Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults

Background To date, standard recommendations for the management of stress urinary incontinence (SUI) would be either pelvic floor muscle training (PFMT) or surgery. A new form of drug treatment with a serotonin‐noradrenaline reuptake inhibitor (SNRI), duloxetine, may now have a place in treatment of this condition. Objectives To determine whether a SNRI is better than placebo (or no treatment, other pharmacological and non‐pharmacological therapies, or surgery) in the treatment of women with SUI, or mixed urinary incontinence that includes stress incontinence (MUI), or both and which doses should be used. Search methods We searched the Cochrane Incontinence Group Specialised Register (searched 5th March 2007), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to January 2007), MEDLINE In‐Process & Other Non‐Indexed Citations (7 February 2007) and the reference lists of relevant articles. Selection criteria All randomised or quasi‐randomised controlled trials of treatment for SUI or MUI, in which at least one management arm involved a SNRI. Data collection and analysis Two authors evaluated the trials for appropriateness for inclusion and methodological quality. Three authors performed the data extraction using predetermined criteria. Analyses were performed using the Cochrane Review Manager software, RevMan. Main results Ten randomised trials were included, involving 3944 adults with predominantly SUI, randomised to receive duloxetine or placebo and/ or PFMT. All arms in individual trials were comparable for various baseline characteristics. Treatment duration was between three weeks and 12 weeks. Duloxetine was significantly better than placebo in terms of improving patients' quality of life (weighted mean difference 5.26, 95% confidence interval 3.84 to 6.68. P less than 0.00001) and perception of improvement. Individual studies demonstrated a significant reduction in the Incontinence Episode Frequency (IEF) by approximately 50% during treatment with duloxetine. With regard to objective cure, however, meta‐analysis of stress pad test and 24 hour pad weight change failed to demonstrate a benefit for duloxetine over placebo though data were relatively few. Subjective cure favoured duloxetine, albeit with a small effect size (3%). One trial suggested that duloxetine was better than pelvic floor muscle training alone in reducing IEF (P less than 0.05) based on median percentage decrease in IEF per week. Although significant side effects wer