Electroacupuncture and Solifenacin for Urgency-predominant Mixed Urinary Incontinence

Study Overview
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Brief Summary
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The study is to determine the effect of electroacupuncture in female patients with urgency-predominant mixed urinary incontinence. A three-arm non-inferior randomized controlled trial (RCT) using electroacupuncture, sham electroacupuncture and solifenacin with a total sample of 282 is proposed. The hypothesis is that the improvement (difference in number of urgency urinary incontinence episodes between baseline and 12-week evaluation) in the electroacupuncture group would be 50% or less of the difference in the improvement between the Solifenacin and the sham electroacupuncture groups.

Detailed Description
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Mixed urinary incontinence (MUI) features complaint or involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing. It is regarded as urgency-predominant mixed urinary incontinence (UMUI) when sudden sensation of voiding accompanied by uncontrolled incontinence domains the symptoms. UMUI can bring shame and inconvenience to patients. As first-line medicine for urge-predominant urinary incontinence, Solifenacin can reduce urgency urinary incontinence episodes in 24 hours. However, the side effects tend to bring about poor compliance among patients. Acupuncture might be effective in treating UMUI. Previous research indicated that electroacupuncture might be noninferior to pelvic floor muscle training plus Solifenacin in reducing the urgency incontinence episodes of UMUI women. However, that study didn't focuse on UMUI exclusively, thus unable to decide whether electroacupuncture is effective in the treatment of UMUI.

Official Title
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Effect of Electroacupuncture for Women With Urgency-predominant Mixed Urinary Incontinence: a Three Armed Non-inferior Randomized Controlled Trial

Conditions
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Mixed Urinary Incontinence, Urgency-predominant Mixed Urinary Incontinence

Intervention / Treatment
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* Device: electroacupuncture
* Device: sham electroacupuncture
* Drug: Solifenacin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Female patients diagnosed with mixed urinary incontinence in accordance with EAU guideline by history intaking and physical examination[8]; Age between 18 and 80 years old; Urgency index greater than stress index by MESA questionnaire[12]; At least 4 episodes of urgency urinary incontinence in 72-hour voiding diary; With MUI for at least 3 months, and more than 50% of the total incontinence episodes is urgency one in 72-hour voiding diary; Positive cough test; A voluntarily-signed written informed content. Exclusion Criteria: Having pure stress urinary incontinence, pure urgency urinary incontinence, overflow urinary incontinence or neurogenic bladder; Uncontrolled urinary tract infection; Tumor in urinary system or pelvic organs; Pelvic organ prolapse≥degreeⅡ; Residual urine volume≥100ml; Maximum flow rate<15ml/s; Treated incontinence by acupuncture or positive medications, such as antimuscarinic drug within the past 1 month; Underwent surgery of anti-incontinence or in pelvic area, metrectomy included; Complication of uncontrolled diabetes and severe hypertension; Complicated diseases in nerves system that could hamper hypourethral function, such as Multiple sclerosis, senile dementia, Parkinson's disease, spinal cord injury, cauda equina nerve injury and multiple system atrophy; Severe complications in cardiac, lungs, cerebrum, hepar, renal system, psychonosology and coagulation function, or obvious cognitive disability; Installed a cardiac pacemaker; Allergic to solifenacin or with contraindications to antimuscarinic drug, like urinary retention, gastrointestinal peristalsis paralysis, myasthenia gravis, ulcerative colitis, angle-closure glaucoma; Allergic to metal or intolerant to the stimulation of electroacupuncture; Already with child or plan to conceive in the future 1 year, or within 1 year after delivery.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: electroacupuncture group<br>Acupoints of bilateral Zhongliao (BL33), Huiyang (BL35) and Sanyinjiao (SP6) are stimulated by Huatuo Brand disposable needles and SDZ-V electronic apparatus. | Device: electroacupuncture<br>* BL33 and BL35 are inserted by needles of 0.30×75mm size till a depth of 60 70mm. SP6 is inserted by needle of 0.30×40mm size till a depth of 25-30mm. After manipulation and deqi sensation generation, the electrodes will be attached to the acupoints transversely with 20Hz continuous wave and an electricity current of 2mA-6.5mA at BL33 and BL35, and 1-3.5mA at SP6. The current is adjusted from zero to the degree where patients can tolerate. Subjects receive 3 sessions per week（every other day ideally) for 12 weeks, 36 sessions in total.<br>* Other names: EA group;|
| Sham Comparator: sham electroacupuncture group<br>Sham acupoints 1 cun(≈15mm) horizontally outwardly lateral to BL33 and BL35, and 0.5 cun(≈10mm) horizontally behind SP6 are stimulated superficially with a small electricity current by needles of 0.30×40mm size and SDZ-V electronic apparatus. | Device: sham electroacupuncture<br>* In sham electroacupuncture group, sham acupoints 1 cun(≈15mm） horizontally outwardly lateral to BL33 and BL35, and 0.5 cun (≈10mm) horizontally behind SP6 are stimulated by needles of 0.30×40mm size. The needles are inserted to a depth of 2-3mm to stand still, without any manipulation and sensation of deqi. The electrodes will also be attached to needles with an electricity current of 0.1-0.3mA. The sessions will be the same as the electroacupuncture group.<br>* Other names: SEA group;|
| Active Comparator: Solifenacin group<br>subjects will orally take Solifenacin 5-10mg per day. | Drug: Solifenacin<br>* Subjects take solifenacin 5-10mg per day for a succession of 36 weeks. The dose change is decided by doctors under a comprehensive consideration of side effects and Patient Global Symptom Control (PGSC), which is applied to evaluate the effectiveness of Solifenacin at the 4th, 8th, 12th and 24th week.The medicine can be discontinued at any time if the adverse effect is rather severe.<br>* Other names: Drug group;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change of urgency urinary incontinence episodes in average 24 hours from baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 12 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change of urgency urinary incontinence episodes in average 24 hours from baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 24, week 36 | 
| Change of urinary incontinence episodes in average 24 hours from baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| Proportion of subjects with at least 50% reduce of urgency urinary incontinence episodes in average 24 hours compared with baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| Proportion of subjects with complete resolution of urgency urinary incontinence episodes in average 24 hours based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| Proportion of subjects with at least 50% reduce of urinary incontinence episodes in average 24 hours compared with baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| Change of voiding episodes in average 24 hours from baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| Change of voiding episodes graded as 3/4 in average 24 hours from baseline based on the Patient Perception of Intensity of Urgency Scale( PPIUS). | Patient Perception of Intensity of Urgency Scale (PPIUS) is recommended by the European Medicines Agency to grade the urgency of voiding. Voiding graded at 1 and 2 levels of urgency are regarded as normal or strong desire to void rather than urgency, while 3 and 4 levels are regarded as urgency episodes. | week 4, week 8, week 12, week 24, week 36 | 
| Change of nocturia episodes in average 24 hours from baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| Change of pad consuming in average 24 hours from baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| volume change of water intake in average 24 hours from baseline based on 3-day voiding diary. | 3-day voiding diary is a reliable objective method to quantify the incontinence episode frequency and are a sensitive measurement to monitor the treatment response. In voiding diary, voiding episodes, urgency episodes, incontinence episodes, the volume drunk and the pads consumed are all recorded. | week 4, week 8, week 12, week 24, week 36 | 
| Change of International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF ) score from baseline. | ICIQ-UI-SF was a questionnaire developed by the International Consultation on Incontinence to evaluate the severity of incontinence and impact to QoL in the past four weeks. It contains four items: frequency, amount of leakage, impact of UI on QoL and a separate item to indicate the cause of incontinence. The score was the sum of the first three items, providing a total score ranging from 0 to 21 with a higher score indicating worse symptoms and greater impact on QoL. | week 4, week 8, week 12, week 24, week 36 | 
| Change of Overactive bladder questionnaire short form (OABq-SF) score from baseline. | OABq-SF is a validated questionnaire to assess the bother of OAB symptoms and effect on QoL in the past four weeks. It includes coping, sleep and emotional interaction. The scores were transformed to a 0- to 100-point scale, and higher scores on the symptom-severity scale indicate worse symptoms, whereas higher scores on the QoL scale indicate better quality of life. | week 4, week 8, week 12, week 24, week 36 | 
| Proportion of subjects with adequate improvement assessed by Patient global impression improvement (PGI-I). | Patient global impression improvement (PGI-I) is a scale range from 1 to 7, with 1 indicating very much better and 7 indicating very much worse. Adequate improvement is defined as a rating of 1 or 2 by PGI-I. | week 12, week 36 | 
| Change of residual urinary volume from baseline tested by abdominal B-ultrasound. | Abdominal B-ultrasound is objective way to test the residual urinary volume. | week 12 |