Evidenced-Based Practice Paper example

Below is an example of a well-done paper. It is not a perfect paper, but it will serve as a helpful guideline while you are working on your own paper. Remember you need a running head with page number and your paper is to be single spaced. When I copied the paper onto this page some of the formatting was lost so it is not completely in APA format.

Note: the EBP Summary requirements have changed a bit since this paper was written.

  • We have added the possibility of Time (T) for your PICOT question.
  • Under Summary of Evidence, we are really encouraging you to use subheadings. These make the summary easier to follow and it helps you with both analysis and it is clearer to you where there is stronger evidence and where there is less substantive evidence. We have also added two short synthesis paragraphs: Limitations of current evidence and strengths of current evidence.
  • Under Summary of Evidence from Organizations, Experience and/or Experts in the Specialty we have provided you with additional specific possibilities such as nurse practice acts, government agencies and healthcare organizations. You need to know what positions these agencies have taken. If they have not addressed your topic then you will want to state that also!
  • In the Apply the Evidence Section you can not make recommendations that were not analyzed in either Summary of Evidence sections. Therefore double check your Apply the Evidence Section and make sure your recommendations are supported with evidence!

 

 

 

EBP Summary Brief:

Treating Stress Urinary Incontinence in Women: Comparing Pelvic Floor Muscle Training to Pharmaceutical Intervention

Molly Harris

Tali Irvin

Suzanna Naramore

Sonoma State University

PICO

Population: All adult women (pregnant women are excluded)

Intervention: Pelvic floor muscle exercises or pharmaceuticals

Comparison: Untreated incontinence

Outcome: The client will experience decreased episodes of stress urinary incontinence

PICO Question

In adult women with stress urinary incontinence, how effective are pelvic floor muscle exercises compared to medications in decreasing the occurrence of stress urinary incontinence?

Background

Stress urinary incontinence (SUI) is the involuntary leakage of urine which occurs during physical activity such as coughing, sneezing, laughing or exercise. This differs from urge incontinence, which is a strong, sudden need to urinate due to bladder contractions. SUI is caused by certain medications, urethral damage, damage to the pelvic area due to trauma or surgery, weakened pelvic muscles associated with the bladder and urethra, or urethral sphincter dysfunction (Liou, 2009). SUI can lead to serious medical conditions such as “urinary tract infections, pressure ulcers and perineal dermatoses”, cause emotional distress in the form of “embarrassment and negative self-perception” and impair physical activity, social interactions, and sexual activity (Dumoulin & Hay-Smith, 2008, p.47). Additionally, the annual cost of urinary incontinence in women is estimated at $12.4 billion (Choi, Palmer, & Park, 2007). These facts point to the necessity of health care professionals to give their patients verifiably effective treatments. Treatment options for SUI include changes in behavior, pelvic floor muscle exercises or training (PFME or PFMT), medication, and surgery (Liou, 2009). We reviewed literature to determine how effective pelvic floor muscle exercises are compared to medications in decreasing the occurrence of stress urinary incontinence in adult women. We wanted to compare a conservative, almost cost-free approach (PFME) to a possibly easy, time-saving solution (pharmaceuticals).

Objective

To determine, based on the evidence, the efficacy of pelvic floor muscle training compared to pharmaceutical intervention in reducing the instances of stress urinary incontinence in adult women.

Search of Evidence

We began our search by looking for everything having to do with urinary incontinence for women over the age of 65. We soon found that our real question had to do with stress urinary incontinence, and that most research involved all adult women. We changed our search accordingly. We also agreed to not include articles about pregnant women, as we wanted to focus on women who deal with more permanent incontinence. We searched the Cochrane Library by using “urinary incontinence” as our search parameters. It returned 59 results and we narrowed them down to five that fit our PICO question. Then we discarded one of those because it was a protocol rather than a review. Out of the remaining four reviews, two studied the effect of pharmacological therapy on SUI, and as a group we decided to use them as our sources for that particular intervention. These reviews were both Level I evidence as they are systematic reviews of many randomized clinical trials on this topic and contained usable data. We searched CINAHL using the “Headings” tab. We found success from searches that included the words “pelvic floor”, “stress urinary incontinence” and “pharmacotherapy”. Out of these phrases, “stress urinary incontinence” worked the best, giving us twelve results. We also only asked for systematic reviews, so the two articles we got from CINAHL were also Level I. Out of those, we chose two articles that appeared to most closely answer our question. We also searched PubMed "Stress Urinary Incontinence treatment" with a limit on the search. The limits to the search of the database were meta-analysis, women and adult (age19-44). PubMed suggests articles that are of interest based on the search and key words and this is how we found the articles on pharmacotherapy and drug therapy and also the systematic review of PFME. We were able to find the full text through CINAHL and request the articles from InterLibrary Services at SSU. Using the limit and advanced search function of the database was essential to finding level 1 and level 2 articles related to SUI, PFMT and drug treatment.

Summary of Evidence

Our findings on PFME were encouraging. Dumoulin and Hay-Smith’s (2008) systematic review compared PFME to no treatment or a placebo treatment, and concluded that PFME is better than no treatment for women with stress, urge, and mixed UI, and that PFME decreased the symptoms of urinary incontinence. Another single-blind, randomized controlled trial with 118 women using PFMT, electrical stimulation and vaginal cones determined that these treatments are equally effective and are superior to no treatment in women with stress urinary incontinence (Castro et al., 2008). According to the systematic review from Choi et al. (2007), PFMT reduced incontinent episodes in adult women, compared to no treatment at all. Liao, Dougherty, Liou and Tseng (2006) also found that “pelvic floor muscles are strengthened and the proximal urethra is stabilized” by PFMT (p. 29). One study found that there was a greater effect in the women who performed PFMT for a longer duration (3-6 months versus 8 weeks). In other words, evidence suggests that the longer a woman performs PFMT the greater improvement she will experience (Dumoulin & Hay-Smith, 2008) . It is interesting to note that none of the studies addressed the time commitment (on the part of the healthcare provider and the patient) and discipline (on the part of the patient) that are necessary to gain the benefits of PFMT.

The goal of pharmacological treatment is to improve urethral function but not cause adverse effects that prevent the patient from continuing treatment. A Cochrane review by Alhasso, Glazener, Pickard and N’Dow (2005) that looked at several adrenergic drugs found that there is weak evidence to suggest that some of these drugs are more effective than placebo in treating SUI. One trial included in this study compared the efficacy of phenylpropanolamine to PFMT and found no significant differences between the drug and the exercises when adjusted to exclude data from participants in the PFMT group who dropped out of the study. Use of adrenergic drugs to treat SUI were shown to cause minimal side effects, usually restlessness or insomnia, but more serious (however rare) adverse effects such as hypertension or cardiac arrhythmias have been reported. Another Cochrane review by Mariappan, Alhasso, Grant and N’Dow (2005) on the effect of the serotonin and norepinephrine reuptake inhibitor (SNRI) duloxetine included one trial comparing its use to PFMT. The group treated with duloxetine 80 mg/day had a significantly reduced frequency of incontinence episodes (IEF) compared with PFMT (57% versus 35%). This review also showed duloxetine decreased IEF by 50% when compared to placebo, as well as significant improvement on quality of life. Approximately one out of three participants reported experiencing a side effect of duloxetine treatment, the most common being nausea. This conclusion is consistent with the findings of Zinner, Koke and Viktrup (2004) which also studied the use of duloxetine to treat SUI compared to placebo and found that duloxetine had greater than 50% median decrease in IEF, which was paralleled with improvements in quality of life. It should be noted that the use of these drugs for treatment of SUI is off-label.

Summary of Evidence from Organizations, Experience and/or Experts in the Specialty

According to www.mayoclinic.com, many methods are recommended for dealing with urinary incontinence. Options include behavioral techniques, physical therapy, medications, medical devices, absorbent pads, catheters and surgery. They recommend beginning with the least invasive treatment and moving on to more aggressive approaches if necessary.

Stakeholders/Change Agents

The patients themselves have a large stake in their options, their education, and the effectiveness of their treatment. Healthcare providers from nurses to doctors to physical therapists will be affected in their work with their patients with SUI. They will be involved in patient education, prescribing medications, and possibly surgery. Also, pharmaceutical companies who make drugs used to treat SUI have a stake in the success of their products—it’s reasonable to be skeptical about their motives in promoting these drugs.

Feasibility

Evidence supports that both PFMT and the use of drugs will reduce the instances of SUI. We believe that some patients will be more likely to use pills as a solution, while others will be more attracted to performing exercises. Similarly, some healthcare providers such as physical therapists, will be more likely to recommend PFMT as that matches their specialty, while some MD’s will be more likely to prescribe medications. Again, time is a factor for both the healthcare provider who is giving information and training, and the patient who has to maintain the exercise regimen. The pharmaceutical companies will most likely recommend the drugs they sell.

Apply the Evidence

  • Healthcare providers screen patients more thoroughly for SUI to determine the symptoms and the degree to which it affects their lives. Because SUI is known to cause negative self-perception and embarrassment, it is reasonable to assume that SUI is underreported without prompting (Dumoulin & Hay-Smith, 2008) .
  • Perform a psychosocial assessment on how symptoms of SUI affect the patient’s life. Women with SUI experience impaired social interaction, physical activity and sexual intimacy.
  • Researchers should standardize success criteria in the outcome of treating stress urinary incontinence so that health care providers and patients are better informed of the effectiveness of the treatments.
  • We recommend the least invasive treatment option, which would be PFMT, because it is effective, has no side effects, and is free for a life time once the patient learns how to properly do the exercises.
  • We also recommend exploring drug options such as duloxetine if further intervention is needed, though use of these drugs for treatment of SUI is off-label. Research has shown these drugs to be effective in reducing incontinence. This is our second treatment option due to the cost and side effects of the drugs.

References

Alhasso, A. A., Glazener, C. M. A., Pickard, R. & N'Dow, J. M. O. (2005). Adrenergic drugs for urinary incontinence in adults. Cochrane Database of Systematic Reviews, (3) DOI:10.1002/14651858.CD001842.pub2.

Castro, R. A., Arruda, R. M., Zanetti, M. R., Santos, P. D., Sartori, M. G., & Girão, M. J. (2008). Single-blind, randomized, controlled trial of pelvic floor muscle training, electrical stimulation, vaginal cones, and no active treatment in the management of stress urinary incontinence. Clinics, 64, 465-472. Retrieved from Pub Med database.

Choi, H., Palmer, H., & Park, J. (2007). Meta-analysis of pelvic floor muscle training: randomized controlled trials in incontinent women. Nursing Research, 56(4), 226-234. Retrieved from CINAHL Plus with Full Text database.

Dumoulin, C., & Hay-Smith, J. (2008). Pelvic floor muscle training versus no treatment, or inactive treatments, for urinary incontinence in women. Cochrane Database of

Systematic Reviews , (1), 47-63. Retrieved from CINAHL Plus with Full Text database.

Liao, Y.M., Dougherty, M. C., Liou, Y.S., & Tseng, I.J. (2006). Pelvic floor muscle training effect on urinary incontinence knowledge, attitudes, and severity: an experimental study. International Journal of Nursing Studies, 43 (1). Retrieved February 26, 2010, from Health Reference Center Academic via Gale.

Liou, L. S. (2009). Stress Incontinence. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000891.htm

Mariappan P., Alhasso A. A., Grant A. & N'Dow J. M. O. (2005). Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults. Cochrane Database of Systematic Reviews (3). DOI:10.1002/14651858.CD004742.pub2.

Mayo Clinic Staff (2009). Urinary incontinence: Treatments and drugs. Retrieved from http://www.mayoclinic.com/health/urinary- incontinence/DS00404/DSECTION=treatments-and-drugs.

Zinner, N. R., Koke, S. C., & Viktrup, L. (2004). Pharmacotherapy for stress urinary incontinence: Present and future options. Drugs, 64(14), 1503-1516. Retrieved from Pub Med database.

 

 

 
Jeanette Koshar, RN, NP, PhD
Office: (707) 664-2649 | Office Hours: Wednesday 9-11, email and by appointment
Email:
jeanette.koshar@sonoma.edu