Self-Management for Men With Lower Urinary Tract Symptoms: A Systematic Review and Meta-Analysis

Loai Albarqouni; Sharon Sanders; Justin Clark; Kari A. O. Tikkinen; Paul Glasziou

doi:10.1370/afm.2609

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Figure 1.
PRISMA flow diagram of included articles.
PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
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Figure 2.
Risk of bias assessment in included studies, both in individual studies and domains (top) and in summary (bottom).
BEDTiMe = Behavior and Exercise Versus Drug Treatment in Men with Nocturia; COBALT = Combined Behavioral and Drug Treatment of Overactive Bladder in Men; MOTIVE = Male Overactive Bladder Treatment in Veterans.
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Figure 3A.
Self-management intervention vs usual care, symptom severity at 6 months.
Notes: Heterogeneity: τ² = 0.15; χ² = 1.17; df= 1 (P = .28); I = 14%. Test for overall effect: Z = 10.54 (P <.001).
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Figure 3B.
Self-management intervention vs drug therapy, symptom severity at 6 to 12 weeks.
Notes: Heterogeneity: τ² = 1.66; χ² = 4.64; df = 2 (P = .10); I = 57%. Test for overall effect: Z = 0.00 (P = 1.00).
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Figure 3C.
Combined self-management intervention and drug therapy vs drug therapy alone, symptom severity at 6 weeks.
Notes: Heterogeneity: not applicable. Test for overall effect: Z = 2.50 (P = .01).

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Table 1

Characteristics of Included Studies (N = 8)

Study Author, Year (Location)	Condition/Symptoms; Setting; Age^{^a}	Groups^{^b}	Cointerventions	No. Randomized^{^c}	Outcomes Assessed Here (Outcome Assessment Tool)	Time of Outcome Assessment^{^d}
Brown et al,^23,36,42 2007 (UK)	LUTS; outpatient clinic; group 1: 63 years, group 2: 63 years	Self-management vs usual care	Escalation of medication or surgery at discretion of patient and clinician	73/67	Symptom severity (IPSS); quality of life (AUA-QoL score); nocturia episodes; 24-hour voiding frequency	3, 6, 12 months^{^e}
Chen et al,²⁶ 2012 (China)	LUTS with BPH; outpatient clinic; group 1: 71 years, group 2: 69 years	Self-management vs usual care	BPH education	119/103	Symptom severity (IPSS); quality of life (BPH-QoL score)	1 week, 3 months, 6 months
Burgio et al (MOTIVE trial),^29,43,44 2011 (USA)	OAB: urgency and frequency ± urge incontinence; community and Veterans Affairs Medical Centers; group 1: 63 years, group 2: 64 years	Behavioral treatment vs antimuscarinic (oxybutynin 5 to 39 mg daily individually titrated)	Fluid management handout, bladder diary, and α-blocker	73/70	Symptom severity (AUA-SI); 24-hour voiding frequency (7-day bladder diary); nocturia episodes	8 weeks
Johnson et al (BEDTiMe trial),^31,45 2016 (USA)	Nocturia; primary care clinics; group 1: 66 years, group 2: 63 years, group 3: 67 years	Behavioral treatment and exercise therapy vs α-blocker (tamsulosin 0.4 mg nightly) vs behavioral treatment and exercise + α-blocker (tamsulosin 0.4 mg nightly)	Antimuscarinic, 5-α reductase inhibitor, sedative-hypnotic as needed	23/25/24	Nocturia episodes (AUA-SI nocturia question)	2, 4, 10, 12 weeks
Hut et al,²⁷ 2017 (Netherlands)	LUTS: moderate to severe; primary care clinics; 51-82 years	Pelvic floor muscle therapy + behavioral treatment vs α-blocker (tamsulosin 0.4 mg daily)	None	22/19	Symptom severity (IPSS)	3 months
Burgio et al (COBALT trial),^30,46,47 2018 (USA)	OAB: urgency and frequency; community; group 1: 63 years, group 2: 65 years, group 3: 63 years	Behavioral treatment vs antimuscarinic + α-blocker (tolterodine 4 mg + tamsulosin 0.4 mg daily) vs behavioral treatment + antimuscarinic + α-blocker (tolterodine 4 mg + tamsulosin 0.4 mg daily)	None	71/68/65	Symptom severity (AUA-SI); 24-hour voiding frequency (7-day bladder diary); nocturia episodes (AUA-SI nocturia question)	6 weeks
Paterson et al,³² 1997 (Australia)	Postmicturition dribble; outpatient clinic; 36-83 years	Counseling vs pelvic muscle exercises vs urethral milking	None	15/15/1 3^{^f}	Urine loss (weight of incontinence pad)	5, 9, 13 weeks
Spigt et al,²⁸ 2006 (Netherlands)	LUTS: moderate; general practice clinics; 55-75 years	Increased water consumption vs placebo	None	70/71	Symptom severity (IPSS)	6 months

AUA-QoL = American Urological Association Quality of Life score; AUA-SI = American Urological Association Symptom Index; BEDTiMe = Behavior and Exercise Versus Drug Treatment in Men With Nocturia; BPH = benign prostatic hyperplasia; COBALT = Combined Behavioral and Drug Treatment of Overactive Bladder in Men; IPSS = International Prostate Symptom Score; LUTS = lower urinary tract symptoms; MOTIVE = Male Overactive Bladder Treatment in Veterans; OAB = overactive bladder.
↵^aMean or range. Groups are described in next column.
↵^bAs described by study authors. Intervention content varies despite similar titles.
↵^cGroup 1/group 2/group 3.
↵^dFrom randomization unless otherwise indicated.
↵^eUnclear whether time from randomization, start of intervention, or end of intervention.
↵^fOnly the number analyzed was available (43 of 49 randomized).

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Table 2

Details of the Self-Management Interventions Evaluated in Included Studies (N = 8)

		Component
Study Author, Year	Education and Reassurance^{^a}	Fluid Management	Caffeine and Alcohol Reduction	Concurrent Medication	Toileting and Bladder Retraining	Miscellaneous (Advice)	Delivery Format/Clinician	Duration/Dose	Fidelity: Planned/Actual
Brown et al,^23,36,42 2007	Causes and natural history of symptoms; reassurance about prostate cancer	Timing (restriction before bedtime/social activities); amount (1.5-2 L)	Caffeine (replace with decaf); alcohol (avoid in evening; reduce intake)	Reschedule and/or substitute (diuretics)	Types of toileting (double voiding, urethral milking); bladder retraining (pelvic floor exercise, urge suppression, bladder diaries)	Avoiding constipation	Group sessions/trained specialist nurses	3 sessions, 1.5-2 hours each	Specialist nurses trained in group facilitation and techniques to enhance self-management skills/93% of participants attended all sessions
Chen et al,²⁶ 2012	Causes of symptoms; reassurance about prostate cancer	Timing (restriction before social activities/evening); amount (not excessive)	Caffeine (avoid); alcohol (avoid)	Reschedule (diuretics)	Types of toileting (double voiding, prompt voiding, urethral milking); bladder retraining (pelvic floor exercise)	Avoiding constipation; drinking cranberry juice	Individual face-toface and telephone follow-up/NR	1 session, 2 hours	NR/NR
Burgio et al,^29,43,44 2011 (MOTIVE trial)	NR	Timing (restriction after 6 pm)	NR	NR	Types of toileting (delayed voiding); bladder retraining (pelvic floor exercise, urge suppression, bladder diaries)	NR	NR/nurse practitioners	4 sessions over 8 weeks	NR/88% of participants attended all sessions
Johnson et al,^31,45 2016 (BEDTime trial)	NR	Timing (restriction before bedtime); amount (1.5-2 L)	Caffeine (avoid); alcohol (reduce before bedtime)	NR	Types of toileting (delayed voiding); bladder retraining (pelvic floor exercise, urge suppression, bladder diaries)	Sleep hygiene; peripheral edema management	Individual face-toface or telephone/nurse practitioners	4 sessions over 10 weeks	Specialist nurses trained on how to administer behavioral treatments (3-hour initial session and twice-monthly research meetings)/median score = 4 on 5-point scale^{^b}
Hut et al,²⁷ 2017	Anatomy, function, and relationship with symptoms	Amount (≥2 L)	Caffeine (limit); alcohol (limit)	NR	Types of toileting (voiding techniques); bladder retraining (pelvic floor exercise, toilet behavior, bladder diaries)	Avoiding constipation	Individual sessions/NR	6 sessions, 0.5-1 hour each, over 90 days	NR/NR
Burgio et al,^30,46,47 2018 (COBALT trial)	NR	Timing (restriction before bedtime and at night)	NR	NR	Types of toileting (incremental delayed voiding); bladder retraining (pelvic floor exercise, bladder diaries)	NR	NR/NR	3 sessions over 6 weeks	NR/NR
Paterson et al,³² 1997^{^c}	NR NR NR	NR NR Timing	NR NR Advice on types of beverages	NR NR NR	Bladder retraining (pelvic floor exercise) Types of toileting (urethral milking) NR	NR NR9Edema management; diet	NR/study chief investigator	NR/NR	NR/99% completed required clinic visits
Spigt et al,²⁸ 2006	NR	Amount (1.5 L of extra water daily)	NR	NR	NR	NR	NR/person not involved in effect measurements		Participants provided with 0.5-L glasses/24-hour water turnover increased by 359-ml in intervention group compared with placebo group

BEDTiMe = Behavior and Exercise Versus Drug Treatment in Men With Nocturia; BPH = benign prostatic hyperplasia; COBALT = Combined Behavioral and Drug Treatment of Overactive Bladder in Men; LUTS = lower urinary tract symptoms; MOTIVE = Male Overactive Bladder Treatment in Veterans; NR = not reported.
↵^aAimed at increasing participants’ knowledge of the causes and natural history of BPH and LUTS.
↵^bNurses asked, “Overall, how completely do you think you followed your treatment instructions?” On scale of 1 to 5 points, 4 corresponded to “most of the time.”
↵^cStudy evaluated 3 single components of self-management for treating lower urinary tract symptoms: pelvic floor exercises (first row) vs urethral milking (second row) vs counseling (third row).