychological (95% CI)
treatment

Participant’s perception of improvement: improved, cured vs unchanged, worse; minimum of 2 months post-treatment (follow-up 12 weeks)

1 randomized serious a not serious no serious serious b none 37/60 45/60 RR 0.88 90 fewer  IMPORTANT
trials indirectness (61.7%) (75%) (0.68 to 1.13) per 1000 LOW
(from 240
fewer to 97
more)

CI: confidence interval; RR: relative risk.

a. Risk of bias: Downgraded once as outcome assessor was not masking in the trial and incomplete data was not managed adequately.
b. Imprecision: Downgraded once as sample size was smaller than 200.

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 17 Evidence profile: urinary incontinence

GRADE table 6: Timed voiding plus other versus usual care for older people with
urinary incontinence

Author: WHO systematic review team

Date: 11 November 2015
Question: Is timed voiding plus other more effective than usual care when used for older
people (men and women) with urinary incontinence?
Settings: Primary care or community
Bibliography: (12) Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of
urinary incontinence in adults. Cochrane Database Syst Rev. 2004;(1):CD002802.
Updated in 2009. [Systematic review updated by WHO in 2015]

Quality assessment Number of patients Effect

Quality Importance
Timed
Number of Risk of Other Relative
Design Inconsistency Indirectness Imprecision voiding plus Usual care Absolute
studies bias considerations (95% CI)
other

Number of patients with reductions in incidence of daytime incontinence (follow-up 8 weeks)

1 randomized serious a not serious serious b serious 4 none 40/120 26/89 RR 1.34 (0.9 99 more per  CRITICAL
trials (33.3%) (29.2%) to 2.01) 1000 (from VERY LOW
29 fewer to
295 more)

Number of patients with reductions in incidence of night-time incontinence (follow-up 8 weeks)

1 randomized serious c not serious serious b serious d none 39/95 18/79 RR 1.80 182 more  CRITICAL
trials a (41.1%) (22.8%) (1.12 to 2.89) per 1000 VERY LOW
(from 27
more to 431
more)

CI: confidence interval; RR: relative risk

a. Risk of bias: Downgraded once as trial method was quasi-experimental design.
b. Indirectness: Downgraded once as trial was conducted in nursing home settings in high income country and generalizing the evidence to other settings is doubtful.
c. Risk of bias: Downgraded once as allocation concealment method and procedure for masking of outcome assessor was unclear in the trial.
d. Imprecision: Downgraded once as sample size was small.

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 18 Evidence profile: urinary incontinence

Part 2: From evidence to recommendations

Summary of evidence

Outcome Effect size

Prompted voiding Habit retraining Pelvic-floor PFMT vs no Bladder training Timed voiding vs
vs no promoted plus other vs muscle training treatment, vs no treatment usual care
voiding usual care (PFMT) with or placebo, control
without controls
biofeedback,
bladder
retraining and
self-monitoring
vs control

GRADE table 1 MD -12 lower

Eustace et al. (11) (-18.79 lower to -5.21
lower)
Mean proportion of
Favours treatment
hourly checks that are
VERY LOW
wet

Change in mean MD -17.60 higher

proportion of hourly (-14.58 lower to 49.78
checks that are wet higher)
VERY LOW
Total number of urinary MD -0.92 lower SMD -0.12 lower WMD -3.63 lower
incontinence episodes (-1.32 lower to -0.53 (-0.47 lower to (-5.19 lower
lower) 0.23 higher) to -0.99 lower)
Favours treatment LOW Favours treatment
VERY LOW MODERATE (continued next page)

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 19 Evidence profile: urinary incontinence

Self-initiated toileting MD -1.9 lower

(-2.29 lower to -1.51
lower)
Favours treatment
LOW
GRADE table 5 RR 4.15 RR 0.88
Wallace et al. (9) (2.70 to 6.37) (0.68 to 1.13)
Favours treatment LOW
Patients’ perception of
MODERATE
improvement in urinary
incontinence

Cure of incontinent RR 3.68

episodes (0.79 to 16.99)
LOW
Number of micturition per MD -0.31 lower
week (daytime) (-0.73 lower to 0.11
higher)
VERY LOW
GRADE table 6 RR 1.34
Ostaszkiewicz et al. (12) (0.90 to 2.01)
VERY LOW
Number of patients with
reductions in incidence
of daytime incontinence

Number of patients with RR 1.80

reductions in incidence (1.12 to 2.89)
of nighttime incontinence Favours treatment
VERY LOW
GRADE table 4 RR 5.34
Dumoulin et al. (13) (2.78 to 10.26)
Participant perceived Favours treatment
cure LOW
(continued next page)

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 20 Evidence profile: urinary incontinence

Urinary incontinence MD -34.16 lower

symptoms (-47.45 to -20.88
lower)
Favours treatment
VERY LOW
Quality of life MD -24.92 lower
(-39.06 lower
to -10.78 lower)
Favours treatment
VERY LOW

Evidence-to-recommendations table

Problem Explanation

Is the problem a priority? The prevalence of urinary incontinence reported in population-based studies ranges from 9.9%
Yes No Uncertain to 36.1%, and is twice as high in older women as in older men. Urinary incontinence has a
profound impact on the quality of life of older people, their subjective health status, levels of
✓
depression and need for care.

Benefits and harms Explanation

Do the desirable effects outweigh the No studies reported harm associated with non-pharmacological management of urinary
undesirable effects? incontinence.
Yes No Uncertain
There is limited low-quality evidence which suggests that prompted voiding may benefit older
✓
people in managing urinary incontinence. Eight trials included in this analysis investigated the
benefit of prompted voiding compared with no prompted voiding for older people with urinary
incontinence. All of the analysed trials were conducted in the United States. Seven of the eight
studies were carried out in nursing home settings. The duration of the interventions ranged from

(continued next page)

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 21 Evidence profile: urinary incontinence

(continued from previous page) 20 days to 32 weeks. Two trials reported the effectiveness of prompted voiding in terms of
reducing the number of urinary incontinence episodes in 24 hours. Both Hu et al. (39) and
Do the desirable effects outweigh the Schnelle et al. (40) found a reduction in the number of incontinent episodes per day in the
undesirable effects? prompted voiding group. The pooled result was statistically significant (weighted mean
Yes No Uncertain difference [WMD]: -0.92, CI: 95% -1.32 to -0.53). Two other trials reported a similar outcome,
✓ but could not be included in the meta-analysis. One of them reported a substantial reduction in
the number of incontinent episodes (60% lower) in the treatment group compared with the
control group (37%). Another trial found a significant decrease in incontinence, falling from 80%
to 20%, in the treatment group, whereas the control group remained almost the same.

There is adequate moderate-quality evidence suggesting that pelvic floor muscle training
(PFMT) combined with bladder training benefits older women to manage urinary incontinence.
Six randomized controlled trials (RCTs), with a total of 1132 participants, investigated the
benefit of PFMT combined with bladder training with or without biofeedback. All six RCTs
recruited older people living in the community; five of them recruited older people aged over 55
years, while in the other trial, participants were aged 65 years and over. The intervention was
delivered at home or in clinical settings. The mean age of the study participants ranged from
65.4 to 74.7 years. In one trial, nearly 34% of study participants were older men; all other
studies only recruited older women.

Three of the six trials tested PFMT with biofeedback and a bladder control strategy with or
without self-monitoring. One RCT examined PFMT without biofeedback, bladder training or self-
monitoring. Two other RCTs combined PFMT with other behavioural interventions: one used a
group education approach consisting of bladder training, a strategy to manage the urge to
urinate, and group support for PFMT, while the other trial administered PFMT and bladder
training with individualized voiding schedules. Apart from one trial that offered a self-help
booklet to the control group, the control groups in all the other trials received no active
intervention.

Five of the analysed trials reported outcome data on the number of incontinence episodes per
week. The overall pooled effect of PFMT plus bladder training, with or without biofeedback, was

(continued next page)

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 22 Evidence profile: urinary incontinence

(continued from previous page) WMD: -3.63 (-5.19 to -0.99 lower), favouring the treatment (P < 0.001). Three trials reported
data on participants’ perception of improvement in urinary incontinence. The pooled estimate for
Do the desirable effects outweigh the this outcome was relative risk [RR]: 4.14 (95% CI: 2.70 to 6.37) in favour of the treatment group.
undesirable effects?
Yes No Uncertain No trial has reported adverse effects, and the guideline development group guideline
✓ development group believed that the potential for harm is likely to be minimal.

Values and preferences/ acceptability Explanation

Is there important uncertainty or Urinary incontinence in older people is associated with significant societal cost, and it impacts
variability about how much people value older people and family caregivers profoundly. The magnitude of the problem is larger in low-
the options? and middle-income countries (LMICs): 9% to 36% of older people suffer from urinary
Major Minor Uncertain incontinence. The majority of them receive care from a close family member, who may be at risk
variability variability of caregiver strain and burden.
✓

Is the option acceptable to key Although there is an absence of evidence from low- and middle-income countries, the evidence
stakeholders? reported in high-income countries indicates that non-pharmacological interventions may be
Major Minor Uncertain acceptable to older people in low-resource settings.
variability variability
✓

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 23 Evidence profile: urinary incontinence

Feasibility/resource use Explanation

How large are the resource Non-pharmacological interventions recommended for urinary incontinence are not resource
requirements? intensive.
Major Minor Uncertain
✓

Is the option feasible to implement? The feasibility of these interventions is not an important limitation; these interventions can be
safely administered by family caregivers. Delivery of care through non-specialist health workers
Yes No Uncertain
seems to be a successful model for low- and middle-income countries. Delivering an
✓ educational intervention has been shown to be feasible and to have promising results. Drawing
on these experiences, the guideline development group believed the recommendation was
feasible to implement in high- and low-resource settings.

Equity Explanation

Would the option improve equity in The guideline development group strongly believed that this recommendation would increase
health? equity in health.

Yes No Uncertain
✓

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 24 Evidence profile: urinary incontinence

Guideline development group recommendation and remarks

Recommendation

Prompted voiding for the management of urinary incontinence can be offered for older
people with cognitive impairment.
Strength of the recommendation: Conditional
Quality of evidence: Very low

Pelvic floor muscle training (PFMT), alone or combined with bladder control strategies
and self-monitoring, should be recommended for older women with urinary
incontinence (urge, stress or mixed).
Strength of the recommendation: Strong
Quality of evidence: Moderate

Remarks

• Apart from one study, all of the trials were conducted in high-income countries.
• Although the majority of PFMT trials involved older women, the recommendation for
PFMT may be applicable to older men.
• The duration of the PFMT intervention trials ranged from 6 to 12 weeks and most of the
trials administered the interventions on a daily regimen.
• Using continence products should be considered for older people who are bedridden or
experiencing severe declines in mental and/or physical capacities.
• Health care providers should take a detailed history and ask specific questions about
urinary incontinence, such as the time of onset, symptoms and frequency.

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 25 Evidence profile: urinary incontinence

• At least half of women with urinary incontinence do not report this issue to their general
practitioner; therefore, health care professionals should routinely check for urinary
incontinence in older women and men.
• Identifying and managing conditions that may cause urinary incontinence, including
urinary tract infections, metabolic disorders, excess fluid intake and impaired mental
conditions (e.g. delirium), are important and should not be neglected.
• Clinicians should review current medications that may cause or worsen urinary
incontinence.
• Although pharmacological therapy can reduce urinary incontinence and even provide
complete continence, many older people discontinue medication because of adverse
effects. Specialist care providers should be consulted when initiating pharmacological
treatment.
• As a first-line treatment, provide advice on bladder training for a minimum of six weeks.
Bladder training involves advising the older people to follow a strict schedule for bathroom
visits. The schedule starts with bathroom visits every 2 hours, but the time between visits
should be gradually increased to improve bladder control.

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 26
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of urinary incontinence in adults. Cochrane Database Syst Rev.
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management of urinary incontinence in adults. Cochrane Database
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New York (NY): Springer Publishing; 1992:196–204.
21. Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ,
Dombrowski M, Candib D. Behavioral vs drug treatment for urge
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precontraction can reduce cough-related urine loss in selected women
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Urinary Incontinence Treatment N. Correlates and predictors of patient
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behavioral training for urgency urinary incontinence in women. Int
Urogynecol J Pelvic Floor Dysfunct. 2011;22(3):327–34.
28. Pereira VS, de Melo MV, Correia GN, Driusso P. Vaginal cone for
postmenopausal women with stress urinary incontinence: randomized,
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Effectiveness of prompted voiding in treating urinary incontinence in
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cognitively impaired homebound older adults. J Wound Ostomy
Continence Nurs. 2002;29(5):252–65.
31. McDowell BJ, Engberg S, Sereika S, Donovan N, Jubeck ME, Weber
E et al. Effectiveness of behavioral therapy to treat incontinence in
homebound older adults. J Am Geriatr Soc. 1999;47(3):309–18.
32. Tobin GW, Brocklehurst JC. The management of urinary incontinence
in local authority residential homes for the elderly. Age Ageing.
1986;15(5):292–8.
33. Ouslander JG, Griffiths PC, McConnell E, Riolo L, Kutner M, Schnelle
J. Functional incidental training: a randomized, controlled, crossover
trial in Veterans Affairs nursing homes. J Am Geriatr Soc.
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34. McFall SL, Yerkes AM, Cowan LD. Outcomes of a small group
educational intervention for urinary incontinence: episodes of
incontinence and other urinary symptoms. J Aging Health.
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35. Goode PS, Burgio KL, Locher JL, Umlauf MG, Lloyd LK, Roth DL.
Urodynamic changes associated with behavioral and drug treatment of
urge incontinence in older women. J Am Geriatr Soc. 2002;50(5):808–
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36. Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The
effect of behavioral therapy on urinary incontinence: a randomized
controlled trial. Obstet Gynecol. 2002;100(1):72–8.
37. Dougherty MC, Dwyer JW, Pendergast JF, Boyington AR, Tomlinson
BU, Coward RT et al. A randomized trial of behavioral management
for continence with older rural women. Res Nurs Health.2002;25(1):3–
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38. Johnson TM, Burgio KL, Redden DT, Wright KC, Goode PS. Effects of
behavioral and drug therapy on nocturia in older incontinent women. J
Am Geriatr Soc. 2005;53(5):846–50.
39. Hu TW, Igou JF, Kaltreider DL, Yu LC, Rohner TJ, Dennis PJ et al. A
clinical trial of a behavioral therapy to reduce urinary incontinence in
nursing homes: outcome and implications. JAMA. 1989;261(18):2656–
62.
40. 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. 1989;37(11):1051–7.
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 28 Evidence profile: urinary incontinence

Annex 1: Search strategy

MEDLINE database supplementary concept, rare disease supplementary concept, title,
original title, abstract, name of substance word, subject heading
1. exp behavior therapy/ word, unique identifier]
2. (behav$ adj25 therapy).mp. [mp=protocol supplementary 11. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 9 or 10
concept, rare disease supplementary concept, title, original title, 12. exp Urinary Incontinence/ or urinary incontinence.mp.
abstract, name of substance word, subject heading word, unique [mp=protocol supplementary concept, rare disease
identifier] supplementary concept, title, original title, abstract, name of
3. exp cognitive therapy/ substance word, subject heading word, unique identifier]
4. (cognit$ adj25 therapy).mp. [mp=protocol supplementary 13. 11 and 12
concept, rare disease supplementary concept, title, original title, 14. 13 not child.mp. [mp=protocol supplementary concept, rare
abstract, name of substance word, subject heading word, unique disease supplementary concept, title, original title, abstract, name
identifier] of substance word, subject heading word, unique identifier]
5. (conservat$ adj25 intervention$).mp. [mp=protocol 15. exp randomized controlled trials/
supplementary concept, rare disease supplementary concept, title, 16. randomized controlled trial.pt.
original title, abstract, name of substance word, subject heading 17. exp random allocation/
word, unique identifier] 18. exp double blind method/
6. toilet training.mp. [mp=protocol supplementary concept, rare 19. exp single blind method/
disease supplementary concept, title, original title, abstract, name 20. exp Clinical Trial/
of substance word, subject heading word, unique identifier] 21. clinical trial.pt.
7. (habit training or habit retraining).mp. [mp=protocol 22. (clin$ adj25 trial$).ti,ab.
supplementary concept, rare disease supplementary concept, title, 23. ((singl$ or doubl$ or treb$ or tripl$) adj25 (blind$ or
original title, abstract, name of substance word, subject heading mask$)).ti,ab.
word, unique identifier] 24. placebo$.ti,ab.
8. timed void$.mp. [mp=protocol supplementary concept, rare 25. random$.ti,ab.
disease supplementary concept, title, original title, abstract, name 26. research design/
of substance word, subject heading word, unique identifier] 27. placebos.mp. [mp=protocol supplementary concept, rare
9. prompted void$.mp. [mp=protocol supplementary concept, rare disease supplementary concept, title, original title, abstract, name
disease supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier]
of substance word, subject heading word, unique identifier] 28. or/15-27
10. (nursing homes and urinary incontinence).mp. [mp=protocol 29. 14 and 28
(continued next page)
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 29 Evidence profile: urinary incontinence

30. exp Aged/ or exp Aging/ 23. (balance$ adj2 block$).tw.

31. exp Frail Elderly/ 24. or/1-23
32. 30 or 31 25. (nonhuman not human).sh.
33. 29 and 32 26. 24 not 25
27. behavior modification/ or behavior therapy/
Embase database 28. (conservat$ adj25 (intervention$ or therap$)).tw.
29. conservative treatment/
1. Randomized Controlled Trial/ 30. (behav$ adj25 (therap$ or train$ or treatment$ or
2. controlled study/ intervention$)).tw.
3. clinical study/ 31. (habit adj2 (train$ or retrain$)).tw.
4. major clinical study/ 32. (void$ adj2 (time$ or prompt$ or schedul$)).tw.
5. prospective study/ 33. toilet$.tw.
6. meta-analysis/ 34. or/27-33
7. exp clinical trial/ 35. bladder disease/ or bladder dysfunction/ or detrusor
8. randomization/ dyssynergia/ or neurogenic bladder/
9. crossover procedure/ or double blind procedure/ or parallel 36. (continen$ or incontinen$).tw.
design/ or single blind procedure/ 37. exp Incontinence/
10. Placebo/ 38. 37 or 35 or 36
11. latin square design/ 39. 26 and 34 and 38
12. exp comparative study/ 40. limit 39 to (embryo or infant or child or preschool child <1 to 6
13. follow up/ years> or school child <7 to 12 years> or adolescent <13 to 17
14. pilot study/ years>)
15. family study/ or feasibility study/ or pilot study/ or study/ 41. limit 39 to (adult <18 to 64 years> or aged <65+ years>)
16. placebo$.tw. 42. 40 not 41
17. random$.tw. 43. 39 not 42
18. (clin$ adj25 trial$).tw. 44. aging/ or aging.mp.
19. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or 45. frail elderly.mp. or frail elderly/
mask$)).tw. 46. 44 or 45
20. factorial.tw. 47. 43 and 46
21. crossover.tw.
22. latin square.tw.

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 30 Evidence profile: urinary incontinence

Annex 2: PRISMA2 2009 flow diagram for non-pharmacological intervention

for managing urinary incontinence
Identification

Records identified Additional records

through database identified through
searching (n = 1893) other sources (n = 19)

Records after duplicates removed (n = 986)

Screening

Records excluded (n = 714)

Records screened (n = 986) • Conference abstract (n = 146)
• Pharmacological intervention (n = 568)
Eligibility

Full-text articles assessed for eligibility (n = 272)

• Systematic reviews (SR) = 111
• Randomized controlled trials (RCTs) = 161
Studies included in qualitative synthesis
• SR = 111
• RCTs = 161
Studies included in quantitative synthesis
Inclusion
Full-text articles excluded, with reasons (n = 265)
Reasons for RCT exclusion:
• Inappropriate age group (n = 123)
• Insufficient information on outcomes (n = 36)
Reasons for review exclusion:
• Not SR (n = 54)
• Quality assessment not performed (n = 29)
• More recent reviews available (n = 23)

(meta-analysis) (n = 27)
• SR = 25 RCTs
• Additional studies = 2 RCTs

_______________________________

2Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA). For more information: http://www.prisma-statement.org
ICOPE guidelines – World Health Organization