Behavioral therapy reduces incontinence after radical prostatectomy

Behavioral training programs that included pelvic floor muscle training, bladder control strategies and fluid management resulted in a significant reduction in incontinence following radical prostatectomy, according to a study in the Jan. 12 Journal of the American Medical Association. Biofeedback and pelvic floor electrical stimulation provided no additional benefit.

The multisite randomized, controlled trial involved 208 community-dwelling men ages 51 through 84 years with incontinence persisting one to 17 years after radical prostatectomy from 2003 to 2008. Participants were stratified by site (one university and two VA medical centers), and by incontinence type (stress, urgency, or mixed) and severity (less than five, five to 10, or more than 10 episodes per week). Then, participants were randomized to three groups: eight weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation (behavior plus); or delayed treatment, which served as the control group. Participants completed seven-day bladder diaries.

The researchers found that at eight weeks, those in the behavioral therapy group had an average reduction of incontinence episodes of 55% (95% CI, 44% to 66%; from 28 to 13 episodes per week), which was significantly greater than the 24% reduction (95% CI, 10% to 39%; from 25 to 21 episodes per week) reported by the control group. Those in the behavior-plus group experienced an average reduction of 51% (95% CI, 37% to 65%; from 26 to 12 episodes per week). Reductions were significant for both treatment groups (P=0.001), and there was no significant difference in incontinence reduction between the treatment groups (P=0.69).

Improvements lasted one year in the active treatment groups, which saw a 50% reduction (13.5 episodes per week) in the behavioral group and a 59% reduction (9.1 episodes per week) in the behavior-plus group. At the end of the eight-week treatment period, 15.7% of men in the behavior therapy group, 17.1% in the behavior-plus group, and 5.9% in the control group achieved complete continence.

Based on the study's results and the small number needed to treat (n=10), the researchers concluded, "Behavioral therapy should be offered to men with persistent postprostatectomy incontinence because it can yield significant, durable improvement in incontinence and quality of life, even years after radical prostatectomy."

An editorial countered that behavioral therapy "likely requires considerable patient and clinician time and effort to implement and is associated with limited benefit" and suggested that "A better strategy would be primary prevention: increased utilization of active surveillance among patients with lower-risk disease and selective application of aggressive interventions in patients with worse prognostic variables."