Effectiveness of Combined Behavioral and Drug Therapy for Overactive Bladder Symptoms in Men: A Randomized Clinical Trial | Urology | JAMA Internal Medicine | JAMA Network
[Skip to Navigation]
Figure 1.  CONSORT Flow Diagram
CONSORT Flow Diagram

ITT indicates intention to treat.

Figure 2.  Changes in 24-Hour Voiding Frequencies With Individual and Combined Therapy
Changes in 24-Hour Voiding Frequencies With Individual and Combined Therapy

Mean 24-hour voiding frequencies at baseline; after 6 weeks of behavioral therapy alone, drug therapy alone, or initial combined therapy; and after an additional 6 weeks of step-up combined therapy for all arms. Error bars indicate SEs.

Table 1.  Baseline Characteristics of Participants
Baseline Characteristics of Participants
Table 2.  Changes in Voiding Frequency and Other Urinary Symptoms
Changes in Voiding Frequency and Other Urinary Symptoms
Table 3.  Patient Global Ratings
Patient Global Ratings
1.
Abrams  P, Cardozo  L, Fall  M,  et al; Standardisation Sub-Committee of the International Continence Society.  The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society.  Urology. 2003;61(1):37-49. doi:10.1016/S0090-4295(02)02243-4PubMedGoogle ScholarCrossref
2.
Irwin  DE, Kopp  ZS, Agatep  B, Milsom  I, Abrams  P.  Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction.  BJU Int. 2011;108(7):1132-1138. doi:10.1111/j.1464-410X.2010.09993.xPubMedGoogle ScholarCrossref
3.
Stewart  WF, Van Rooyen  JB, Cundiff  GW,  et al.  Prevalence and burden of overactive bladder in the United States.  World J Urol. 2003;20(6):327-336.PubMedGoogle ScholarCrossref
4.
Markland  AD, Goode  PS, Redden  DT, Borrud  LG, Burgio  KL.  Prevalence of urinary incontinence in men: results from the national health and nutrition examination survey.  J Urol. 2010;184(3):1022-1027. doi:10.1016/j.juro.2010.05.025PubMedGoogle ScholarCrossref
5.
Jackson  S.  The patient with an overactive bladder—symptoms and quality-of-life issues.  Urology. 1997;50(6A)(suppl):18-22. doi:10.1016/S0090-4295(97)00580-3PubMedGoogle ScholarCrossref
6.
McVary  KT, Roehrborn  CG, Avins  AL,  et al.  Update on AUA guideline on the management of benign prostatic hyperplasia.  J Urol. 2011;185(5):1793-1803. doi:10.1016/j.juro.2011.01.074PubMedGoogle ScholarCrossref
7.
Madhuvrata  P, Cody  JD, Ellis  G, Herbison  GP, Hay-Smith  EJ.  Which anticholinergic drug for overactive bladder symptoms in adults.  Cochrane Database Syst Rev. 2012;(1):CD005429. doi:10.1002/14651858.CD005429.pub2PubMedGoogle Scholar
8.
Chung  DE, Te  AE, Staskin  DR, Kaplan  SA.  Efficacy and safety of tolterodine extended release and dutasteride in male overactive bladder patients with prostates >30 grams.  Urology. 2010;75(5):1144-1148. doi:10.1016/j.urology.2009.12.010PubMedGoogle ScholarCrossref
9.
Chung  SD, Chang  HC, Chiu  B, Liao  CH, Kuo  HC.  The efficacy of additive tolterodine extended release for 1-year in older men with storage symptoms and clinical benign proastatic hyperplasia.  Neurourol Urodyn. 2011;30(4):568-571. doi:10.1002/nau.20923PubMedGoogle ScholarCrossref
10.
Chapple  C, Herschorn  S, Abrams  P, Sun  F, Brodsky  M, Guan  Z.  Tolterodine treatment improves storage symptoms suggestive of overactive bladder in men treated with alpha-blockers.  Eur Urol. 2009;56(3):534-541. doi:10.1016/j.eururo.2008.11.026PubMedGoogle ScholarCrossref
11.
Kaplan  SA, Roehrborn  CG, Rovner  ES, Carlsson  M, Bavendam  T, Guan  Z.  Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial.  JAMA. 2006;296(19):2319-2328. doi:10.1001/jama.296.19.2319PubMedGoogle ScholarCrossref
12.
Lee  SH, Chung  BH, Kim  SJ, Kim  JH, Kim  JC, Lee  JY.  Initial combined treatment with anticholinergics and α-blockers for men with lower urinary tract symptoms related to BPH and overactive bladder: a prospective, randomized, multi-center, double-blind, placebo-controlled study.  Prostate Cancer Prostatic Dis. 2011;14(4):320-325. doi:10.1038/pcan.2011.22PubMedGoogle ScholarCrossref
13.
Drake  MJ, Chapple  C, Sokol  R,  et al; NEPTUNE Study Group.  Long-term safety and efficacy of single-tablet combinations of solifenacin and tamsulosin oral controlled absorption system in men with storage and voiding lower urinary tract symptoms: results from the NEPTUNE study and NEPTUNE II open-label extension.  Eur Urol. 2015;67(2):262-270. doi:10.1016/j.eururo.2014.07.013PubMedGoogle ScholarCrossref
14.
Yamaguchi  O, Kakizaki  H, Homma  Y,  et al; ASSIST Study Group.  Solifenacin as add-on therapy for overactive bladder symptoms in men treated for lower urinary tract symptoms—ASSIST, randomized controlled study.  Urology. 2011;78(1):126-133. doi:10.1016/j.urology.2011.02.055PubMedGoogle ScholarCrossref
15.
Kaplan  SA, Roehrborn  CG, Abrams  P, Chapple  CR, Bavendam  T, Guan  Z.  Antimuscarinics for treatment of storage lower urinary tract symptoms in men: a systematic review.  Int J Clin Pract. 2011;65(4):487-507. doi:10.1111/j.1742-1241.2010.02611.xPubMedGoogle ScholarCrossref
16.
Oelke  M, Bachmann  A, Descazeaud  A,  et al; European Association of Urology.  EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction.  Eur Urol. 2013;64(1):118-140. doi:10.1016/j.eururo.2013.03.004PubMedGoogle ScholarCrossref
17.
Gormley  EA, Lightner  DJ, Faraday  M, Vasavada  SP; American Urological Association; Society of Urodynamics, Female Pelvic Medicine.  Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment.  J Urol. 2015;193(5):1572-1580. doi:10.1016/j.juro.2015.01.087PubMedGoogle ScholarCrossref
18.
Dumoulin  C, Adewuyi  T, Booth  J,  et al. Adult conservative management. In: Abrams  P, Cardozo  L, Wagg  A, Wein  A, eds.  Incontinence. 6th ed. Bristol, UK: International Continence Society; 2017:1443-1628.
19.
Hartmann  KE, McPheeters  ML, Biller  DH,  et al.  Treatment of overactive bladder in women.  Evid Rep Technol Assess (Full Rep). 2009;(187):1-120, v.PubMedGoogle Scholar
20.
Shamliyan  TA, Kane  RL, Wyman  J, Wilt  TJ.  Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women.  Ann Intern Med. 2008;148(6):459-473. doi:10.7326/0003-4819-148-6-200803180-00211PubMedGoogle ScholarCrossref
21.
Burgio  KL, Locher  JL, Goode  PS,  et al.  Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial.  JAMA. 1998;280(23):1995-2000. doi:10.1001/jama.280.23.1995PubMedGoogle ScholarCrossref
22.
Burgio  KL, Goode  PS, Johnson  TM,  et al.  Behavioral versus drug treatment for overactive bladder in men: the Male Overactive Bladder Treatment in Veterans (MOTIVE) trial.  J Am Geriatr Soc. 2011;59(12):2209-2216. doi:10.1111/j.1532-5415.2011.03724.xPubMedGoogle ScholarCrossref
23.
Goode  PS, Burgio  KL, Johnson  TM  II,  et al.  Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial.  JAMA. 2011;305(2):151-159. doi:10.1001/jama.2010.1972PubMedGoogle ScholarCrossref
24.
Burgio  KL, Goode  PS, Locher  JL,  et al.  Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial.  JAMA. 2002;288(18):2293-2299. doi:10.1001/jama.288.18.2293PubMedGoogle ScholarCrossref
25.
Goode  PS, Burgio  KL, Locher  JL, Umlauf  MG, Lloyd  LK, Roth  DL.  Urodynamic changes associated with behavioral and drug treatment of urge incontinence in older women.  J Am Geriatr Soc. 2002;50(5):808-816. doi:10.1046/j.1532-5415.2002.50204.xPubMedGoogle ScholarCrossref
26.
Burgio  KL, Locher  JL, Goode  PS.  Combined behavioral and drug therapy for urge incontinence in older women.  J Am Geriatr Soc. 2000;48(4):370-374. doi:10.1111/j.1532-5415.2000.tb04692.xPubMedGoogle ScholarCrossref
27.
Mattiasson  A, Blaakaer  J, Høye  K, Wein  AJ; Tolterodine Scandinavian Study Group.  Simplified bladder training augments the effectiveness of tolterodine in patients with an overactive bladder.  BJU Int. 2003;91(1):54-60. doi:10.1046/j.1464-410X.2003.03076.xPubMedGoogle ScholarCrossref
28.
Burgio  KL, Kraus  SR, Menefee  S,  et al; Urinary Incontinence Treatment Network.  Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial.  Ann Intern Med. 2008;149(3):161-169. doi:10.7326/0003-4819-149-3-200808050-00005PubMedGoogle ScholarCrossref
29.
Mattiasson  A, Masala  A, Morton  R, Bolodeoku  J; SOLAR Study Group.  Efficacy of simplified bladder training in patients with overactive bladder receiving a solifenacin flexible-dose regimen: results from a randomized study.  BJU Int. 2010;105(8):1126-1135. doi:10.1111/j.1464-410X.2009.08910.xPubMedGoogle ScholarCrossref
30.
Borson  S, Scanlan  JM, Chen  P, Ganguli  M.  The Mini-Cog as a screen for dementia: validation in a population-based sample.  J Am Geriatr Soc. 2003;51(10):1451-1454. doi:10.1046/j.1532-5415.2003.51465.xPubMedGoogle ScholarCrossref
31.
Johnson  TM  II, Vaughan  CP, Goode  PS,  et al.  Pilot results from a randomized trial in men comparing alpha-adrenergic antagonist versus behavior and exercise for nocturia and sleep  [published online October 28, 2016].  Clin Ther. doi:10.1016/j.clinthera.2016.10.001PubMedGoogle Scholar
32.
Wyman  JF, Choi  SC, Harkins  SW, Wilson  MS, Fantl  JA.  The urinary diary in evaluation of incontinent women: a test-retest analysis.  Obstet Gynecol. 1988;71(6, pt 1):812-817.PubMedGoogle Scholar
33.
Nixon  A, Colman  S, Sabounjian  L,  et al.  A validated patient reported measure of urinary urgency severity in overactive bladder for use in clinical trials.  J Urol. 2005;174(2):604-607. doi:10.1097/01.ju.0000165461.38088.7bPubMedGoogle ScholarCrossref
34.
Coyne  K, Revicki  D, Hunt  T,  et al.  Psychometric validation of an overactive bladder symptom and health-related quality of life questionnaire: the OAB-q.  Qual Life Res. 2002;11(6):563-574. doi:10.1023/A:1016370925601PubMedGoogle ScholarCrossref
35.
Badia  X, Rodríguez  F, Carballido  J,  et al; ESECI-98 Group.  Influence of sociodemographic and health status variables on the American Urological Association symptom scores in patients with lower urinary tract symptoms.  Urology. 2001;57(1):71-77. doi:10.1016/S0090-4295(00)00894-3PubMedGoogle ScholarCrossref
36.
Burgio  KL, Goode  PS, Richter  HE, Locher  JL, Roth  DL.  Global ratings of patient satisfaction and perceptions of improvement with treatment for urinary incontinence: validation of three global patient ratings.  Neurourol Urodyn. 2006;25(5):411-417. doi:10.1002/nau.20243PubMedGoogle ScholarCrossref
37.
Norton  JM, Bavendam  TG, Elwood  W,  et al.  Research needs to understand self-management of lower urinary tract symptoms: summary of NIDDK workshop.  J Urol. 2018;199(6):1408-1410. doi:10.1016/j.juro.2017.11.079PubMedGoogle ScholarCrossref
38.
Johnson  TM  II, Burgio  KL, Redden  DT, Wright  KC, Goode  PS.  Effects of behavioral and drug therapy on nocturia in older incontinent women.  J Am Geriatr Soc. 2005;53(5):846-850. doi:10.1111/j.1532-5415.2005.53260.xPubMedGoogle ScholarCrossref
39.
Johnson  TM  II, Markland  AD, Goode  PS,  et al.  Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia.  BJU Int. 2013;112(1):100-108. doi:10.1111/j.1464-410X.2012.11736.xPubMedGoogle ScholarCrossref
40.
Cindolo  L, Pirozzi  L, Sountoulides  P,  et al.  Patient’s adherence on pharmacological therapy for benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS) is different: is combination therapy better than monotherapy?  BMC Urol. 2015;15:96. doi:10.1186/s12894-015-0090-xPubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    January 13, 2020

    Effectiveness of Combined Behavioral and Drug Therapy for Overactive Bladder Symptoms in Men: A Randomized Clinical Trial

    Author Affiliations
    • 1Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
    • 2Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama
    • 3Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio
    • 4Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Atlanta, Georgia
    • 5Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, Georgia
    • 6Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham
    • 7School of Nursing, University of Alabama at Birmingham, Birmingham
    • 8Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham
    JAMA Intern Med. 2020;180(3):411-419. doi:10.1001/jamainternmed.2019.6398
    Key Points

    Question  What is the effectiveness of combining behavioral and drug therapy compared with each therapy alone for overactive bladder symptoms in men, and what is the best sequence for combining therapies?

    Findings  In this 2-stage, multisite randomized clinical trial including 204 men with overactive bladder symptoms, reductions in voiding frequency were significantly greater in those receiving combined therapy compared with those receiving drug therapy alone but not compared with those receiving behavioral therapy alone and greater in those receiving behavioral therapy alone compared with those receiving drug therapy alone. After all groups received combined therapy, outcomes tended to be better for those initially receiving combined therapy, but there were no significant group differences.

    Meaning  When using a stepped approach to combined therapy, it is reasonable to begin with behavioral therapy.

    Abstract

    Importance  First-line behavioral and drug therapies for overactive bladder (OAB) symptoms in men are effective but not usually curative.

    Objective  To determine whether combining behavioral and drug therapies improves outcomes compared with each therapy alone for OAB in men and to compare 3 sequences for implementing combined therapy.

    Design, Setting, and Participants  In this 3-site, 2-stage, 3-arm randomized clinical trial, participants were randomized to 6 weeks of behavioral therapy alone, drug therapy alone, or combined therapy followed by step-up to 6 weeks of combined therapy for all groups. Participants were recruited from 3 outpatient clinics and included community-dwelling men 40 years or older with urinary urgency and 9 or more voids per 24 hours. Data were collected from July 2010 to July 2015 and analyzed from April 2016 to September 2019.

    Interventions  Behavioral therapy consisted of pelvic floor muscle training with urge suppression strategies and delayed voiding. Drug therapy included an antimuscarinic (sustained-release tolterodine, 4 mg) plus an α-blocker (tamsulosin, 0.4 mg).

    Main Outcomes and Measures  Seven-day bladder diaries completed before and after each 6-week treatment stage were used to calculate reduction in frequency of urination (primary outcome) and other symptoms (ie, urgency, urgency incontinence, and nocturia). Other secondary outcomes included validated patient global ratings of improvement and satisfaction, Overactive Bladder Questionnaire score, and International Prostate Symptom Score.

    Results  Of the 204 included men, 133 (65.2%) were white, and the mean (SD) age was 64.1 (11.1) years. A total of 21 men discontinued treatment and 183 completed treatment. Mean (SD) voids per 24 hours decreased significantly in all 3 groups from baseline to 6-week follow-up (behavioral therapy: 11.7 [2.4] vs 8.8 [2.1]; change, 2.9 [2.4]; percentage change, 24.7%; P < .001; drug therapy: 11.8 [2.5] vs 10.3 [2.7]; change, 1.5 [2.3]; percentage change, 12.7%; P < .001; combined therapy: 11.8 [2.4] vs 8.2 [2.3]; change, 3.6 [2.1]; percentage change, 30.5%; P < .001). Intention-to-treat analyses indicated that posttreatment mean (SD) voiding frequencies were significantly lower in those receiving combined therapy compared with drug therapy alone (8.2 [2.3] vs 10.3 [2.7]; P < .001) but not significantly lower compared with those receiving behavioral therapy alone (8.2 [2.3] vs 8.8 [2.1]; P = .19) and were lower for behavioral therapy alone compared with drug therapy alone (8.8 [2.1] vs 10.3 [2.7]; P < .001). At 12-week follow-up, after all groups had received combined therapy, improvements in mean (SD) voids per 24 hours were also greatest for those receiving initial combined therapy compared with baseline (behavioral therapy: 11.7 [2.4] vs 8.0 [2.2]; change, 3.7 [2.3]; percentage change, 31.6%; P < .001; drug therapy: 11.8 [2.5] vs 8.6 [2.3]; change, 3.2 [2.5]; percentage change, 27.1%; P < .001; combined therapy: 11.8 [2.4] vs 8.0 [2.2]; change, 3.8 [2.1]; percentage change, 32.2%; P < .001), but there were no statistically significant group differences on primary or secondary measures.

    Conclusions and Relevance  Combining behavioral and drug therapy yields greater improvements in OAB symptoms than drug therapy alone but not behavioral therapy alone. When using a stepped approach, it is reasonable to begin with behavioral therapy alone.

    Trial Registration  ClinicalTrials.gov identifier: NCT01175382

    Introduction

    Overactive bladder (OAB) symptoms of urgency, frequent urination, urge incontinence, and/or nocturia1 are common, distressing symptoms that affect the lives of millions of men.2,3 Epidemiological studies indicate that these symptoms affect between 12% and 17% of community-dwelling adults and increase in prevalence with age in both men and women.2-4 Research on OAB symptoms and especially incontinence shows that they can have a major effect on quality of life5 and that frequency and/or urgency can be as bothersome as leakage.2

    Overactive bladder symptoms are most often treated with drug or behavioral therapies. Common first-line drugs for men include α-adrenergic receptor antagonists (α-blockers) to reduce smooth muscle tone in the bladder outlet to decrease resistance as well as antimuscarinic agents to inhibit detrusor contractions.6,7 The efficacy and safety of combined 2-drug therapy in men with OAB has been demonstrated repeatedly.8-16

    Behavioral therapies are a group of interventions recommended as first-line therapy for OAB by several guidelines and high-quality reviews.17-20 Studies demonstrate that behavioral interventions are free of adverse effects and effective for reducing OAB symptoms, particularly urge incontinence and voiding frequency, in both men and women.21,22 Behavioral training is one such intervention that combines pelvic floor muscle training and urge suppression strategies to improve bladder control by teaching patients to voluntarily control urgency and inhibit detrusor contractions.21-24

    While behavioral and drug therapies reduce symptoms, most patients are not completely cured with either modality alone. Based on evidence that these treatments work by different mechanisms, it seems likely they could have additive effects.25 Evidence suggests that combining behavioral and drug therapy improves outcomes in women,26-29 yet the effectiveness of behavioral therapy in combination with drugs for men is less clear. Therefore, the objective of this study was to determine whether combining behavioral and drug therapy improves outcomes compared with behavioral or drug therapy alone in men with OAB. Further, the study compared 3 models for implementing combined treatment: (1) stepped therapy with behavioral therapy started first, (2) stepped therapy with drug therapy started first, and (3) combined therapy with both therapies initiated at the same time.

    Methods
    Design

    This trial was a 3-site, 2-stage, 3-arm, parallel-group randomized clinical trial conducted from July 2009 to July 2015. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline. The trial protocol can be found in Supplement 1. Men with OAB symptoms were randomized to 6 weeks of behavioral training alone, drug therapy alone, or combined behavioral and drug therapy. After 6 weeks of treatment, participants receiving monotherapy were stepped up to combined behavioral and drug therapy for an additional 6 weeks (eFigure in Supplement 2). The study was approved by the University of Alabama at Birmingham Institutional Review Board for Human Use, and participants provided written informed consent.

    Participants and Screening

    Participants were community-dwelling men 40 years or older with urinary urgency and frequent urination with or without urge incontinence. After telephone screening, in-clinic evaluation consisted of a medical history, physical examination, mental status screening with the Mini-Cog,30 urinalysis, and, for participants with diabetes, testing for glycated hemoglobin level (unless there was documentation of test results of 9% or less of total hemoglobin within the past 3 months). Simple uroflowmetry was conducted (to measure average and peak urine flow), followed by postvoid residual determination by ultrasonography. Participants completed a 7-day bladder diary in which they recorded the time of every void and severity of urinary urgency associated with each. They also completed a 24-hour frequency/volume log in which they recorded the time and volume of each void. Inclusion required participants to have 9.0 or more voids per 24 hours (on average) on the 7-day baseline bladder diary. Exclusion criteria included indicators of outlet obstruction, positive dementia screening, and medical conditions that could have been contributing to urinary symptoms, such as diabetes, urinary tract infection, cancer, or neurological conditions. The complete list of exclusion criteria is included in eTable 1 in Supplement 2.

    Randomization

    To assure between-group comparability, participants were stratified on 2 dimensions: presence/absence of urge incontinence and frequency of urination based on baseline bladder diaries (9 to 12 voids per 24-hour day vs more than 12 voids per 24-hour day). Within each stratum, randomization was performed by a study biostatistician using a table of random numbers, a 1:1:1 ratio, sealed envelopes, and a variable block size to avoid large inequity in the total number of participants assigned to each group. Participants were then assigned to 6 weeks of behavioral therapy alone (to be followed by 6 weeks of combined therapy), drug therapy alone (to be followed by 6 weeks of combined therapy), or combined behavioral and drug therapy (to be sustained for 12 weeks).

    Interventions
    Stage 1: Behavioral Therapy Alone

    Behavioral therapy was implemented in 3 clinic visits over a period of 6 weeks. It consisted of behavioral training, including skills and strategies for postponing urination, controlling urgency, and preventing urge incontinence. This included pelvic floor muscle training and daily bladder diaries to track increasing voiding intervals and enhance awareness of bladder habits.

    Pelvic floor muscle training was conducted using verbal feedback based on anal palpation to teach participants how to contract and relax the pelvic floor muscles while keeping abdominal muscles relaxed. Participants were taught to contract their muscles during 2-second to 10-second periods separated by equal periods of relaxation, depending on initial ability. Recommendations for home practice included 45 exercises daily, usually 3 sessions of 15 exercises. Across sessions, duration was increased gradually to a maximum of 10 seconds.

    In treatment visit 2 (at 2 weeks), a treatment adherence questionnaire was completed and reviewed to identify barriers to adherence and make recommendations for improving adherence. Participants were taught urge suppression strategies, ie, how to respond adaptively to urgency, using techniques such as relaxation and pelvic floor muscle contractions to diminish urgency, postpone urination, and prevent urine loss.22,24 Over the next several weeks, they were encouraged to incrementally delay voiding after suppressing the urge to void.22 In addition, nocturia was managed with fluid restriction (3 hours before bedtime and during the night) and with urge suppression strategies.31

    Treatment visit 3 (at 4 weeks) was used to review progress, address adherence problems, reinforce and adjust participants’ home practice, and encourage persistence. During the 6 weeks of treatment, participants continued to keep a bladder diary so project staff could monitor progress and guide interventions.

    Stage 1: Drug Therapy Alone

    Participants in the drug therapy alone group received 2 drugs: an antimuscarinic (sustained-release tolterodine, 4 mg, once daily) and an α-blocker (tamsulosin, 0.4 mg, once daily before bed). In treatment visit 1, a baseline adverse effects profile was completed, and participants were educated about each drug and its possible adverse effects. They were provided with educational materials to assist with managing dry mouth and constipation, the most common adverse effects of antimuscarinics. They were given a 6-week supply of medication and an appointment for the posttreatment assessment visit. Bladder diaries were completed before randomization and following each stage of treatment.

    At 3 weeks, the interventionist conducted a telephone evaluation to assess adverse effects and adherence. Minor adverse effects were treated symptomatically. If needed, the sustained-release tolterodine dose was reduced to 2 mg daily to improve tolerability.

    Stage 1: Combined Behavioral and Drug Therapy

    Participants receiving combined therapy were given behavioral and drug therapy as described above. Participants followed the same visit schedule as the behavioral therapy alone group.

    Stage 2: Stepped Therapy

    After the posttreatment assessment for stage 1 (6 weeks), participants in the behavioral therapy alone group had their behavioral instructions reinforced and then were stepped up to combined therapy. They were started on drug therapy and underwent follow-up as described above. Participants in the drug therapy alone group were also stepped up to combined therapy. They were instructed in pelvic floor muscle exercises followed by delayed voiding and behavioral strategies in the same visit sequence, as described above. They continued to take their medications at the doses established. Participants in the combined therapy group continued with combined therapy following the same visit schedule as the drug therapy alone group.

    Measurement

    Assessments were completed at baseline and after each 6-week treatment stage. The primary outcome was change in voiding frequency as documented in the bladder diaries.32 Changes in other symptoms, including urgency, incontinence, and nocturia, were secondary outcomes. For every void and incontinent episode, participants recorded the presence and severity of urgency using the Indevus Urgency Severity Scale,33 an event-specific scale embedded in the bladder diary.

    Other outcome measures included (1) change from baseline in the Overactive Bladder Questionnaire score (to measure symptom bother and condition-specific health-related quality of life)34 and (2) change from baseline in the International Prostate Symptom Score (to measure frequency of lower urinary tract symptoms).35 Three validated single-question global ratings of improvement, the Patient Satisfaction Question, Estimated Percent Improvement, and Global Perception of Improvement, were used to assess patients’ perceptions of their treatment outcomes.36 All outcome measures were assessed and scored in a blinded fashion. Pill counts were used to assess adherence to drug therapy, and an adherence questionnaire was used to assess adherence to behavioral therapy.

    Sample Size Calculations

    Based on the results of an earlier trial,22 we assumed normally distributed outcomes, an average of 9 voids per day after 6 weeks of single therapy, and an SD of 2.5 for average number of voids per day. Under these conditions, sample sizes of 60 per group would provide 90% power to detect a difference of 1.5 voids per day with estimated group SDs of 2.5 for each and a significance level (α) of .025 using a 1-sided, 2-sample t test. The overall sample size was increased to 204 (68 per group) in anticipation of 10% loss to follow-up.

    Statistical Analyses

    The effectiveness of each intervention was calculated by comparing the frequency of voiding (primary) and other (secondary) symptoms during the final 7 days of the 6-week intervention period with the 7-day baseline period. The primary analysis was an effectiveness analysis based on the intention-to-treat approach, which included all randomized participants. For participants who missed visits, the outcomes were imputed using multiple imputation assuming missing at random. A complete cases analysis was also conducted for sensitivity by using only the participants who completed therapy.

    To examine the effects of combined therapy (6 weeks), planned comparisons were conducted comparing combined therapy with each therapy alone. Analysis of covariance models were used to test the hypotheses after adjusting for baseline voiding frequency and age (based on prior evidence of their potential effects on outcomes). To examine the effects of combining behavioral and drug therapy from the beginning vs in a stepped fashion, outcomes at 12-week follow-up were compared. All tests were 2-sided, and the significance level was set as P < .025 for the primary outcome after Bonferroni correction and P < .05 for all secondary outcomes. Analyses were performed using SAS version 9.4 (SAS Institute).

    Results
    Overview of Participant Flow

    A total of 432 men were enrolled in the study. Of these, 228 were found to be ineligible, and 204 were randomized to behavioral therapy alone (n = 71), drug therapy alone (n = 68), or combined therapy (n = 65) (Figure 1). Twenty-one participants discontinued treatment, and 183 completed treatment and the stage 1 posttreatment assessment (63 in the behavioral therapy alone group, 61 in the drug therapy alone group, and 59 in the combined therapy group). Characteristics of the participants are presented in Table 1.

    Effects of Individual and Combined Therapy (Stage 1: 6-Week Outcomes)

    Mean (SD) voids per 24 hours decreased significantly in all 3 groups from baseline to 6-week follow-up (behavioral therapy: 11.7 [2.4] vs 8.8 [2.1]; change, 2.9 [2.4]; percentage change, 24.7%; P < .001; drug therapy: 11.8 [2.5] vs 10.3 [2.7]; change, 1.5 [2.3]; percentage change, 12.7%; P < .001; combined therapy: 11.8 [2.4] vs 8.2 [2.3]; change, 3.6 [2.1]; percentage change, 30.5%; P < .001). Intention-to-treat analyses indicated that posttreatment mean voiding frequencies were significantly lower in the combined therapy group compared with the drug therapy alone group (8.2 [2.3] vs 10.3 [2.7]; P < .001) but not significantly lower than the behavioral treatment alone group (8.2 [2.3] vs 8.8 [2.1]; P = .19) after adjustment for baseline voiding frequency and age (Table 2) (Figure 2). Further, mean voiding frequencies were lower for the behavioral therapy alone group compared with the drug therapy alone group (8.8 [2.1] vs 10.3 [2.7]; P < .001). Similar results were obtained from the complete cases analyses (eTables 2 and 3 in Supplement 2).

    Mean frequency of nocturia decreased significantly in all 3 groups (Table 2). Analysis of covariance indicated significant between-group differences in favor of combined therapy, with drug therapy alone showing the smallest changes (mean [SD]: behavioral therapy alone, 1.3 [0.8]; drug therapy alone, 1.8 [1.2]; combined therapy, 1.3 [1.0]; P < .001). Mean urgency scores decreased significantly in the combined therapy group but not in the behavioral therapy alone or drug therapy alone groups. Using maximum daily urgency scores, decreases were significant in both the combined therapy group and the drug therapy alone group but not in the behavioral therapy alone group.

    Scores on the Overactive Bladder Questionnaire and the International Prostate Symptom Score decreased significantly in all 3 groups (Table 2). Analysis of covariance yielded significant group differences, with combined therapy being superior (mean [SD] Overactive Bladder Questionnaire score: behavioral therapy alone, 43.0 [28.2]; drug therapy alone, 39.5 [30.0]; combined therapy, 23.8 [22.1]; P < .001; mean [SD] International Prostate Symptom Score: behavioral therapy alone, 11.4 [5.3]; drug therapy alone, 11.5 [5.8]; combined therapy, 9.2 [4.8]; P < .001).

    On patient global ratings, more participants receiving combined therapy rated themselves as better or much better, and more were completely satisfied (Table 3). Adverse effects were lowest in the behavioral therapy group. No adverse effects or no bothersome adverse effects were reported by 86% (55 of 64) in the behavioral therapy alone group compared with 32% (21 of 65) in the drug therapy alone group and 34% (21 of 61) in the combined therapy group (P < .001).

    Comparison of Combined Therapy Models (Stage 2: 12-Week Outcomes)

    At 12-week follow-up, after all groups had received combined therapy, improvements in mean (SD) voids per 24 hours were also greatest for those receiving initial combined therapy compared with baseline (behavioral therapy: 11.7 [2.4] vs 8.0 [2.2]; change, 3.7 [2.3]; percentage change, 31.6%; P < .001; drug therapy: 11.8 [2.5] vs 8.6 [2.3]; change, 3.2 [2.5]; percentage change, 27.1%; P < .001; combined therapy: 11.8 [2.4] vs 8.0 [2.2]; change, 3.8 [2.1]; percentage change, 32.2%; P < .001) (Table 2). There were no longer differences between the groups on the primary outcome.

    Following a similar pattern, at 12-week follow-up, improvements were greatest in the combined therapy group but without between-group differences on the other bladder diary and questionnaire measures. Patient perception of improvement as better or much better was similar across groups (89% [55 of 62] in the group receiving behavioral therapy alone first; 85% [52 of 61] in the group receiving drug therapy alone first; 95% [56 of 59] in the group receiving combined therapy; P = .32) (Table 3). Similarly, the percentage of patients completely satisfied after 12 weeks was similar across groups (52% [32 of 62] in the group receiving behavioral therapy alone first; 52% [32 of 61] in the group receiving drug therapy alone first; 47% [28 of 59] in the group receiving combined therapy throughout; P = .82). Adverse effects no longer differed by group; 21% (13 of 62) in the group receiving behavioral therapy alone first reported no adverse effects compared with 15% (9 of 61) in the group receiving drug therapy alone first and 20% (12 of 59) in the group receiving combined therapy throughout (P = .55).

    Discussion

    This 2-stage, 3-arm, multisite randomized clinical trial explored the effects of combining behavioral and drug therapy compared with each therapy alone for men with OAB symptoms. The results show that combining behavioral and drug therapy yielded significantly greater short-term reductions in voiding frequency compared with drug therapy alone but not compared with behavioral therapy alone. Combined therapy also yielded the best outcomes for nocturia and urinary urgency as well as other secondary outcomes, including patient-perceived improvement and satisfaction, but with more adverse effects than behavioral therapy alone.

    These findings help to address the paucity of data on combining behavioral and drug therapy for OAB in men.37 They are consistent with prior studies of combining behavioral therapy with drug therapy in predominantly female samples.26-29 Similar to our trial, 2 studies of adding delayed voiding (one component of behavioral therapy in the current trial) to antimuscarinic therapy for men and women with OAB27,29 also demonstrated significant decreases in voiding frequency with combined therapy compared with drug therapy alone. One other study in men with OAB who had insufficient improvement with an α-blocker alone22 demonstrated that adding behavioral therapy was at least as effective as adding an antimuscarinic medication and was well tolerated. To our knowledge, the current study is the fourth randomized clinical trial to show the efficacy of behavioral therapy for reducing nocturia31,38,39 and the third demonstrating that behavioral therapy offers statistically superior nocturia reductions compared with drug therapy alone.21,22

    In the present study, the 3 approaches to combined therapy all resulted in similar 12-week outcomes. When using a stepped approach, it is reasonable to begin with behavioral therapy alone, not just because of the better adverse effect profile but also because behavioral therapy yields better 6-week outcomes than drug therapy and, thus, results are achieved more quickly than starting with drug therapy alone. A stepped approach starting with behavioral therapy alone allows patients to evaluate its effect before discussing with their clinicians the advantages and disadvantages of adding drugs with accompanying adverse effects for a small degree of additional improvement. Adding to the adverse effects and cost considerations, a 2015 study40 demonstrated that only 29% of men prescribed α-blockers for lower urinary tract symptoms are adherent after 1 year, and rates may be even lower among men using more than 1 drug. In contrast, a 2011 study of behavioral therapy for postprostatectomy incontinence23 showed 91% adherence at 1 year. Thus, offering behavioral therapy first may be important to patients in making decisions about drug therapy.

    Limitations

    A limitation of this trial was that participants and interventionists could not be blinded. However, all participants knew they were receiving an active therapy with proven efficacy and could be expected to have a reasonable expectation of benefit. Further, there were salient features of the protocol that were common across the 3 treatment arms and supported the internal validity of the study. Participants in all groups interacted with the interventionist, completed diaries, and received individualized adjustment of their treatment program. The behavioral treatment did involve more in-person visits and bladder diaries, making it more intensive in these aspects. However, these features are intrinsic to behavioral treatment, which depends on active patient engagement and self-monitoring to be minimally effective and are not essential to usual drug therapy. Therefore, we designed this trial to represent how both therapies are usually implemented in a real-world clinical setting.

    Another limitation is that each stage of therapy was 6 weeks in duration, while similar trials test 12 weeks of therapy. The rationale for choosing 6 weeks was based on previous work showing a flattening of symptom improvement curves after 4 to 6 weeks with drug therapy11 and behavioral therapy21 and enabled participants to step up to combined therapy in an additional 6 weeks of the study. Because the results of the different sequences for combining therapy were similar at 12 weeks, our study highlights the opportunity to integrate patient preferences (for or against behavioral or drug therapy) in shared decision-making.

    Additionally, the results of this study provide new evidence for behavioral therapy in men to inform changes in practice guidelines. Although treatment guidelines for OAB recommend behavioral therapy as first-line treatment,16,17 this has been based on research on women. Further, men’s OAB symptoms overlap considerably with benign prostatic hyperplasia, and benign prostatic hyperplasia treatment guidelines recommend drug therapy as first-line treatment.6 Men with symptoms attributed to benign prostatic hyperplasia but with primarily urgency, frequency, and nocturia may well be treated more satisfactorily with behavioral therapy alone, avoiding adverse effects of drug therapy.

    Conclusions

    This study yields important information related to optimizing treatment of OAB symptoms in men. Although some clinicians advocate combined treatment, most do not integrate behavioral components, such as pelvic floor muscle training or delayed voiding, into standard therapy. Behavioral therapy can be implemented by nurses, nurse practitioners, and physical therapists and has potential for widespread application in a variety of outpatient settings.

    Back to top
    Article Information

    Accepted for Publication: October 31, 2019.

    Corresponding Author: Kathryn L. Burgio, PhD, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, 700 S 19th St, Birmingham VA Medical Center, 11G, Birmingham, AL 35233 (kburgio@uabmc.edu).

    Published Online: January 13, 2020. doi:10.1001/jamainternmed.2019.6398

    Author Contributions: Drs Li and Redden had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Burgio, Kraus, Johnson, Markland, Vaughan, Redden, Goode.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Burgio, Li, Redden.

    Obtained funding: Burgio, Redden, Goode.

    Administrative, technical, or material support: Burgio, Kraus, Johnson, Vaughan, Goode.

    Study supervision: Burgio, Kraus, Johnson, Markland, Goode.

    Conflict of Interest Disclosures: Drs Burgio, Markland, and Goode have received grants from the National Institute of Diabetes and Digestive and Kidney Diseases and the Department of Veterans Affairs. Dr Kraus has received grants from University of Texas Health Science Center at San Antonio; personal fees for consulting from Allergan, Astellas Pharma, Medtronic, and InCube; and personal fees for speaking/teaching from Laborie and Astellas Pharma. Dr Johnson has received grants from the National Institutes of Health and the Department of Veterans Affairs and is an employee of the Department of Veterans Affairs and has received author royalties from UpToDate. Dr Markland has received grants from the National Institutes of Health and the Department of Veterans Affairs. Dr Vaughan has received grants from the Department of Veterans Affairs and is married to an employee of Kimberly-Clark Corporation. Dr Redden has received grants from the National Institutes of Health. No other disclosures were reported.

    Funding/Support: This study was supported by grant R01DK082548 from the National Institute of Diabetes and Digestive and Kidney Diseases.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The contents of this article do not represent the views of the Department of Veterans Affairs or the US government.

    Meeting Presentation: Results of this study were presented at the American Urological Association 2018 Annual Meeting; May 21, 2018; San Francisco, California; and at the International Continence Society 48th Annual Meeting; August 31, 2018; Philadelphia, Pennsylvania.

    Data Sharing Statement: See Supplement 3.

    Additional Contributions: We thank R. Jeannine McCormick, MSN, CRNP (University of Alabama at Birmingham, Birmingham), Betsy Nielsen-Omeis, RN, BSN (University of Texas Health Science Center, San Antonio), Edna Moore, MSN, ARNP/WHNP-BC (Emory University, Atlanta, Georgia), and Lisa Muirhead, DNP, APRN-BC (Emory University), for implementing interventions; Susan Barnacastle, BA (University of Alabama at Birmingham), Caren Prather, RN (University of Texas Health Science Center), Sean Halpin, MS (Emory University), and Zobair Nagamia, MD (Emory University), for project management; and Jean Marie White, BA (University of Alabama at Birmingham), for data entry and data management. All contributors received compensation for their contributions.

    References
    1.
    Abrams  P, Cardozo  L, Fall  M,  et al; Standardisation Sub-Committee of the International Continence Society.  The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society.  Urology. 2003;61(1):37-49. doi:10.1016/S0090-4295(02)02243-4PubMedGoogle ScholarCrossref
    2.
    Irwin  DE, Kopp  ZS, Agatep  B, Milsom  I, Abrams  P.  Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction.  BJU Int. 2011;108(7):1132-1138. doi:10.1111/j.1464-410X.2010.09993.xPubMedGoogle ScholarCrossref
    3.
    Stewart  WF, Van Rooyen  JB, Cundiff  GW,  et al.  Prevalence and burden of overactive bladder in the United States.  World J Urol. 2003;20(6):327-336.PubMedGoogle ScholarCrossref
    4.
    Markland  AD, Goode  PS, Redden  DT, Borrud  LG, Burgio  KL.  Prevalence of urinary incontinence in men: results from the national health and nutrition examination survey.  J Urol. 2010;184(3):1022-1027. doi:10.1016/j.juro.2010.05.025PubMedGoogle ScholarCrossref
    5.
    Jackson  S.  The patient with an overactive bladder—symptoms and quality-of-life issues.  Urology. 1997;50(6A)(suppl):18-22. doi:10.1016/S0090-4295(97)00580-3PubMedGoogle ScholarCrossref
    6.
    McVary  KT, Roehrborn  CG, Avins  AL,  et al.  Update on AUA guideline on the management of benign prostatic hyperplasia.  J Urol. 2011;185(5):1793-1803. doi:10.1016/j.juro.2011.01.074PubMedGoogle ScholarCrossref
    7.
    Madhuvrata  P, Cody  JD, Ellis  G, Herbison  GP, Hay-Smith  EJ.  Which anticholinergic drug for overactive bladder symptoms in adults.  Cochrane Database Syst Rev. 2012;(1):CD005429. doi:10.1002/14651858.CD005429.pub2PubMedGoogle Scholar
    8.
    Chung  DE, Te  AE, Staskin  DR, Kaplan  SA.  Efficacy and safety of tolterodine extended release and dutasteride in male overactive bladder patients with prostates >30 grams.  Urology. 2010;75(5):1144-1148. doi:10.1016/j.urology.2009.12.010PubMedGoogle ScholarCrossref
    9.
    Chung  SD, Chang  HC, Chiu  B, Liao  CH, Kuo  HC.  The efficacy of additive tolterodine extended release for 1-year in older men with storage symptoms and clinical benign proastatic hyperplasia.  Neurourol Urodyn. 2011;30(4):568-571. doi:10.1002/nau.20923PubMedGoogle ScholarCrossref
    10.
    Chapple  C, Herschorn  S, Abrams  P, Sun  F, Brodsky  M, Guan  Z.  Tolterodine treatment improves storage symptoms suggestive of overactive bladder in men treated with alpha-blockers.  Eur Urol. 2009;56(3):534-541. doi:10.1016/j.eururo.2008.11.026PubMedGoogle ScholarCrossref
    11.
    Kaplan  SA, Roehrborn  CG, Rovner  ES, Carlsson  M, Bavendam  T, Guan  Z.  Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial.  JAMA. 2006;296(19):2319-2328. doi:10.1001/jama.296.19.2319PubMedGoogle ScholarCrossref
    12.
    Lee  SH, Chung  BH, Kim  SJ, Kim  JH, Kim  JC, Lee  JY.  Initial combined treatment with anticholinergics and α-blockers for men with lower urinary tract symptoms related to BPH and overactive bladder: a prospective, randomized, multi-center, double-blind, placebo-controlled study.  Prostate Cancer Prostatic Dis. 2011;14(4):320-325. doi:10.1038/pcan.2011.22PubMedGoogle ScholarCrossref
    13.
    Drake  MJ, Chapple  C, Sokol  R,  et al; NEPTUNE Study Group.  Long-term safety and efficacy of single-tablet combinations of solifenacin and tamsulosin oral controlled absorption system in men with storage and voiding lower urinary tract symptoms: results from the NEPTUNE study and NEPTUNE II open-label extension.  Eur Urol. 2015;67(2):262-270. doi:10.1016/j.eururo.2014.07.013PubMedGoogle ScholarCrossref
    14.
    Yamaguchi  O, Kakizaki  H, Homma  Y,  et al; ASSIST Study Group.  Solifenacin as add-on therapy for overactive bladder symptoms in men treated for lower urinary tract symptoms—ASSIST, randomized controlled study.  Urology. 2011;78(1):126-133. doi:10.1016/j.urology.2011.02.055PubMedGoogle ScholarCrossref
    15.
    Kaplan  SA, Roehrborn  CG, Abrams  P, Chapple  CR, Bavendam  T, Guan  Z.  Antimuscarinics for treatment of storage lower urinary tract symptoms in men: a systematic review.  Int J Clin Pract. 2011;65(4):487-507. doi:10.1111/j.1742-1241.2010.02611.xPubMedGoogle ScholarCrossref
    16.
    Oelke  M, Bachmann  A, Descazeaud  A,  et al; European Association of Urology.  EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction.  Eur Urol. 2013;64(1):118-140. doi:10.1016/j.eururo.2013.03.004PubMedGoogle ScholarCrossref
    17.
    Gormley  EA, Lightner  DJ, Faraday  M, Vasavada  SP; American Urological Association; Society of Urodynamics, Female Pelvic Medicine.  Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment.  J Urol. 2015;193(5):1572-1580. doi:10.1016/j.juro.2015.01.087PubMedGoogle ScholarCrossref
    18.
    Dumoulin  C, Adewuyi  T, Booth  J,  et al. Adult conservative management. In: Abrams  P, Cardozo  L, Wagg  A, Wein  A, eds.  Incontinence. 6th ed. Bristol, UK: International Continence Society; 2017:1443-1628.
    19.
    Hartmann  KE, McPheeters  ML, Biller  DH,  et al.  Treatment of overactive bladder in women.  Evid Rep Technol Assess (Full Rep). 2009;(187):1-120, v.PubMedGoogle Scholar
    20.
    Shamliyan  TA, Kane  RL, Wyman  J, Wilt  TJ.  Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women.  Ann Intern Med. 2008;148(6):459-473. doi:10.7326/0003-4819-148-6-200803180-00211PubMedGoogle ScholarCrossref
    21.
    Burgio  KL, Locher  JL, Goode  PS,  et al.  Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial.  JAMA. 1998;280(23):1995-2000. doi:10.1001/jama.280.23.1995PubMedGoogle ScholarCrossref
    22.
    Burgio  KL, Goode  PS, Johnson  TM,  et al.  Behavioral versus drug treatment for overactive bladder in men: the Male Overactive Bladder Treatment in Veterans (MOTIVE) trial.  J Am Geriatr Soc. 2011;59(12):2209-2216. doi:10.1111/j.1532-5415.2011.03724.xPubMedGoogle ScholarCrossref
    23.
    Goode  PS, Burgio  KL, Johnson  TM  II,  et al.  Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial.  JAMA. 2011;305(2):151-159. doi:10.1001/jama.2010.1972PubMedGoogle ScholarCrossref
    24.
    Burgio  KL, Goode  PS, Locher  JL,  et al.  Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial.  JAMA. 2002;288(18):2293-2299. doi:10.1001/jama.288.18.2293PubMedGoogle ScholarCrossref
    25.
    Goode  PS, Burgio  KL, Locher  JL, Umlauf  MG, Lloyd  LK, Roth  DL.  Urodynamic changes associated with behavioral and drug treatment of urge incontinence in older women.  J Am Geriatr Soc. 2002;50(5):808-816. doi:10.1046/j.1532-5415.2002.50204.xPubMedGoogle ScholarCrossref
    26.
    Burgio  KL, Locher  JL, Goode  PS.  Combined behavioral and drug therapy for urge incontinence in older women.  J Am Geriatr Soc. 2000;48(4):370-374. doi:10.1111/j.1532-5415.2000.tb04692.xPubMedGoogle ScholarCrossref
    27.
    Mattiasson  A, Blaakaer  J, Høye  K, Wein  AJ; Tolterodine Scandinavian Study Group.  Simplified bladder training augments the effectiveness of tolterodine in patients with an overactive bladder.  BJU Int. 2003;91(1):54-60. doi:10.1046/j.1464-410X.2003.03076.xPubMedGoogle ScholarCrossref
    28.
    Burgio  KL, Kraus  SR, Menefee  S,  et al; Urinary Incontinence Treatment Network.  Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial.  Ann Intern Med. 2008;149(3):161-169. doi:10.7326/0003-4819-149-3-200808050-00005PubMedGoogle ScholarCrossref
    29.
    Mattiasson  A, Masala  A, Morton  R, Bolodeoku  J; SOLAR Study Group.  Efficacy of simplified bladder training in patients with overactive bladder receiving a solifenacin flexible-dose regimen: results from a randomized study.  BJU Int. 2010;105(8):1126-1135. doi:10.1111/j.1464-410X.2009.08910.xPubMedGoogle ScholarCrossref
    30.
    Borson  S, Scanlan  JM, Chen  P, Ganguli  M.  The Mini-Cog as a screen for dementia: validation in a population-based sample.  J Am Geriatr Soc. 2003;51(10):1451-1454. doi:10.1046/j.1532-5415.2003.51465.xPubMedGoogle ScholarCrossref
    31.
    Johnson  TM  II, Vaughan  CP, Goode  PS,  et al.  Pilot results from a randomized trial in men comparing alpha-adrenergic antagonist versus behavior and exercise for nocturia and sleep  [published online October 28, 2016].  Clin Ther. doi:10.1016/j.clinthera.2016.10.001PubMedGoogle Scholar
    32.
    Wyman  JF, Choi  SC, Harkins  SW, Wilson  MS, Fantl  JA.  The urinary diary in evaluation of incontinent women: a test-retest analysis.  Obstet Gynecol. 1988;71(6, pt 1):812-817.PubMedGoogle Scholar
    33.
    Nixon  A, Colman  S, Sabounjian  L,  et al.  A validated patient reported measure of urinary urgency severity in overactive bladder for use in clinical trials.  J Urol. 2005;174(2):604-607. doi:10.1097/01.ju.0000165461.38088.7bPubMedGoogle ScholarCrossref
    34.
    Coyne  K, Revicki  D, Hunt  T,  et al.  Psychometric validation of an overactive bladder symptom and health-related quality of life questionnaire: the OAB-q.  Qual Life Res. 2002;11(6):563-574. doi:10.1023/A:1016370925601PubMedGoogle ScholarCrossref
    35.
    Badia  X, Rodríguez  F, Carballido  J,  et al; ESECI-98 Group.  Influence of sociodemographic and health status variables on the American Urological Association symptom scores in patients with lower urinary tract symptoms.  Urology. 2001;57(1):71-77. doi:10.1016/S0090-4295(00)00894-3PubMedGoogle ScholarCrossref
    36.
    Burgio  KL, Goode  PS, Richter  HE, Locher  JL, Roth  DL.  Global ratings of patient satisfaction and perceptions of improvement with treatment for urinary incontinence: validation of three global patient ratings.  Neurourol Urodyn. 2006;25(5):411-417. doi:10.1002/nau.20243PubMedGoogle ScholarCrossref
    37.
    Norton  JM, Bavendam  TG, Elwood  W,  et al.  Research needs to understand self-management of lower urinary tract symptoms: summary of NIDDK workshop.  J Urol. 2018;199(6):1408-1410. doi:10.1016/j.juro.2017.11.079PubMedGoogle ScholarCrossref
    38.
    Johnson  TM  II, Burgio  KL, Redden  DT, Wright  KC, Goode  PS.  Effects of behavioral and drug therapy on nocturia in older incontinent women.  J Am Geriatr Soc. 2005;53(5):846-850. doi:10.1111/j.1532-5415.2005.53260.xPubMedGoogle ScholarCrossref
    39.
    Johnson  TM  II, Markland  AD, Goode  PS,  et al.  Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia.  BJU Int. 2013;112(1):100-108. doi:10.1111/j.1464-410X.2012.11736.xPubMedGoogle ScholarCrossref
    40.
    Cindolo  L, Pirozzi  L, Sountoulides  P,  et al.  Patient’s adherence on pharmacological therapy for benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS) is different: is combination therapy better than monotherapy?  BMC Urol. 2015;15:96. doi:10.1186/s12894-015-0090-xPubMedGoogle ScholarCrossref
    ×