BJOG Exchange
A report from #BlueJC: ‘How to manage incontinence after childbirth?’ Paper discussed: Glazener CM, MacArthur C, Hagen S, Elders A, Lancashire R, Herbison GP, Wilson PD; ProLong Study Group. Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial. BJOG 2014;121:112–20. Location: Twitter, Facebook and RCOG World Congress 2014 Number of participants : 22 Start date of journal club: 26 March 2014 Number of tweets: 160 Paper summary: Participants Intervention Comparison Outcomes Study design Findings
Women who had urinary incontinence (UI) 3 months after their delivery Three one-to-one pelvic floor muscle training (PFMT) sessions, with bladder training if indicated, at 5, 7 and 9 months after birth Standard care Primary outcome: The prevalence of UI at 12 years after randomisation Randomised controlled trial (RCT) Improvement of urinary and faecal incontinence did not persist at 12-year follow up. Only half of the women in each group still perform PFMT 12 years after the study
Research literacy Stratification in RCT Stratification aims to randomise participants according to predefined characteristics, to control for known factors that could influence treatment effectiveness. However, too many strata could reduce the efficiency of stratification (Kernan et al. J Clin Epidemiol 1999;52:19–26).
Key discussion points Response bias and optimising response rates The response rate (63.1%) 12 years after the start of this well-designed RCT was commendable. However, women who did not respond to the 12-year survey had reported worse symptoms at baseline (before intervention). Under-reporting of incontinence symptoms was possible. Various suggestions were made to improve response rates, including multiple reminders and alternative survey methods (e.g. electronic mail). PFMT training in this study In the ProLong study women with postnatal UI received three one-to-one PFMT sessions at 5, 7 and 9 months after birth. Although this was a pragmatic approach aiming to promote clinical implementation, the length of PFMT and the lack of follow-up care might have reduced the long-term efficacy of this intervention. Moreover, despite most women still experiencing UI, only half of them performed any PFMT at 12 years. A Cochrane systematic review (Cochrane Database Syst Rev 2011;(12):CD009508) compared approaches of PFMT for UI in women. It identified 11 possible comparators of different approaches previously tested, but none has provided sufficient evidence for recommendation as the best approach.
Take-home messages Four in five women who experienced UI at 3 months after birth remained incontinent after 12 years. The provision of three one-to-one PFMT sessions within 1 year after delivery did not confer either long-term compliance with PFMT or improvement in urinary and faecal incontinence.
Acknowledgements We are grateful for all contributions to this journal club. Storify summary and a list of contributors can be viewed at https://storify.com/BlueJC/20140326. The Altmetric summary of the discussed paper can be viewed at http://bit.ly/ 1kVPabq. EYL Leung Women’s Health Research Unit, Queen Mary, University of London, London, UK
ª 2014 Royal College of Obstetricians and Gynaecologists
1177
A report from #BlueJC: ‘How to manage incontinence after childbirth?’ Paper discussed: Glazener CM, MacArthur C, Hagen S, Elders A, Lancashire R, Herbison GP, Wilson PD; ProLong Study Group. Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial. BJOG 2014;121:112–20. Location: Twitter, Facebook and RCOG World Congress 2014 Number of participants : 22 Start date of journal club: 26 March 2014 Number of tweets: 160 Paper summary: Participants Intervention Comparison Outcomes Study design Findings
Women who had urinary incontinence (UI) 3 months after their delivery Three one-to-one pelvic floor muscle training (PFMT) sessions, with bladder training if indicated, at 5, 7 and 9 months after birth Standard care Primary outcome: The prevalence of UI at 12 years after randomisation Randomised controlled trial (RCT) Improvement of urinary and faecal incontinence did not persist at 12-year follow up. Only half of the women in each group still perform PFMT 12 years after the study
Research literacy Stratification in RCT Stratification aims to randomise participants according to predefined characteristics, to control for known factors that could influence treatment effectiveness. However, too many strata could reduce the efficiency of stratification (Kernan et al. J Clin Epidemiol 1999;52:19–26).
Key discussion points Response bias and optimising response rates The response rate (63.1%) 12 years after the start of this well-designed RCT was commendable. However, women who did not respond to the 12-year survey had reported worse symptoms at baseline (before intervention). Under-reporting of incontinence symptoms was possible. Various suggestions were made to improve response rates, including multiple reminders and alternative survey methods (e.g. electronic mail). PFMT training in this study In the ProLong study women with postnatal UI received three one-to-one PFMT sessions at 5, 7 and 9 months after birth. Although this was a pragmatic approach aiming to promote clinical implementation, the length of PFMT and the lack of follow-up care might have reduced the long-term efficacy of this intervention. Moreover, despite most women still experiencing UI, only half of them performed any PFMT at 12 years. A Cochrane systematic review (Cochrane Database Syst Rev 2011;(12):CD009508) compared approaches of PFMT for UI in women. It identified 11 possible comparators of different approaches previously tested, but none has provided sufficient evidence for recommendation as the best approach.
Take-home messages Four in five women who experienced UI at 3 months after birth remained incontinent after 12 years. The provision of three one-to-one PFMT sessions within 1 year after delivery did not confer either long-term compliance with PFMT or improvement in urinary and faecal incontinence.
Acknowledgements We are grateful for all contributions to this journal club. Storify summary and a list of contributors can be viewed at https://storify.com/BlueJC/20140326. The Altmetric summary of the discussed paper can be viewed at http://bit.ly/ 1kVPabq. EYL Leung Women’s Health Research Unit, Queen Mary, University of London, London, UK
ª 2014 Royal College of Obstetricians and Gynaecologists
1177
