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Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial.

Publication ,  Journal Article
Sung, VW; Borello-France, D; Newman, DK; Richter, HE; Lukacz, ES; Moalli, P; Weidner, AC; Smith, AL; Dunivan, G; Ridgeway, B; Nguyen, JN ...
Published in: JAMA
September 17, 2019

IMPORTANCE: Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman's quality of life. Studies evaluating treatments to simultaneously improve both components are lacking. OBJECTIVE: To determine whether combining behavioral and pelvic floor muscle therapy with midurethral sling is more effective than sling alone for improving mixed urinary incontinence symptoms. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial involving women 21 years or older with moderate or severe stress and urgency urinary incontinence symptoms for at least 3 months, and at least 1 stress and 1 urgency incontinence episode on a 3-day bladder diary. The trial was conducted across 9 sites in the United States, enrollment between October 2013 and April 2016; final follow-up October 2017. INTERVENTIONS: Behavioral and pelvic floor muscle therapy (included 1 preoperative and 5 postoperative sessions through 6 months) combined with midurethral sling (n = 209) vs sling alone (n = 207). MAIN OUTCOMES AND MEASURES: The primary outcome was change between baseline and 12 months in mixed incontinence symptoms measured by the Urogenital Distress Inventory (UDI) long form; range, 0 to 300 points; minimal clinically important difference, 35 points, with higher scores indicating worse symptoms. RESULTS: Among 480 women randomized (mean [SD] age, 54.0 years [10.7]), 464 were eligible and 416 (86.7%) had postbaseline outcome data and were included in primary analyses. The UDI score in the combined group significantly decreased from 178.0 points at baseline to 30.7 points at 12 months, adjusted mean change -128.1 points (95% CI, -146.5 to -109.8). The UDI score in the sling-only group significantly decreased from 176.8 to 34.5 points, adjusted mean change -114.7 points (95% CI, -133.3 to -96.2). The model-estimated between-group difference (-13.4 points; 95% CI, -25.9 to -1.0; P = .04) did not meet the minimal clinically important difference threshold. Related and unrelated serious adverse events occurred in 10.2% of the participants (8.7% combined and 11.8% sling only). CONCLUSIONS AND RELEVANCE: Among women with mixed urinary incontinence, behavioral and pelvic floor muscle therapy combined with midurethral sling surgery compared with surgery alone resulted in a small statistically significant difference in urinary incontinence symptoms at 12 months that did not meet the prespecified threshold for clinical importance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01959347.

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Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

September 17, 2019

Volume

322

Issue

11

Start / End Page

1066 / 1076

Location

United States

Related Subject Headings

  • Urologic Surgical Procedures
  • Urinary Incontinence
  • Treatment Outcome
  • Suburethral Slings
  • Pelvic Floor
  • Middle Aged
  • Humans
  • General & Internal Medicine
  • Follow-Up Studies
  • Female
 

Citation

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Sung, V. W., Borello-France, D., Newman, D. K., Richter, H. E., Lukacz, E. S., Moalli, P., … NICHD Pelvic Floor Disorders Network, . (2019). Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial. JAMA, 322(11), 1066–1076. https://doi.org/10.1001/jama.2019.12467
Sung, Vivian W., Diane Borello-France, Diane K. Newman, Holly E. Richter, Emily S. Lukacz, Pamela Moalli, Alison C. Weidner, et al. “Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial.JAMA 322, no. 11 (September 17, 2019): 1066–76. https://doi.org/10.1001/jama.2019.12467.
Sung VW, Borello-France D, Newman DK, Richter HE, Lukacz ES, Moalli P, Weidner AC, Smith AL, Dunivan G, Ridgeway B, Nguyen JN, Mazloomdoost D, Carper B, Gantz MG, NICHD Pelvic Floor Disorders Network. Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial. JAMA. 2019 Sep 17;322(11):1066–1076.
Journal cover image

Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

September 17, 2019

Volume

322

Issue

11

Start / End Page

1066 / 1076

Location

United States

Related Subject Headings

  • Urologic Surgical Procedures
  • Urinary Incontinence
  • Treatment Outcome
  • Suburethral Slings
  • Pelvic Floor
  • Middle Aged
  • Humans
  • General & Internal Medicine
  • Follow-Up Studies
  • Female