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      Internet-based treatment of stress urinary incontinence: a randomised controlled study with focus on pelvic floor muscle training

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          What’s known on the subject? and What does the study add?

          • Stress urinary incontinence (SUI) affects 10–35% of women, and it is sometimes very distressful. Pelvic floor exercises are the first line of treatment, but access barriers or embarrassment may prevent women from seeking help. There is a need for new, simple, and effective ways to deliver treatment.

          • Management of SUI without face-to-face contact is possible, and Internet-based treatment is a new, promising treatment alternative.


          • To compare two treatment programmes for stress urinary incontinence (SUI) without face-to-face contact: one Internet-based and one sent by post.

          Patients and Methods

          • Randomised, controlled trial conducted in Sweden 2009–2011. Computer-generated block-randomisation, allocation by independent administrator. No ‘blinding’.

          • The study included 250 community-dwelling women aged 18–70 years, with SUI ≥1 time/week. Consecutive online recruitment.

          • The women had 3 months of either; (i) An Internet-based treatment programme (124 women), including e-mail support and cognitive behavioural therapy assignments or (ii) A treatment programme sent by post (126). Both programmes focused mainly on pelvic floor muscle training.

          • Primary outcomes: symptom-score (International Consultation on Incontinence Questionnaire Short Form, ICIQ-UI SF) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life, ICIQ-LUTSQoL). Secondary outcomes: (i) Patient Global Impression of Improvement, (ii) Incontinence aids, (iii) Patient satisfaction, (iv) Health-specific QoL (EQ5D-Visual Analogue Scale), and (v) Incontinence episode frequency. Follow-up after 4 months via self-assessed postal questionnaires.


          • In all, 12% (30 women) were lost to follow-up. Intention-to-treat analysis showed highly significant improvements ( P < 0.001) with large effect sizes (>0.8) with both interventions, but there were no significant differences between groups in primary outcomes. The mean ( sd) changes in symptom-score were: Internet 3.4 (3.4), Postal 2.9 (3.1) ( P = 0.27). The mean ( sd) changes in condition-specific QoL were: Internet 4.8 (6.1), Postal 4.6 (6.7) ( P = 0.52).

          • Compared with the postal-group, more participants in the Internet-group perceived they were much or very much improved (40.9% (43/105) vs 26.5% (30/113), P = 0.01), reported reduced usage of incontinence aids (59.5% (47/79) vs 41.4% (34/82), P = 0.02) and were satisfied with the treatment programme (84.8% (89/105) vs 62.9% (71/113), P < 0.001).

          • Health-specific QoL improved in the Internet-group (mean change 3.7 (10.9), P = 0.001), but not in the postal-group (1.9 (13.0), P = 0.13).

          • Overall, 69.8% (120/172) of participants reported complete lack of leakage or reduced number of leakage episodes by >50%.


          • Concerning primary outcomes, treatment effects were similar between groups whereas for secondary outcomes the Internet-based treatment was more effective.

          • Internet-based treatment for SUI is a new, promising treatment alternative.

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          Most cited references 36

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          EuroQol: the current state of play.

          The EuroQol Group first met in 1987 to test the feasibility of jointly developing a standardised non-disease-specific instrument for describing and valuing health-related quality of life. From the outset the Group has been multi-country, multi-centre, and multi-disciplinary. The EuroQol instrument is intended to complement other forms of quality of life measures, and it has been purposefully developed to generate a cardinal index of health, thus giving it considerable potential for use in economic evaluation. Considerable effort has been invested by the Group in the development and valuation aspects of health status measurement. Earlier work was reported upon in 1990; this paper is a second 'corporate' effort detailing subsequent developments. The concepts underlying the EuroQol framework are explored with particular reference to the generic nature of the instrument. The valuation task is reviewed and some evidence on the methodological requirements for measurement is presented. A number of special issues of considerable interest and concern to the Group are discussed: the modelling of data, the duration of health states and the problems surrounding the state 'dead'. An outline of some of the applications of the EuroQol instrument is presented and a brief commentary on the Group's ongoing programme of work concludes the paper.
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            International experiences with the Hospital Anxiety and Depression Scale--a review of validation data and clinical results.

            More than 200 published studies from most medical settings worldwide have reported experiences with the Hospital Anxiety and Depression Scale (HADS) which was specifically developed by Zigmond and Snaith for use with physically ill patients. Although introduced in 1983, there is still no comprehensive documentation of its psychometric properties. The present review summarizes available data on reliability and validity and gives an overview of clinical studies conducted with this instrument and their most important findings. The HADS gives clinically meaningful results as a psychological screening tool, in clinical group comparisons and in correlational studies with several aspects of disease and quality of life. It is sensitive to changes both during the course of diseases and in response to psychotherapeutic and psychopharmacological intervention. Finally, HADS scores predict psychosocial and possibly also physical outcome.
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              ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence.

              To develop and evaluate the International Consultation on Incontinence Questionnaire (ICIQ), a new questionnaire to assess urinary incontinence and its impact on quality of life (QoL). A developmental version of the questionnaire was produced following systematic literature review and views of an expert committee and patients. Several studies were undertaken to evaluate the psychometric properties of the questionnaire, including content, construct and convergent validity, reliability and sensitivity to change. The ICIQ was easily completed, with low levels of missing data (mean 1.6%). It was able to discriminate among different groups of individuals, indicating good construct validity. Convergent validity was acceptable, with most items demonstrating 'moderate' to 'strong' agreement with other questionnaires. Reliability was good, with 'moderate' to 'very good' stability in test-retest analysis and a Cronbach's alpha of 0.95. Items identified statistically significant reductions in symptoms from baseline following surgical and conservative treatment. Item reduction techniques were used to determine the final version and scoring scheme, which also demonstrated good psychometric properties. The final ICIQ comprises three scored items and an unscored self-diagnostic item. It allows the assessment of the prevalence, frequency, and perceived cause of urinary incontinence, and its impact on everyday life. The ICIQ is a brief and robust questionnaire that will be of use in outcomes and epidemiological research as well as routine clinical practice. Copyright 2004 Wiley-Liss, Inc.

                Author and article information

                BJU Int
                BJU Int
                Bju International
                Blackwell Publishing Ltd
                August 2013
                25 January 2013
                : 112
                : 3
                : 362-372
                Department of Public Health and Clinical Medicine, Umeå University Umeå, Sweden
                [* ]Department of Psychology, Stockholm University Stockholm, Sweden
                []Department of Behavioural Sciences and Learning, Linköping University Linköping, Sweden
                Author notes
                Correspondence: Malin Sjöström, The Research Unit, Jämtland County Council, Box 654, SE-831 57 Östersund, Sweden., e-mail: malin.sjostrom@
                BJUI © 2013 BJU International

                Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit commercial exploitation.

                Functional Urology


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