Beruflich Dokumente
Kultur Dokumente
discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/6616821
26 104 76
4 AUTHORS, INCLUDING:
SEE PROFILE
Sheila Wallace
University of Aberdeen
39 PUBLICATIONS 1,180 CITATIONS
SEE PROFILE
1
Brenda Roe PhD RN RHV FRSH R O E B . , O S T A S Z K I E W I C Z J . , M I L N E J . & W A L L A C E S . ( 2 0 0 7 ) Systematic
Professor of Health Sciences reviews of bladder training and voiding programmes in adults: a synopsis of findings
Faculty of Health and Applied Social from data analysis and outcomes using metastudy techniques. Journal of Advanced
Sciences,
Nursing 57(1), 1531
Liverpool John Moores University,
doi: 10.1111/j.1365-2648.2006.04097.x
Liverpool, UK
2
Joan Ostaszkiewicz MSN RN Abstract
Coordinator Aged Care and Rehabilitation Title. Systematic reviews of bladder training and voiding programmes in adults: a
Nursing Research synopsis of findings from data analysis and outcomes using metastudy techniques
The Peter James Centre, Aim. This paper reports a comparison of the data analysis and outcomes from
Deakin University, four Cochrane systematic reviews on bladder training and voiding programmes
Melbourne, Australia
for the management of urinary incontinence using metastudy descriptive tech-
3 niques to inform clinical practice, generate new ideas and identify future research
Jill Milne PhD RN
Postdoctoral Fellow directions.
School of Nursing, Background. Bladder training is used for cognitively and physically able adults to
University of Alberta, regain continence by increasing the time interval between voids. Prompted void-
Edmonton, Canada ing, habit retraining and timed voiding, collectively known as voiding pro-
grammes, are generally used for people with cognitive and physical impairments
4
Sheila Wallace BSc MSc in institutional settings. Bladder training and voiding programmes feature as
Search Coordinator
common clinical practice for the management of urinary incontinence.
Cochrane Incontinence Reviews Group,
Health Services Research Unit,
Methods. A synopsis of four Cochrane systematic reviews that included rand-
University of Aberdeen, omized controlled trials on bladder training, prompted voiding, habit retraining
Aberdeen, UK and timed voiding was undertaken using metastudy techniques for the synthesis of
qualitative research, and has provided a discursive comparison and contrast of the
Correspondence to Brenda Roe: meta-data analysis and outcomes of these reviews.
e-mail: b.h.roe@ljmu.ac.uk Results. Frequency of incontinence was the most common and constant outcome
measure of effectiveness in the reviews. Limited data were available on other
health outcomes, change in dependency status, quality of life and cost-effective-
ness. The systematic review on bladder training included different types of urinary
incontinence, whereas those on voiding programmes did not differentiate the type
of incontinence. There is evidence on the effectiveness of bladder training but
long-term follow up studies are needed. Evidence on the effectiveness of voiding
programmes is limited and not available for many outcomes.
Conclusion. Future research needs to consider the theory underpinning interven-
tions for bladder training and voiding programmes for urinary incontinence and
should incorporate recognized quality research designs, established outcomes and
long-term follow up. It is unclear whether health outcomes for people with
The study
Background
Aim
Systematic reviews of RCTs that have investigated the value
of bladder training, prompted voiding, habit retraining and The aim of the study was to provide a synopsis of the findings
timed voiding for the management of urinary incontinence in from meta-data analysis and outcomes from the metastudy of
adults are available in the Cochrane Library (Eustice et al. four Cochrane systematic reviews on behavioural interven-
2002, Ostaszkiewicz et al. 2004a, 2004b, Wallace et al. tions which include, bladder training, prompted voiding,
2004). These behavioural interventions commonly form habit retraining and timed voiding. The purpose was to
bladder re-education strategies and voiding programmes compare and contrast outcomes in relation to the interven-
frequently used by nurses for the management of urinary tions and study designs to inform clinical practice, generate
incontinence in community, clinic and institutional settings new ideas and future directions for research.
(Hadley 1986, Kennedy 1992). The development of these
interventions dates back to the mid to late 1970s with
Methodology
bladder training being the earliest and aimed at people who
are physically and cognitively able (Willington 1975, Frewen Methods for the synthesis of qualitative research are
1978). Habit retraining evolved at a similar time and aimed evolving (Thorne et al. 2004) and a useful framework and
to be delivered by motivated staff to people with cognitive techniques have been developed for metastudy, which allow
and physical disabilities (Clay 1978). Timed voiding (Castl- discursive comparison and contrast (Paterson et al. 2001).
eden & Duffin 1981) and prompted voiding (Hu 1989) are While the four systematic reviews in this paper are
also used for people with cognitive and physical disabilities quantitative research, RCTs in particular, such metastudy
by care staff, and are common in institutional settings techniques allow a useful synopsis to be undertaken. In this
(Hadley 1986, Kennedy 1992). Definitions of the terms used paper, the references to each of the trials and their related
Table 1 (Continued)
Table 1 (Continued)
PFMT, pelvic floor muscle exercise training; BT, bladder training; PV, prompted voiding; TV, timed voiding.
statistically significant between group differences were noted treatment group compared with the control group (RR 180;
on this outcome. 95% CI 112 to 289) (Tobin & Brocklehurst 1986).
Timed voiding
Severity of incontinence
Outcome data that could be used in a meta-view were
available for one of the two trials included in the systematic Severity of incontinence was calculated as an outcome
review on timed voiding. There was a statistically significant measure by three trials (Colling et al. 1992, 2003, Tobin &
increase in the number of individuals with reductions in the Brocklehurst 1986) (Table 2). Two of these trials described a
frequency of night-time incontinence for individuals in the habit retraining protocol (Colling et al. 1992, 2003) whilst the
HT other vs. Mean volume of incontinence Colling (1992) Gp 1: (51) This data could not be
usual care per individual per 24 hours mean = 600 cc (SD missing data) used in the standard
based on pad weighing Gp 2: (37) metaview analysis
mean = 650 cc (SD missing data) due to missing data
Colling (2003) Gp 1: (32) WMD 045;
mean = 292 cc (SD 202 cc) 95% CI 008 to 099
Gp 2: (24)
mean = 193 cc (SD 233 cc)
TV other vs. Number of individuals with Tobin & Gp 1: (65) 16 RR 101;
usual care improvement in volume of Brocklehurst Gp 2: (45) 11 95% CI 052 to 196
incontinence based on pad (1986)
weighing
Objective outcomes Relevant comparisons Unit of measure Relevant trial Results Analysis
Self-initiated PV vs. no PV Number of Hu (1989, 1990) Gp 1: (65) This data could not
requests for self-initiated mean = 265 be used in the standard
toileting requests for (SD missing data) metaview analysis due
toileting vs. Gp 2: (68) to missing data
caregiver mean = 112
initiated toileting (SD missing data)
Schnelle (1983) Gp 1: (11) This data could not
mean = 200 be used in the standard
(SD missing data) metaview analysis due
Gp 2: (10) to missing data
mean = 023
(SD missing data)
Schnelle (1989, Gp 1: (63) Statistical
1990) mean = 270 significance
(SD 120) favouring PV
Gp 2: (63) OR 190: 95% CI 151
mean = 080 to 229
(SD 100)
Percentage of Surdy (1992) F (1, 7) = 1026, This data could not
independent P = 001 be used in the standard
requests for metaview analysis due
toileting to missing data
PV other vs. Number of Ouslander Treatment This data could not be
PV alone self-initiated (1995) mean = 06 used in the standard
(i.e. oxybutynin) requests for (SD 15) vs. metaview tables as it
toileting vs. 05 (SD 10) was reported at the end
caregiver initiated of the study period and
toileting not given separately for
the first phase
The frequency of BT vs. no BT Number of daytime Fantl (1991) Gp 1: (45) WMD 500; 95% CI
voiding micturitions per mean = 51 1179 to 179
week immediately (SD 1100)
after treatment for Gp 2: (43)
stress incontinence mean = 56
(SD 2000)
Number of Gp 1: (45) WMD 300; 95% CI
night-time mean = 500 514 to 086
micturitions per (SD 400)
week immediately Gp 2: (43)
after treatment for mean = 800
stress incontinence (SD 600)
Number of day-time Gp 1: (15) WMD 400; 95% CI
micturitions per mean = 5600 2238 to 1438
week immediately (SD 2000)
after treatment for Gp 2: (20)
other incontinence mean = 6000
(SD 3500)
Number of Gp 1: (15) WMD 100; 95% CI
night-time mean = 800 569 to 369
micturitions per (SD 700)
week immediately Gp 2: (20)
after treatment for mean = 900
other incontinence (SD 700)
Table 3 (Continued)
Objective outcomes Relevant comparisons Unit of measure Relevant trial Results Analysis
Table 4 (Continued)
PFMT, pelvic floor muscle exercise training; QOL, quality of life; GSI, genuine stress incontinence; BT, bladder training.
recommended for the frail elderly (Fonda et al. 2005). Tobin offered increased opportunity for toileting assistance and
and Brocklehurst (1986) reported that in a sample of 278 favourable reinforcement for continence (Schnelle 1990). If
older adults, 78% of whom had cognitive impairment, only the value of systematic voiding programmes pertains to the
three individuals were recommended for urodynamic proce- fact that they provide individuals with otherwise limited
dures and this was determined on the basis that the result was toileting opportunities, then clearly, there is little need for
likely to affect management and thus, be of direct benefit to intensive assessment procedures to identify the aetiological
that individual. type of incontinence.
At this stage, on the basis of the limited data, it is unclear if The most common and consistent measure of effectiveness
certain types of incontinence are more responsive to system- was the frequency of incontinence. Although there were four
atic voiding programmes or if the value of these programmes statistically significant measures that favoured bladder train-
lies in none other than the fact that they provide dependent ing compared with two trials with statistically significant
individuals with regular voiding opportunities. This propo- results in favour of prompted voiding, none on habit
sition is not without precedence as other research has retraining and one on timed voiding, it would be simplistic
identified immediate improvements associated with the at the very least to suggest that bladder training is more
introduction of a prompted voiding protocol (Schnelle effective than systematic voiding programmes. At the same
1990). This observation led Schnelle to hypothesize that time, based on the sample of 1366 participants from 10
responders were not developing new skills related to contin- trials, the body of evidence on bladder training is greater
ence, instead they were responding to an environment that than that on prompted voiding (n = 479, 6 trials), habit
retraining (n = 337, 3 trials) and timed voiding (n = 298, 2 these types of outcomes are related to supportive contact
trials). from researchers compared with the intervention itself.
Another measure of effectiveness was the frequency of An important comparison that has not been addressed to
voiding; however, this was limited to the review on bladder date is that of prompted voiding compared with either habit
training. This is consistent with the aim of bladder training, retraining or timed voiding or both. In the absence of this
which is targeted to individuals with an overactive bladder, research it remains unclear which, if any, of the various types
urgency and/or urge incontinence and urinary frequency. of systematic voiding programmes are most effective and how
In terms of health outcomes, data were confined to the clinicians should choose between the three types. A lack of
incidence of adverse drug effects, skin breakdown and rash outcome data also means that there is a lack of clarity about
and/or urinary tract infection although no further analysis the optimal methods for assessment, implementation and
could be applied to these data. Other health factors that evaluation. As noted previously, prompted voiding assess-
could be considered in future trials could include; changes in ment and evaluation procedures represent a function of the
bladder capacity and post void residual volume. The first of intervention itself. These procedures involve intensive and
these two conditions is particularly relevant for individuals arguably, intrusive contact with individuals. Two trials on
undergoing bladder training. Assessment of a post void habit retraining described the concurrent use of an electronic
residual is particularly relevant for individuals with poor data logger to obtain accurate data on individuals voiding
mobility and for those who often rely on another person for patterns thus mitigating some of the resource and privacy
toileting assistance. issues associated with hourly or two hourly wet checks
The review on prompted voiding reported on three trials conducted by other individuals.
(Schnelle 1983, 1989, Hu 1989) that evaluated the number More trials were included in the bladder training system-
of self initiated requests for toileting. This is consistent with atic review and there was an attempt to establish its
the aim of prompted voiding which uses positive reinforce- effectiveness for specific types of incontinence, while the
ment in an effort to increase individuals ability to discrim- other systematic reviews lumped all urinary incontinence
inate their continence status and initiate toileting. Whilst together and did not differentiate between conditions. It is of
individuals enrolled in the reviews on habit retraining and note that the more recent trials on bladder training, since the
timed voiding were similarly dependent, there was no 1990s have more complex RCT designs (Fantl 1991, Wyman
strategic effort made to alter this dependence. Instead, 1998 compared with Jarvis 1981). Such trials involve a
efforts were directed toward accommodating this depend- number of arms or interventions that have a cross over
ence by identifying and mimicking the individuals unique element over time. They also combine a number of therapies
voiding pattern (habit retraining) or providing regular and which reflects custom and clinical practice, but can ulti-
systematic voiding opportunities at times that are based on mately tease out the effectiveness of an individual therapy
the notion of a rhythmic bladder storage/voiding cycle under test, in this case bladder training. Based on the findings
(timed voiding). and outcomes of Wyman (1998) combining therapies of
Cost data were evaluated by two trials on prompted voiding bladder training, pelvic floor muscle exercise training and
(Hu 1989, Surdy 1992) and one trial on habit retraining biofeedback was statistically significantly more effective
(Colling et al. 2003). It is noteworthy that the cost data on compared with PFMT and biofeedback alone, for stress
prompted voiding are now more than 10 years old. No cost incontinence and other incontinence at the end of the
data were available for bladder training or for timed voiding. intervention. Trial designs and methods are evolving and are
Evaluations of individuals perception of cure or improve- becoming more complex combining therapies for both urge
ment were limited to the review on bladder training. Again, and stress incontinence. These developments in design and
this may relate to the higher cognitive status of individuals methods need to be considered when designing future studies.
involved in trials on bladder training compared to those who A further observation from this metastudy was that none of
were enrolled in trials on systematic voiding programmes. the trials in the systematic reviews undertook long-term
Nevertheless, given the necessity for caregivers (i.e. either follow up of patients included in the studies to establish
informal or formal) to implement voiding programmes, their benefits over time which again requires more complex study
perceptions, morale and QOL are of paramount importance. designs, methods and incurs considerable expenses. However,
The one trial that evaluated this outcome in caregivers of such long-term follow up of cohorts are required if we want
community-dwelling and cognitively impaired older adults to not only explore the effectiveness of current and future
stated that caregivers were less stressed at outcome (Colling interventions and treatments but also to study prevention of
et al. 2003). It is also important to know the extent to which incontinence over the life course.
complex designs than those from the 1970s and 1980s, with
What is already known about this topic greater emphasis on quality, power calculations, sample size,
Systematic reviews on bladder training, prompted blinding and intention-to-treat analysis (MRC 1998). Meth-
voiding, habit retraining and timed voiding are avail- ods for the systematic review of research evidence are also
able in the Cochrane Library. evolving with synthesis and meta-analysis of quantitative
There is evidence that bladder training is effective for research, notably RCTs (Egger et al. 2005), being electron-
the management of urinary incontinence in adults and ically disseminated via the Cochrane Library. Systematic
suggestive evidence for the use of prompted voiding. review, metastudy, metasynthesis or integration of qualitative
There is insufficient evidence to support habit retraining research evidence are also evolving and methods being
or timed voiding, despite timed voiding, in particular, developed (Thorne et al. 2004, Whittemore & Knafl 2005),
being common custom and practice for the management although there is not a specific electronic library for their
of urinary incontinence in people with cognitive and dissemination. The challenge is now to systematically review
physical impairments. and integrate evidence from quantitative and qualitative
research, which The Joanna Briggs Foundation (2005) is
pioneering. Synopses of systematic reviews across related
What this paper adds subjects, diagnostic categories and groups of patients, such as
It is unclear whether diagnostic and assessment inves- those with long-term conditions, for example, of quantitative
tigations for urinary incontinence will improve health evidence, qualitative evidence or those integrating both
outcomes for people with comorbidities, cognitive and quantitative and qualitative evidence are warranted. This
physical impairments. study has provided a synopsis of systematic reviews of four
Frequency of urinary incontinence is the most com- main behavioural interventions used by nurses for the
monly cited outcome measure in randomized controlled management of urinary incontinence. The individual reviews
trials on bladder training and voiding programmes, but took nearly 10 years to be completed and published and are
limited or no data are available on other health out- in the process of being added to and updated, which is a
comes, change in dependency status, quality of life or requirement of the Cochrane Collaboration and Library.
cost effectiveness. None of these reviews received external funding, which is an
The theory under-pinning bladder training and voiding important consideration for future systematic reviews irres-
programmes for the management of urinary incontin- pective of the types of evidence being synthesized and
ence, the research design and interventions, outcomes integrated. The metastudy framework and techniques while
and long-term follow up need to be considered in future developed for review of qualitative studies, provides a useful
research. methodology for the descriptive comparison and contrast of
systematic reviews of quantitative evidence.
whereas those on voiding programmes made no attempt to subsequent papers and publications arising from the original
accurately diagnose the type of incontinence and may reflect trial included under that author and date.
that patients had limited cognitive and physical abilities as
Castleden C.M. & Duffin H.M. (1981) Guidelines for controlling
well as clinical custom and practice. It is unknown whether urinary incontinence without drugs or catheters. Age and Ageing
intensive diagnostic and assessment investigations will 10, 186190.
improve health outcomes or people with comorbidities and Clay E.C. (1978) Incontinence of urine: a regimen for retraining.
impairments. It is also unknown whether systematic voiding Nursing Mirror 146, 2324.
programmes are more effective for different types of urinary Closs S.J. & Cheater F.M. (1999) Evidence for nursing practice:
A clarification of the issues. Journal of Advanced Nursing 30,
incontinence and whether the more dependent individuals
1017.
they are targeted at might benefit equally from regular Colling J., Ouslander J., Hadley B.J., Eisch J. & Campbell E. (1992)
voiding opportunities. The theories underpinning bladder The effects of patterned urge-response toileting (PURT) on urinary
training and voiding programmes, their future classification incontinence among nursing home residents. Journal of the
and interventions studies are warranted (Ostaszkiewicz et al. American Geriatrics Society 40(2), 135141.
Colling J., Owen T.R., McCreedy M. & Newman D. (2003) The
2005, Roe et al. 2007). The most common and constant
effects of a continence program on frail community dwelling
measure of effectiveness was the frequency of incontinence. elderly persons. Urology Nursing 23(2), 117122.
The body of evidence on this was greatest for bladder Colombo M., Zanetta G., Scalambrino S. & Milani R. (1995)
training, and more limited for prompted voiding, habit Oxybutinin and bladder training in the management of female
retraining and timed voiding. There were insufficient studies urinary urge incontinence. A randomised study. International
undertaken and therefore included in the latter two system- Urogynecology Journal and Pelvic Floor Dysfunction 6, 6367.
Egger M., Davey, Smith G. & Altman D.G. (2005) Systematic Re-
atic reviews to make definitive recommendations for clinical
views in Health care. Meta-analysis in Context. BMJ Publishing,
practice. Limited data on other health outcomes, change in London.
dependency status, QOL and cost effectiveness were available Eustice S., Roe B. & Paterson J. (2002) Prompted Voiding for
and need to feature in future research. The theory underpin- the Management of Urinary Incontinence in Adults (Cochrane
ning these interventions, future research design, long-term Review). In The Cochrane Library. Issue 2, John Wiley and Sons,
Ltd Chichester.
follow up and outcomes measured need careful consideration
in future research and need to adhere standards for good
practice so that evidence on effectiveness of interventions is Fantl 1991
obtained and future meta-analyses can be performed. Meta-
Fantl A., Wyman J.F., McCLish D.K., Harkins S.W., Elswick R.K.,
study techniques provide a useful methodology for the Taylor J.R. et al. (1991) Efficacy of bladder training in older
synopsis of systematic reviews of quantitative evidence. women with urinary incontinence. Journal of the American
Medical Association 265(5), 609613.
Fantl J.A., Wyman J.F., Harkins S.W. & Taylor J.R. (1988) Bladder
Acknowledgement training in women with urinary incontinence (Abstract). Neu-
rourology and Urodynamics 7(3), 276277.
We would like to thank Margarete Sandelowski and Sally
McLish D.K., Fantl J.A., Wyman J.F., Pisani G. & Bump R.C. (1991)
Thorne for their support and encouragement in pursuing this Bladder training in older women with urinary incontinence:
approach and application of metastudy techniques. relationship between outcome and changes in urodynamic
observations. Obstetrics and Gynecology 77(2), 281286.
Wyman J.F., Fantl J.A., McClish D.K., Harkins S.W., Uebersax J.S.
Author contributions & Ory M.G. (1997) Quality of life following bladder training
in older women with urinary incontinence. International
BR was responsible for the study conception and design. BR, Urogynecology Journal 8(40), 223229.
JO, JM and SW were responsible for drafting of the Wyman J.F., McClish D.K., Ory M.G. & Fantl J.A. (1992) Changes
manuscript. BR, JO, JM and SW performed the data in quality of life following bladder training in older women with
collection and data analysis. BR made critical revisions to urinary incontinence (Abstract). Neurourology and Urodynamics
the paper. 11(40), 426427.
Fonda D., DuBeau C.E., Harari D., Ouslander J.G., Palmer M. &
Roe B. (2005) Incontinence in the Frail Elderly. In Incontinence:
References Management Volume 2. 3rd International Consultation on
Incontinence. Chapter 18 (Abrams P., Cardozo L., Khoury S.,
Note the references in bold adhere to the Cochrane Library
Wein A., eds), Health Publications Ltd, Plymouth, pp. 1165
convention, where each trial is cited by first author/principal 1239.
investigator only and year of initial publication, with all
Frewen W.K. (1978) An objective assessment of unstable bladder of Cochrane Library. Issue 1, Update Software, John Wiley and Sons
psychosomatic origin. British Journal of Urology 50(4), 246249. Ltd, Chichester.
Hadley E.C. (1986) Bladder training and related therapies for urinary Ostaszkiewicz J., Johnson L. & Roe B. (2004b) Habit Training for
incontinence in older people. Journal of the American Medical Urinary Incontinence in Adults (Cochrane Review). In The
Association 256(3), 372379. Cochrane Library. Issue 2, Update Software. John Wiley and Sons
Ltd, Chichester.
Ostaszkiewicz J., Roe B. & Johnson L. (2005) Effects of
Hu 1989 timed voiding for the management of urinary incontinence in
adults: systematic review. Journal of Advanced nursing 52(4), 420
Hu T.W., Igou J.F., Kaltreider D.C., Yu L.C., Rohner T.J.,
431.
Dennis P.J., Craighead W.E., Hadley E.C. & Ory M.G. (1989)
Paterson B.L., Thorne S.E., Canam C. & Jillings C. (2001) Meta-
A clinical trial to reduce urinary incontinence in nursing
study of Qualitative Health Research. A Practical Guide to Meta-
homes. Journal of the American Medical Association 261(18),
Analysis and Meta-Synthesis. Sage Publications, Thousand Oaks,
26562662.
CA.
Hu T.W., Kaltreider D.L., Igou J.F., Yu L.C. & Rohner T.J. (1990)
Roe B. & Moore K.N. (2000) Utilization of Incontinence Clinical
Cost effectiveness of training incontinent elderly in nursing homes:
practice Guidelines. Journal of Wound, Ostomy and Continence
a randomised clinical trial. Health Services Research 25(3), 455
Nursing 28(6), 287304.
477.
Roe B., Milne J., Ostaszkiewicz J. & Wallace S. (2007) Systematic
Kennedy A.P. (1992) Bladder re-education for the promotion of
review of bladder training and voiding programmes for the
continence. In Clinical Nursing Practice: The Promotion and
management of urinary incontinence in adults: A synopsis of
Management of Continence (Roe B., ed.), Prentice Hall, London,
findings on theory and methods using metastudy techniques.
pp. 7894.
Journal of Advanced Nursing in press.
Jarvis 1981
Schnelle 1983
Jarvis G.J. (1981) A controlled trial of bladder drill and drug therapy
Schnelle J.F., Traugher B., Morgan D.B., Embry J.E., Binion A.F. &
in the management of detrusor instability. British Journal of
Coleman A. (1983) Management of geriatric incontinence in nur-
Urology 53(6), 565566.
sing homes. Journal of Applied Behavior Analysis 16(2), 235241.
Jarvis G.J. (1981) The Unstable Bladder A Psychosomatic Disease?
(Abstract). Conference Proceedings of the International Continence
Society (ICS), 11th Annual Meeting, pp. 4546. Schnelle 1989
Jirovec M.M. & Templin T. (2001) Predicting success using in-
Schnelle J. (1990) Treatment of urinary incontinence in nursing home
dividualized scheduled toileting for memory impaired elders at
patients by prompted voiding. Journal of American Geriatrics
home. Research in Nursing & Health 24(1), 18.
Society 38(3), 356360.
Schnelle J.F., Traugher B., Sowell V.A., Newman D.R., Petrilli C.O.
& Ory M. (1989) Prompted voiding treatment of urinary incon-
Lagro-Janssen 1992
tinence in nursing home patients. A behavior management
Lagro-Janssen A.L., Debruyne F.M., Smits A.J. & Van Weel C. approach for nursing home staff. Journal of the American
(1992) The effects of treatment of urinary incontinence in general Geriatrics Society 37(11), 10511057.
practice. Family Practice 9(30), 284289.
Smith D.A., Newman D.K., McDowell B.J. & Burgio L.D. (1992)
Lagro-Janssen T. & Van Weel C. (1998) Long term effect of treat-
Reduction of incontinence among elderly in a nursing home set-
ment of female incontinence in general practice. British Journal of
ting. In Key Aspects of Elder care: Managing Falls, Incontinence
General Practice 48(436), 17351738.
and Cognitive Impairment (Funk S.G., Tornquist E.M., Cham-
Lagro-Jansen T.L.M., Debruyne F.M.J., Smits A.J.A. & Van Weel C.
pagne M.T. & Wiese R.A., eds), Springer Publishing, New York,
(1991) Controlled trail of pelvic floor exercises in the treatment of
pp. 196204.
urinary stress incontinence in general practice. British Journal of
Surdy T.M. (1992) Rehabilitation of Urinary Incontinent Nursing
General Practice 41(352), 445449.
Home Patients. Doctoral Thesis, University of Wisconsin-Mil-
MRC (1998) Guidelines for Good Clinical Practice in Clinical Trials. waukee, Milwaukee, WI.
Medical Research Council, London, UK. http://www.mrc.ac.uk/ Tobin G.W. & Brocklehurst J.C. (1986) The management of urinary
pdf-ctg.pdf last accessed 13/10/2004. incontinence in local authority residential homes for the elderly.
Ouslander J.G., Schnelle J.F., Uman G., Fingold S., Nigam J.G., Age and Ageing 15(50), 292298.
Tuico E. & Jensen B.B. (1995) Does oxybutinin add to the effec- The Joanna Briggs Foundation (2005) http://www.joannabriggs.
tiveness of prompted voiding for urinary incontinence among edu.au/about/home.php# (Accessed 28/9/2005).
nursing home residents? A placebo-controlled trial. Journal of the Thorne S., Jensen L., Kearney M.H., Noblit G. & Sandelowski M.
American Geriatrics Society 43, 610617. (2004) Qualitative metasynthesis: reflections on methodological
Ostaszkiewicz J., Johnson L. & Roe B. (2004a) Timed Voiding for orientation and ideological agenda. Qualitative Health Research
Urinary Incontinence in Adults (Cochrane Review). In The 14(10), 13421365.
Wallace S., Roe B., Williams K. & Palmer M. (2004) Bladder Elser D.M., Wyman J.F., McClish D.K., Robinson D., Fantl J.A. &
Training for Urinary Incontinence in Adults (Cochrane Review). In Bump R.C. (1999) The effect of bladder training, pelvic floor
The Cochrane Library. Issue 1, Update Software, John Wiley and muscle training or combination training on urodynamic para-
Sons Ltd. meters in women with urinary incontinence. Neurourology and
Whittemore R. & Knafl K. (2005) The integrative review. Updated Urodynamics 18(50), 427436.
methodology. Journal of Advanced Nursing 52, 18. Theofrastous J.P., Wyamn J.F., Bump R.C., McClish D.K., Elser
Willington F.L. (1975) Training and retraining for continence. Nur- D.M., Bland D.R. et al. (2002) Effects of pelvic floor muscle
sing Times 71, 500503. training on strength and predictors of response in the treatment of
urinary incontinence. Neurourology and Urodynamics 21(5), 486
490.
Wyman 1998 Wyman J.F., Fantl J.A., McClish D.K., Bump R.C. & the Continence
Program for Women Research Group (1998) Comparative efficacy
Barber M.D., Visco A.G., Wyman J.F., Fanlt R.C., Bump R.C. for the
of the behavioural interventions in the management of female
Continence Program for Women Research Group (2002) Sexual
urinary incontinence. American Journal of Obstetrics and
function in women with urinary incontinence and pelvic organ
Gynecology 179(4), 9991007.
prolapse. Obstetrics and Gynecology 99(2), 281289.
Wyman J.F., McClish D.K., Sale B. & Camp J. (1999) Long term
Elser D.M., Fantl J.A., McClish D.Y. for the Continence Program for
follow-up of behavioural interventions in incontinent women
Women Research group (1995) Comparison of subjective and
(Abstract). International Urogynecology Journal & Pelvic Floor
objective measures of severity of urinary incontinence in women.
Dysfunction 10(Suppl. 1), S33.
Neurourology and Urodynamics 14(4), 311316.