title: Surgery versus physiotherapy for stress urinary incontinence.
abstract: BACKGROUND
  Physiotherapy involving pelvic-floor muscle training is advocated as first-line treatment for stress urinary incontinence; midurethral-sling surgery is generally recommended when physiotherapy is unsuccessful. Data are lacking from randomized trials comparing these two options as initial therapy.
  
  
  METHODS
  We performed a multicenter, randomized trial to compare physiotherapy and midurethral-sling surgery in women with stress urinary incontinence. Crossover between groups was allowed. The primary outcome was subjective improvement, measured by means of the Patient Global Impression of Improvement at 12 months.
  
  
  RESULTS
  We randomly assigned 230 women to the surgery group and 230 women to the physiotherapy group. A total of 49.0% of women in the physiotherapy group and 11.2% of women in the surgery group crossed over to the alternative treatment. In an intention-to-treat analysis, subjective improvement was reported by 90.8% of women in the surgery group and 64.4% of women in the physiotherapy group (absolute difference, 26.4 percentage points; 95% confidence interval [CI], 18.1 to 34.5). The rates of subjective cure were 85.2% in the surgery group and 53.4% in the physiotherapy group (absolute difference, 31.8 percentage points; 95% CI, 22.6 to 40.3); rates of objective cure were 76.5% and 58.8%, respectively (absolute difference, 17.8 percentage points; 95% CI, 7.9 to 27.3). A post hoc per-protocol analysis showed that women who crossed over to the surgery group had outcomes similar to those of women initially assigned to surgery and that both these groups had outcomes superior to those of women who did not cross over to surgery.
  
  
  CONCLUSIONS
  For women with stress urinary incontinence, initial midurethral-sling surgery, as compared with initial physiotherapy, results in higher rates of subjective improvement and subjective and objective cure at 1 year. (Funded by ZonMw, the Netherlands Organization for Health Research and Development; Dutch Trial Register number, NTR1248.).
authors.affiliation: University Medical Center Utrecht, Utrecht, The Netherlands. j.labrie@umcutrecht.nl
authors.forename: Julien
authors.initials: J
authors.lastname: Labrie
authors.forename: Bary L C M
authors.initials: BL
authors.lastname: Berghmans
authors.forename: Kathelijn
authors.initials: K
authors.lastname: Fischer
authors.forename: Alfredo L
authors.initials: AL
authors.lastname: Milani
authors.forename: Ileana
authors.initials: I
authors.lastname: van der Wijk
authors.forename: Dina J C
authors.initials: DJ
authors.lastname: Smalbraak
authors.forename: Astrid
authors.initials: A
authors.lastname: Vollebregt
authors.forename: René P
authors.initials: RP
authors.lastname: Schellart
authors.forename: Giuseppe C M
authors.initials: GC
authors.lastname: Graziosi
authors.forename: J Marinus
authors.initials: JM
authors.lastname: van der Ploeg
authors.forename: Joseph F G M
authors.initials: JF
authors.lastname: Brouns
authors.forename: E Stella M
authors.initials: ES
authors.lastname: Tiersma
authors.forename: Annette G
authors.initials: AG
authors.lastname: Groenendijk
authors.forename: Piet
authors.initials: P
authors.lastname: Scholten
authors.forename: Ben Willem
authors.initials: BW
authors.lastname: Mol
authors.forename: Elisabeth E
authors.initials: EE
authors.lastname: Blokhuis
authors.forename: Albert H
authors.initials: AH
authors.lastname: Adriaanse
authors.forename: Aaltje
authors.initials: A
authors.lastname: Schram
authors.forename: Jan-Paul W R
authors.initials: JP
authors.lastname: Roovers
authors.forename: Antoine L M
authors.initials: AL
authors.lastname: Lagro-Janssen
authors.forename: Carl H
authors.initials: CH
authors.lastname: van der Vaart
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D007431:Intraoperative Complications; D008875:Middle Aged; D017060:Patient Satisfaction; D026741:Physical Therapy Modalities; D011183:Postoperative Complications; D053825:Suburethral Slings; D016896:Treatment Outcome; D014550:Urinary Incontinence, Stress / Q000601:surgery / Q000628:therapy*