Conservative Treatment of Stress Urinary Incontinence

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Conservative Treatment of Stress Urinary
Incontinence

• Hann-Chorng Kuo. M.D.
• Department of Urology
• Buddhist Tzu Chi General Hospital, Hualien, Taiwan

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Pathophysiology of Stress urinary incontinence

• Intrinsic sphincteric deficiency
• Defects in extrinsic continence mechanism
• Defects of attachments to archus tendineus
  fascia pelvis
• Defects of attachments to levator ani
• Damage or degenerative change of endopelvic
  fascia
• Pelvic floor muscle relaxation
• Damage of anococcygeal ligaments
• Urethrovesical facilitative reflex (detrusor
  overactivity ?)

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Damage of continence mechanism
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Hypermobility of Bladder Neck
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Factors Influencing Continence

• Bladder neck
• Urethral smooth muscle
• External urethral sphincter
• Pelvic floor musculatures
• Connective tissue and collagen
• Intact neurological innervation

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Conservative management of Stress incontinence

• Weight reduction
• Stop smoking
• Reduced caffeine intake
• Decrease fluid intake
• Resolving chronic straining and constipation
• Prevent heavy exertion or exercise

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Physical Therapies for Stress Incontinence

• Bladder retraining
• Pelvic floor muscle exercises
• Vaginal cones
• Biofeedback
• Functional electrical stimulation

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Pelvic floor muscle training (PFMT)

• Kegel 1948
• Effective PFM contractions increase urethral
  resistance, increase activated motor units,
  frequency of excitation, and muscle volume
• Repeat PFMT may reflexly inhibit detrusor
  contractions
• Successful PFMT depends on ability to perform a
  correct contraction, 50 women failed to do PFMT

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ICS recommendedIdeal PFMT Program

• Three sets of 8 to 12 slow velocity maximal
  contractions
• Sustained for 6 to 8 seconds each
• Performed 3 to 4 times a week
• Continued for at least 15 to 20 weeks

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Correct PMF contraction

• Co-contraction of related muscles should be
  discouraged
• Use of voluntary PFMC prior to anticipated
  increased intra-abdominal pressure
• Near maximal contractions are the most
  significant factor in increasing strength
• Prevent muscle fatigue with vigorous exercise
• Assessed by a specialist for correct PFMC

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Effects of PFMT in Incontinence

• A meta-analysis of 10 studies concluded
  improvement ranges from 61 to 85
• Cure ranges from3 to 38
• Severity of urine loss decreases by 61 to 82 in
  women who leaks after PFMT
• In 23 women with repeat training for 5 years, 14
  were satisfied with current condition, 15 were
  continent, a high durability was noted

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Combination of PFMT with other Physical therapies

• For a woman with stress, urge, and mixed
  incontinence, PFMT is better than no treatment
• Combined PFMT with electrical stimulation
• PFMT with biofeedback
• PFMT with intravaginal resistance devises
• No consistent data proves that combination
  therapies are better than PFMT alone, but can be
  used as an initial training for women who cannot
  perform VPFC

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Effects of Conservative Treatment

• Increased maximal cystometric capacity
• Fewer detrusor contractions
• Less incontinence episodes
• Expected cure/improvement rates 65-75
• About 50 of patients avoid surgery

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Predictive Factors for a Successful Physiotherapy

• Low patient age and presence of estrogen
• Absence of detrusor instability
• Absence of intrinsic sphincteric deficiency
• Low urethral hypermobility
• Good compliance with treatment

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Postulated Physiological Changes after PFMT

• Press urethra against pubis symphysis
• Increase activated motor units and muscle volume
• Build a structural support for urethra
• Reflexic inhibition of detrusor contractions

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Reported Urodynamic Findings in PFMT

• Increased in MUCP (Wilson 1987, Bo 1990, Elia
  1993)
• Increased in MUCP and FPL (Benevenuti 1987)
• No changes in MUCP or FPL (Ferguson 1990, Meyer
  1992, Burns 1993)
• No changes in all urodynamic parameters (McClish
  1991, Elser 1999)

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Videourodynamics in Evaluation of PFMT

• Determine abdominal leak point pressure
• Measure bladder base descent during straining
• Measure bladder base elevation during PME
• Educate patient to perform an effective PME

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Dynamic Urethral Pressure Profilometry

• Resting UPP Maximal urethral closure
  pressure Functional profile length
• Stress UPP Pressure transmission ratio
• PFMT UPP Maximal pelvic floor muscle
  contractions
• Concomitant recording Pves and Pabd

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Materials and Methods

• 40 women with GSI with/out frequency urgency
• Gr. 3 or 4 cystocele and pure ISD were excluded
• Structured 12-week PFMT with biofeedback
• Videourodynamic study and UPP study
• Abdominal leak point pressure determination
• Compare the parameters between successful and
  failed treatment groups

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PFMT Program

• A 12- week structured treatment course
• Performed by a trained nurse specialist
• Involve a gradual home exercise and 6 office
  biofeedback sessions
• 15 sustained 10-second contractions, 3 timed
  daily
• Results assessed by subjective satisfaction and
  improvement rate

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Abdominal Muscle EMG Recording
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Correct Pelvic Floor Muscle Contractions No
Abdominal muscle contractions
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PFM Contractions with Abdominal muscle
contractions
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PFMT 2 weeks, Weak Contractions
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PFMT 6 weeks Strengthening
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Strengthened PFM after 3 M training
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Results of PFMT

• Cure or improvement in 22 patients (55)
• Treatment failure in 18 patients (45)
• Mean age 45 12 and 47 15 years (pgt0.05) of
  successful and failed treatment group

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Urodynamic Changes after PFMT

• Increase in first sensation, full sensation and
  cystometric capacity
• No change in MUCP, PTR, and FPL
• Significant increase in pelvic floor contraction
  pressure in PFC - UPP
• Successfully treated patients had more changes
• ALPP changed little in patients with persistent
  UI

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The Urodynamic Parameters after Pelvic Floor
Muscle Training (I)
Pre-treatment Post-treatment Statistics (p value)
Qmax (mL/s) Total 22.6 13.0 20.9 10.2 0.390
Successful 26.0 10.77 23.4 10.7 0.236
Failure 18.3 14.9 17.8 9.2 0.881
Voided volume Total 340.5 123.4 386.1 152.9 0.240
Successful 395.4 69.8 414.1 176.3 0.780
Failure 273.3 144.5 351.9 119.4 0.021
FSF (mL) Total 101.0 26.8 128.2 41.6 0.025
Successful 96.1 21.1 136.4 45.8 0.027
Failure 107.0 32.7 118.1 35.7 0.484
FS (mL) Total 189.0 47.5 229.5 46.9 0.006
Successful 190.4 51.4 245.0 47.4 0.015
Failure 187.3 45.2 210.4 40.9 0.218
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The Urodynamic Parameters after Pelvic Floor
Muscle Training (II)
Pre-treatment Post-treatment Statistics (p value)
Cystometric Capacity (mL) Total 288.2 83.8 338.0 96.1 0.050
Cystometric Capacity (mL) Successful 303.0 82.9 377.8 100.6 0.086
Cystometric Capacity (mL) Failure 270.1 86.0 289.3 66.8 0.376
Compliance (mL / cmH2O) Total 63.8 69.7 138.3 170.3 0.069
Compliance (mL / cmH2O) Successful 58.7 53.0 190.4 208.0 0.045
Compliance (mL / cmH2O) Failure 70.0 89.1 74.7 80.4 0.914
Pdet (cmH2O) Total 22.5 9.0 21.9 10.3 0.777
Successful 21.5 8.9 18.3 8.3 0.328
Failure 23.8 9.5 26.2 11.3 0.465
LPP(cmH2O) Total 111.7 43.9 113.9 20.7 0,816
Successful 122.3 44.9 109.3 23.3 0.518
Failure 99.6 42.8 119.3 17.4 0.233
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The Urodynamic Parameters after Pelvic Floor
Muscle Training (III)
Pre-treatment Post-treatment Statistics (p value)
MUCP (cmH2O) Total 75.4 30.2 70.5 23.9 0.304
MUCP (cmH2O) Successful 72.5 24.3 76.9 23.6 0.393
MUCP (cmH2O) Failure 78.9 37.5 62.7 23.3 0.047
FPL (mm) Total 34.5 4.59 36.6 4.9 0.300
FPL (mm) Successful 34.4 4.9 36.3 5.1 0.089
FPL (mm) Failure 34.8 4.4 36.9 5.0 0.198
PTR () Total 47.9 15.1 50.8 10.2 0.486
Successful 51.6 17.4 50.2 9.9 0.847
Failure 43.4 11.1 51.7 11.1 0.049
PFC (cmH2O) Total 15.7 13.4 23.0 22.2 0.043
Successful 20.5 12.5 36.0 21.2 0.009
Failure 9.9 12.7 7.1 9.6 0.051
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Bladder Base Changes after PFMT

• Less bladder neck descent after PFMT
• Increased bladder neck elevation after PFMT
• Both successfully and failure treated patients
  had significant reduction of BN descent after
  PFMT
• BN descent and increase of BN elevation after
  PFMT

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The Urodynamic Parameter after Pelvic Floor
Muscle Training (?)
Pre-treatment Post-treatment Statistics (p value)
Resting BN position (cm) Total 1.40 0.74 1.65 1.13 0.304
Resting BN position (cm) Successful 1.14 0.95 1.54 1.21 0.213
Resting BN position (cm) Failure 1.72 1.20 1.77 1.06 0.886
Straining BN position (cm) Total 2.79 1.78 2.29 1.47 0.138
Straining BN position (cm) Successful 2.55 1.56 2.18 1.53 0.372
Straining BN position (cm) Failure 3.13 2.12 2.44 1.45 0.270
BN descent (cm) Total 1.45 1.01 0.68 0.49 0.000
BN descent (cm) Successful 1.31 1.19 0.59 0.37 0.031
Failure 1.61 0.78 0.78 0.62 0.004
BN elevated PFMT (cm) Total 0.83 0.49 1.40 0.74 0.000
BN elevated PFMT (cm) Successful 1.14 0.32 1.91 0.44 0.000
BN elevated PFMT (cm) Failure 0.44 0.39 0.78 0.51 0.022
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Prediction for a Successful PFMT

• Young age, fewer pad changes, less urethral
  incompetence, higher MUCP
• A greater voluntary BN elevation on PME
• A greater PFM contractility
• Pretreatment BN position and BN descent does not
  affect outcome of PFMT

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Results of PFMT for SUI

• PFM can be strengthened by a 12-week PFMT program
• Effective PFMT increases Pura during voluntary
  contractions
• Strengthened PFM do not change BN resting
  position
• Strengthened PFM reduce BN descent on straining
• 55 of SUI patients have benefit from PFMT

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Pelvic floor muscle training for Stress urinary
incontinence

• An improved hammock effect after PFMT can be
  achieved
• No effect of PFMT on intrinsic continence
  mechanism
• Patients with ISD might not benefit from PFMT
• Patients with low cortical control of PFM have
  unfavorable results
• Good patient intention and compliance are the
  utmost important

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Electrical Stimulation for SUI

• Transvaginal ES has been used for genuine SUI,
  urge and mixed urinary incontinence
• Reported efficacy ranges 35 to70
• A placebo-controlled study revealed after 15-week
  treatment course, pad usage diminished by gt50 in
  62 women compared to 19 in sham device,
  incontinence episode reduced gt50 in 48 women
  compared to 13 in sham device

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Transvaginal electrical simulator
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Transvaginal electrical stimulation for Urge
incontinence

• Leach reported 6 after long period of
  stimulation
• McGuire observed improvement in 93 women with
  urge incontinence
• Plevnik found 52 improved (30 cured) in pure
  urge incontinence
• Brubaker used 20 Hz frequency current and cured
  49 with urodynamic DI
• Smith found ES reduced urine loss by 50 in
  20women
• Sand reported 38 success rate in 20 women with DI

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Transvaginal electrical stimulation

• Low frequency (20 Hz) was applied
• Contrasting data of effects on genuine SUI
• Transvaginal ES is effective in urge UI
• First line treatment for women with pure urge
  incontinence
• For the women with mixed type UI who does not
  wish to undergo PME or surgery

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Other Non-surgical Therapiesfor Incontinence

• Vaginal cones are a method of biofeedback
• 70 (19/27) with mild SUI had complete or gt50
  improvement after vaginal cone therapy, 7/50
  with severe SUI had similar success rate
• Electrostimulation of pudendal nerve (prolonged
  pudendal nerve conduction velocity in 97 SUI) is
  effective in 62 with SUI and 20 were dry
• Electromagnetic stimulation

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Multiple purposesElectrostimulator and
Biofeedback
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Patient visualization biofeedback
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Cystometry biofeedback for urge incontinence

• For women who failed electrical stimulation, were
  intolerant to anticholinergics,
• Urodynamic detrusor overactivity was proven
• Performed several voluntary PFMC at episodes of
  DI while watching CMG tracing and EMG activity
• Try to inhibit urge incontinence as longer
  duration as possible at home

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Detrusor overactivity and CMG biofeedback
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Biofeedback to inhibit detrusor instability