Urinary Incontinence

Evidence Reviewed as of before: 21-02-2017
Author(s)*: Tatiana Ogourtsova, MSc BSc OT; Nicol Korner-Bitensky, PhD
Editor(s): Annabel McDermott, OT; Annie Rochette PhD, OT
Expert Reviewer: Chantal Dumoulin, PhD PT
Patient/Family Information Table of contents

Introduction

Urinary incontinence (UI) is the loss of control of urine, or the inability to hold urine in until a bathroom can be reached. Unfortunately, UI following a stroke is common. The prevalence ranges from 37% to 79% in the days and weeks following the stroke. While many individuals with stroke will regain control of their bladder, one-third will remain incontinent at one year post-stroke.

There are multiple etiologies for UI post-stroke. UI may result from infarction or cerebral edema affecting central micturition pathways. Alternatively, impairments of consciousness; cognitive or language difficulties and motor and sensory loss, can also affect toileting, despite normal bladder function. Frequent coughing in individuals who experience dysphagia post-stroke may also exacerbate UI. In addition, certain medications; depression; constipation; pre-morbid conditions such as peripheral neuropathies from diabetes; pre-existing UI and environmental factors that impede toileting – or a combination of these – will increase the likelihood of UI post-stroke.

In most cases, UI can be treated successfully. Management of UI takes many forms including behavioural, pharmacological, surgical and supportive devices. The present review focuses on the behavioural management, the first line treatment for UI secondary to bladder dysfunction. Specific behavioural intervention for UI include:

  1. Timed voiding: fixed time interval toileting assistance program determined by the person’s own habits;
  2. Prompted voiding: teaches individuals to initiate their own toileting through requests for help in combination with positive reinforcement by a caregiver;
  3. Bladder retraining with urge suppression: education about the mechanisms underlying incontinence and continence, scheduled voiding regimen and urgency control strategy;
  4. Pelvic muscle exercises: program of repeated voluntary pelvic floor muscle contractions;
  5. Bladder retraining with urge suppression in combination with pelvic floor muscle exercises;
  6. Compensatory rehabilitation approaches to neurological impairment: rehabilitation approaches focused on optimization of the general function of an individual with stroke.
  7. Transcutaneous electrical nerve stimulation (TENS): electrical stimulation to the pelvic floor region using electrodes.

Patient/Family Information

Author: Chantale Dumoulin, PhD PT

What is urinary incontinence?

Urinary incontinence (UI) is the loss of the ability to hold in urine. This can make it difficult to get to the bathroom on time.

How does urination work?

When we eat or drink, liquid is absorbed into the bloodstream. The kidneys then filter the blood and get rid of liquid waste by way of urine. Special tubes called “ureters” bring this waste to the bladder.

The bladder is a muscular sac that serves as a reservoir for urine. When the bladder becomes full, your brain triggers the urge to void. Once you make it to the bathroom, your brain does two things to allow urination:

  1. It tells the bladder muscles to squeeze the urine out.
  2. It tells the muscles of the urethral sphincter to relax.

You can think of the urethral sphincter and pelvic floor muscles as a faucet that controls urination. Together the urethral sphincter and the pelvic floor muscles tighten around the urethra to hold urine. These muscles loosen to let it flow out, just like a faucet.

UI occurs if the bladder muscles contract uncontrollably or if the sphincter and pelvic floor muscles relax before you reach a bathroom.

How frequent is urinary incontinence after a stroke?

UI following a stroke is a common problem. 37%-79% of individuals have UI during the days and weeks after a stroke. Many people with UI after stroke regain control of their bladder. However, as many as 30% of individuals still have UI one year after the stroke.

What causes urinary incontinence after a stroke?

There are multiple causes for UI after a stroke:

  • UI may result directly from the stroke. The stroke can affect the part of the brain that controls the urge to pass urine. The voluntary control of continence (ability to hold in urine) is then lost.
  • Functional difficulties using the arm and leg affected by the stroke may make it hard to get to the bathroom, undress, sit on the toilet, and urinate, even if you have normal bladder function.
  • Having to wait for someone to assist you may make it harder to get to the bathroom on time.
  • Speech problems may make it difficult to express the need to go to the bathroom.
  • Your level of consciousness or cognitive problems from the stroke may make it difficult to get to the bathroom.
  • Having nerve damage caused by diabetes (diabetic neuropathies) before the stroke could also cause UI.
  • Certain medications and constipation may also make it difficult to hold in urine.
  • Coughing from dysphagia (difficulty swallowing) after a stroke can contribute to UI.
  • Finally, your environment, for example the distance to the bathroom and specific bathroom features such as the height of the toilet seat may make toileting difficult.

Can urinary incontinence after a stroke be treated?

In most cases, UI can be treated. Different techniques are used for UI, depending on the cause of the problem. These include behavioural interventions (described below), use of special devices such as pads or catheters, medications, and surgery.

The information provided here is specific to rehabilitation, and does not include a discussion of surgery or medications. Medications may be used to treat a specific bladder problem and you should discuss this with your physician.

If your UI is not related to a bladder problem but rather to your capacity to walk, stand up or communicate your need to go to the bathroom, specific functional interventions are needed. For example, someone with communication difficulty may benefit from a picture of a toilet that they can show to the nurse or therapist when they need to go to the bathroom.

It is important to know that UI can be treated or controlled no matter the cause. Don’t keep this problem to yourself or hidden within the family. Talk to your doctor or nurse or have someone talk to him or her for you. They will be able to help you find the best treatment for your specific problem.

What are behavioural interventions?

Behavioural interventions for UI after a stroke include:

  • Timed voiding: This is a set schedule for urinating that is determined by your habits. First you will need to write down when you urinate and when you have “accidents” over several days. Then, a customized program with fixed times for going to the bathroom can be used to help you avoid accidents.
  • Prompted voiding: A family member or health professional, often a nurse, will remind (prompt) you to go to the bathroom at regular intervals and will encourage you to maintain bladder control in between.
  • Bladder retraining with urge suppression: This has three parts:
    • Education by a health care professional about the causes of your incontinence;
    • Scheduled bathroom visits with gradually increasing time between visits;
    • Controlling the need to urinate using distractions and relaxation techniques (suppressing the urge to urinate).
  • Pelvic floor muscle exercises: Pelvic floor muscle exercises are taught by a health care professional – typically a physical therapist. These exercises are designed to help strengthen weak muscles around the bladder. By strengthening muscles around the bladder, leaking of urine may be reduced or prevented.
  • Compensatory rehabilitation approaches to neurological impairment: This treatment focuses on getting to the bathroom on time, and considers functional ways to help you do this. For example, you can use a urinal at your bedside if you are not able to get to a far-away bathroom. So, if you have physical problems caused by the stroke that make toileting difficult, the goal of this intervention is to help you compensate for these with solutions that often an occupational therapist, physical therapist, or nurse can suggest.

Are behavioural interventions effective for urinary incontinence after a stroke?

Experts have done some research to see if the interventions described above help decrease UI in people who have had a stroke.

  • Timed voiding (urination): There are no research studies that looked at the effect of timed voiding on UI in people with stroke. However, studies on individuals with UI caused by similar problems have shown success. So, experts suggest that timed voiding should be used for UI in people who have had a stroke and are somewhat mobile.
  • Prompted voiding: There are no research studies that looked at the effect of prompted voiding on UI in individuals with stroke. However, studies on adults with UI caused by other problems had shown success using prompted voiding. So, experts suggest that this treatment should be used if the person who has had a stroke is somewhat mobile and is able to cooperate with the regime.
  • Bladder retraining with urge suppression: No studies have looked at the effect of bladder retraining with urge suppression alone in people who have had a stroke. However studies in adults with UI showed successful results using a bladder-training program to manage urge UI. Urge UI is a specific type of UI that causes an uncontrollable urge to urinate that results in UI.
  • Bladder retraining with urge suppression in combination with pelvic floor exercises: One study has looked at the benefit of bladder retraining with urge suppression in combination with pelvic floor exercises on UI in men following stroke. The results suggest that this intervention may be helpful in reducing UI in males after stroke.
  • Pelvic floor exercises: No high quality research study has looked at the effect of using only pelvic floor exercises to reduce UI in people with stroke.
  • Compensatory rehabilitation approaches to neurological impairment: One study has looked at the effect of using a compensatory rehabilitation approach for UI after stroke. There is some evidence that this approach results in less UI than the usual approach used in people with stroke.

As you can see from this review, UI after a stroke is a complex condition that needs expert advice. There are many possible treatments that may work well for you so speak up about the problem so that solutions can be found to meet your needs.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The effectiveness of the various behavioural approaches in the management of urinary incontinence (UI) in individuals post-stroke is not well studied. This review presents eight RCTs, of which six are high quality RCTs (two of which are secondary analyses of one RCT) and two are fair quality RCTs. Of the studies included, one study examined patients in the acute phase of stroke recovery and one study included patients in the subacute phase of recovery; all remaining studies included patients across recovery phases (classified here as ‘Phase of stroke recovery not specific to one period’).

Results Table

View results table

Outcomes

Acute phase - Compensatory rehabilitation

Functional independence/ADLs
Effective
2A

One fair quality RCT (Wikander et al., 1998) investigated the effect of a rehabilitation program based on the Functional Independence Measure (FIM) on functional independence/activities of daily living (ADLs) in patients with acute stroke. This fair quality RCT randomized patients to receive FIM-based rehabilitation or Bobath-based rehabilitation for the duration of hospitalisation (average 83 and 75 days respectively). ADLs were measured by the Katz ADL Index at baseline and at post-treatment. Significant between-group differences in ADLs were seen at post-treatment, favoring FIM-based rehabilitation vs. the Bobath approach.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that rehabilitation based on the FIM is more effective than a comparison intervention (Bobath approach) in improving functional independence/ADLs in patients with acute stroke.

Mobility
Effective
2A

One fair quality RCT (Wikander et al., 1998) investigated the effect of a rehabilitation program based on the Functional Independence Measure (FIM) on transfers and mobility among patients with acute stroke. This fair quality RCT randomized patients to receive FIM-based rehabilitation or Bobath-based rehabilitation for the duration of their hospitalisation (average 83 and 75 days respectively). Mobility was measured at baseline and at post-treatment using a non-standardised 3-point rating scale during clinical observation of transfers (bed to wheelchair, wheelchair to toilet), wheelchair use and walking. Significant between-group differences in transfers and wheelchair use (but not walking scores) were seen at post-treatment, favoring FIM-based rehabilitation vs. the Bobath approach.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that FIM-based rehabilitation is more effective than a comparison intervention (Bobath approach) in improving transfers and wheelchair skills (but not walking ability) in patients with acute stroke.

Urinary continence
Effective
2A

One fair quality RCT (Wikander et al., 1998) investigated the effect of a rehabilitation program based on the Functional Independence Measure (FIM) on urinary incontinence in patients with acute stroke. This fair quality RCT randomized patients to receive FIM-based rehabilitation or Bobath-based rehabilitation for the duration of their hospitalisation (average 83 and 75 days respectively). Urinary continence was measured by the FIM-G (urinary incontinence) at baseline and at post-treatment. Significant between-group differences in urinary continence were seen at post-treatment, favoring FIM-based rehabilitation vs. the Bobath approach.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that FIM-based rehabilitation is more effective than a comparison intervention (Bobath approach) in improving urinary continence in patients with acute stroke.

Well-being
Effective
2A

One fair quality RCT (Wikander et al., 1998) investigated the effect of rehabilitation based on the Functional Independence Measure (FIM) on well-being in patients with acute stroke. This fair quality RCT randomized patients to receive FIM-based rehabilitation or Bobath-based rehabilitation for the duration of hospitalisation (average 83 and 75 days respectively). Well-being was measured by the Psychological General Well-Being Index at baseline and at post-treatment. Significant between-group differences in well-being were seen at post-treatment, favoring FIM-based rehabilitation vs. the Bobath approach.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that rehabilitation based on the FIM is more effective than a comparison intervention (Bobath approach) in improving well-being in patients with acute stroke.

Subacute phase - Systematic voiding program

Functional independence/ADLs
Not effective
1B

One high quality RCT (Thomas et al., 2014) investigated the effect of a systematic voiding program (SVP) on functional independence/activities of daily living (ADLs) in patients with subacute stroke. This high quality RCT randomized patients to receive a SVP, a supported SVP, or usual continence care for the duration of hospitalization. Functional independence/ADLs were measured by the Barthel Index at baseline, 6 weeks and 12 weeks post-stroke. No significant between-group differences in functional independence/ADLs were found between any group at either time point post-treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a systematic voiding program (SVP) is not more effective than a comparison intervention (usual continence care) in improving functional independence/ADLs in patients with subacute stroke.

Health-related quality of life
Not effective
1B

One high quality RCT (Thomas et al., 2014) investigated the effect of a systematic voiding program (SVP) on health-related quality of life in patients with subacute stroke. This high quality RCT randomized patients to receive a SVP, a supported SVP or usual continence care for the duration of hospitalization. Health-related quality of life was measured by the EuroQOL (mobility, self-care, usual activity, pain or discomfort, anxiety or depression) and the Incontinence Quality of Life Instrument at baseline (EuroQOL only), 6 weeks and 12 weeks post-stroke. There were no significant between-group differences between any group on either measure of health-related quality of life at either time point post-treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a systematic voiding program (SVP) is not more effective than a comparison intervention (usual continence care) in improving health-related quality of life in patients with subacute stroke.

Urinary incontinence
Not effective
1B

One high quality RCT (Thomas et al., 2014) investigated the effect of a systematic voiding program (SVP) on urinary incontinence symptoms in patients with subacute stroke. This high quality RCT randomized patients to receive a SVP, a supported SVP, or usual continence care for the duration of hospitalization. Urinary incontinence was measured by the International Consultation on Incontinence Questionnaire – Short Form (ICIQ-SF), the Incontinence Severity Index (ISI), and the Leicester Urinary Symptom Questionnaire at baseline (ICIQ-SF and ISI only), 6 weeks and 12 weeks post-stroke. There were no significant between-group differences in urinary incontinence between any group at either time point post-treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a systematic voiding program (SVP) is not more effective than a comparison intervention (usual continence care) in improving urinary continence in patients with subacute stroke.

Phase of stroke recovery not specific to one period - Pelvic floor muscle training

Health-related quality of life
Not effective
1b

One high quality RCT (Tibaek et al., 2004, 2007) investigated the effects of pelvic floor muscle training on health-related quality of life in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive pelvic floor muscle training and education (including home and group exercises) or no training/education. Health-related quality of life was measured by the Short-Form 36 (SF-36) and the Incontinence Impact Questionnaire (IIQ) at baseline and at post-treatment (12 weeks – Tibaek et al., 2004) and again at 6-month follow-up (Tibaek et al., 2007). There were no significant between-group differences on either measure of health-related quality of life at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that pelvic floor muscle training and education is not more effective than no training/education in improving health-related quality of life in patients with stroke.

Pelvic floor muscle activity
Conflicting
4

Two high quality RCTs (Tibaek et al., 2005, Shin et al., 2016) investigated the effect of pelvic floor muscle training on pelvic floor muscle activity in patients with stroke.

The first high quality RCT (Tibaek et al., 2005) randomized patients with subacute/chronic stroke to receive pelvic floor muscle training and education (including home and group exercises) or no training/education. Pelvic floor muscle activity (function, strength, dynamic endurance, static endurance) were measured by vaginal palpation of the pelvic floor muscle at baseline and at post-treatment (12 weeks). At post-treatment there was a significant between-group difference for one parameter only (pelvic floor muscle dynamic endurance), favoring pelvic floor muscle training vs. no training/education.

The second high quality RCT (Shin et al., 2016) randomized patients with subacute/chronic stroke to receive pelvic floor muscle training or no training. Pelvic floor muscle activity (resting, contracting, relaxed) was measured at baseline and at post-treatment (6 weeks). Significant between-group differences in pelvic floor muscle activity (resting, contracting, relaxed) were seen at post-treatment, favoring pelvic floor muscle training vs. no training.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of pelvic floor muscle training in improving pelvic floor muscle activity in patients with stroke. While one high quality RCT found found significant differences on only one measure of pelvic floor muscle activity (dynamic endurance), a second high quality RCT found that pelvic floor muscle training was more effective than no training in improving pelvic floor muscle activity in patients with stroke.

Urinary incontinence
Effective
1A

Two high quality RCTs (Tibaek et al., 2005, Shin et al., 2016) investigated the effect of pelvic floor muscle training on urinary incontinence symptoms in patients with stroke.

The first high quality RCT (Tibaek et al., 2005) randomized patients with subacute/chronic stroke to receive pelvic floor muscle training and education (including home and group exercises) or no training/education. Urinary incontinence symptoms (frequency of voiding over 24 hours, during the day and during the night; number of incontinence episodes; number of incontinence pads used; 24-hour Home Pad Test) were measured at baseline and at post-treatment (12 weeks). Significant between-group differences in two measures of incontinence (frequency of daytime voiding; 24-hour Home Pad Test) were seen at post-treatment, favoring pelvic floor muscle training vs. no training/education.

The second high quality RCT (Shin et al., 2016) randomized patients with subacute/chronic stroke to receive pelvic floor muscle training no training. Urinary incontinence symptoms were measured by the Bristol Female Urinary Symptoms Questionnaire (inconvenience in activities of daily living, urinary symptoms) at baseline and at post-treatment (6 weeks). Significant between-group differences were found at post-treatment, favoring pelvic floor muscle training vs. no training.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that pelvic floor muscle training is more effective than no training in improving urinary incontinence symptoms in patients with stroke.

Vaginal muscle strength
Effective
1B

One high quality RCT (Shin et al., 2016) investigated the effect of pelvic floor muscle training on vaginal muscle strength in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive pelvic floor muscle training or no pelvic floor muscle training. Vaginal muscle strength was measured according to maximal vaginal squeeze pressure by perineometer at baseline and at post-treatment (6 weeks). Significant between-group differences in maximal vaginal squeeze pressure were found at post-treatment, favoring pelvic floor muscle training vs. no training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that pelvic floor muscle training is more effective than no training in improving vaginal muscle strength (maximal vaginal squeeze pressure) in patients with stroke.

Phase of stroke recovery not specific to one period - Timed voiding

Urinary incontinence
Consensus
3

There are no studies addressing the efficacy of timed voiding for urinary incontinence (UI) in patients with stroke. Two clinical practice guidelines (CPGs) (Fantl et al., 1996, Abrams et al., 2010) recommend timed voiding for cooperative and mobile stroke patients. These guidelines are based on results of randomized controlled trials (RCTs) in non-stroke neurogenic UI patients and from expert opinion.

Conclusion: There is a consensus opinion (Level 3) that timed voiding should be implemented for the rehabilitation of urinary incontinence in cooperative and mobile individuals with stroke.

Phase of stroke recovery not specific to one period - Transcutaneous electrical nerve stimulation (TENS)

Functional independence/ADLs
Effective
1B

One high quality RCT (Liu et al., 2016) and one fair quality RCT (Guo et al., 2014) investigated the effect of transcutaneous electrical nerve stimulation (TENS) on functional independence/activities of daily living (ADLs) in patients with stroke.

The high quality RCT (Liu et al., 2016) randomized patients with subacute/chronic stroke to receive TENS at 20 Hz, TENS at 75 Hz, or no TENS. Functional independence/ADLs were measured by the Barthel Index at baseline and at post-treatment (90 days). There were significant between-group differences in functional independence/ADLs at post-treatment, favoring TENS at 20 Hz vs. 75 Hz, TENS at 20 Hz vs. no therapy, and TENS at 75 Hz vs. no therapy.

The fair quality RCT (Guo et al., 2014) randomized patients with acute/subacute stroke to receive TENS at 75 Hz or no TENS. Functional independence/ADLs were measured by the Barthel Index (bowels, bladder, grooming, toilet use, feeding, transfers, mobility, dressing, stairs, bathing scores) at baseline and at post-treatment (60 days). Significant between-group differences were found for several measures of functional independence/ADLs (Barthel Index – bowels, bladder, toilet use, transfers, mobility, stairs, bathing) at post-treatment, favoring TENS at 75 Hz vs. no TENS.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that TENS is more effective than no TENS in improving functional independence/ADLs in patients with stroke. Further, one high quality RCT found that TENS applied at 20Hz was more effective than 75Hz.

Overactive bladder symptoms
Effective
1B

One high quality RCT (Liu et al., 2016) and one fair quality RCT (Guo et al., 2014) investigated the effect of transcutaneous electrical nerve stimulation (TENS) on overactive bladder symptoms in patients with stroke.

The high quality RCT (Liu et al., 2016) randomized patients with subacute/chronic stroke to receive TENS at 20 Hz, TENS at 75 Hz or no TENS. Overactive bladder symptoms were measured by the Overactive Bladder Symptom Score (OABSS total score) at baseline and at post-treatment (90 days). There were significant between-group differences in OABSS scores at post-treatment, favoring TENS at 20 Hz vs. vs. 75 Hz, TENS at 20 Hz. vs. no TENS, and favoring TENS at 75 Hz vs. no TENS.

The fair quality RCT (Guo et al., 2014) randomized patients with acute/subacute stroke to receive TENS at 75 Hz or no TENS. Overactive bladder symptoms were measured by the OABSS (daily micturition, nocturia, urgent urination, urge urinary incontinence scores) at baseline and at post-treatment (60 days). Significant between-group differences were found for all OABSS scores at post-treatment, favoring TENS vs. no TENS.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that TENS is more effective than no TENS in improving overactive bladder symptoms in patients with stroke. Further, one high quality RCT found that TENS applied at 20Hz was more effective than TENS at 75Hz.

Urodynamic parameters
Effective
1B

One high quality RCT (Liu et al., 2016) and one fair quality RCT (Guo et al., 2014) investigated the effect of transcutaneous electrical nerve stimulation (TENS) on urodynamic parameters in patients with stroke.

The high quality RCT (Liu et al., 2016) randomized patients with subacute/chronic stroke to receive TENS at 20 Hz, TENS at 75 Hz or no TENS. Urodynamic parameters (maximum cystometric capacity, detrusor pressure, maximum flow rate) were measured at baseline and at post-treatment (90 days). There were significant between-group differences in all urodynamic parameters at post-treatment, favoring TENS at 20 Hz vs. vs. 75 Hz, TENS at 20 Hz. vs. no TENS, and favoring TENS at 75 Hz vs. no TENS.

The fair quality RCT (Guo et al., 2014) randomized patients with acute/subacute stroke to receive TENS at 75 Hz or no TENS. Urodynamic parameters (maximum cystometric capacity, detrusor pressure, maximum flow rate) were measured at baseline and at post-treatment (60 days). Significant between-group differences were found for all urodynamic parameters at post-treatment, favoring TENS vs no TENS.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that TENS is more effective than no TENS in improving urodynamic parameters in patients with stroke. Moreover, one high quality RCT found that TENS at 20Hz was more effective than TENS at 75Hz.

Voiding parameters
Effective
1B

One high quality RCT (Liu et al., 2016) investigated the effect of transcutaneous electrical nerve stimulation (TENS) on voiding parameters in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive TENS at 20 Hz, TENS at 75 Hz, or no TENS. Voiding parameters (24-hour frequency, average voided volume, 24-hour incontinence episodes) were measured at baseline and at post-treatment (90 days). There were significant between-group differences on all voiding parameters at post-treatment, favoring TENS at 20 Hz vs. vs. 75 Hz, TENS at 20 Hz. vs. no TENS, and favoring TENS at 75 Hz vs. no TENS.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that TENS is more effective than no TENS in improving voiding parameters in patients with stroke. Further, results from the high quality RCT showed that TENS at 20Hz is more effective than TENS at 75Hz.

References

Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple C, Cottenden A, Davila W, de Ridder D, Dmochowski R, Drake M, Dubeau C, Fry C, Hanno P, Smith JH, Herschorn S, Hosker G, Kelleher C, Koelbl H, Khoury S, Madoff R, Milsom I, Moore K, Newman D, Nitti V, Norton C, Nygaard I, Payne C, Smith A, Staskin D, Tekgul S, Thuroff J, Tubaro A, Vodusek D, Wein A, Wyndaele JJ; Members of Committees; Fourth International Consultation on Incontinence. (2010). Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn. 2010;29(1):213-40.
https://www.ncbi.nlm.nih.gov/pubmed/20025020

Fantl, J. A., Newman, D. K., Colling, J., DeLancey, J. O. L., Keeys, C., Loughery, R., et al. (1996, March). Urinary incontinence in adults: Acute and chronic management (Clinical Practice Guideline, No. 2, 1996 Update, AHCPR Publication No. 96-0682). Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.
https://www.ncbi.nlm.nih.gov/pubmed/9016151

Guo, Z-f., Lui, Y., Hu, G-h., Liu, H., & Xu, Y-f. (2014). Transcutaneous electrical nerve stimulation in the treatment of patients with poststroke urinary incontinence. Clinical Interventions in Aging, 9, 851-6.
https://www.ncbi.nlm.nih.gov/pubmed/24904204

Liu, Y., Xu, G., Luo, M., & Teng, H-f. (2016). Effects of transcutaneous electrical nerve stimulation at two frequencies on urinary incontinence in poststroke patients: a randomized controlled trial. American Journal of Physical Medicine and Rehabilitation, 95, 183-93.
https://www.ncbi.nlm.nih.gov/pubmed/26259053

Shin, D.C., Shin, S.H., Lee, M.M., Lee, K.J., & Song, C.H. (2016). Pelvic floor muscle training for urinary incontinence in female stroke patients: a randomized, controlled and blinded trial. Clinical Rehabilitation, 30(3), 259-67.
https://www.ncbi.nlm.nih.gov/pubmed/25862769

Tibaek, S., Gard, G., & Jensen, R. (2005). Pelvic floor muscle training is effective in women with urinary incontinence after stroke: a randomized, controlled and blinded study. Neurourology and Urodynamics, 24, 348-57.
https://www.ncbi.nlm.nih.gov/pubmed/15791633

Tibaek S., Jensen R., Lindskov G., & Jensen, M. (2004). Can quality of life be improved by pelvic floor muscle training in women with urinary incontinence after ischemic stroke? A randomised, controlled and blinded study. International Urogynecology Journal and Pelvic Floor Dysfunction, 15(2), 117-123.
http://www.ncbi.nlm.nih.gov/pubmed/15014939

Tibaek, S., Gard, G., & Jensen, R. (2007). Is there a long-lasting effect of pelvic floor muscle training in women with urinary incontinence after ischemic stroke? A 6-month follow-up study. International Urogynecology Journal, 18, 281-7.
https://www.ncbi.nlm.nih.gov/pubmed/16673051

Thomas, L.H., Watkins, C.L., Sutton, C.J., Forshaw, D., Leathley, M.J., French, B., Burton, C.R>, Cheater, F., Roe, B., Britt, D., Booth, J., McColl, E., ICONS Project Team, ICONS Patient/Public/Carer Involvement Groups. (2104). Identifying continence options after stroke (ICONS): a cluster randomized controlled feasibility trial. Trials, 509, 1-15.
https://www.ncbi.nlm.nih.gov/pubmed/25539714

Wikander B., Ekelund P., & Milsom, I. (1998). An evaluation of multidisciplinary intervention governed by functional independence measure (FIMSM) in incontinent stroke patients. Scandinavian Journal of Rehabilitation Medicine, 30(1), 15-21.
http://www.ncbi.nlm.nih.gov/pubmed/9526750

Excluded Studies

Chesworth, B., Leathley, M., Thomas, L., Forshaw, D., Sutton, C., French, B., et al. (2013). Assessing fidelity to complex interventions: The ICONS experience. Trials, 14(1), 4.
Reason for Exclusion: No health-related outcomes studied.

Chesworth, B., Leathley, M., Thomas, L., Sutton, C., Forshaw, D., Watkins, C.L., et al. (2015). Assessing fidelity to treatment delivery in the ICONS (Identifying Continence OptioNs after Stroke) cluster randomised feasibility trial. BMC Medical Research Methodology15, 68.
Reason for Exclusion: No health-related outcomes studied.

Engberg, S., Sereika, S. M., McDowell, B. J., Weber, E., & Brodak, I. (2002). Effectiveness of prompted voiding in treating urinary incontinence in cognitively impaired homebound older adults. Journal of Wound Ostomy & Continence Nursing, 29(5), 252-265.
Reason for Exclusion: Patients with stroke represent less than 50% of the sample.

Forshaw, D., Thomas, L.H., Watkins, C.L., French, B., Sutton, C., Cheater, F., et al. (2012). ICONS: Identifying continence options after stroke. International Journal of Stroke, 7(1), 45A.
Reason for Exclusion: Not RCT, conference abstract.

French, B., Booth, J., Brittain, K., Burton, C., Cheater, F., Leathley, M., et al (2009). Preparing an intervention for incontinence after stroke: what might work? International Journal of Stroke, 4(2), A36-A37.
Reason for Exclusion: Conference abstract.

Gong, J. & Gong, W. (2013). Bladder function training combined with water-drinking plan in the treatment of post-stroke patients with urinary incontinence. Modern Clinical Nursing, 12(4), 49-52.
Reason for Exclusion: Unable to obtain English version of the full-text.

McDowell, B. J., Engberg, S., Sereika, S., Donovan, N., Jubeck, M. E., Weber, E., & Engberg, R. (1999). Effectiveness of behavioral therapy to treat incontinence in homebound older adults. Journal of the American Geriatrics Society, 47(3), 309-318.
Reason for Exclusion: Patients with stroke represent less than 50% of the sample.

Smilskalne, B., Berzina, G., Gormalova, J., & Vetra, A. (2009). Post-stroke urinary incontinence. Effectiveness of management. International Journal of Rehabilitation Research, 32(1), S111.
Reason for Exclusion: Conference abstract.

Sutton, C.J., Thomas, L., Forshaw, D., Watkins, C.L. (2011). Practical and methodological challenges in the design and implementation of a cluster-randomised feasibility trial of the management of urinary incontinence after stroke. Trials, 12(1), A151.
Reason for Exclusion: Not a treatment RCT.

Sutton, C.J., Watkins, C.L., Thomas, L.H., French, B., Forshaw, D., Bullock, M. (2012). Comparison of recruitment rates and participant characteristics: an assessment of potential selection bias in the ICONS (Identifying Continence OptioNs after Stroke) cluster-randomised trial (Abstract number 110). International Journal of Stroke7(s2), 49.
Reason for Exclusion: No health-related outcomes studied.

Thomas, L., Barrett, J., Booth, J., Brittain, K., Burton, C., Carter, B. (2009). ICONS: Identifying Continence OptioNs after stroke. 4th UK Stroke Forum.
Reason for Exclusion: Conference abstract.

Thomas, L.H., Watkins, C.L., French, B., Sutton, C., Forshaw, D., Cheater, F., et al. (2012). ICONS: Identifying Continence Options after Stroke: Preliminary findings from a randomised trial. International Journal of Stroke,7(2), 6-7.
Reason for Exclusion: Abstract.

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