urinary incontinence after stroke
Incontinence urinaire post-AVC : évaluation de l'acupuncture
| ☆☆☆ | Evidence for effectiveness and a specific effect of acupuncture |
| ☆☆ | Evidence for effectiveness of acupuncture |
| ☆ | Limited evidence for effectiveness of acupuncture |
| Ø | No evidence or insufficient evidence |
1.1. Generic Acupuncture
1.1.1. Thomas 2019 ☆
Thomas LH, Coupe J, Cross LD, Tan AL, Watkins CL. Interventions for treating urinary incontinence after stroke in adults. Cochrane Database Syst Rev. 2019. [197279].
| Background | Urinary incontinence can affect 40% to 60% of people admitted to hospital after a stroke, with 25% still having problems when discharged from hospital and 15% remaining incontinent after one year. This is an update of a review published in 2005 and updated in 2008. OBJECTIVES: To assess the effects of interventions for treating urinary incontinence after stroke in adults at least one-month post-stroke. |
| Methods | SEARCH METHODS: We searched the Cochrane Incontinence and Cochrane Stroke Specialised Registers (searched 30 October 2017 and 1 November 2017 respectively), which contain 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 handsearched journals and conference proceedings. SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials. DATA COLLECTION AND ANALYSIS: Two review authors independently undertook data extraction, risk of bias assessment and implemented GRADE. |
| Main results | We included 20 trials (reporting 21 comparisons) with 1338 participants. Data for prespecified outcomes were not available except where reported below. Intervention versus no intervention/usual care Behavioural interventions: Low-quality evidence suggests behavioural interventions may reduce the mean number of incontinent episodes in 24 hours (mean difference (MD) -1.00, 95% confidence interval (CI) -2.74 to 0.74; 1 trial; 18 participants; P = 0.26). Further, low-quality evidence from two trials suggests that behavioural interventions may make little or no difference to quality of life (SMD -0.99, 95% CI -2.83 to 0.86; 55 participants).Specialized professional input interventions: One trial of moderate-quality suggested structured assessment and management by continence nurse practitioners probably made little or no difference to the number of people continent three months after treatment (risk ratio (RR) 1.28, 95% CI 0.81 to 2.02; 121 participants; equivalent to an increase from 354 to 453 per 1000, 95% CI 287 to 715).Complementary therapy: Five trials assessed complementary therapy using traditional acupuncture, electroacupuncture and ginger-salt-partitioned moxibustion plus routine acupuncture. Low-quality evidence from five trials suggested that complementary therapy may increase the number of participants continent after treatment; participants in the treatment group were three times more likely to be continent (RR 2.82, 95% CI 1.57 to 5.07; 524 participants; equivalent to an increase from 193 to 544 per 1000, 95% CI 303 to 978). Adverse events were reported narratively in one study of electroacupuncture, reporting on bruising and postacupuncture abdominal pain in the intervention group. Physical therapy: Two trials reporting three comparisons suggest that physical therapy using transcutaneous electrical nerve stimulation (TENS) may reduce the mean number of incontinent episodes in 24 hours (MD -4.76, 95% CI -8.10 to -1.41; 142 participants; low-quality evidence). One trial of TENS reporting two comparisons found that the intervention probably improves overall functional ability (MD 8.97, 95% CI 1.27 to 16.68; 81 participants; moderate-quality evidence).Intervention versus placebo. Physical therapy: One trial of physical therapy suggests TPTNS may make little or no difference to the number of participants continent after treatment (RR 0.75, 95% CI 0.19 to 3.04; 54 participants) or number of incontinent episodes (MD -1.10, 95% CI -3.99 to 1.79; 39 participants). One trial suggested improvement in the TPTNS group at 26-weeks (OR 0.04, 95% CI 0.004 to 0.41) but there was no evidence of a difference in perceived bladder condition at six weeks (OR 2.33, 95% CI 0.63 to 8.65) or 12 weeks (OR 1.22, 95% CI 0.29 to 5.17). Data from one trial provided no evidence that TPTNS made a difference to quality of life measured with the ICIQLUTSqol (MD 3.90, 95% CI -4.25 to 12.05; 30 participants). Minor adverse events, such as minor skin irritation and ankle cramping, were reported in one study. Pharmacotherapy interventions: There was no evidence from one study that oestrogen therapy made a difference to the mean number of incontinent episodes per week in mild incontinence (paired samples, MD -1.71, 95% CI -3.51 to 0.09) or severe incontinence (paired samples, MD -6.40, 95% CI -9.47 to -3.33). One study reported no adverse events. Specific intervention versus another intervention. Behavioural interventions: One trial comparing a behavioural intervention (timed voiding) with a pharmacotherapy intervention (oxybutynin) contained no useable data. Complementary therapy: One trial comparing different acupuncture needles and depth of needle insertion to assess the effect on incontinence reported that, after four courses of treatment, 78.1% participants in the elongated needle group had no incontinent episodes versus 40% in the filiform needle group (57 participants). This trial was assessed as unclear or high for all types of bias apart from incomplete outcome data. Combined intervention versus single intervention One trial compared a combined intervention (sensory motor biofeedback plus timed prompted voiding) against a single intervention (timed voiding). The combined intervention may make little or no difference to the number of participants continent after treatment (RR 0.55, 95% CI 0.06 to 5.21; 23 participants; equivalent to a decrease from 167 to 92 per 1000, 95% CI 10 to 868) or to the number of incontinent episodes (MD 2.20, 95% CI 0.12 to 4.28; 23 participants).Specific intervention versus attention control Physical therapy interventions: One study found TPTNS may make little or no difference to the number of participants continent after treatment compared to an attention control group undertaking stretching exercises (RR 1.33, 95% CI 0.38 to 4.72; 24 participants; equivalent to an increase from 250 to 333 per 1000, 95% CI 95 to 1000). |
| Authors' conclusions | There is insufficient evidence to guide continence care of adults in the rehabilitative phase after stroke. As few trials tested the same intervention, conclusions are drawn from few, usually small, trials. Cis were wide, making it difficult to ascertain if there were clinically important differences. Only four trials had adequate allocation concealment and many were limited by poor reporting, making it impossible to judge the extent to which they were prone to bias. More appropriately powered, multicentre trials of interventions are required to provide robust evidence for interventions to improve urinary incontinence after stroke. |
1.1.2. Wang 2010 ☆
Wang Zai-Ling, Fu Li-Xiri, Xiong Jun. [Systematic review of therapeutic effect on acupuncture for treatment of urinary incontinence after stroke]. Journal of Clinical Acupuncture and Moxibustion 2010;26(1):39. [172522]
| Objective | To evaluate the therapeutic effect of acupuncture in treatment of urinary incontinence after stroke in China. |
| Methods | Randomized contiolled trials (RCTs) involving acupuncture versus other methods in the treatment of urinary incontinence in China were identified from CNKI, VIP, WANFANG Database arid CBM. We also hand searched relevant journals and conference proceedings. Data were extracted and evaluated by two reviewers independently with a specially designed extraction form. The Cochrane Collaboration' s Rev- Man4. 2. 10 software was used for data analyses. At the same time, we do Fail - safe number analysis and use Funnel plot for the possible existence of publication bias. |
| Results | A total of 11 trials involving 1053 patients were included. Meta - analyses showed that the total effective rate in the treatment group was better than control group: electrical - acupuncture group versus the group without acupuncture (RR = 2. 10,95% CI [1. 79,2. 45]); acupuncture group versus the group without acupuncture ( RR:: 1. 29 ,95% CI [1. 19, 1 ,40]. Fail - safe number analysis revealed a relatively stable result. Funnel plot is asymmetrical ,which showed the possible existence of publication bias. |
| Conclusion | Acupuncture is better than other treatments, but further large - scale trials are required to define the role of acupuncture in the treatment of urinary incontinence after stroke in China. |
1.1.3. Thomas 2008 Ø
Thomas L, Cross S, Barrett J, French B, Leathley M, Sutton C, Watkins C. Treatment of Urinary Incontinence after Stroke in Adults. Cochrane Database Syst Rev. 2008. [148085].
| Objectives | Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year. OBJECTIVES: To determine the optimal methods for treatment of urinary incontinence after stroke in adults. |
| Methods | SEARCH STRATEGY: We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke. DATA COLLECTION AND ANALYSIS: Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer. |
| Results | Twelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery.Behavioural interventionsThree trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide.Specialised professional input interventionsTwo trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care.Complementary therapy interventionsThree small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality.Pharmacotherapy and hormonal interventionsThere were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62). |
| Conclusions | Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke. |
1.1.4. Thomas 2005 ☆
Thomas L, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and Treatment of Urinary Incontinence after Stroke in Adults. Cochrane Database Syst Rev. 2005. [140617].
| Objectives | Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and around 15% remaining incontinent at one year. OBJECTIVES: To determine the optimal methods for prevention and treatment of urinary incontinence after stroke in adults. |
| Methods | SEARCH STRATEGY: We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 December 2004 and 26 October 2004, respectively), CINAHL (January 1982 to November 2004), national and international trial databases for unpublished data, and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke. DATA COLLECTION AND ANALYSIS: Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer. |
| Results | Seven trials with a total of 399 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. No two trials addressed the same comparison.Four trials tested an intervention against usual care, including acupuncture, timed voiding, and two types of specialist professional intervention. One cross-over trial tested an intervention (oestrogen) against placebo. One trial tested a specific intervention (oxybutynin) against another intervention (timed voiding), and one trial tested a combined intervention (sensory-motor biofeedback plus timed voiding) against a single component intervention (timed voiding alone).Reported data were insufficient to evaluate acupuncture or timed voiding versus usual care, oxybutynin versus timed voiding, or sensory motor biofeedback plus timed voiding versus usual care. Evidence from a single small trial suggested that structured assessment and management of care in early rehabilitation may reduce the number of people with incontinence at hospital discharge (1/21 versus 10/13; RR 0.06, 95% CI 0.01 to 0.43), and have other benefits. Evidence from another trial suggested that assessment and management of care by Continence Nurse Practitioners in a community setting may reduce the number of urinary symptoms (48/89 versus 38/54; RR 0.77, 95% CI 0.59 to 0.99), and increase satisfaction with care. |
| Conclusions | There was suggestive evidence that specialist professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence after stroke. Data from trials of other physical, behavioural, complementary and anticholinergic drug interventions are insufficient to guide continence care of adults after stroke |
1.2. Special Acupuncture Techniques
1.2.1. Electroacupuncture ☆
Tan 2015
Tan Zhi-Gao , Zhang Wei, Gong Hou-Wu, Qin Zuo-Ai, Zhong Feng ,Cao Yue. [A Meta-analysis on Effectiveness of Electro-acupuncture on Post-Stroke Urinary incontinence], Journal of Clinical Acupuncture and Moxibustion. 2015;31(2):74-7. [169600].
| Objective | To evaluate the effectiveness of electro-acupuncture (EA)on post-stroke urinary incontinence ( PSUI) by Meta-analysis. |
| Methods | Clinical randomized controlled trials of EA for PSUI were searched from database of Cochrane library, PubMed,CNKI, VIP and WanFang, and further retrieval was carried out concerning the reference of the related paper. Trials that EA was compared with positive drug, placebo, or blank (or both EA and A intervention were compared with A intervention) were collected. Quality assessment and Meta-ana1ysis would be made by using software RevMan5. 2. 1 1 for the included studies while the studies were of small clinical heterogeneity. If the studies' heterogeneity was significant, qualitative analysis would be made. |
| Results | A total of 16 studies involving 1377 cases were included in the study, with 15 better research homogeneity. Meta-analysis showed that the combined effect of the amount of OR=5.63,95%CI [3.35,9.47], P <0.01, and the difference was statistically significant, suggesting that EA treatment for PSUI had a better clinical efficacy than that in the control group. Thus EA treatment for PSUI could be considered to be with higher efficacy compared with other therapies. Funnel chart showed an asymmetry distribution of the research object, suggesting that there was a possibility of publication bias. |
| Conclusion | EA treatment for PSUI shows a tendency that it is more effective than other treatments in terms of overall clinical efficacy, however, more high-quality researches in order to increase the strength of the evidence are still needed. |
1.2.2. Moxibustion
1.2.2.1. Li 2021
Li X, Li ZM, Tan JY, Wang T, Chen JX, Chen X, Yang L, Suen LKP. Moxibustion for post-stroke urinary incontinence in adults: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Clin Pract. 2021. [216618]. doi
| Background and purpose | Urinary incontinence (UI) is a frequently identified complication among stroke survivors. Moxibustion is commonly used to treat post-stroke UI in Asian countries. This study aimed to synthesize the evidence of using moxibustion for post-stroke UI management. |
| Methods | Twelve databases were searched to identify randomized controlled trials (RCTs) using moxibustion to improve post-stroke UI management. Four Chinese journals were also manually screened for potentially eligible articles. |
| Results | Ten studies with a total of 719 participants and one completed trial without published results were included. Compared with “routine methods of treatment and/or care,” the meta-analyses revealed that moxibustion had superior effects in improving UI symptoms and alleviating the severity of UI. |
| Conclusion | This systematic review identified preliminary research evidence that moxibustion may be effective in managing the symptoms of post-stroke UI. More rigorously designed, large-scale RCTs are warranted to provide more robust evidence in this area. |
2. Clinical Practice Guidelines
⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence) |
2.1. Brazilian Academy of Neurology 2022 Ø
Minelli C, Bazan R, Pedatella MTA, Neves LO, Cacho RO, Magalhães SCSA, Luvizutto GJ, Moro CHC, Lange MC, Modolo GP, Lopes BC, Pinheiro EL, Souza JT, Rodrigues GR, Fabio SRC, Prado GFD, Carlos K, Teixeira JJM, Barreira CMA, Castro RS, Quinan TDL, Damasceno E, Almeida KJ, Pontes-Neto OM, Dalio MTRP, Camilo MR, Tosin MHS, Oliveira BC, Oliveira BGRB, Carvalho JJF, Martins SCO. Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I. Arq Neuropsiquiatr. 2022 Jun;80(6):634-652. https://pubmed.ncbi.nlm.nih.gov/35946713.
| Neurogenic lower urinary tract dysfunction and fecal incontinence: For post-stroke NLUTD, behavioral interventions, specialized professional care, complementary therapies such as acupuncture (electroacupuncture and moxibustion), transcutaneous electrical stimulation, physical therapy techniques, pharmacotherapy, and a combination of interventions have uncertain benefits. (Recommendation IIb-B) |
