Interventions for treating urinary incontinence after stroke in adults



Urinary incontinence can affect 40% to 60% of people admitted to hospital after a stroke, with 25% still having problems when discharged from hospital and 15% remaining incontinent after one year.

This is an update of a review published in 2005 and updated in 2008.


To assess the effects of interventions for treating urinary incontinence after stroke in adults at least one‐month post‐stroke.

Search methods

We searched the Cochrane Incontinence and Cochrane Stroke Specialised Registers (searched 30 October 2017 and 1 November 2017 respectively), which contain trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL,, WHO ICTRP and handsearched journals and conference proceedings.

Selection criteria

We included randomised or quasi‐randomised controlled trials.

Data collection and analysis

Two review authors independently undertook data extraction, risk of bias assessment and implemented GRADE.

Main results

We included 20 trials (reporting 21 comparisons) with 1338 participants. Data for prespecified outcomes were not available except where reported below.

Intervention versus no intervention/usual care

Behavioural interventions: Low‐quality evidence suggests behavioural interventions may reduce the mean number of incontinent episodes in 24 hours (mean difference (MD) –1.00, 95% confidence interval (CI) –2.74 to 0.74; 1 trial; 18 participants; P = 0.26). Further, low‐quality evidence from two trials suggests that behavioural interventions may make little or no difference to quality of life (SMD ‐0.99, 95% CI ‐2.83 to 0.86; 55 participants).

Specialised professional input interventions: One trial of moderate‐quality suggested structured assessment and management by continence nurse practitioners probably made little or no difference to the number of people continent three months after treatment (risk ratio (RR) 1.28, 95% CI 0.81 to 2.02; 121 participants; equivalent to an increase from 354 to 453 per 1000, 95% CI 287 to 715).

Complementary therapy: Five trials assessed complementary therapy using traditional acupuncture, electroacupuncture and ginger‐salt‐partitioned moxibustion plus routine acupuncture. Low‐quality evidence from five trials suggested that complementary therapy may increase the number of participants continent after treatment; participants in the treatment group were three times more likely to be continent (RR 2.82, 95% CI 1.57 to 5.07; 524 participants; equivalent to an increase from 193 to 544 per 1000, 95% CI 303 to 978). Adverse events were reported narratively in one study of electroacupuncture, reporting on bruising and postacupuncture abdominal pain in the intervention group.

Physical therapy: Two trials reporting three comparisons suggest that physical therapy using transcutaneous electrical nerve stimulation (TENS) may reduce the mean number of incontinent episodes in 24 hours (MD –4.76, 95% CI –8.10 to –1.41; 142 participants; low‐quality evidence). One trial of TENS reporting two comparisons found that the intervention probably improves overall functional ability (MD 8.97, 95% CI 1.27 to 16.68; 81 participants; moderate‐quality evidence).

Intervention versus placebo

Physical therapy: One trial of physical therapy suggests TPTNS may make little or no difference to the number of participants continent after treatment (RR 0.75, 95% CI 0.19 to 3.04; 54 participants) or number of incontinent episodes (MD –1.10, 95% CI –3.99 to 1.79; 39 participants). One trial suggested improvement in the TPTNS group at 26‐weeks (OR 0.04, 95% CI 0.004 to 0.41) but there was no evidence of a difference in perceived bladder condition at six weeks (OR 2.33, 95% CI 0.63 to 8.65) or 12 weeks (OR 1.22, 95% CI 0.29 to 5.17). Data from one trial provided no evidence that TPTNS made a difference to quality of life measured with the ICIQLUTSqol (MD 3.90, 95% CI –4.25 to 12.05; 30 participants). Minor adverse events, such as minor skin irritation and ankle cramping, were reported in one study.

Pharmacotherapy interventions: There was no evidence from one study that oestrogen therapy made a difference to the mean number of incontinent episodes per week in mild incontinence (paired samples, MD –1.71, 95% CI –3.51 to 0.09) or severe incontinence (paired samples, MD –6.40, 95% CI –9.47 to –3.33). One study reported no adverse events.

Specific intervention versus another intervention

Behavioural interventions: One trial comparing a behavioural intervention (timed voiding) with a pharmacotherapy intervention (oxybutynin) contained no useable data.

Complementary therapy: One trial comparing different acupuncture needles and depth of needle insertion to assess the effect on incontinence reported that, after four courses of treatment, 78.1% participants in the elongated needle group had no incontinent episodes versus 40% in the filiform needle group (57 participants). This trial was assessed as unclear or high for all types of bias apart from incomplete outcome data.

Combined intervention versus single intervention

One trial compared a combined intervention (sensory motor biofeedback plus timed prompted voiding) against a single intervention (timed voiding). The combined intervention may make little or no difference to the number of participants continent after treatment (RR 0.55, 95% CI 0.06 to 5.21; 23 participants; equivalent to a decrease from 167 to 92 per 1000, 95% CI 10 to 868) or to the number of incontinent episodes (MD 2.20, 95% CI 0.12 to 4.28; 23 participants).

Specific intervention versus attention control

Physical therapy interventions: One study found TPTNS may make little or no difference to the number of participants continent after treatment compared to an attention control group undertaking stretching exercises (RR 1.33, 95% CI 0.38 to 4.72; 24 participants; equivalent to an increase from 250 to 333 per 1000, 95% CI 95 to 1000).

Authors’ conclusions

There is insufficient evidence to guide continence care of adults in the rehabilitative phase after stroke. As few trials tested the same intervention, conclusions are drawn from few, usually small, trials. CIs were wide, making it difficult to ascertain if there were clinically important differences. Only four trials had adequate allocation concealment and many were limited by poor reporting, making it impossible to judge the extent to which they were prone to bias. More appropriately powered, multicentre trials of interventions are required to provide robust evidence for interventions to improve urinary incontinence after stroke.

Plain language summary

Treatments for urinary incontinence after stroke in adults

Review question

We wanted to assess the effectiveness of interventions aimed at helping urinary incontinence in adults who had a stroke more than one month before.


Half of people admitted to hospital with a stroke have urinary incontinence. As well as involuntary loss of urine, symptoms of urinary incontinence include having an urgent desire to pass urine (urge incontinence) or leaking urine when laughing or sneezing (stress incontinence). These symptoms are more severe in stroke survivors than in other people with urinary incontinence. They cause embarrassment and distress and affect people’s ability to take part in rehabilitation. Urinary incontinence reduces feelings of self‐worth and depression is common. It also has a major impact on families and may affect whether patients are able to return home.

Search date

The search is current to 1 November 2017.

Study characteristics

We identified 20 studies identifying 21 comparisons and involving 1338 people. These studies included a variety of behavioural therapies (e.g. pelvic floor muscle training), complementary therapies (e.g. manual acupuncture or electroacupuncture) and physical therapies (e.g. transcutaneous electrical nerve stimulation, TENS), as well as medicines (e.g. oxybutynin, oestrogen). One trial investigated the effect of assessment and treatment by a continence nurse practitioner. Control groups were generally ‘usual care’ or no treatment.

Key results

We found that behavioural interventions may reduce the mean number of incontinent episodes in 24 hours but may make little or no difference to quality of life. However, intervention from a continence nurse practitioner probably made little or no difference to the number of people continent three months after treatment. Complementary therapies such as acupuncture may increase the number of participants continent after treatment. Physical therapies, such as transcutaneous electrical nerve stimulation, may reduce the average number of incontinent episodes in 24 hours and probably improves functional ability.

Quality of the evidence

The quality of the evidence was limited due to poor reporting of study details (particularly in the earlier studies) and the small number of study participants in most comparisons. More than half of the studies did not provide information on side effects.

Authors’ conclusions

High‐quality trials comparing different treatments to usual care or no treatment involving larger numbers of participants are needed.

Authors’ conclusions

Implications for practice

There is very little evidence from stroke‐specific studies to guide practice. The lack of trials testing the same category of intervention means that recommendations for practice are based on the results of a few, usually small trials, providing generally low‐quality evidence overall.

Implications for research

Evidence suggesting that beneficial outcomes may be achieved by structuring the management of care for people with urinary continence problems following a stroke points to the need for larger trials (Brittain 2000b). Given the variety of problems that can hinder the maintenance of continence after stroke, the use of individualised assessment and goal setting to tailor interventions to the neurological and functional problems of the individual would seem to be especially worthy of consideration.

Trials of complementary therapies, namely acupuncture alone (Chu 1997Chu 2011Liu 2006Liu 2013Song 2013Zhang 1996Zhang 2002Zhou 1999), or combined with ginger‐salt‐partitioned moxibustion (Liu 2006), suggest these interventions may be worth investigating further with more rigorous study design.

Transcutaneous electrical nerve stimulation may reduce the number of incontinent episodes and warrants further investigation with the stroke population, particularly given its simplicity and ease of use (Booth 2016Guo 2014Liu 2016a and Liu 2016b).

Methods of managing continuing urinary incontinence (UI) such as behavioural interventions (e.g. bladder training, prompted voiding and pelvic floor muscle training) require testing with the stroke population, both in hospital and in the community post‐discharge.

There is a need for more appropriately powered, multi‐centre trials of interventions to provide robust evidence to improve UI after stroke. These trials may be simple (e.g. pharmacological interventions) but many will be complex interventions exploring behavioural interventions and more technical interventions, such as acupuncture or electrical stimulation.

Further research should use standardised definitions and classification systems to record details of the type and severity of stroke, as well as the type and severity of UI. Pre‐stroke continence status, time since stroke and stroke recurrence should also be recorded, with clear inclusion criteria for continence status. Exclusion criteria should be given for comorbidities and clinical indicators of underlying urogenital or systemic conditions such as infection. Specific details of structured assessment and intervention protocols need to be given, with standardisation of treatment, measures of between groups contamination or differences, and tailoring of intervention to the early or later phases of rehabilitation. Outcome measures of UI and of urinary symptoms should be standardised with attention to their validity and reliability and the blinding of outcome assessment. The measurement of changes in health‐related quality of life would be valuable. The time periods for review should be standardised for the early and later phases of rehabilitation. Lastly, sample size calculations and secure randomisation at either the cluster or individual participant level should be used appropriately.

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