INVESTIGADORES
AUGUSTOVSKI Federico Ariel
artículos
Título:
Biofeedback for Women with Urinary, Fecal or Combined Incontinence
Autor/es:
PICHON RIVIERE, A.; AUGUSTOVSKI, F.; GARCIA MARTI, S.; ALCARAZ, A.; GLUJOVSKY, D.; LOPEZ, A.; REY-ARES, L.; BARDACH, A.; CIAPPONI, A
Revista:
Documento de Evaluación de tecnologías Sanitarias
Editorial:
IECS
Referencias:
Año: 2013 p. 1 - 30
ISSN:
1668-2793
Resumen:
Urinary incontinence (UI) is the incapacity to keep the urinary function under control. Its cause is neurogenic or idiopathic, and nearly 16% of adults suffer from it. Fecal incontinence (FI) is the lack of bowel movement control; its prevalence ranges between 5% and -10% in adults. Half of the FI cases also experiences associated UI. Biofeedback is proposed for the treatment of patients with these disorders in order to increase the effectiveness of pelvic floor exercises.TechnologyBiofeedback is intended to teach how to control certain body functions by using sensors to identify when certain muscles contract; subsequently they can then be displayed in charts or as audible sounds to patients.Two small sensors, stuck to a pad placed on both sides of the anus together with others placed on the abdomen, are used. By plotting muscle contractions, the patient may identify which muscles contract and therefore exercise the appropriate ones. It generally takes four 30-minute sessions, every 3-4 weeks, although the number may vary.PurposeTo assess the available evidence on the efficacy, safety and coverage related issues regarding the use of biofeedback in women with fecal, urinary or combined incontinence.MethodsA bibliographic search was carried out on the main databases: DARE, NHS EED, on Internet general search engines, in health technology evaluation agencies and health sponsors. Priority was given to the inclusion of systematic reviews (SR); controlled, randomized clinical trials (RCTs); health technology assessments and economic evaluations; clinical practice guidelines and coverage policies of other health systems.ResultsThis report presents two SR, one RCT, two clinical practice guidelines, two HTAs and six coverage policies.One 2012 SR about stress UI, urge UI and mixed UI identified 24 RCTs or quasi-randomized trials. Although the individuals receiving biofeedback reported treatment failures less frequently (RR 0.75; CI95% 0.66-0.86), no statistically significant differences were found in incontinence episodes.Another 2012 SR on FI identified 21 RCTs or quasi-randomized trials. One RCT showed that, with biofeedback and exercises, the rate of patients not achieving total continence decreased, compared to those performing exercises only (RR 0.7; CI95% 0.52-0.94). On the other hand, conservative methods (biofeedback or exercises) were less effective than sacral nerve stimulation, which further reduced incontinence episodes at 12 months of treatment (mean 6.3; IC95% 2.3-10.3).One 2013 RCT randomized 46 women with stress UI to perform only pelvic floor muscle exercises, or in combination with biofeedback. In both groups, symptoms decreased, but there were no significant differences between both groups.In 2007, the American Society of Colon and Rectal Surgeons published guidelines stating that biofeedback is recommended for patients with FI who have some voluntary contraction of the sphincter and who are willing to do it, based on quasi-experimental studies..In 2012, the Canadian Urological Association published some guidelines updating one previously published SR. Regarding stress urinary incontinence, they mention that the benefit of biofeedback is unknown.The British Agency, NICE, mentions that conservative treatment with exercises and nerve stimulation of the pelvic floor (in some cases with biofeedback) is the first line treatment for FI. For urge urinary incontinence due to neurological causes, biofeedback is mentioned as a treatment option in combination with exercises. The Scottish Agency, SIGN, considers biofeedback is not more effective than pelvic floor muscle exercises alone.Except for one case which considers this procedure as investigational, the rest of the U.S. health sponsors consulted agree to cover biofeedback in patients with fecal or urinary incontinence.The estimated cost of each biofeedback session is $40 (Argentine Pesos, March/2013, equivalent to about USD 8 US dollars).ConclusionsThe evidence found is limited and it comes from low methodological quality studies. Although the few studies of good methodological quality found in the systematic reviews for fecal incontinence suggest that exercise therapy could benefit by adding biofeedback, this is not so evident for patients with urinary incontinence. In agreement with these findings, the clinical practice guidelines consulted agree to include biofeedback for fecal incontinence, but not for urinary incontinence. In spite of this, several health sponsors cover this technology for both indications.To conclude, more studies of good methodological quality are needed to compare biofeedback with other therapeutic options in order to get more definitive conclusions, mainly for UI.