Behavioral Therapy Rivals Drug Treatment for Men With Overactive Bladder
By Jill Stein
Medscape Medical News
June 3, 2010 (San Francisco, California) — A comprehensive behavioral therapy program is as effective as antimuscarinic drug therapy for treating overactive bladder (OAB) in men without significant bladder outlet obstruction, investigators announced here at the American Urological Association (AUA) 2010 Annual Scientific Meeting.
"Although some providers recommend behavioral treatments for OAB in men and women, most clinicians do not offer such therapies, which can include pelvic floor muscle training and urge-suppression techniques, in their clinical practices," Kathryn L. Burgio, PhD, professor of medicine at the University of Alabama at Birmingham, told Medscape Urology.
The researchers randomized 143 men with OAB to an 8-week course of behavioral or drug therapy.
OAB was defined as urgency and frequent urination (>8 voids per day), with or without incontinence, and without significant obstruction (<10?mL/s on simple uroflowmetry or >150?mL postvoid residual urine).
All participants in the trial had persistent OAB symptoms after alpha-blocker therapy during a 4-week run-in period.
Behavioral therapy consisted of a comprehensive training program, which included pelvic floor muscle exercises, delayed voiding, self-monitoring with bladder diaries, and urge-suppression techniques to inhibit detrusor contraction and reduce urgency, frequency, and incontinence.
Patients assigned to drug therapy received standard antimuscarinic therapy consisting of individually titrated, extended-release oxybutynin, 5 to 30?mg daily, initiated at 10?mg. The goal of dose escalation was to help the patient reach the most effective dose they could achieve without intolerable adverse effects.
Seven-day bladder diaries completed by subjects prior to randomization and after the last treatment session were used to calculate changes in 24-hour frequency of urination, as well as nocturia and incontinence.
The 64 patients who completed behavioral treatment demonstrated a reduction in the mean number of voids per day, from 11.3 at baseline to 9.1 after treatment (P?< .001). The 60 patients who received drug therapy showed a reduction from 11.4 at baseline to 9.5 after treatment (P?< .001). Statistical analysis indicated that the posttreatment voiding frequencies were equivalent (P?< .001).
After 8 weeks of treatment, 36% of patients randomized to behavioral treatment and 30% assigned to drug therapy had 8 or fewer voids per day (P?= .48). Nocturia was reduced by a mean of 0.72 episodes per night in the behavior group and 0.32 episodes in the drug group (P?= .04).
On the global perception of improvement, assessed at the end of treatment, 38% of patients receiving behavioral therapy reported that they were "much better," compared with 29% of those receiving drug therapy (P?= .34). On the patient satisfaction question, 56% receiving behavioral therapy reported being "completely satisfied," compared with 43% receiving drug therapy (P?= .17).
The results of this trial demonstrate that behavioral treatment with pelvic floor muscle training, delayed voiding, and urge-suppression techniques are effective for reducing frequency of voiding in men with OAB, and yield outcomes at least as good as drug therapy, Dr. Burgio said.
"Given its lower side-effect profile, behavioral therapy is an appropriate first-line treatment for OAB in men without obstruction," she said. "Also, because no consistent predictors of outcome have been identified, we maintain that there is no clinical reason to deny behavioral treatment to any nondemented patient who wishes to try it."
"While the study was small, the findings are interesting, and the lack of a large difference between the medical and behavioral therapy groups suggests that there is some benefit with the behavioral therapy," Anthony Y. Smith, MD, chair of the AUA public media committee and professor and chief of the Division of Urology at the University of New Mexico in Albuquerque, told Medscape Urology.
Although behavioral therapy seems to be effective, the intervention is a mixed bag, he cautioned. "Obviously, behavioral therapy won't have the well-described side effects of some of the OAB medications, but the downside is the complexity of setting up a model to treat patients, because you need someone to teach the various techniques and then you need someone to make sure that the patients are performing the techniques correctly. So behavioral therapy can be very labor-intensive."
The study was funded by the Department of Veterans Affairs, Veterans Health Administration, Rehabilitation Research and Development Service. Dr. Burgio reports relevant financial relationships collectively for the research team with Pfizer, Asellas, Ferring, Alza, and Johnson Johnson. Dr. Smith has disclosed no relevant financial relationships.
American Urological Association (AUA) 2010 Annual Scientific Meeting: Abstract?1516. Presented June?1, 2010.
