Chapter Outline
The Bladder Diary: A Valuable Clinical Tool
Behavioral Intervention: Pelvic Floor Muscle Training and Exercise
Teaching Pelvic Floor Muscle Control
Daily Exercise to Improve Strength and Control
Using Muscles to Prevent Stress Incontinence: Stress Strategies
Using Muscles to Prevent Urge Incontinence: Urge Suppression Strategies
Pelvic Floor Muscle Training and Exercise for Pelvic Organ Prolapse
Behavioral Intervention: Bladder Training
Estrogen and Stress Incontinence
Other Pharmacologic Therapies for Stress Urinary Incontinence
The Ins and Outs of Pessary Use
Efficacy of Pessaries for Stress Urinary Incontinence
Efficacy of Pessaries for Pelvic Organ Prolapse
Pessary Placement and Management
Introduction
Recent research advances have contributed to clinical practice approaches to the nonsurgical management of stress urinary incontinence (SUI), and to a lesser extent pelvic organ prolapse (POP). Most patients are not aware of the existence of nonsurgical treatments for incontinence and prolapse, and they are often relieved that treatment options other than surgery are available. Behavioral treatment, the current “gold standard” conservative approach for SUI, improves bladder control by changing the incontinent patient’s behavior, including learning skills for preventing urine loss. Multicomponent behavioral interventions include pelvic floor muscle training and exercise, biofeedback, bladder inhibition, and bladder training. As part of the first-line treatment, estrogen optimizes urogenital tissue health and relieves some lower urinary tract symptoms. Although no Food and Drug Administration (FDA)-approved medications exist in the United States for the treatment of SUI, certain medications, including duloxetine, may offer effective treatment for mild-to-moderate stress incontinence. Pessaries stabilize the proximal urethra and urethral inserts increase urethral pressure. Pessaries also provide support for symptomatic POP. Such devices provide valuable alternatives to surgery.
This chapter describes the full range of nonsurgical options for the treatment of SUI and POP, allowing us to offer a broad spectrum of less invasive treatment options in an individualized manner. Optimal behavioral therapy for urinary incontinence depends on several factors, including the type and severity of incontinence; the presence of associated conditions, such as prolapse or other abdominal pelvic pathology; prior surgical or nonsurgical therapy; the patient’s medical status; and the patient’s ability and willingness to actively participate with treatment. Similarly, nonsurgical therapy for prolapse may be used in those women with significant medical comorbidities that preclude them from having surgery, those who do not wish to undergo surgical therapy, or those who want a temporizing measure before surgical intervention.
The Bladder Diary: A Valuable Clinical Tool
Before initiating nonsurgical treatment for incontinence, it is advisable to have the patient complete a bladder diary for 5 to 7 days. At a minimum, the patient should record the time, volume, and circumstances of each incontinent episode ( Fig. 17.1 : sample bladder diary). The bladder diary assists the clinician in determining the type and severity of urine loss and in planning appropriate intervention. Using the diary, the circumstances of incontinence can be reviewed with the patient and instructions can be given that are specific to the patient’s situation. During treatment, the number of incontinent episodes can be monitored to determine the efficacy of treatment and to guide further intervention. It is useful to ask the patient to record the times she urinates during the day and night. This information can identify women who may benefit from more frequent urination to avoid a full bladder, especially during physical activity. It may also reveal cases in which voiding frequency is excessive and may be contributing to reduced bladder capacity and urgency. These women may be targeted for interventions, such as bladder training, that focus on increasing voiding intervals and bladder capacity.
Although more burdensome, it is also suggested that women record voided volumes for a 24 h period. This record can identify patients with abnormal urine production, especially those with increased nighttime urine production resulting in nocturia.
In addition to the value of the bladder diary to the clinician, completing a daily diary appears to benefit the patient directly. As a form of self-monitoring, it enhances the patient’s awareness of her voiding habits and incontinence patterns, and it facilitates her recognition of the relationship between her activities and incontinence. Specifically, understanding clearly the precipitants of urine leakage optimizes the patient’s readiness to implement the continence skills she learns through behavioral treatment.
Behavioral Intervention: Pelvic Floor Muscle Training and Exercise
Pelvic muscle training and exercise is the foundation of behavioral treatment for SUI and may be beneficial for the treatment and prevention of POP ( ). It was first popularized by gynecologist Arnold Kegel in the late 1940s. He asserted that women with stress incontinence lack awareness and coordination of the pelvic floor muscles and that stress incontinence could be resolved with pelvic floor muscle training ( ). Through the years, this intervention has evolved both as a behavioral therapy and a physical therapy, combining principles from both fields into a widely accepted conservative treatment for stress and urge incontinence.
Literature on outpatient behavioral treatment with pelvic floor muscle training and exercise has demonstrated that it is effective for reducing stress, urge, and mixed incontinence in most patients who cooperate with training. Behavioral treatments have been recognized for their efficacy by multiple organizations and panels, including the International Consultation on Incontinence and the American Urological Association Guideline on Overactive Bladder ( ). Although the majority of women are not cured with this approach, most can achieve significant improvement.
Teaching Pelvic Floor Muscle Control
The goal of behavioral intervention for incontinence is to teach patients how to improve urethral closure by contracting pelvic muscles during physical activities that cause urine leakage, such as coughing, sneezing, or lifting, and when they experience urgency. The premise is that deliberate muscle contraction will increase intraurethral pressure and prevent urine loss caused by the brief rise in bladder pressure. Using biofeedback or other teaching methods, patients are taught to identify the pelvic muscles and to contract and relax them selectively (without increasing intra-abdominal pressure).
Many women fail pelvic muscle exercise by religiously exercising the wrong muscles. It is an essential yet often overlooked step to help women identify and isolate the correct muscles. The most common approach to pelvic muscle training is to give women a pamphlet or brief verbal instructions to “lift the pelvic floor” or to interrupt the urinary stream during voiding. This approach is generally ineffective, most likely because the majority of women do not properly identify the pelvic muscles or persist long enough to reap the benefits of behavioral treatment. It is more effective to begin treatment by ensuring that the patient understands which muscles to use. This understanding is often accomplished by palpating the vagina during pelvic examination and guiding her with verbal feedback to find the proper muscles. Pelvic muscle control can also be taught using biofeedback or electrical stimulation.
Biofeedback is a teaching technique that helps patients learn by giving them immediate feedback of their bladder or pelvic muscle activity. introduced a biofeedback device he called the perineometer, consisting of a pneumatic chamber that was placed in the vagina and a hand-held pressure gauge that registered increased vaginal pressure generated by pelvic muscle contraction. This device provided immediate visual feedback to the woman learning to identify her pelvic muscles and monitoring her practice.
Current biofeedback instruments are computerized. Pelvic muscle activity can be measured using vaginal or anal manometry or electromyography, with a probe or perianal surface electrodes. Signals are augmented through a computer, and muscle activity is displayed on a monitor where patients can receive immediate visual or auditory feedback. Patients learn better control through operant conditioning (learning by trial and error) by observing the results of their attempts to control bladder and pelvic muscle responses. Biofeedback-assisted behavioral training has been tested in several studies, producing mean reductions of incontinence ranging from 60% to 85%. Patients can usually identify their pelvic muscles in a single session; treatment may require less repetition of biofeedback than was originally thought.
The most common problem in identifying the pelvic muscles is that women tend to contract other muscles, typically the abdominal or gluteal muscles, instead of or in conjunction with pelvic muscles. Contracting abdominal muscles is counterproductive, because it increases pressure on the bladder rather than the urethra. Thus, it is important to notice this Valsalva response and to teach the patient to relax her abdominal muscles.
Daily Exercise to Improve Strength and Control
Once patients learn to properly contract and relax the pelvic muscles selectively, a program of daily exercise is prescribed. The purpose of the daily regimen is not only to increase muscle strength but also to enhance the skill of using the muscles through practice. The optimal exercise regimen has yet to be determined; however, good results are generally achieved using 45 to 50 exercises per day. To avoid muscle fatigue, the exercises should be spaced across the day, usually in two to three sessions per day ( Box 17.1 : pelvic muscle exercise patient handout). Patients generally find it easiest to practice their exercises in the lying position at first. It is important to encourage them to practice sitting or standing as well, so they become comfortable using their muscles to avoid urine loss in any position.
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To improve muscle strength, contractions should be sustained for 2 to 10 s, depending on the patient’s initial ability. Programs should be individualized ( ), so patients begin by holding contractions for a brief period (1-2 s) and gradually progress to 10 s. Each exercise consists of contracting the muscle for up to 10 s, followed by a period of relaxation using a 1:1 or 1:2 ratio. This program allows the muscles to recover between contractions.
Using Muscles to Prevent Stress Incontinence: Stress Strategies
Although exercise alone can improve urethral support and continence status, optimal results depend on patients learning to use their muscles actively to prevent urine loss during physical exertion. With practice and encouragement, patients can develop the habit of consciously contracting the pelvic muscles to occlude the urethra before and during coughing, sneezing, or other activities causing urine loss. This skill has been referred to as the stress strategy, counterbracing, and the “Knack.” Some women will benefit simply from learning how to control their pelvic floor muscles and use them to prevent incontinent episodes ( ). Others will need a more comprehensive program of pelvic muscle rehabilitation to increase strength and skill.
Using Muscles to Prevent Urge Incontinence: Urge Suppression Strategies
Traditionally, pelvic muscle training and exercise was used almost exclusively for stress incontinence. However, voluntary pelvic muscle contraction can also inhibit detrusor contraction. Therefore, pelvic muscle training is now frequently used as a component in the behavioral treatment of urgency incontinence as well. In addition to using pelvic muscles to occlude the urethra, patients learn to use pelvic muscle contractions and other urge suppression strategies to inhibit bladder contraction. Furthermore, patients are taught a new way to respond to the sensation of urgency: instead of rushing to the toilet, which increases intra-abdominal pressure and exposes patients to visual cues that can trigger incontinence, patients are encouraged to pause; sit down if possible; relax the entire body; and contract pelvic muscles repeatedly to diminish urgency, inhibit detrusor contraction, and prevent urine loss. When urgency subsides, they are to proceed to the toilet at a normal pace.
Behavioral training for urgency incontinence has been tested in several clinical series using pre-post designs and also in randomized trials. In controlled trials using intention-to-treat models, mean reduction of incontinence episodes ranges from 60% to 80% ( ).
Pelvic Floor Muscle Training and Exercise for Pelvic Organ Prolapse
Pelvic floor muscle training has been used for the treatment of POP. By improving pelvic floor muscle strength, it is thought that training can lead to improved structural support for pelvic organs. In addition, active contraction of pelvic floor muscles can be taught to brace against increases in intra-abdominal pressure and thus protect the pelvic floor during coughing and sneezing or any activity that increases pressure on the pelvic floor.
There is a small literature on the effectiveness of pelvic floor muscle training for POP, including four randomized trials comparing training with no treatment ( ). The evidence indicates that training has a beneficial effect on pelvic floor muscle function, prolapse symptom burden, prolapse severity, and quality of life ( ).
Adherence and Maintenance
Pelvic muscle training and exercise requires the active participation of a motivated patient. It is often challenging to remember to use muscles strategically in daily life and to persist in a regular exercise regimen to maintain strength and skill. This reliance on patient behavior change represents the major limitation of this treatment approach. In addition, improvement with behavioral treatment is gradual, usually evident by the fourth week of training and continuing for up to 6 months. Herein lies the challenge for behavioral treatment: sustaining the patient’s motivation for long enough that she will experience noticeable change in her bladder control.
It is important in initiating behavioral treatment to make it clear to the patient that her improvement will be gradual and will depend on consistent practice and use of her new skills. The patient who understands the usual course of treatment will be better prepared to persist until results are achieved. Clinicians can provide support by scheduling follow-up appointments to track and reinforce patient progress, make adjustments to the exercise regimen, and encourage persistence.
The long-term effectiveness of pelvic floor muscle exercise in treating incontinence symptoms is still unclear, because little work has been done in this area and most studies follow patients for only 1 or 2 years. An exception is the work of , who demonstrated sustained effects at 5 years after training. Other work has shown that after 6 years of a postpartum pelvic muscle exercise program, initial improvements in SUI did not persist and incontinence was similar to that of the control group ( ). Only half the women were still performing the exercises.
Electrical Stimulation
Pelvic floor electrical stimulation (PFES) has been used for the treatment of urinary incontinence since 1952 ( ). In this original study, PFES was added to pelvic muscle exercises to treat stress incontinence in women who had failed treatment with exercise alone; seven of 17 women were cured. Fifteen years later, PFES was reported by using a vaginal probe and thereafter was more widely used.
PFES stimulates pudendal nerve afferents, activating pudendal and hypogastric nerve efferents, causing contraction of smooth and striated periurethral muscles and striated pelvic muscles. This stimulation provides a form of passive exercise with the goal of improving the urethral closure mechanism. In addition, PFES can be useful in teaching pelvic muscle contraction to women who cannot identify or contract these muscles voluntarily. Stimulation is generally applied via vaginal or anal probe for 15 min at a time, one to three times per day.
Research has demonstrated the efficacy of PFES compared with sham PFES ( ). There is also some evidence that PFES yields results similar to that of pelvic muscle training ( ), although found pelvic muscle exercise to be superior. Several studies have combined PFES with various methods of pelvic floor muscle training and exercise, with mixed results ( ). Thus, although PFES shows promise in the treatment of stress incontinence, the role of electrical stimulation in combination with behavioral treatment with pelvic floor muscle training and exercise has not been clearly delineated.
Behavioral Intervention: Bladder Training
Bladder training is a behavioral intervention developed originally for urgency incontinence. The premise of bladder training is that the habit of frequent urination can lead to reduced bladder capacity and detrusor overactivity that, in turn, causes urgency incontinence. The goal of the intervention is to break this cycle by encouraging patients to resist the sensation of urgency and postpone urination. Using consistent voiding schedules, the patient voids at predetermined intervals and, over time, gradually increases the voiding interval. This behavior is believed to increase capacity and decrease overactivity, resulting in improved bladder control.
The most definitive randomized trial of bladder training was reported by and demonstrated an average 57% reduction of incontinence in older women. Interestingly, the training not only reduced urgency incontinence but also stress incontinence. The presumed mechanism for improving stress incontinence is that regular voiding helps to avoid situations in which the bladder is full, making the patient less vulnerable to urine loss during physical activities. It is also possible that training leads the patient to greater awareness of bladder function and that postponing urination increases the use of pelvic muscles.
Bowel Management
Constipation and fecal impaction have been implicated as contributing factors in urinary incontinence. In severe cases, fecal impaction can obstruct normal voiding, contribute to overflow incontinence, or irritate overactive bladder symptoms already present. Simple disimpaction can alleviate symptoms, a practice that is especially common in nursing home patients. In outpatients who report that constipation aggravates urinary incontinence, it is often beneficial to implement a bowel management program, including instructions on normal fluid intake and dietary fiber (or supplements) to maintain normal stool consistency and regular bowel movements. When fiber is not enough, enemas can be used to stimulate a regular daily bowel movement.
Weight Loss and Incontinence
Epidemiologic research has established obesity as a strong, independent risk factor for prevalent and incident incontinence ( ; ). There is a clear dose–response effect: each 5 unit increase in body mass index is associated with a 20% to 70% increase in the risk of prevalent incontinence and a 30% to 60% increase in the odds of 5- to 10-year incident incontinence. Furthermore, intervention studies show that weight loss has a beneficial effect on incontinence ( ). Urinary symptoms significantly improve in morbidly obese women with dramatic weight loss (45-50 kg) after bariatric surgery ( ) and when women lose as little as 5% of their baseline weight with behavioral weight loss programs ( ), a reasonable goal for many overweight or obese women.
The most definitive study is a randomized controlled trial in which overweight and obese women with incontinence were given a self-administered behavioral program and randomized to a 6 month behavioral weight loss program or a control intervention. The weight loss group showed a 47% reduction in frequency of incontinence, significantly greater than the 28% shown by the control group ( ). Group differences were significant for stress incontinence and total incontinence after 12 months and for urgency incontinence after 18 months ( ). The weight loss group also had greater patient satisfaction ratings at 6, 12, and 18 months. Because modest weight loss is achievable for many women, it should be considered in the first-line behavioral treatment of women with stress, urge, or mixed incontinence.
Estrogen and Stress Incontinence
Estrogen is discussed separately from other pharmacologic therapies for SUI, because of the controversy over the effects of oral estrogen replacement therapy on overall health and prevention of chronic disease. Despite this controversy, the benefits of oral and vaginal estrogen for urogenital health are undeniable. The prevalence of symptomatic urogenital atrophy in postreproductive women may approach 50%. Because the lower urinary tract and vagina develop from the same embryologic origin, it is not surprising that estrogen receptors are present throughout the vagina, urethra, bladder trigone, pelvic connective tissue, and pelvic muscles. Decreased estrogen effect and the resulting urogenital atrophy produce symptoms of vaginal dryness, pruritus, dyspareunia, vaginitis, recurrent urinary tract infections, dysuria, urinary frequency, urinary urgency, nocturia, and incontinence. Painful urination or “urethral syndrome” secondary to decreased estrogen effect responds to local estrogen therapy as does nocturia, irritative bladder symptoms, and recurrent urinary tract infections.
Outcomes regarding the effect of estrogen on SUI have been mixed. Estrogen exerts beneficial effects in the urethra by increasing the concentration of α-adrenergic receptors in the urethra and bladder, improving vascularity and perfusion of the periurethral tissue, and increasing thickness of the urethral epithelium. These changes facilitate coaptation and increase urethral pressure ( ). Most of the nonrandomized studies with oral estrogen, few with control groups, showed significant benefit of oral estrogen alone or in combination with progestin, in the treatment of SUI. Improvements have been reported on both subjective and objective parameters, including improved abdominal pressure transmission to the proximal urethra, increased functional urethral length, and increased maximal urethral closure pressure. Some studies found only subjective benefit.
A Cochrane review assessed the effect of systemic and intravaginal estrogen in women with symptomatic or a urodynamic diagnosis of stress, urgency, or mixed urinary incontinence ( ). Thirty-three trials including 19,313 women (1262 in trials of topical administration) revealed that women taking systemic (oral) estrogen had worse incontinence than those taking a placebo (relative risk [RR], 1.32; 95% confidence interval [CI], 1.17-1.48). In those women taking both systemic estrogen and progesterone (uterus in situ), there also was significantly worse incontinence (RR, 1.11; 95% CI, 1.04-1.18). There was evidence that intravaginal estrogen may improve incontinence (RR, 0.74; 95% CI, 0.64-0.86), but little long-term data exist.
Urogenital atrophy is an FDA-approved indication for estrogen therapy. Lower urinary tract symptoms associated with atrophy also significantly improve with hormonal therapy. Therefore, we strongly recommend optimizing urogenital tissue health as the first-line treatment with intravaginal estrogen therapy, before or concurrently with behavioral therapy, pessary use, or any other nonsurgical treatment, and before surgical intervention for stress incontinence. When the uterus is present, progestin treatment should be considered on an individual basis because few data are available to guide clinicians ( ). We typically recommend 0.5 g of vaginal estrogen cream nightly for 4 to 6 weeks, with maintenance doses of 0.5 g two to three times per week thereafter. Estrogen rings and tablets have standardized recommended regimens ( Table 17.1 ).
| Product | Dosage | Manufacturer |
|---|---|---|
| Estradiol cream | 0.1 mg/g | Warner Chilcott, Inc., Rockaway, NJ |
| Estrace vaginal cream | ||
| Conjugated estrogens cream | 0.625 mg/g | Pfizer Pharmaceuticals Inc., New York, NY |
| Premarin vaginal cream | ||
| Dienestrol cream | 0.1 mg/g | Orth-McNeil Pharmaceuticals Inc., Raritan, NJ |
| Ortho-dienestrol cream | ||
| Estradiol vaginal ring | 2 mg/3 months | Pfizer Pharmaceuticals Inc., New York, NY; Warner Chilcott, Inc., Rockaway, NJ |
| Estring, Femring | ||
| Estradiol vaginal tablets | 10 μg/tablet | Novo Nordisk FemCare AG, Inc., Princeton, NJ |
| Vagifem |
Other Pharmacologic Therapies for Stress Urinary Incontinence
Numerous medications have been used to treat SUI ( ); however, none are FDA approved for this primary indication. Pharmacotherapy for SUI takes advantage of the effects of certain medications on increasing urethral outlet resistance that is mediated by sympathetic, parasympathetic, and somatic innervation coordinated by the central nervous system. Increased outlet resistance may occur with α-adrenergic agonists, β-adrenergic antagonists and agonists, tricyclic antidepressants, and serotonergic and noradrenergic reuptake inhibitors ( ).
α-Adrenergic Agonists
The proximal urethra and bladder neck contain α-adrenergic receptors that when stimulated result in increased smooth muscle tone and increased outlet resistance both during bladder filling and voiding, continuously increasing urethral closure pressure. Several α-adrenergic agents have been studied, including phenylpropanolamine. The Agency for Health Care Policy and Research Clinical Practice Guideline described the results of eight randomized controlled trials for women with SUI ( ). Cure rates were 0%–14%; reduction of incontinence episodes, 19% to 60%; side effects, 5% to 33%; and dropouts, 0% to 4.3%. However, phenylpropanolamine was withdrawn from the market due to an increased risk of hemorrhagic stroke when used as an appetite suppressant.
Midodrine is selective for a subtype adrenergic receptor α-1. Midodrine produced subjective improvement but no significant changes in maximum urethral closure pressure at rest ( ). Rarely is total dryness reported in patients with moderate-to-severe SUI when using midodrine and other similar medications. Potential side effects of all α-adrenergic medications include hypertension, anxiety, hemorrhagic stroke, cardiac arrhythmias, palpitations, tremor, weakness, insomnia, and headache.
β-Adrenergic Receptor Antagonists and Agonists
β-Adrenergic blocking agents should theoretically potentiate the activity of norepinephrine on α-receptors and increase urethral outlet resistance. Early studies demonstrated efficacy with propranolol in patients with SUI; however, subsequent randomized controlled trials have not been as successful. At this time, the role of β-adrenergic receptor antagonists for SUI is limited. Significant potential side effects include heart failure, lethargy, and pulmonary compromise.
Animal studies have shown that β 2 -adrenergic agonists, such as clenbuterol, may prevent SUI by increasing the contractility of fast-contracting striated muscle fibers and suppressing slow-contracting fibers. A double-blind, placebo-controlled trial with clenbuterol was performed in 165 women with SUI ( ). Significant effectiveness was observed over placebo with respect to subjective evaluation of incontinence frequency, pads per day, and global assessment. Maximum urethral closure pressure increased significantly in the continent patients.
Tricyclic Antidepressants
Tricyclic antidepressants, in particular, doxepin and imipramine hydrochloride, improve SUI symptoms by decreasing bladder contractility and increasing urethral resistance. It is thought that they exert central and peripheral anticholinergic effects at some sites. They block the active transport system in the presynaptic nerve ending responsible for the reuptake of norepinephrine and serotonin. They act as sedatives, presumably centrally but potentially related to antihistaminic properties. No placebo-controlled trials of the effects of tricyclic antidepressants on SUI exist ( ). reported on 30 women with SUI who received imipramine 75 mg daily for 4 weeks. Subjective continence was reported in 21 participants. Mean maximum urethral closure pressures increased from 34.1 mm Hg to 48.2 mm Hg. Another study by reported on 40 women with SUI treated with imipramine 25 mg orally three times a day for 3 months. A 35% cure rate by pad testing was reported, and one-quarter of the subjects described at least 50% improvement. Success in this study correlated with increased urethral closure pressures. A placebo-controlled trial with doxepin reported significant improvement on subjective and objective outcomes for mainly urge incontinence ( ).
Side effects associated with tricyclic antidepressants include dry mouth, blurred vision, urinary retention, constipation, orthostatic hypotension, sedation, tremors, sexual side effects, fatigue, rash, jaundice, and weakness. Older patients in particular are prone to side effects such as disorientation, falls, and heart rhythm abnormalities and decreased force of cardiac contraction. Lower doses should be used in older patients, who we typically start on a 10 mg nightly dose, to determine tolerance and titrate up from there ( Table 17.2 ).
