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Background: Lower urinary tract symptoms (LUTS) in men may indicate bladder outlet obstruction (BOO) or weakness, known as detrusor underactivity (DU). Severe bothersome LUTS are a common indication for surgery. The diagnostic tests may include urodynamics (UDS) to confirm whether BOO or DU is the cause, potentially reducing the number of people receiving (inappropriate) surgery., Objectives: The primary objective was to determine whether a care pathway including UDS is no worse for symptom outcome than one in which it is omitted, at 18 months after randomisation. Rates of surgery was the key secondary outcome., Design: This was a pragmatic, multicentre, two-arm (unblinded) randomised controlled trial, incorporating a health economic analysis and qualitative research., Setting: Urology departments of 26 NHS hospitals in England., Participants: Men (aged ≥ 18 years) seeking further treatment, potentially including surgery, for bothersome LUTS. Exclusion criteria were as follows: unable to pass urine without a catheter, having a relevant neurological disease, currently undergoing treatment for prostate or bladder cancer, previously had prostate surgery, not medically fit for surgery and/or unwilling to be randomised., Interventions: Men were randomised to a care pathway based on non-invasive routine tests (control) or routine care plus invasive UDS (intervention arm)., Main Outcome Measures: The primary outcome was International Prostate Symptom Score (IPSS) at 18 months after randomisation and the key secondary outcome was rates of surgery. Additional secondary outcomes included adverse events (AEs), quality of life, urinary and sexual symptoms, UDS satisfaction, maximum urinary flow rate and cost-effectiveness., Results: A total of 820 men were randomised (UDS, 427; routine care, 393). Sixty-seven men withdrew before 18 months and 11 died (unrelated to trial procedures). UDS was non-inferior to routine care for IPSS 18 months after randomisation, with a confidence interval (CI) within the margin of 1 point (-0.33, 95% CI -1.47 to 0.80). A lower surgery rate in the UDS arm was not found (38% and 36% for UDS and routine care, respectively), with overall rates lower than expected. AEs were similar between the arms at 43-44%. There were more cases of acute urinary retention in the routine care arm. Patient-reported outcomes for LUTS improved in both arms and satisfaction with UDS was high in men who received it. UDS was more expensive than routine care. From a secondary care perspective, UDS cost an additional £216 over an 18-month time horizon. Quality-adjusted life-years (QALYs) were similar, with a QALY difference of 0.006 in favour of UDS over 18 months. It was established that UDS was acceptable to patients, and valued by both patients and clinicians for its perceived additional insight into the cause and probable best treatment of LUTS., Limitations: The trial met its predefined recruitment target, but surgery rates were lower than anticipated., Conclusions: Inclusion of UDS in the diagnostic tests results in a symptom outcome that is non-inferior to a routine care pathway, but does not affect surgical rates for treating BOO. Results do not support the routine use of UDS in men undergoing investigation of LUTS., Future Work: Focus should be placed on indications for selective utilisation of UDS in individual cases and long-term outcomes of diagnosis and therapy., Trial Registration: Current Controlled Trials ISRCTN56164274., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 42. See the NIHR Journals Library website for further project information., Competing Interests: Outside this work, Paul Abrams reports grants and personal fees for being a consultant and speaker for Astellas Pharma Inc. (Tokyo, Japan), and personal fees for being a consultant for Ipsen (Paris, France) and a speaker for Pfizer Inc. (New York City, NY, USA) and Sun Pharmaceutical Industries Ltd (Mumbai, India). He also reports personal fees from Pierre Fabre S.A. (Paris, France) and Coloplast Ltd (Peterborough, UK). Christopher Chapple reports being an author for Allergan plc (Dublin, Ireland) and Astellas Pharma; being an investigator for scientific studies/trials with Astellas Pharma and Ipsen; being a patent holder with Symimetics; receiving personal fees as a consultant/advisor for Astellas Pharma, Bayer Schering Pharma GmbH (Berlin, Germany), Ferring Pharmaceuticals (Saint-Prex, Switzerland), Galvani Bioelectronics (GlaxoSmithKline; Stevenage, UK), Pierre Fabre, Symimetics, TARIS Biomedical Inc. (Lexington, MA, USA), and Urovant Sciences (Irvine, CA, USA); and receiving personal fees as a meeting participant/speaker for Astellas Pharma and Pfizer. J Athene Lane was a member of the Clinical Trials Unit funded by the National Institute for Health Research during the conduct of this trial. Marcus J Drake reports being on associated advisory boards and has received grants, personal fees and non-financial support from Allergan, Astellas Pharma and Ferring Pharmaceuticals. He has also received personal fees from Pfizer.

Background: Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence., Objectives: To assess the effectiveness of traditional suburethral sling procedures for treating stress urinary incontinence in women; and summarise the principal findings of relevant economic evaluations., Search Methods: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), as well as MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); we handsearched journals and conference proceedings (searched 27 February 2017) and the reference lists of relevant articles. On 23 January 2019, we updated this search; as a result, several additional reports of studies are awaiting classification., Selection Criteria: Randomised or quasi-randomised trials that assessed traditional suburethral slings for treating stress or mixed urinary incontinence., Data Collection and Analysis: At least two review authors independently extracted data from included trials and assessed risk of bias. When appropriate, a summary statistic was calculated: risk ratio (RR) for dichotomous data, odds ratio (OR) for continence and cure rates that were expected to be high, and mean difference (MD) for continuous data. We adopted the GRADE approach to assess the quality of evidence., Main Results: A total of 34 trials involving 3244 women were included. Traditional slings were compared with 10 other treatments and with each other. We did not identify any trials comparing suburethral slings with no treatment or sham treatment, conservative management, anterior repair, or laparoscopic retropubic colposuspension. Most trials did not distinguish between women having surgery for primary or recurrent incontinence. One trial compared traditional slings with bladder neck needle suspension, and another trial compared traditional slings with single-incision slings. Both trials were too small to be informative. Traditional suburethral sling operation versus drugs One small trial compared traditional suburethral sling operations with oxybutynin to treat women with mixed urinary incontinence. This trial did not report any of our GRADE-specific outcomes. It is uncertain whether surgery compared with oxybutynin leads to more women being dry (83% vs 0%; OR 195.89, 95% confidence interval (CI) 9.91 to 3871.03) or having less urgency urinary incontinence (13% vs 43%; RR 0.29, 95% CI 0.09 to 0.94) because the quality of this evidence is very low. Traditional suburethral sling versus injectables One small trial compared traditional slings with suburethral injectable treatment. The impact of surgery versus injectables is uncertain in terms of the number of continent women (100% were dry with a traditional sling versus 71% with the injectable after the first year; OR 11.57, 95% CI 0.56 to 239.74), the need for repeat surgery for urinary incontinence (RR 0.52, 95% CI 0.05 to 5.36) or the occurrence of perioperative complications (RR 1.57, 95% CI 0.29 to 8.49), as the quality of evidence is very low. Traditional suburethral sling versus open abdominal retropubic colposuspension Eight trials compared slings with open abdominal retropubic colposuspension. Moderate-quality evidence shows that the traditional suburethral sling probably leads to more continent women in the medium term (one to five years) (69% vs 59% after colposuspension: OR 1.70, 95% CI 1.22 to 2.37). High-quality evidence shows that women were less likely to need repeat continence surgery after a traditional sling operation than after colposuspension (RR 0.15, 95% CI 0.05 to 0.42). We found no evidence of a difference in perioperative complications between the two groups, but the CI was very wide and the quality of evidence was very low (RR 1.24, 95% CI 0.83 to 1.86). Traditional suburethral sling operation versus mid-urethral slings Fourteen trials compared traditional sling operations and mid-urethral sling operations. Depending on judgements about what constitutes a clinically important difference between interventions with regard to continence, traditional suburethral slings are probably no better, and may be less effective, than mid-urethral slings in terms of number of women continent in the medium term (one to five years) (67% vs 74%; OR 0.67, 95% CI 0.44 to 1.02; n = 458; moderate-quality evidence). One trial reported more continent women with the traditional sling after 10 years (51% vs 32%: OR 2.22, 95% CI 1.07 to 4.61). Mid-urethral slings may be associated with fewer perioperative complications (RR 1.74, 95% CI 1.16 to 2.60; low-quality evidence). One type of traditional sling operation versus another type of traditional sling operation Nine trials compared one type of traditional sling operation with another. The different types of traditional slings, along with the number of different materials used, mean that trial results could not be pooled due to clinical heterogeneity. Complications were reported by two trials - one comparing non-absorbable Goretex with a rectus fascia sling, and the second comparing Pelvicol with a rectus fascial sling. The impact was uncertain due to the very low quality of evidence., Authors' Conclusions: Low-quality evidence suggests that women may be more likely to be continent in the medium term (one to five years) after a traditional suburethral sling operation than after colposuspension. It is very uncertain whether there is a difference in urinary incontinence after a traditional suburethral sling compared with a mid-urethral sling in the medium term. However, these findings should be interpreted with caution, as long-term follow-up data were not available from most trials. Long-term follow-up of randomised controlled trials (RCTs) comparing traditional slings with colposuspension and mid-urethral slings is essential. Evidence is insufficient to suggest whether traditional suburethral slings may be better or worse than other management techniques. This review is confined to RCTs and therefore may not identify all of the adverse effects that may be associated with these procedures. A brief economic commentary (BEC) identified three eligible economic evaluations, which are not directly comparable due to differences in methods, time horizons, and settings. End users of this review will need to assess the extent to which methods and results of identified economic evaluations may be applicable (or transferable) to their own setting., (Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Several treatment options are available for stress urinary incontinence (SUI), including pelvic floor muscle training (PFMT), drug therapy and surgery. Problems exist such as adherence to PFMT regimens, side effects linked to drug therapy and the risks associated with surgery. We have evaluated an alternative treatment, electrical stimulation (ES) with non-implanted devices, which aims to improve pelvic floor muscle function to reduce involuntary urine loss., Objectives: To assess the effects of electrical stimulation with non-implanted devices, alone or in combination with other treatment, for managing stress urinary incontinence or stress-predominant mixed urinary incontinence in women. Among the outcomes examined were costs and cost-effectiveness., Search Methods: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearches of journals and conference proceedings (searched 27 February 2017). We also searched the reference lists of relevant articles and undertook separate searches to identify studies examining economic data., Selection Criteria: We included randomised or quasi-randomised controlled trials of ES with non-implanted devices compared with any other treatment for SUI in women. Eligible trials included adult women with SUI or stress-predominant mixed urinary incontinence (MUI). We excluded studies of women with urgency-predominant MUI, urgency urinary incontinence only, or incontinence associated with a neurologic condition. We would have included economic evaluations had they been conducted alongside eligible trials., Data Collection and Analysis: Two review authors independently screened search results, extracted data from eligible trials and assessed risk of bias, using the Cochrane 'Risk of bias' tool. We would have performed economic evaluations using the approach recommended by Cochrane Economic Methods., Main Results: We identified 56 eligible trials (3781 randomised participants). Eighteen trials did not report the primary outcomes of subjective cure, improvement of SUI or incontinence-specific quality of life (QoL). The risk of bias was generally unclear, as most trials provided little detail when reporting their methods. We assessed 25% of the included trials as being at high risk of bias for a variety of reasons, including industry funding and baseline differences between groups. We did not identify any economic evaluations.For subjective cure of SUI, we found moderate-quality evidence that ES is probably better than no active treatment (risk ratio (RR) 2.31, 95% CI 1.06 to 5.02). We found a similar result for cure or improvement of SUI (RR 1.73, 95% CI 1.41 to 2.11), but the quality of evidence was lower. We are very uncertain if there is a difference between ES and sham treatment in terms of subjective cure because of the very low quality of evidence (RR 2.21, 95% CI 0.38 to 12.73). For subjective cure or improvement, ES may be better than sham treatment (RR 2.03, 95% CI 1.02 to 4.07). The effect estimate was 660/1000 women cured/improved with ES compared to 382/1000 with no active treatment (95% CI 538 to 805 women); and for sham treatment, 402/1000 women cured/improved with ES compared to 198/1000 with sham treatment (95% CI 202 to 805 women).Low-quality evidence suggests that there may be no difference in cure or improvement for ES versus PFMT (RR 0.85, 95% CI 0.70 to 1.03), PFMT plus ES versus PFMT alone (RR 1.10, 95% CI 0.95 to 1.28) or ES versus vaginal cones (RR 1.09, 95% CI 0.97 to 1.21).Electrical stimulation probably improves incontinence-specific QoL compared to no treatment (moderate quality evidence) but there may be little or no difference between electrical stimulation and PFMT (low quality evidence). It is uncertain whether adding electrical stimulation to PFMT makes any difference in terms of quality of life, compared with PFMT alone (very low quality evidence). There may be little or no difference between electrical stimulation and vaginal cones in improving incontinence-specific QoL (low quality evidence). The impact of electrical stimulation on subjective cure/improvement and incontinence-specific QoL, compared with vaginal cones, PFMT plus vaginal cones, or drugs therapy, is uncertain (very low quality evidence).In terms of subjective cure/improvement and incontinence-specific QoL, the available evidence comparing ES versus drug therapy or PFMT plus vaginal cones was very low quality and inconclusive. Similarly, comparisons of different types of ES to each other and of ES plus surgery to surgery are also inconclusive in terms of subjective cure/improvement and incontinence-specific QoL (very low-quality evidence).Adverse effects were rare: in total nine of the women treated with ES in the trials reported an adverse effect. We identified insufficient evidence to compare the risk of adverse effects in women treated with ES compared to any other treatment. We were unable to identify any economic data., Authors' Conclusions: The current evidence base indicated that electrical stimulation is probably more effective than no active or sham treatment, but it is not possible to say whether ES is similar to PFMT or other active treatments in effectiveness or not. Overall, the quality of the evidence was too low to provide reliable results. Without sufficiently powered trials measuring clinically important outcomes, such as subjective assessment of urinary incontinence, we cannot draw robust conclusions about the overall effectiveness or cost-effectiveness of electrical stimulation for stress urinary incontinence in women.

Background: Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence (SUI) in women. About a third of adult women experience urinary incontinence. SUI imposes significant health and economic burden to the society and the women affected., Objectives: To determine the effects of anterior vaginal repair (anterior colporrhaphy) on urinary incontinence in comparison with other management options., Search Methods: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 September 2009) and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence., Data Collection and Analysis: Two review authors independently extracted data and assessed trial quality. Three trial investigators were contacted for additional information., Main Results: Ten trials were identified which included 385 women having an anterior vaginal repair and 627 who received comparison interventions.A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with bladder neck needle suspension appeared similar (risk ratio (RR) for failure after one year 1.16, 95% confidence interval (CI) 0.86 to 1.56), but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic colposuspensions, or compared alternative vaginal operations.Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the medium term (failure rate within one to five years after anterior repair 97/259 (38%) versus 57/327 (17%); RR 2.29, 95% confidence Interval (CI) 1.70 to 3.08) and in the long term (after five years, (49/128 (38%) versus 31/145 (21%); RR 2.02, 95% CI 1.36 to 3.01). There was evidence from three of these trials that this was reflected in a need for more repeat operations for incontinence (25/107 (23%) versus 4/164 (2%); RR 8.87, 95% CI 3.28 to 23.94). These findings held, irrespective of the co-existence of prolapse (pelvic relaxation). Although fewer women had a prolapse after anterior repair (RR 0.24, 95% CI 0.12 to 0.47), later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation.In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension., Authors' Conclusions: There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in eight trials, even in women who had prolapse in addition to stress incontinence (six trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about postoperative complications and morbidity.A Brief Economic Commentary (BEC) identified one study suggesting that vaginoplasty may be more cost-effective compared with tension-free vaginal tape (TVT-O).

Background: Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of these have moderate or severe symptoms. Stress urinary incontinence (SUI) imposes significant health and economic burdens on society and the women affected., Objectives: To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options., Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 12 November 2014), and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence., Data Collection and Analysis: At least two authors assessed trials and extracted data independently. Two trial investigators provided additional information., Main Results: We identified 10 trials, which included 375 women having six different types of needle suspension procedures and 489 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension. There was a higher subjective failure rate after the first year (91/313 (29%) failed versus 47/297 (16%) failed after open abdominal retropubic suspension). The risk ratio (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72), although the difference in peri-operative complications was not significant (17/75 (23%) versus 12/77 (16%); RR 1.44, 95% CI 0.73 to 2.83). There were no significant differences for the other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (50/156 (32%) failed after needle suspension versus 64/181 (35%) after anterior repair; RR 0.86, 95% CI 0.64 to 1.16), but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population.No trials compared needle suspensions with conservative management, peri-urethral injections, or sham or laparoscopic surgery., Authors' Conclusions: Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity. A Brief Economic Commentary (BEC) identified no cost-effectiveness studies comparing bladder neck needle suspension with other surgeries.

Background: Concerns have been raised about the safety of surgery for stress urinary incontinence and pelvic organ prolapse using transvaginal mesh. We assessed adverse outcomes after first, single mesh procedures and comparable non-mesh procedures., Methods: We did a cohort study of women in Scotland aged 20 years or older undergoing a first, single incontinence procedure or prolapse procedure during 1997-98 to 2015-16 identified from a national hospital admission database. Primary outcomes were immediate postoperative complications and subsequent (within 5 years) readmissions for later postoperative complications, further incontinence surgery, or further prolapse surgery. Poisson regression models were used to compare outcomes after procedures carried out with and without mesh., Findings: Between April 1, 1997, and March 31, 2016, 16 660 women underwent a first, single incontinence procedure, 13 133 (79%) of which used mesh. Compared with non-mesh open surgery (colposuspension), mesh procedures had a lower risk of immediate complications (adjusted relative risk [aRR] 0·44 [95% CI 0·36-0·55]) and subsequent prolapse surgery (adjusted incidence rate ratio [aIRR] 0·30 [0·24-0·39]), and a similar risk of further incontinence surgery (0·90 [0·73-1·11]) and later complications (1·12 [0·98-1·27]); all ratios are for retropubic mesh. During the same time period, 18 986 women underwent a first, single prolapse procedure, 1279 (7%) of which used mesh. Compared with non-mesh repair, mesh repair of anterior compartment prolapse was associated with a similar risk of immediate complications (aRR 0·93 [95% CI 0·49-1·79]); an increased risk of further incontinence (aIRR 3·20 [2·06-4·96]) and prolapse surgery (1·69 [1·29-2·20]); and a substantially increased risk of later complications (3·15 [2·46-4·04]). Compared with non-mesh repair, mesh repair of posterior compartment prolapse was associated with a similarly increased risk of repeat prolapse surgery and later complications. No difference in any outcome was observed between vaginal and, separately, abdominal mesh repair of vaginal vault prolapse compared with vaginal non-mesh repair., Interpretation: Our results support the use of mesh procedures for incontinence, although further research on longer term outcomes would be beneficial. Mesh procedures for anterior and posterior compartment prolapse cannot be recommended for primary prolapse repair. Both vaginal and abdominal mesh procedures for vaginal vault prolapse repair are associated with similar effectiveness and complication rates to non-mesh vaginal repair. These results therefore do not clearly favour any particular vault repair procedure., Funding: None., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The use of transvaginal mesh and biological graft material in prolapse surgery is controversial and has led to a number of enquiries into their safety and efficacy. Existing trials of these augmentations are individually too small to be conclusive. We aimed to compare the outcomes of prolapse repair involving either synthetic mesh inlays or biological grafts against standard repair in women., Methods: We did two pragmatic, parallel-group, multicentre, randomised controlled trials for our study (PROSPECT [PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trials]) in 35 centres (a mix of secondary and tertiary referral hospitals) in the UK. We recruited women undergoing primary transvaginal anterior or posterior compartment prolapse surgery by 65 gynaecological surgeons in these centres. We randomly assigned participants by a remote web-based randomisation system to one of the two trials: comparing standard (native tissue) repair alone with standard repair augmented with either synthetic mesh (the mesh trial) or biological graft (the graft trial). We assigned women (1:1:1 or 1:1) within three strata: assigned to one of the three treatment options, comparison of standard repair with mesh, and comparison of standard repair with graft. Participants, ward staff, and outcome assessors were masked to randomisation where possible; masking was obviously not possible for the surgeon. Follow-up was for 2 years after the surgery; the primary outcomes, measured at 1 year and 2 years, were participant-reported prolapse symptoms (i.e. the Pelvic Organ Prolapse Symptom Score [POP-SS]) and condition-specific (ie, prolapse-related) quality-of-life scores, analysed in the modified intention-to-treat population. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN60695184., Findings: Between Jan 8, 2010, and Aug 30, 2013, we randomly allocated 1352 women to treatment, of whom 1348 were included in the analysis. 865 women were included in the mesh trial (430 to standard repair alone, 435 to mesh augmentation) and 735 were included in the graft trial (367 to standard repair alone, 368 to graft augmentation). Because the analyses were carried out separately for each trial (mesh trial and graft trial) some women in the standard repair arm assigned to all treatment options were included in the standard repair group of both trials. 23 of these women did not receive any surgery (15 in the mesh trial, 13 in the graft trial; five were included in both trials) and were included in the baseline analyses only. Mean POP-SS at 1 year did not differ substantially between comparisons (standard 5·4 [SD 5·5] vs mesh 5·5 [5·1], mean difference 0·00, 95% CI -0·70 to 0·71; p=0·99; standard 5·5 [SD 5·6] vs graft 5·6 [5·6]; mean difference -0·15, -0·93 to 0·63; p=0·71). Mean prolapse-related quality-of-life scores also did not differ between groups at 1 year (standard 2·0 [SD 2·7] vs mesh 2·2 [2·7], mean difference 0·13, 95% CI -0·25 to 0·51; p=0·50; standard 2·2 [SD 2·8] vs graft 2·4 [2·9]; mean difference 0·13, -0·30 to 0·56; p=0·54). Mean POP-SS at 2 years were: standard 4·9 (SD 5·1) versus mesh 5·3 (5·1), mean difference 0·32, 95% CI -0·39 to 1·03; p=0·37; standard 4·9 (SD 5·1) versus graft 5·5 (5·7); mean difference 0·32, -0·48 to 1·12; p=0·43. Prolapse-related quality-of-life scores at 2 years were: standard 1·9 (SD 2·5) versus mesh 2·2 (2·6), mean difference 0·15, 95% CI -0·23 to 0·54; p=0·44; standard 2·0 (2·5) versus graft 2·2 (2·8); mean difference 0·10, -0·33 to 0·52; p=0·66. Serious adverse events such as infection, urinary retention, or dyspareunia or other pain, excluding mesh complications, occurred with similar frequency in the groups over 1 year (mesh trial: 31/430 [7%] with standard repair vs 34/435 [8%] with mesh, risk ratio [RR] 1·08, 95% CI 0·68 to 1·72; p=0·73; graft trial: 23/367 [6%] with standard repair vs 36/368 [10%] with graft, RR 1·57, 0·95 to 2·59; p=0·08). The cumulative number of women with a mesh complication over 2 years in women actually exposed to synthetic mesh was 51 (12%) of 434., Interpretation: Augmentation of a vaginal repair with mesh or graft material did not improve women's outcomes in terms of effectiveness, quality of life, adverse effects, or any other outcome in the short term, but more than one in ten women had a mesh complication. Therefore, follow-up is vital to identify any longer-term potential benefits and serious adverse effects of mesh or graft reinforcement in vaginal prolapse surgery., Funding: UK National Institute of Health Research., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.)

Background: Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make an objective diagnosis. The investigations are invasive and time consuming., Objectives: To determine if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, leads to more effective clinical care and better clinical outcomes., Search Methods: Cochrane Incontinence Group Specialized Register (searched February 19, 2013); reference lists of relevant articles., Selection Criteria: Randomized and quasi-randomized trials in people who were and were not investigated using urodynamics, or comparing one type of urodynamic test against another., Data Collection and Analysis: At least two independent review authors carried out trial assessment, selection, and data abstraction., Results: We found eight trials but data were available for only 1,036 women in seven trials. Women undergoing urodynamics were more likely to have their management changed (17% vs. 3%, risk ratio [RR] 5.07, 95% CI 1.87-13.74). Two trials suggested that women were more likely to receive drugs (RR 2.09, 95% CI 1.32-3.31), but, in five trials, women were not more likely to undergo surgery (RR 0.99, 95% CI 0.88-1.12). There was no statistically significant difference in urinary incontinence in women who had urodynamics (37%) compared with those undergoing history and clinical examination alone (36%) (RR 1.02, 95% CI 0.86-1.21)., Authors' Conclusions: While urodynamics did change clinical decision-making, there was some high-quality evidence that this did not result in lower urinary incontinence rates after treatment., (© 2014 Wiley Periodicals, Inc.)

Background: Urinary incontinence is common after radical prostatectomy and can also occur in some circumstances after transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training with or without biofeedback, electrical stimulation, extra-corporeal magnetic innervation (ExMI), compression devices (penile clamps), lifestyle changes, or a combination of methods., Objectives: To determine the effectiveness of conservative management for urinary incontinence up to 12 months after transurethral, suprapubic, laparoscopic, radical retropubic or perineal prostatectomy, including any single conservative therapy or any combination of conservative therapies., Search Methods: We searched the Cochrane Incontinence Group Specialised Register (5 February 2014), CENTRAL (2014, Issue 1), EMBASE (January 2010 to Week 3 2014), CINAHL (January 1982 to 18 January 2014), ClinicalTrials.gov and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (both searched 29 January 2014), and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence in men after prostatectomy., Data Collection and Analysis: Two or more review authors assessed the methodological quality of the trials and abstracted data. We tried to contact several authors of included studies to obtain extra information., Main Results: Fifty trials met the inclusion criteria, 45 in men after radical prostatectomy, four trials after TURP and one trial after either operation. The trials included 4717 men of whom 2736 had an active conservative intervention. There was considerable variation in the interventions, populations and outcome measures. Data were not available for many of the pre-stated outcomes. Men's symptoms improved over time irrespective of management.There was no evidence from eight trials that pelvic floor muscle training with or without biofeedback was better than control for men who had urinary incontinence up to 12 months after radical prostatectomy; the quality of the evidence was judged to be moderate (for example 57% with urinary incontinence in the intervention group versus 62% in the control group, risk ratio (RR) for incontinence after 12 months 0.85, 95% confidence interval (CI) 0.60 to 1.22). One large multi-centre trial of one-to-one therapy showed no difference in any urinary or quality of life outcome measures and had narrow CIs. It seems unlikely that men benefit from one-to-one PFMT therapy after TURP. Individual small trials provided data to suggest that electrical stimulation, external magnetic innervation, or combinations of treatments might be beneficial but the evidence was limited. Amongst trials of conservative treatment for all men after radical prostatectomy, aimed at both treatment and prevention, there was moderate evidence of an overall benefit from pelvic floor muscle training versus control management in terms of reduction of urinary incontinence (for example 10% with urinary incontinence after one year in the intervention groups versus 32% in the control groups, RR for urinary incontinence 0.32, 95% CI 0.20 to 0.51). However, this finding was not supported by other data from pad tests. The findings should be treated with caution because the risk of bias assessment showed methodological limitations. Men in one trial were more satisfied with one type of external compression device, which had the lowest urine loss, compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remained undetermined as no trials involving these interventions were identified., Authors' Conclusions: The value of the various approaches to conservative management of postprostatectomy incontinence after radical prostatectomy remains uncertain. The evidence is conflicting and therefore rigorous, adequately powered randomised controlled trials (RCTs) which abide by the principles and recommendations of the CONSORT statement are still needed to obtain a definitive answer. The trials should be robustly designed to answer specific well constructed research questions and include outcomes which are important from the patient's perspective in decision making and are also relevant to the healthcare professionals. Long-term incontinence may be managed by an external penile clamp, but there are safety problems.

Background: Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of these have moderate or severe symptoms., Objectives: To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options., Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 12 November 2014), and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence., Data Collection and Analysis: At least two authors assessed trials and extracted data independently. Two trial investigators provided additional information., Main Results: We identified 10 trials, which included 375 women having six different types of needle suspension procedures and 489 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension. There was a higher subjective failure rate after the first year (91/313 (29%) failed versus 47/297 (16%) failed after open abdominal retropubic suspension). The risk ratio (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72), although the difference in peri-operative complications was not significant (17/75 (23%) versus 12/77 (16%); RR 1.44, 95% CI 0.73 to 2.83). There were no significant differences for the other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (50/156 (32%) failed after needle suspension versus 64/181 (35%) after anterior repair; RR 0.86, 95% CI 0.64 to 1.16), but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population.No trials compared needle suspensions with conservative management, peri-urethral injections, or sham or laparoscopic surgery., Authors' Conclusions: Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.

Objective: To determine the long-term (12-year) effects of a conservative nurse-led intervention for postnatal urinary incontinence., Design: Follow-up of a randomised controlled trial., Setting: Community-based intervention in three centres (in the UK and New Zealand)., Population: A cohort of 747 women with urinary incontinence at 3 months after childbirth, of whom 471 (63%) were followed up after 12 years., Methods: Women were randomly allocated to active conservative treatment after delivery (pelvic floor muscle training and bladder training), or to a control group receiving standard care., Main Outcome Measures: Prevalence of urinary incontinence (primary outcome) and faecal incontinence, symptoms and signs of prolapse, and performance of pelvic floor muscle training at 12 years., Results: The significant improvements relative to controls that had been found in urinary incontinence (60 versus 69%; risk difference, RD, -9.1%; 95% confidence interval, 95% CI, -17.3 to -1.0%) and faecal incontinence (4 versus 11%; RD -6.1%; 95% CI -10.8 to -1.6%) at 1 year did not persist for urinary incontinence (83 versus 80%; RD 2.1%; 95% CI -4.9 to 9.1%) or faecal incontinence (19 versus 15%; RD 4.3%; 95% CI -2.5 to 11.0%) at the 12-year follow up, irrespective of incontinence severity at trial entry. The prevalence of prolapse symptoms or objectively measured pelvic organ prolapse also did not differ between the groups. In the short term the intervention motivated more women to perform pelvic floor muscle training (83 versus 55%), but this fell in both groups by 12 years (52 versus 49%)., Conclusions: The moderate short-term benefits of a brief nurse-led conservative treatment for postnatal urinary incontinence did not persist. About four-fifths of women with urinary incontinence 3 months after childbirth still had this problem 12 years later., (© 2013 Royal College of Obstetricians and Gynaecologists.)

Background: Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive, objective diagnosis. The aim is to help select the treatment most likely to be successful. The investigations are invasive and time consuming., Objectives: The objective of this review was to determine if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of people with urinary incontinence and better clinical outcomes.The intention was to test the following hypotheses in predefined subgroups of people with incontinence:(i) urodynamic investigations improve the clinical outcomes;(ii) urodynamic investigations alter clinical decision making;(iii) one type of urodynamic test is better than another in improving the outcomes of management of incontinence or influencing clinical decisions, or both., Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process, handsearching of journals and conference proceedings (searched 19 February 2013), and the reference lists of relevant articles., Selection Criteria: Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamic test against another were included. Trials were excluded if they did not report clinical outcomes., Data Collection and Analysis: Two review authors independently assessed trial quality and extracted data., Main Results: Eight trials involving around 1100 people were included but data were only available for 1036 women in seven trials, of whom 526 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was significant evidence that the tests did change clinical decision making. Women in the urodynamic arms of three trials were more likely to have their management changed (proportion with change in management compared with the control arm 17% versus 3%, risk ratio (RR) 5.07, 95% CI 1.87 to 13.74), although there was statistical heterogeneity. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31). On the other hand, in five trials women undergoing treatment following urodynamic investigation were not more likely to undergo surgery (RR 0.99, 95% CI 0.88 to 1.12).There was no statistically significant difference however in the number of women with urinary incontinence if they received treatment guided by urodynamics (37%) compared with those whose treatment was based on history and clinical findings alone (36%) (for example, RR for the number with incontinence after the first year 1.02, 95% CI 0.86 to 1.21). It was calculated that the number of women needed to treat was 100 women (95% CI 86 to 114 women) undergoing urodynamics to prevent one extra individual being incontinent at one year.One trial reported adverse effects and no significant difference was found (RR 1.10, 95% CI 0.81 to 1.50)., Authors' Conclusions: While urodynamic tests did change clinical decision making, there was some evidence that this did not result in better outcomes in terms of a difference in urinary incontinence rates after treatment. There was no evidence about their use in men, children, or people with neurological diseases. Larger definitive trials are needed in which people are randomly allocated to management according to urodynamic findings or to management based on history and clinical examination to determine if performance of urodynamics results in higher continence rates after treatment.

Objective: To assess the effect of a research prioritization partnership that aimed to influence the research agenda relating to urinary incontinence (UI)., Study Design and Setting: Research often neglects important gaps in existing evidence so that decisions must be made about treatments without reliable evidence of their effectiveness. In 2007-2009, a United Kingdom partnership of eight patient and 13 clinician organizations identified and prioritized gaps in the evidence that affect everyday decisions about treatment of UI. The top 10 prioritized research questions were published and reported to research funders in 2009. A year later, new research or funding applications relating to the prioritized topics were identified through reviews of research databases and consultation with funding organizations, elements of the research community, and organizations that participated in the partnership., Results: Since dissemination of the prioritized topics, five studies are known to have been funded, three in development; five new systematic reviews are under way, one is being updated; five questions are under consideration by a national research commissioning body., Conclusion: The partnership successfully developed and used a methodology for identification and prioritization of research needs through patient-clinician consensus. Prioritization through consensus can be effective in informing the development of clinically useful research., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aims: The impact of urinary incontinence (UI) on health-related quality of life (HRQoL) has been less well researched in men than women and the general population. This study aims to assess the association between UI and HRQoL in men 1 year after prostate surgery., Methods: Planned secondary analysis of data from two parallel randomized controlled trials of active conservative treatment for UI in 853 men following radical prostatectomy (RP) and transurethral resection of the prostate (TURP). Men of any age were eligible for trial inclusion if they were experiencing UI 6 weeks after undergoing RP or TURP at 34 centers in the United Kingdom. Univariate and multivariate analysis considered associations between health status (SF-12 and EQ-5D) and self-reported UI. Multivariate analysis controlled for age, obesity, UI prior to surgery, and concomitant fecal incontinence., Results: Mean age of 411 men in the RP trial was 62.3 years (SD 5.7) and 442 men in the TURP trial was 68.0 (SD 7.9). Of men with UI at 6 weeks after surgery, 76.7% in the RP group and 63.2% in the TURP group still had UI at 12 months. Any UI at 12 months was significantly associated with reduced HRQoL in the RP group and lower EQ-5D and SF-12 Mental Component Scores in the TURP group., Conclusion: Any UI is a significant factor in reduced HRQoL in men following prostate surgery, particularly younger men who undergo RP. Its importance to patients as an adverse outcome should not be underestimated., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive objective diagnosis. The aim is to help to select the treatment most likely to be successful. The investigations are invasive and time consuming., Objectives: The objective of this review was to discover if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of urinary incontinence and better clinical outcomes., Search Methods: We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings (searched 24 May 2011), and the reference lists of relevant articles., Selection Criteria: Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamics against another. Trials were excluded if they did not report clinical outcomes., Data Collection and Analysis: Two reviewers independently assessed trial quality and extracted data., Main Results: Seven small trials involving around 400 people were included but data were only available for 385 women in five trials, of whom 197 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was some evidence that the tests did change clinical decision making. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31) but not, in three trials, surgery (RR 1.75, 95% CI 0.39 to 7.75). Women in the urodynamic arms of two trials were more likely to have their management changed but this did not quite reach statistical significance (proportion with no change in management 76% versus 99%, RR 0.79, 95% CI 0.57 to 1.10).However, there was not enough evidence to demonstrate whether or not this resulted in a clinical benefit. For example there was no statistically significant difference in the number of women with urinary incontinence if they received treatment guided by urodynamics (70%) versus those whose treatment was based on history and clinical findings alone (62%) (e.g. RR for number with incontinence after first year 1.23, 95% CI 0.60 to 2.55).No trials reported whether or not there were any adverse effects., Authors' Conclusions: While urodynamic tests may change clinical decision making, there was not enough evidence to suggest whether this would result in better clinical outcomes. There was no evidence abut their use in men, children or people with neurological diseases. Larger definitive trials are needed, in which people are randomly allocated to management according to urodynamic findings or to standard management based on history and clinical examination.

Background: Urinary incontinence is common after both radical prostatectomy and transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training with or without biofeedback, electrical stimulation, extra-corporeal magnetic innervation (ExMI), compression devices (penile clamps), lifestyle changes, or a combination of methods., Objectives: To assess the effects of conservative management for urinary incontinence after prostatectomy., Search Methods: We searched the Cochrane Incontinence Group Specialised Register (searched 24 August 2011), EMBASE (January 1980 to Week 48 2009), CINAHL (January 1982 to 20 November 2009), the reference lists of relevant articles, handsearched conference proceedings and contacted investigators to locate studies., Selection Criteria: Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence in men after prostatectomy., Data Collection and Analysis: Two or more review authors assessed the methodological quality of trials and abstracted data. We tried to contact several authors of included studies to obtain extra information., Main Results: Thirty-seven trials met the inclusion criteria, 33 amongst men after radical prostatectomy, three trials after transurethral resection of the prostate (TURP) and one trial after either operation. The trials included 3399 men, of whom 1937 had an active conservative intervention.  There was considerable variation in the interventions, populations and outcome measures.  Data were not available for many of the pre-stated outcomes.  Men's symptoms improved over time irrespective of management. Adverse effects did not occur or were not reported.There was no evidence from eight trials that pelvic floor muscle training with or without biofeedback was better than control for men who had urinary incontinence after radical prostatectomy (e.g. 57% with urinary incontinence versus 62% in the control group, risk ratio (RR) for incontinence after 12 months 0.85, 95% confidence interval (CI) 0.60 to 1.22) as the confidence intervals were wide, reflecting uncertainty. However, one large multicentre trial of one-to-one therapy showed no difference in any urinary or quality of life outcome measures and had narrower confidence intervals. There was also no evidence of benefit for erectile dysfunction (56% with no erection in the pelvic floor muscle training group versus 55% in the control group after one year, RR 1.01, 95% CI 0.84 to 1.20). Individual small trials provided data to suggest that electrical stimulation, external magnetic innervation or combinations of treatments might be beneficial but the evidence was limited. One large trial demonstrated that there was no benefit for incontinence or erectile dysfunction from a one-to-one pelvic floor muscle training based intervention to men who were incontinent after transurethral resection of the prostate (TURP) (e.g. 65% with urinary incontinence versus 62% in the control group, RR after 12 months 1.05, 95% CI 0.91 to 1.23).In eight trials of conservative treatment of all men after radical prostatectomy aimed at both treatment and prevention, there was an overall benefit from pelvic floor muscle training versus control management in terms of reduction of UI (e.g. 10% with urinary incontinence after one year versus 32% in the control groups, RR for urinary incontinence 0.32, 95% CI 0.20 to 0.51). However, this finding was not supported by other data from pad tests. The findings should be treated with caution, as most trials were of poor to moderate quality and confidence intervals were wide. Men in one trial were more satisfied with one type of external compression device, which had the lowest urine loss, compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remains undetermined as no trials involving these interventions were identified., Authors' Conclusions: The value of the various approaches to conservative management of postprostatectomy incontinence after radical prostatectomy remains uncertain. It seems unlikely that men benefit from one-to-one pelvic floor muscle training therapy after transurethral resection of the prostate (TURP).  Long-term incontinence may be managed by external penile clamp, but there are safety problems.

Introduction and Hypothesis: A previous version of the Cochrane review for prolapse surgery in 2008 provided two conclusions: abdominal sacrocolpopexy had lower recurrent vault prolapse rates than sacrospinous colpopexy but this was balanced against a longer time to return to activities of daily life. An additional continence procedure at the time of prolapse surgery might be beneficial in reducing post-operative stress urinary incontinence; however, this was weighed against potential adverse effects. The aim of this review is to provide an updated summary version of the current Cochrane review on the surgical management of pelvic organ prolapse., Methods: We searched the Cochrane Incontinence Group Specialised Register and reference lists of randomised or quasi-randomised controlled trials on surgery for pelvic organ prolapse. Trials were assessed independently by two reviewers., Results: We identified 40 trials including 18 new and three updates. There were no additional studies on surgery for posterior prolapse. Native tissue anterior repair was associated with more anterior compartment failures than polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23-3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29-5.51). There were no differences in subjective outcomes, quality of life data, de novo dyspareunia, stress urinary incontinence, reoperation rates for prolapse or incontinence, although some of these data were limited. Mesh erosions were reported in 10% (30/293). Including new studies on the impact of continence surgery at the time of prolapse surgery, meta-analysis revealed that concurrent continence surgery did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53-3.70; random-effects model)., Conclusion: The inclusion of new randomised controlled trials showed that the use of mesh at the time of anterior vaginal wall repair reduced the risk of recurrent anterior vaginal wall prolapse on examination. However, this was not translated into improved functional or quality of life outcomes. The value of a continence procedure in addition to a prolapse operation in women who are continent pre-operatively remains uncertain. Adequately powered randomised controlled trials are needed and should particularly include women's perceptions of prolapse symptoms and functional outcome.

Background: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse., Objectives: To determine the effects of the many different surgeries used in the management of pelvic organ prolapse., Search Strategy: We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field., Selection Criteria: Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse., Data Collection and Analysis: Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding., Main Results: Forty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model)., Authors' Conclusions: Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

Background: It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women., Objectives: To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence., Search Strategy: We searched the Cochrane Incontinence Group Specialised Register of trials (2 April 2009) and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause., Data Collection and Analysis: Trials were evaluated for methodological quality and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken., Main Results: Thirty- three trials were identified which included 19,313 (1,262 involved in trials of local administration) incontinent women of whom 9417 received oestrogen therapy. Sample sizes ranged from 16 to 16,117. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.Systemic administration (of oral oestrogens) resulted in worse incontinence than on placebo (RR 1.32, 95% CI 1.17 to 1.48). This result is heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year; all the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen combined were used also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or tablets) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours and nocturnal voids amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery., Authors' Conclusions: Local oestrogen treatment for incontinence may improve or cure it, but there was little evidence from the trials on the period after oestrogen treatment had finished and none about long-term effects. However, systemic hormone replacement therapy, using conjugated equine oestrogen, may make incontinence worse. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence on route of administration. The risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in those women with an intact uterus.

Background: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse., Objectives: To determine the effects of the many different surgeries in the management of pelvic organ prolapse., Search Strategy: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field., Selection Criteria: Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse., Data Collection and Analysis: Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding., Main Results: Twenty two randomised controlled trials were identified evaluating 2368 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated., Authors' Conclusions: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed., (Copyright 2007 Wiley-Liss, Inc.)

Background: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse., Objectives: To determine the effects of the many different surgeries in the management of pelvic organ prolapse., Search Strategy: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field., Selection Criteria: Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse., Data Collection and Analysis: Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding., Main Results: Twenty two randomised controlled trials were identified evaluating 2368 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated., Authors' Conclusions: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.

Background: Urinary incontinence is common after both radical prostatectomy (RP) and transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training (PFMT) with or without biofeedback, electrical stimulation, compression devices (penile clamps), lifestyle changes, extra-corporeal magnetic innervation or a combination of methods., Objectives: To assess the effects of conservative management for urinary incontinence after prostatectomy., Search Strategy: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 23 January 2006), MEDLINE (January 1966 to January 2006), EMBASE (January 1988 to January 2006), CINAHL (January 1982 to January 2006), PsycLIT (January 1984 to January 2006), ERIC (January 1984 to January 2006), the reference lists of relevant articles, handsearched conference proceedings and contacted investigators to locate studies., Selection Criteria: Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence after prostatectomy., Data Collection and Analysis: At least two review authors assessed the methodological quality of trials and abstracted data., Main Results: Seventeen trials met the inclusion criteria, fifteen trials amongst men after radical prostatectomy (RP), one trial after transurethral resection of the prostate (TURP) and one trial after either operation. There was considerable variation in the interventions, populations and outcome measures. The majority of trials in this area continue to be of moderate quality, although more recent studies have been of higher quality in terms of both randomization and blinding. Data were not available in all the trials for many of the pre-stated outcomes. Confidence intervals have tended to be wide except for the more recent studies, and it continues to be difficult to reliably identify or rule out a useful effect. There were several important variations in the populations being studied. Therefore the decision was made by the review authors to separate in the analysis the men having the intervention as prevention (whether administered before or after operation, to all men having surgery) or as treatment (postoperatively to those men who did have urinary incontinence), as well as separating those treated with TURP or RP. Amongst seven treatment trials of postoperative PFMT for urinary incontinence after RP, one trial suggested benefits, whereas the estimates from the others were consistent with no effect. There was clinical and statistical heterogeneity, precluding meta-analysis. There was no clear reason for this heterogeneity. Trials of preventative PFMT started pre or post-operatively also showed heterogeneity: only one large trial favoured PFMT but the data from the others were conflicting. Analysis of other conservative interventions such as transcutaneous electrical nerve stimulation and anal electrical stimulation, or combinations of these interventions were inconclusive. There were too few data to determine treatment effects on incontinence after TURP. The findings should continue to be treated with caution, as most studies were of poor to moderate quality. With respect to other management, men in one trial reported a preference for one type of external compression device compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remains undetermined as no trials involving these interventions were identified. Men's symptoms tended to improve over time, irrespective of management., Authors' Conclusions: The value of the various approaches to conservative management of postprostatectomy incontinence remains uncertain. Long-term incontinence may be managed by external penile clamp, but there are safety problems.

This systematic review examined the use of incontinence-specific quality of life (QOL) measures in clinical trials of female incontinence treatments, and systematically evaluated their quality using a standard checklist. Of 61 trials included in the review, 58 (95.1%) used an incontinence-specific QOL measure. The most commonly used were IIQ (19 papers), I-QoL (12 papers) and UDI (9 papers). Eleven papers (18.0%) used measures which were not referenced or were developed specifically for the study. The eight QOL measures identified had good clinical face validity and measurement properties. We advise researchers to evaluate carefully the needs of their specific study, and select the QOL measure that is most appropriate in terms of validity, utility and relevance, and discourage the development of new measures. Until better evidence is available on the validity and comparability of measures, we recommend that researchers consider using IIQ or I-QOL with or without UDI in trials of incontinence treatments.

Objective: To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery., Design: Longitudinal study., Setting: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand)., Population: Women (4214) who returned postal questionnaires three months and six years after the index birth., Methods: Symptom data were obtained from both questionnaires and obstetric data from case-notes for the index birth and the second questionnaire for subsequent births. Logistic regression investigated the independent effects of mode of first delivery and delivery mode history., Main Outcome Measures: Urinary incontinence-persistent (at three months and six years after index birth) and long term (at six years after index birth)., Results: The prevalence of persistent urinary incontinence was 24%. Delivering exclusively by caesarean section was associated with both less persistent (OR=0.46, 95% CI 0.32-0.68) and long term urinary incontinence (OR=0.50, 95% CI 0.40-0.63). Caesarean section birth in addition to vaginal delivery, however, was not associated with significantly less persistent incontinence (OR 0.93, 95% CI 0.67-1.29). There were no significant associations between persistent or long term urinary incontinence and forceps or vacuum extraction delivery. Other significantly associated factors were increasing number of births and older maternal age., Conclusions: The risk of persistent and long term urinary incontinence is significantly lower following caesarean section deliveries but not if there is another vaginal birth. Even when delivering exclusively by caesarean section, the prevalence of persistent symptoms (14%) is still high.

Objective: To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth., Design: Questionnaire survey of women., Setting: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand)., Population: A total of 3405 primiparous women with singleton births delivered during 1 year., Methods: Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence., Main Outcome Measures: Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth., Results: The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI>25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age., Conclusions: Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.

Background: Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use., Objectives: To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults., Search Strategy: We searched the Cochrane Incontinence Group specialised trials register (searched 9 March 2005) and the reference lists of relevant articles., Selection Criteria: Randomised or quasi-randomised controlled trials in adults with urinary incontinence which included an adrenergic agonist drug in at least one arm of the trial., Data Collection and Analysis: Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook., Main Results: Twenty-two eligible randomised trials were identified, of which 11 were crossover trials. The trials included 1099 women with 673 receiving an adrenergic drug (phenylpropanolamine in 11 trials, midodrine in two, norepinephrine in three, clenbuterol in another three, terbutaline in one, eskornade in one and Ro-115-1240 in one). No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing the number of pad changes and incontinence episodes, as well as improving subjective symptoms. In two small trials, the drugs also appeared to be better than pelvic floor muscle training, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination. Over a quarter of women reported adverse effects. There were similar numbers of adverse effects with adrenergics, placebo or alternative drug treatment. However, when these were due to recognised adrenergic stimulation (insomnia, restlessness and vasomotor stimulation) they were only severe enough to stop treatment in 4% of women., Authors' Conclusions: There was weak evidence to suggest that use of an adrenergic agonist was better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Further larger trials are needed to identify when adrenergics may be useful. Patients using adrenergic agonists may suffer from minor side effects, which sometimes cause them to stop treatment. Rare but serious side effects, such as cardiac arrhythmias and hypertension, have been reported.

Background: Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults., Objectives: To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions., Search Strategy: We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles., Selection Criteria: All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods., Data Collection and Analysis: Two reviewers independently assessed the quality of the eligible trials, and extracted data., Main Results: Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94)., Authors' Conclusions: Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Background: Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults., Objectives: To assess the effects of complementary interventions and others such as surgery or diet on nocturnal enuresis in children, and to compare them with other interventions., Search Strategy: We searched the Cochrane Incontinence Group Specialised Register (searched 22 November 2004), the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) (January 1984 to June 2004) and the reference lists of relevant articles., Selection Criteria: All randomised or quasi-randomised trials of complementary and other miscellaneous interventions for nocturnal enuresis in children were included except those focused solely on daytime wetting. Comparison interventions could include no treatment, placebo or sham treatment, alarms, simple behavioural treatment, desmopressin, imipramine and miscellaneous other drugs and interventions., Data Collection and Analysis: Two reviewers independently assessed the quality of the eligible trials, and extracted data., Main Results: In 15 randomised controlled trials, 1389 children were studied, of whom 703 received a complementary intervention. The quality of the trials was poor: four trials were quasi-randomised, five showed differences at baseline and ten lacked follow up data. The outcome was better after hypnosis than imipramine in one trial (relative risk (RR) for failure or relapse after stopping treatment 0.42, 95% confidence interval (CI) 0.23 to 0.78). Psychotherapy appeared to be better in terms of fewer children failing or relapsing than both alarm (RR 0.28, 95% CI 0.09 to 0.85) and rewards (0.29, 95% 0.09 to 0.90) but this depended on data from only one trial. Acupuncture had better results than sham control acupuncture (RR for failure or relapse after stopping treatment 0.67, 95% CI 0.48 to 0.94) in a further trial. Active chiropractic adjustment had better results than sham adjustment (RR for failure or relapse after stopping treatment 0.74, 95% CI 0.60 to 0.91). However, each of these findings came from small single trials, and need to be verified in further trials. The findings for diet and faradization were unreliable, and there were no trials including homeopathy or surgery., Authors' Conclusions: There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects carefully monitored.

Objective: To determine the long term effects of a conservative nurse-led intervention for postnatal urinary incontinence., Design: Randomised controlled trial., Setting: Community based intervention in three centres in the United Kingdom and New Zealand., Participants: 747 women with urinary incontinence at three months after childbirth, of whom 516 were followed up again at 6 years (69%)., Intervention: Active conservative treatment (pelvic floor muscle training and bladder training) at five, seven, and nine months after delivery or standard care., Main Outcome Measures: Urinary and faecal incontinence, performance of pelvic floor muscle training., Results: Of 2632 women with urinary incontinence, 747 participated in the original trial. The significant improvements relative to controls in urinary (60% v 69%) and faecal (4% v 11%) incontinence at one year were not found at six year follow up (76% v 79% (95% confidence interval for difference in means -10.2% to 4.1%) for urinary incontinence, 12% v 13% (-6.4% to 5.1%) for faecal incontinence) irrespective of subsequent obstetric events. In the short term the intervention had motivated more women to perform pelvic floor muscle training (83% v 55%) but this fell to 50% in both groups in the long term. Both urinary and faecal incontinence increased in prevalence in both groups during the study period., Conclusions: The moderate short term benefits of a brief nurse-led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. About three quarters of women with urinary incontinence three months after childbirth still have this six years later.

Background and Method: This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies)., Results: From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41-75 per cent of patients achieved complete faecal continence and 75-100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off., Conclusion: SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation., (Copyright 2004 British Journal of Surgery Society Ltd.)

Background: Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse., Objectives: To determine the effects of surgery in the management of pelvic organ prolapse., Search Strategy: We searched the Cochrane Incontinence Group trials register (8 June 2004) and reference lists of relevant articles. We also contacted researchers in the field., Selection Criteria: Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse., Data Collection and Analysis: Trials were assessed and data extracted independently by at least two reviewers. Four investigators were contacted for additional information with two responding., Main Results: Fourteen randomised controlled trials were identified evaluating 1004 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were to evaluate other clinical outcomes and adverse events. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by Vicryl mesh overlay (RR 1.39, 95% CI 1.02 to 1.90) but data on morbidity and other clinical outcomes were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh overlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new symptoms after surgery. However, more women with occult stress urinary incontinence developed postoperative stress urinary incontinence after endopelvic fascia plication alone than after endopelvic fascia plication and tension-free vaginal tape (RR 5.5, 95% CI 1.36 to 22.32)., Reviewers' Conclusions: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of a polyglactin mesh overlay at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. Adequately powered randomised controlled clinical trials are urgently needed.

Objectives: Stress urinary incontinence affects between 10 percent and 50 percent of women. Surgery is commonly recommended for troublesome incontinence that does not respond to nonsurgical management. Tension-free vaginal tape (TVT) is a newer, minimal access surgical sling procedure, which is being increasingly adopted worldwide. The cost-effectiveness of TVT in comparison with other surgical procedures, particularly open colposuspension, is assessed., Methods: Effectiveness estimates came from a systematic review of TVT compared with other surgical procedures (open and laparoscopic colposuspension, traditional slings, and injectables). Deterministic and probabilistic analyses were used to assess the likelihood of TVT being cost-effective. Sensitivity analyses assessed the impact of changing assumptions about cure rates and costs for TVT, cure rates for retreatment open colposuspension, and proportions of women who choose retreatment., Results: Reliable estimates of relative effectiveness were difficult to derive because the few randomized controlled comparisons had not been optimally analyzed or fully reported. Results of the economic model suggested that TVT dominates open colposuspension (lower cost and same quality of life years [QALYs]) within 5 years after surgery. Stochastic analysis indicated that the likelihood of TVT being cost-effective was 100 percent if decision-makers are unwilling to pay for additional QALYs. TVT's dominance depended on the assumption fact that retreatment open colposuspension has lower cure rates than a first colposuspension., Conclusions: Analysis based on current short-term data indicates dominance of TVT over open colposuspension from approximately 5 years. There is a need for longer-term follow-up data from methodologically rigorous randomized trials to provide a sounder basis for estimating the relative benefits and cost implications.

Background: Childhood nocturnal enuresis (bedwetting) affects many families. Although it has a high rate of spontaneous remission, bedwetting may bring social and emotional stigma, stress, and inconvenience to both the child with enuresis and his or her family., Design: Summary of systematic reviews of treatment for nocturnal enuresis in children, published in the Cochrane Library, using evidence only from randomized and quasi-randomized trials to compare interventions. Interventions included behavioral, alarm, and pharmacologic treatments., Setting and Methods: Six Cochrane Reviews contributed evidence to this review: simple behavioral interventions, alarms, complex behavioral or educational interventions, desmopressin, tricyclics and related drugs, and other drugs., Subjects: The participants were children (usually up to the age of 16)., Results: Much of the available evidence was of poor quality, and there were few direct comparisons between different types of intervention. Simple behavioral Interventions, such as reward systems, are widely used as standard first-line treatment, but they require a high level of parental involvement. There is currently little evidence to show that these interventions work, but they may be worth trying because they have only a few adverse effects. The use of an alarm intervention reduced nighttime bed wetting in a majority of children both during and after treatment. Overlearning or dry-bed training may reduce the relapse rate. Before embarking on alarm treatment, families need to be made aware of both the time and the high level of parental involvement necessary to attain success. Drug therapy, such as desmopressin and tricyclics, reduced the number of wet nights per week compared with placebo but only while the drug was used. Patients and their families need to be warned about possible side effects of some of the drugs., Conclusions: Alarms are the most effective treatment for nocturnal enuresis in children, but desmopressin may be considered for temporary relief.

Background: Urinary incontinence is common after both radical prostatectomy and transurethral resection. Conservative management includes pelvic floor muscle training, biofeedback, electrical stimulation, compression devices (penile clamps), lifestyle changes, extra-corporeal magnetic innervation or a combination of methods., Objectives: To assess the effects of conservative managements for urinary incontinence prostatectomy., Search Strategy: We searched the Cochrane Incontinence Group trials register (searched 2 July 2003), MEDLINE (January 1966 to January 2004), EMBASE (January 1988 to January 2004), CINAHL (January 1982 to January 2004), PsycLIT (January 1984 to January 2004), ERIC (January 1984 to January 2004), the reference lists of relevant articles, handsearched conference proceedings and contacted investigators to locate studies., Selection Criteria: Randomised controlled trials evaluating conservative interventions for urinary continence after prostatectomy., Data Collection and Analysis: At least two reviewers assessed the methodological quality of trials and abstracted data., Main Results: Ten trials met the inclusion criteria, eight trials amongst men after radical prostatectomy, one trial after transurethral resection of prostate and one after either operation. There was considerable variation in the interventions, populations and outcome measures. The trials were of moderate quality and data were not available for many of the pre-stated outcomes. Confidence intervals were wide: it was not possible to reliably identify or rule out a useful effect. There was some support from five trials for pelvic floor muscle training with biofeedback being better than no treatment or sham treatment in the short term for men after radical prostatectomy: relative risk for incontinence with pelvic floor muscle training and biofeedback versus no treatment: 0.74 (95% confidence interval 0.60 to 0.93). Analysis of other conservative interventions such as pelvic floor muscle training alone, transcutaneous electrical nerve stimulation and rectal electrical stimulation, or combinations of these interventions were inconclusive. There were too few data to determine effects on incontinence after transurethral resection of the prostate. The findings should be treated with caution as there were few studies, all of moderate quality. Men in one trial reported a preference for one type of external compression device compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remains undetermined as no trials involving these interventions were identified. Men's symptoms tended to improve over time, irrespective of management., Reviewers' Conclusions: The value of the various approaches to conservative management of postprostatectomy incontinence remains uncertain. There may be some benefit of offering pelvic floor muscle training with biofeedback early in the postoperative period immediately following removal of the catheter as it may promote an earlier return to continence. Long-term incontinence may be managed by external penile clamp, but there are safety problems.

Background: Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of them have moderate or severe symptoms., Objectives: To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options., Search Strategy: We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference lists of relevant articles were also searched., Selection Criteria: Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence., Data Collection and Analysis: Trials were assessed and data extracted independently by at least two reviewers. Two trial investigators provided additional information., Main Results: Nine trials were identified which included 347 women having six different types of needle suspension procedures and 437 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension (higher subjective failure rate after the first year (91/313, 29% failed versus 47/297, 16% failed after open abdominal retropubic suspension: the relative risk (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72) although the difference in peri-operative complications was not significant (17/75, 23% versus 12/77, 16%; RR 1.44, 95% CI 0.73 to 2.83): there were no significant differences for other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (46/128, 36% failed after needles versus 50/129, 39% after anterior repair; RR 0.93, 95% CI 0.68 to 1.26) but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population. No trials compared needle suspensions with conservative management, peri-urethral injections, sham or laparoscopic surgery., Reviewers' Conclusions: Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.

Background: Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Simple behavioural methods of treating bedwetting include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction., Objectives: To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions., Search Strategy: We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference list of a previous version of this review was also searched., Selection Criteria: All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded., Data Collection and Analysis: Two reviewers independently assessed the quality of the eligible trials and extracted data., Main Results: Thirteen trials met the inclusion criteria, involving 702 children of whom 387 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped. Another suggested that imipramine was better than fluid deprivation and avoidance of punishment., Reviewers' Conclusions: Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.

Background: Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults., Objectives: To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions., Search Strategy: We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002., Selection Criteria: All randomised or quasi-randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclics, and miscellaneous other interventions., Data Collection and Analysis: Two reviewers independently assessed the quality of the eligible trials, and extracted data., Main Results: Sixteen trials involving 1081 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (eg RR for failure or relapse after stopping DBT 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (eg RR for failure or relapse after DBT alone versus DBT plus alarm 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (eg RR for failure or relapse after DBT plus alarm versus alarm alone 0.5; 95% CI 0.31 to 0.80).There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources., Reviewer's Conclusions: Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.

Postnatal morbidity is increasingly recognized, but standard assessments may not capture what is most important to the woman with such morbidity in terms of her quality of life. The Mother-Generated Index (MGI) is a proposed postnatal quality-of-life instrument which allows the mother to determine both content and scoring. In this pilot study we found that although a degree of psychological and physical morbidity (including tiredness) is common, and may be very significant, for most women these factors are low-grade, and other aspects of their lives are more important. A quality-of-life approach allows the mother to determine her own postnatal assessment, and encourages practitioners to view her more holistically.

The effectiveness of interventions for the treatment of nocturnal enuresis in children published in a recent issue of Effective Health Care is reviewed.

Background: Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults., Objectives: To assess the effects of tricyclic and related drugs on nocturnal enuresis in children, and to compare them with other interventions., Search Strategy: We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles including two previously published versions of this review. Date of the most recent searches: December 2002., Selection Criteria: All randomised and quasi-randomised trials of tricyclics or related drugs for nocturnal enuresis in children were included in the review. Comparison interventions included placebo, other drugs, alarms, behavioural methods or complementary/miscellaneous interventions. Trials focused solely on daytime wetting were excluded., Data Collection and Analysis: Two reviewers independently assessed the quality of the eligible trials, and extracted data., Main Results: Fifty four randomised trials met the inclusion criteria, involving 3379 children. The quality of many of the trials was poor. Most comparisons or outcomes were addressed only by single trials. Treatment with most tricyclic drugs (such as imipramine, amitriptyline, viloxazine, nortriptyline, clomipramine and desipramine) was associated with a reduction of about one wet night per week while on treatment (eg imipramine compared with placebo, weighted mean difference (WMD) -1.19, 95% CI -1.56 to -0.82). The exception was mianserin, where results from one small trial did not reach statistical significance. About a fifth of the children became dry while on treatment (relative risk for failure (RR) 0.77, 95% CI 0.72 to 0.83), but this effect was not sustained after treatment stopped (eg imipramine versus placebo, RR 0.98, 95% CI 0.95 to 1.03). There was not enough information to assess the relative performance of one tricyclic against another, except that imipramine was better than mianserin. The evidence comparing desmopressin with tricyclics was unreliable or conflicting, but in one small trial all the children failed or relapsed after stopping active treatment with either drug.The evidence comparing tricyclics with alarms was also unreliable or conflicting during treatment. In one small trial all the children failed or relapsed after tricyclics stopped, compared with about half after alarms. This result was compatible with the results in the Cochrane review of alarm treatment, which found that about half the children remained dry after alarm treatment was finished. There was a little evidence from single trials to suggest that imipramine might be better than a simple reward system with star charts during treatment; worse than a complex intervention involving education, counseling, waking and retention control training; better than a restricted diet; and worse than hypnosis. However, these results need to be confirmed by further research., Reviewer's Conclusions: Although tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, most children relapse after stopping active treatment. In contrast, only half the children relapse after alarm treatment. Parents should be warned of the potentially serious adverse effects of tricyclic overdose when choosing treatment. Further research is needed into comparisons between drug and behavioural or complementary treatments, and should include relapse rates after treatment is finished.

Background: Faecal incontinence is a common symptom which causes significant distress and reduction in quality of life. Available treatment options for faecal incontinence include conservative treatments (biofeedback, pelvic floor muscle training, dietary manipulation or drug therapy) or surgical treatments (e.g. sphincter repair, post anal repair, neosphincter). Drug treatment is often given either alone or in combination with other treatment modalities., Objectives: To assess the effects of drug therapy for the treatment of faecal incontinence. In particular, to assess the effects of individual drugs relative to placebo or other drugs, and to compare drug therapy with other treatment modalities., Search Strategy: We searched the Cochrane Incontinence Group trials register (January 2003) and the reference lists of relevant articles. Date of the most recent search: January 2003., Selection Criteria: All randomised or quasi-randomised controlled trials of the use of pharmacological agents for the treatment of faecal incontinence in adults., Data Collection and Analysis: Working independently, reviewers selected studies from the literature, assessed the methodological quality of each trial, and extracted data., Main Results: Eleven trials were identified for inclusion in this review. Nine trials were of cross-over design. Seven trials included only people with faecal incontinence related to liquid stool (either chronic diarrhoea or following ileoanal pouch surgery). Three trials (total 58 participants) compared topical phenylephrine gel with placebo. Two trials (56 participants) compared loperamide with placebo. One trial (11 participants) compared loperamide oxide with placebo. One trial (15 participants) compared diphenoxylate plus atropine with placebo. One trial (17 participants) compared sodium valproate with placebo. One trial (30 participants) compared loperamide with codeine with diphenoxylate plus atropine. Two further trials (total 265 participants) assessed the use of lactulose in elderly people.No studies comparing drugs with other treatment modalities were identified. There was limited evidence that antidiarrhoeal drugs and drugs which enhance anal sphincter tone may reduce faecal incontinence in patients with liquid stools. However, the trials were small and of short duration., Reviewer's Conclusions: The small number of trials identified for this review assessed several different drugs in a variety of patient populations. The focus of most of the included trials was on the treatment of diarrhoea, rather than faecal incontinence. There is little evidence to guide clinicians in the selection of drug therapies for faecal incontinence. Larger, well-designed controlled trials, which include clinically important outcome measures, are required.

Background: Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use., Objectives: To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults., Search Strategy: We searched the Cochrane Incontinence Group trials register (January 2002) and the reference lists of relevant articles. Date of the most recent searches: January 2002., Selection Criteria: Randomised or quasi-randomised controlled trials which include an adrenergic agonist drug in at least one arm for adults with urinary incontinence., Data Collection and Analysis: Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook., Main Results: Fifteen randomised trials were identified, which included 832 women, of whom 506 received an adrenergic drug (phenylpropanolamine in 11 trials, Midodrine in two and Clenbuterol in another two). Of these, six were crossover trials. No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing number of pad changes and incontinence episodes, as well as improvement in subjective symptoms. The drugs also appeared to be better than pelvic floor muscle training in two small trials, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination., Reviewer's Conclusions: There was weak evidence to suggest that use of an adrenergic agonist is better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Patients using adrenergic agonists may suffer from minor side effects, only occasionally leading them to stop treatment. Rare but serious side effects such as cardiac arrhythmias and hypertension have been reported, however.

Background: Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults., Objectives: To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions., Search Strategy: We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002., Selection Criteria: All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods., Data Collection and Analysis: Two reviewers independently assessed the quality of the eligible trials, and extracted data., Main Results: Fifty three trials met the inclusion criteria, involving 2862 children. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.36, 95% CI 0.31 to 0.43). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (RR 4/22 (18%) vs 16/24 (67%),RR 0.27, 95% CI 0.11 to 0.69). Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94)., Reviewer's Conclusions: Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm) and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Background: Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great., Objectives: To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children, and to compare them with other interventions., Search Strategy: We searched the Cochrane Incontinence Group trials register. Date of the most recent search: December 2002. The reference list of a previous version of this review was also searched., Selection Criteria: All randomised trials of drugs (excluding desmopressin or tricyclics) for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting. Trials focused solely on daytime wetting were excluded., Data Collection and Analysis: Two reviewers independently assessed the quality of the eligible trials and extracted data., Main Results: In 32 randomised controlled trials (25 new in this update), a total of 1225 out of 1613 children received an active drug other than desmopressin or a tricyclic. In all, 28 different drugs or classes of drugs were tested, but the trials were generally small or of poor methodological quality (five were quasi-randomised and the remainder failed to give adequate details about the randomisation process). Although indomethacin and diclofenac were better than placebo during treatment, desmopressin was better than both of them, with less chance of adverse effects. There were no data regarding what happened after treatment stopped. Limited data suggested that an alarm was better than drugs during treatment., Reviewer's Conclusions: There was not enough evidence to judge whether the included drugs reduced bedwetting. There was limited evidence to suggest that desmopressin, imipramine and alarms were better than the drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective.

Infertility is relative. Research into effective treatment must focus on couples with single, identifiable causes for their infertility, and must take into account the effect of chance and time on eventual success. Women with ovulatory infertility, who have no other subfertility factors, can expect normal conception rates when ovulation is restored. Unfortunately, there is no similar simple treatment for male infertility, although complicated and expensive treatment may help. Selection of the couples most likely to benefit from such help will result in the most cost-effective use of scarce resources. Knowledge of duration of infertility and the postcoital test result can help to identify those couples who have a reasonable chance of conception without treatment and those who have virtually no chance without it.

Background: Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Simple behavioural methods of treating bedwetting include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction., Objectives: To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions., Search Strategy: We searched the Cochrane Incontinence Group trials register. The reference list of a previous version of this review was also searched. Date of the most recent search: December 2001., Selection Criteria: All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded., Data Collection and Analysis: In a previous version of this review, trials up to 1997 were independently assessed by two reviewers. Previous trials were re-assessed, and further trials were assessed for quality, and data were extracted by another reviewer., Main Results: Twelve reliable trials met the inclusion criteria, involving 748 children of whom 365 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped., Reviewer's Conclusions: Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.