__Pelvic_Floor_Re_education__Principles_and_Practice__Second_Edition

3.3. Electrical Stimulation 193 should ideally specify the mode of application, stimulation site, electrical parameters, pro - tocol, and equipment characteristics (Interna- tional Continence Society standardization LUT rehabilitation). Stress Urinary Incontinence FIGURE 3.3.2. Position ofavaginal probe between thelevator ani Electrical stimulation is adjunctive to voluntary crura and an anal probe (Source: Laycock, J. Plevnik S, Senn E. exercise in increasing the strength and recruit- Electrical Stimulation In: Schussler B, Laycock J,Norton P, Stanton ment of a weak PFM and should be the introduc- S, editors. Pelvic floor re-education. Principles and practice. tion to specific functional recruitment of the London: Springer-Verlag; 1994144.) PFM. Clinicians usually are not in favor of elec- trical stimulation as a stand-alone modality once bladder-training maneuvers. Some patients are a patient has achieved palpable voluntary recruit- unwilling to focus so acutely on self-help, prefer- ment of the PFM. ring medication or surgical correction. Electrical stimulation is known to be better Contraindications to the use of electrical than no treatment at all.\" In regard to electrical stimulation include: poor patient cognition, stimulation versus placebo electrical stimula- pregnancy, puerperium, atrophic vaginitis or tion , \"in women with SUI the findings of two recurring infection, recent or recurrent hemor- good quality trials using similar stimulation pro - rhage, and adverse skin reaction under surface tocols are contradictory.t \" :\" Most of the other electrodes. Some initial irritative symptoms may trials favored electrical stimulation over placebo be reported\" when commencing stimulation with stimulation.P'\":\" However, in some cases, the body cavity electrodes, which can be managed placebo devices generated stimulation of a limited effectively with shorter progressive treatment output, which the investigators considered would sessions.\" The presence or history of a local not have a therapeutic effect. There is no trial malignancy is generally considered a contraindi- comparing vaginal versus anal electrical stimula- cation to electrotherapy because current may tion for the indication of stress incontinence. stimulate rapidly dividing cells. However, in practice, this concern has not been proven. For Pooled data for electrical stimulation versus similar reasons, the use of electrotherapy in PFM training alone found self-reported cure and pregnancy has never been advocated. improvement to be greater in women not using electrotherapy. Not all studies measured urine Evidence for Use of leakage or utilized valid quality of life measure- Electrical Neurostimulation ment tools . It could be argued that once a patient has sufficient muscle awareness and motor In general, the results of electrical stimulation in control to recruit the PFM that electrical stimula- the management of lower urinary tract (LUT) tion is no longer appropriate and, therefore, symptoms and PFM dysfunction are difficult studies should only include subjects with imper- to interpret because electrical stimulation ceptible voluntary muscle activity. No evidence is offers numerous combinations of current types, currently available to indicate that add ing elec- waveforms, frequencies , intensities, and elec- tri cal stimulation to biofeedback-assisted PFM trode placements. Electrotherapy description training is beneficial.\" Urge and Mixed Incontinence Symptoms of mixed stress and urge incont- inence should theoretically respond to a tailored program that includes stimulation at both 50Hz and <20 Hz. This addresses deficiencies in both

194 W.F.Bower PFM strength and central inhibition. A 40- To date, none of the pharmacological thera- minute program divided evenly between the two peutic options to treat pelvic floor spasticity have protocols has been suggested; however, if surface proved efficacious. Although alpha-blockers electrodes are used to deliver the inhibitory improve obstructive voiding symptoms in men, current, longer duration treatment is probably this is not the case in patients with impaired warranted. Evidence from two studies\":\" did not capability of relaxation of the pelvic floor muscles. find added self-report or objective benefit from A study of intrasphincteric injection of botuli- electrical stimulation given in addition to active num toxin in six women with nonneurogenic PFM exercises. Again, it is possible that the sub - pelvic floor dysfunction did not show any jects were already competent in PFM recruitment benefit.\":\" Electrotherapy applied across the and not initially a suitable subject for electrical sacral region has application for both urinary stimulation. urge incontinence and urinary retention.\" It is not known whether the mode of action is Fecal Incontinence enhanced PFMproprioception facilitating greater awareness of PFM and sphincter relaxation or Anal continence requires sensory feedback from deactivation of the urethral guarding reflex.\" the anorectum and the ability to discern rectal Shaker and Hassouna reported the treatment distension.\" The internal anal sphincter will of 20 patients with nonobstructive retention. relax in response to fecal fullness, leaving conti- Voiding function improved significantly during nence dependent on closure pressure exerted by stimulation, but most of the patients were unable the external anal sphincter.\" It has been postu- to void without having the sensation of the stim- lated that in addition to actual skeletal muscle ulation. This may support the proposition that hypertrophy, electrical stimulation may induce the stimulation has a modulatory, but not stimu- plastic changes centrally and increase the repre- latory, effect on the afferent nerve pathways .\" sentational area of the anorectum.\" A Cochrane Additional clinical and experimental studies are review of trials using electrical stimulation for required to elucidate the true efficacy of electro- fecal incontinence highlighted the difficulties in therapy for the overactive PF. comparing treatment approaches that used dif- ferent protocols, parameters, and clinical appli- References cations. Nonetheless, it was noted that electrical stimulation \"may have a therapeutic effect\" in 1. Abrams P,Cardozo L, Fall M, Griffiths D, et al. The patients with fecal incontinence and that efficacy standardisation of terminology of lower urinary could only be determined after appropriately tract function: report from the sub-committee of sized randomized controlled trials.\" the International Continence Society. Neurourol Urodyn .2002;21:167-178. Overactive Pelvic Floor and Voiding Dysfunction 2. Brubaker 1. Electrical stimulation in overactive bladder. Urology. 2000;55(SuppI5A):17-23. Voluntary relaxation of the external urethral sphincter and the PFM normally precedes activa- 3. Dudley GA. Harris, RT. Strength and power in tion of the micturition reflex and subsequent sport. Komi PV, editor. Use of electrical stimula- voiding. Either detrusor weakness (hypocontrac- tion in strength and power training. Oxford: tility or acontractility) or incomplete relaxation Blackwell Scientific Publications; 1992:329-337. of the PFM may precipitate urinary retention and voiding difficulties. Fowler et al.25 described a 4. Bouchard C, Shephard RJ, Stephens T, editors . series of young women with urinary retention Physical activity, fitness, and health: status and and abnormal electrical activity in the urethral determinants. Adjuvants to physical activity. sphincter EMG whose sphincter overactivity was Physical activit y, fitness and health. Consensus associated with impaired relaxation of the pelvic statement. Champaign: Human Kinetics Publish- floor muscles . ers; 1993:33-40. 5. B0 K, Talseth T. Change in urethral pressure during voluntary pelvic floor muscle contraction and vaginal electrical stimulation. Int Urogynecol J. 1997;8:3-7.

3.3. Electrical Stimulation 195 6. Henalla S, Hutchins C, Robinson P, et al. Non- therapy with and without stimulation of the pelvic operative methods in the treatment of female floor in the treatment of genuine stress inconti- genuine stress incontinence of urine. J Obstet nence. Physiotherapy. 1991;77:661. Gynaecol. 1989;92:22-25. 19. Knight S, Laycock J, Naylor D. Evaluation of neu- romu scular electrical stimulation in the treatment 7. Bower WF, Yeung CK. A review of non- invasive of genuine stress incontinence. Physiotherapy. electro neuromodulation as an intervention for 1998;84:61. non -neurogenic bladder dysfunction in children. 20. Wang AC, Wang YY, Chen Me. Single-blind, ran- Neurourol Urodyn. 2004;23(1):63-67. domized trial of pelvic floor muscle training, biofeedback-assisted pelvic floor muscle train- 8. Ahlstrom K, Eriksen B, Fall M. Electrostimula- ing , and electrical stimulation in the manage- tion. Female urinary incontinence. Sjoberg N-O, ment of overactive bladder. Urology. 2004;63(1): Holmdahl TH, Crafoord K, editors. Parthenon 61-66. Publishing Group ; 2000. 21. Berghmans B,van Waalwijk van Doorn E, Nieman F, et al. Efficacy of physical therapeutic modalities 9. Romanzi LJ. Pelvic floor exercise , biofeedback, in women with proven bladder overactivity. Eur electyrical stimulation, and behav iour modifica- Urol. 2002 Jun;41(6):581-587. tion . In: Blaivas JG, editor. Evaluation and treat- 22. Hobday DI, Aziz Q, Thacker N, et al. A study of ment of urinary incontinence. Tokyo: Igaku-Shoin the cortical processing of ano-rectal sensation Med Publishers; 1996. using functional MRI. Brain. 2001;124(Pt 2):361- 368. 10. Laycock J, Jerwood D. Does pre-modulated inter- 23. Salvioli B, Bharucha AE, Rath-Harvey D, et al. ferential therapy cure genuine stress incontinence? Rectal compliance, capacity, and rectoanal sensa- Physiother. 1993;79:553. tion in fecal incontinence. Am J Gastroenterol. 2001;96(7):2158-2168. 11. Lindstrom S, Fall M, Carlsson CA, Erlandson BE. 24. Hosker G, Norton C, Brazzelli M. Electrical stimu- The neurophysiological basis of bladder inhibi- lation for faecal incontinence in adults. Cochrane tion in response to intravaginal electrical stimula- Database Syst Rev. 2000;(2):CD0013IO. tion . J Urol. 1983;129(2):405-410. 25. Fowler q , Kirby RS. Electromyography of ure- thral sphincter in women with urinary retention. 12. Yamanishi T, Yasunda K. Electrical stimulation Lancet. 1986;1:1455-1457. for stress incontinence. Int Urogynecol. 1998;9: 26. Phelan M, Franks M, Somogyi G, et al. Botulinum 281-290. toxin urethral sphincter injection to restore bladder emptying in men and women with voiding 13. Indrekvam S, Sandvik H, Hunskaar S. A Norwe- dysfunction. J Urol. 2001;165:1107-1110. gian national cohort of 3198 women treated with 27. Fowler CJ, Betts CD, Christmas TJ, et al. Botuli- home-managed electrical sti mulation for urinary num toxin in the treatment of chronic urinary incont inence - effectiveness and treatment results. retention in women. Br J Urol. 1992;70:387- Scand J Urol Nephrol. 2001;35:32. 389. 28. Tanagho EA, Schmidt RA. Electrical stimulation 14. Laycock J, Vodusek DB. Electrical stimulation. In: in the clinical management of the neurogenic Laycock J, Haslam J, editors. Therapeutic manage- bladder. J Urol. 1988;140:1331-1339. ment of incontinence and pelvic pain. London : 29. Shaker HS, Hassouna M. Sacral root neuromodu- Springer-Verlag ; 2002. lation in idiopathic nonobstructive chronic uri - nary retention. J Urol. 1998;159:1476-1478. 15. Luber KM, Wolde-Tsadik G. Efficacy of functional 30. DasGupta R, Fowler C], The management of female electrical stimulation in treating genuine stress voiding dysfunction: Fowler's syndrome - a con- incontinence: a randomized clinical trial. Neuro- temporary update. Curr Opin Urol. 2003;13 (4):293- urol Urodyn. 1997;16:543. 299. 16. Sand PK, Richardson DA, Staskin DR, et al. Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter, placebo -controlled trial. Am J Obstet Gynecol. 1995;173:72. 17. Yamanishi T, Yasuda K, Sakakibara R, et al. Pelvic floor electrical stimulation in the treatment of stress incontinence: an investigational study and a placebo controlled double -blind trial. J Urol. 1997;158:21 27. 18. Blowman C, Pickles C, Emery S, et al. Prospective double blind controlled trial of intensive physio-

3.4 Extracorporeal Magnetic Stimulation Alastair R. Morris and Kate H. Moore Key Messages changing magnetic field. The changing magnetic field induces local eddy currents in tissues lying • Magnetic stimulation is an electric current that within it. The eddy currents in turn evoke depo- is induced by a time-varying magnetic field. larization of adjacent peripheral nerves, with stimulation of the pelvic floor muscles (PFMs). • Deep structures can be stimulated without pain; stimulation is generated externally. The characteristics of the magnetic fielddepend on several factors. Strength is primarily deter- • Sessions with 10Hz to reduce overactive bladder mined by the current applied to the stimulating symptoms and with 50Hz to treat stress incon- coil, and the larger the current the stronger the tinence are commonly used over 6-8 weeks, 1-2 field. However, field strength reduces inversely times per week. with the square of the distance from the stimulat- ing coil. Shape is determined principally by that of • Success rates vary and decline over time, with the coil itself. Singlecoils produce a doughnut-like a maximum of 33% of patients being dry. field with centrally reduced stimulation, whereas double coils generate a field that is saddle shaped . Introduction Unlike electrical current, a magnetic field is Until recently, stimulation of the pelvic tissues not significantly attenuated by skin tissue . Con- was only possible by the direct application of sequently, deep structures can be stimulated electrical current. However, new devices utilizing without causing the cutaneous pain that often a pulsed electromagnetic field have been devel- limits conventional electrostimulation.' Addi- oped, which may achieve a similar effect. This tionally, probes do not need to be inserted into chapter will describe the theory upon which the vaginal or anal canal, allowing the patient to magnetic stimulation is based, indications for remain clothed throughout treatment. Some its use, and summaries of current clinical devices have been developed to allow treatment experiences. at home, but the majority still require hospital attendance.' Principles ofElectromagnetic Reponse ofNeuromuscular Tissue to Induction Therapy Electrical and Magnetic Stimulation: How Does It Work? Magnetic stimulation therapy is based on the principle that an electric current can be induced Depolarization of neural tissue following either by a time-varying magnetic field. Modern devices electrical or magnetic stimulation appears indis - contain a coil through which a large alternating tinguishable.Y Thus, presumably, they affect the current is passed, thereby generating a constantly 196

3.4. Extracorporeal Magnetic Stimulation 197 pelvic floor musculature in a similar fashion. Indications Magnetic stimulation may lead to hypertrophy of the PFM, alter the proportions of type 1 and 2 Magnetic stimulation is useful to treat stress fibers, and allow greater recruitment if a neuro - urinary incontinence (SUI) and may have a role trophic effect occurs. However, no studies have in treating the overactive bladder. It is contrain- assessed histological changes in striated or detru- dicated in patients with either a cardiac pace- sor muscle fibers after magnetic stimulation. maker or metallic hip implant. Optimal electrical stimulation of striated muscle is achieved using a 50-Hz current,' whereas inhi- Treatment Protocols bition of detrusor contraction is maximal using 10Hz.6 No standardized treatment regime has been accepted. Most published protocols are modeled The acute mechanism of action of magnetic on those traditionally used for electrical stimula- stimulation on detrusor function is unknown. tion. These often require 2 to 3 treatments per Early studies suggest that electrical stimulation week over a 6 to 8 week period. Individual treat- of the pudendal nerve evokes reflex inhibition of ment sessions generally comprise two 10-minutes the detrusor muscle and contraction of the cycles of maximal-tolerated therapy separated by striated pelvic musculature.\" In both normal a short rest period (often 2 minutes). The first patients' and those with idiopathic detrusor period of stimulation generally uses a low fre- overactivity (DO),8 there is an immediate fall in quency (5-15 Hz) and the second a higher one intravesical pressure after magnetic stimulation (50Hz). No randomized controlled trials (RCTs) is applied over the sacral foramina, suggesting have reported data comparing the effects that immediate detrusor relaxation. McFarlane sug- this may have on pelvic floor or detrusor gested that this reflex cannot be mediated entirely muscle. by contraction of the external sphincter, and pos- tulated that inhibition of parasympathetic effer- Two categories of magnetic stimulation device ent output by blockage of sensory afferent and are currently commercially available. These are a sympathetic input is the most likely effect. Hyper- portable hand device that is placed over the sacral reflexic bladder contractions in spinally injured area to stimulate the sacral nerve roots or a chair- patients can also be decreased by stimulating the like device containing the magnetic coil in its sacral nerve roots with a handheld magnetic base , such as the Neotonus\" Chair (Fig. 3.4.1). unit.\" Stimulation using the latter device is commonly called ExMI and has received Federal Drug In a group of patients with neuropathic DO, bladder capacity at initial desire to void increased FIGURE 3.4.1. The Neotonus®chair. from 175ml (±67) to 225ml (±65; P = 0.017) when magnetic stimulation using a chair device was applied during cystometry. The maximum cysto- metric capacity (MCC) also rose significantly from 290ml (±62) to 348ml (±69; P = 0.003), as did the maximum urethral closure pressure (P < 0.0001). Similarly, among 10 women with idio - pathic DO, a significant rise in MCC (P = 0.02) was observed, in addition to a significant reduc - tion in maximum detrusor pressure (P = 0.004V ' These findings have also been noted during ambulatory monitoring of 8 patients with idio- pathic DO following therapy,\" Hence, acute extracorporeal magnetic inner- vation (ExMI) appears to contract the urethra, reduce contraction of the detrusor, and allow a larger bladder capacity.

198 A.R. Morris andK.H. Moore Administration approval in the United States for The protocol of the second RCT (n = 62) uti- the treatment of SUI. Although handheld devices lized a hand held device placed over the sacrum.IS require the constant presence of an operator, the However, active therapy comprised only a single chair-like device does not. No RCTs have been treatment at 15Hz, rather than the usual 50Hz undertaken to compare the efficacy of these two for SUI, and outcome was determined after only types of device. 1 week. Though intergroup differences in leaks per day and pad loss were significant, so were the Studies Relating to Pure Urodynamic reductions in the sham group alone . Why such a Stress Incontinence short treatment should result in an immediate and identifiable effect is unclear, as muscle hyper- Two RCTs in patients with proven urodynamic trophy normally takes 8 weeks to become clini- stress incontinence (USI) have been reported. In cally evident. the first, 70 patients were randomized equally to receive active ExMI using a Neotonus Chair or Studies Relating to Patients with USI sham therapy on an identical, but nonfunction- and Urgency/Urge Incontinence ing, device.\" Concurrent symptoms of OAB were not exclusion criteria. All patients also under- The reported success of treatment has varied. went a \"low-intensity\" PFMexercise training pro- After twice weekly treatment over 6 weeks (n = gram supervised by a physiotherapist.\" Unfort- 64), 36 patients were reviewed at 6 months with unately, the sham group was significantly more 10 (28%) being dry and 8 (22%) using less than 1 wet at the baseline of the 24-hour pad test . At 8 continence pad per day.\" At 1 year, 27 patients weeks, 17%of active treatment patients were dry were seen, of whom 11 (38%) remained cured versus 9% of sham patients, presumably the latter with 12 (41%) improved. \" as a result of the PFM training program (Table 3.4.1). Both had similar significant reductions in In contrast, in 91 patients treated twice weekly pad test leakage. over 8 weeks, 34 (37%) were dry immediately after treatment, although by 3,6, and 12 months, TABLE 3.4.1. Randomized sham controlled trialofneotonus ExMI 47%, 61.7%, and 94%, respectively, had become in USI13 wet again. IS Pretreatment Posttreatment In another trial, 17 pat ients with USI and 20 (Mean, SD) (Mean, SD) with urge incontinence received combined lO-Hz and 50-Hz therapy. \" Of the urge patients, 25% Active neotonus 24.0 (4.7) 10.1 (3.1)* were dry on bladder diary, whereas 53% of the 39.5 (5.1) 19.4 (4.6)** USI women were dry on l-hour pad test and 24-hour pad test 1.6(0.3) 2.7 (0.4)* bladder diary. Urodynamic data was not fully 20-min pad test 5.0 (0.4) 5.3 (0.4) reported, but only 8 of the 20 urge patients had PFX strength 6.9 (0.1) 0.6 (0.1)* DO, so the study is difficult to interpret. CMR score 63.7 (2.8) 71.2 (3.3) ** Pads/day on FVC 9.6 (0.8) 6.9 (0.7)* * * Studies Relating tothe IQOL Overactive Bladder Kings HQ 37.2 (7.2) 22.0 (5.2)** 39.9 (7.4) 32.4 (6.7) Two randomized trials involving sham therapy Sham chairgroup 1.7 (0.3) 1.9 (0.4) are currently available. The largest recruited 44 4.4 (0.4) 4.6 (0.4) consecutive patients with idiopathic DO and 24-hourpad test 1.2 (0.2) administered 20 treatments at 10Hz over 6 weeks, 20-min pad test 62.6 (4.0) 1.0 (0.1) using the Neotonus Chair.\" A sham chair con- PFX strength 9.7 (0.9) 67.3 (4.4)* taining a deflector plate was available, which was CMR score 8.6 (1.0) indistinguishable in sight and sound from the Pads/dayon FVC fQOL Kings HQ * P< 0.05; ** P< 0.01; *** P< 0.001.

3.4. Extracorporeal Magnetic Stimulation 199 active chair. Only 29 patients (65%) completed fail to complete their treatment regime because the protocol, 15 (51%) receiving active therapy. At of the onerous time commitment needed.P:\" 6 weeks after treatment, active therapy only sig- nificantly decreased episodes of urgency P = The optimal ExMI regime has yet to be defined, 0.003 over sham therapy. and this should be addressed by well-constructed RCTs. Adequate sham limbs in such studies In the other trial, 37 women with OAB symp- are technically difficult to achieve, and few have toms were randomized to a single treatment at been published so far. The high rate of attrition 15Hz using a handheld magnetic device placed amongst women in such trials suggests that over the sacrum, or sham therapy with assess- multicenter studies will be required to achieve ment one week later,\" Intergroup comparison adequate power. Short-term benefits in SUI are showed leaks per day and volume per void frequently reported, but consistent mediuml decreased significantly with active treatment long-term data to confirm ongoing benefit is lacking. Units offering ExMI participate in well- (P =0.04 and P =0.04, respectively). Again, it is constructed clinical trials to help answer these questions. unclear how a single treatment could achieve this significant benefit. In women with USI who are unable to isolate or adequately contract their PFM, magnetic stim- In a small open trial of 18 patients with idio- ulation has proven benefit over sham therapy.\" It pathic DO, only 9 completed the protocol of twice has also been pointed out that ExMI using a chair weekly treatments for 6 weeks; the rest found it device was particularly well accepted by elderly too time consuming.\" Of these 9, urge symptoms women.\" However, once magnetic stimulation improved in 8, but urge incontinence improved therapy ends, its benefits often rapidly disappear in only 2 cases. and a continued program of treatment appears necessary to maintain any improvement. Fecal Incontinence A small study of 16 women who were treated for References fecal incontinence at both 5 and 50Hz on the ExMI chair revealed a significant reduction of the 1. Hallet M, Cohen LG. Magnetism. A new method modified Wexner score from 10/24 to 7/24 (P < for stimulation of nerve and brain. JAMA. 1989; 0.05) after 8 weeks.\" The best response was seen 262:538-541. in women with an intact anal sphincter and weak levator muscles; those with fecal urgency or a 2. But 1. Conservative treatment of female urinary diarrhea component did not respond. incontinence with functional magnetic stimula- tion Uro!. 2003;61:558-561. Place of ExMI ina Pelvic Floor Rehabilitation Program 3. Olney RK, So YT, Goodin DS, et a!' A comparison of magnetic and electrical stimulation of periph- The place of magnetic stimulation in a pelvic eral nerves. Muscle Nerve. 1990;13:957-963. floor re-education program remains uncertain. It is generally well tolerated and avoids the place- 4. Brodack PP, Bidair M, Joseph A, et a!' Magnetic ment of internal probes. However, the equipment stimulation of the sacral roots. Neurourol Urodyn. is expensive and the chair device is not portable. 1993;152:533-540. Consequently, these techniques may be difficult to offer outside of specialist clinics, although 5. Brubaker L. Electrical stimulation in overactive small devices for home use have been trialed.' bladder. Urology. 2000;55 (Suppi 5A}:17-23. Current protocols are based on those developed for traditional electrical stimulation, so multiple 6. Fall M, Lindstrom S. Electrical stimulation. weekly attendances are required. Women find A physiological approach to the treatment of this time consuming, so they must be highly urinary incontinence. Urol Clin N Am. 1991;18: motivated before commencing treatment. Many 393-40 7. 7. Craggs MD, McFarlane JP, Knight SL, et a!' Detrusor relaxation of the normal and patholo- gical bladder. Br J Uro!' 1997;79(Suppl 4}:58- 59. 8. McFarlane JP, Foley SJ, De Winter P, et a!' Acute suppression of idiopathic detrusor instability with

200 A.R. Morris and K.H. Moore magnetic stimulation of the sacral nerve roots. Br 16. Galloway NT, EI-Galley RES, Russell H, et al. I Urol. 1997;80:734-741. Extracorporeal magnetic innervation (ExMI) 9. SherriffMK, Shah PI, Fowler C, et al. Neuromodu- therapy for stress urinary incontinence. I Urol. lation of detrusor hyperreflexia by functional 1999;53(6):1108-1111. magnetic stimulation of the sacral nerve roots. Br I Urol. 1996;78:39-46. 17. Unsall A, Saglam R, Cimentepe E. Extracorporeal 10. Yamanishi T, Yasuda K, Suda S, et al. Effect magnetic stimulation for the treatment of stress of functional continuous magnetic stimulation and urge incontinence in women. Scand I Urol for urinary incontinence. I Urol. 2000;163;456- Nephrol. 2004;37:424-428. 464. 18. Almeida FG, Bruschini H, Srougi M. Urodynamic 11. Morris AR, Dunkley P, O'Sullivan R, et al. Idio- and clinical evaluation of 91 female patients with pathic detrusor instability - a double blind, ran- urinary incontinence treated with perineal mag- domised trial of electromagnetic stimulation therapy versus sham therapy. Proc Inti Cont Soc netic stimulation; l-year followup. I Urol. 2004; Heidelberg. 2002;142-143. 12. Bradshaw HD, Barker AT, Radley SC, et al. The 171;1571-1575. acute effect of magnetic stimulation of the pelvic floor on involuntary detrusor activity during 19. Yokoyama T, Fujita 0, Nishiguchi I, et al. Extra natural filling and overactive bladder symptoms. corporeal magnetic innervation treatment for BIU Int. 2003;91:810-813. urinary incontinence. Int I Urol. 2004;11:602-606. 13. Gilling P, Kennett I, Bell D, et al. A double blind randomized trial comparing magnetic stimula- 20. Morris AR, O'Sullivan RO,Dunkley P et al. Extra- tion of the pelvic floor to sham treatment for corporeal magnetic stimulation if female detrusor women with stress urinary incontinence. Proc overactivity: simultaneous cystometry testing and Aust Urol Soc. 2000. a randomized sham controlled trial. in press. 14. Bo K, Hagen R, Kvarstein B, et al Pelvic floor muscle exercise for the treatment of female stress 21. Fujishiro T, Satoru T, Enomoto H et al. Magnetic urinary incontinence: III. Effects of two different stimulation of the sacral roots for the treatment of degrees of pelvic floor muscle exercise. Neurourol urinary frequency and urge incontinence: an Urodyn . 1990;9:489-502. investigational study and placebo controlled trial. 15. Fujishiro T, Enomoto H, Ugawa Y,et al. Magnetic stimulation of the sacral roots for the treatment of I Urol. 2002;168:1036-1039. stress incontinence: an investigational study and placebo controlled trial. I Urol. 2000;164:1277- 22. Shoberi SA, Chesson RR, Echols KT, et al. Evalua- 1279. tion of extracorporeal magnetic innervation for the treatment of faecal incontinence. Proc Int Cont Soc Florence. 2003; Abstract # 324. 23. Madersbacher H, Pilloni. Efficacy of extracorpo- real magnetic innervation therapy (ExMI) in com- parison to standard therapy for stress, urge and mixed incontinence: a randomized prospective trial. Proc IntI Cont Soc Florence. 2003; Abstract # 367.

3.5 Devices Ingrid Nygaard and Peggy A. Norton Key Messages Devices Used toTrain Pelvic Floor Muscles • Intravaginal resistance device;weighted vaginal specula, and cones (weights) can be used to Devices can be used both to assess the strength assess and train the pelvic floor. of pelvic floor muscles and to train these muscle groups. Although biofeedback and electrical • Pelvic floor muscle training with vaginal cones stimulation are covered in Chapters 3.2 and 3.3, (weights) has been shown to significantly this section will describe vaginal devices used for improve stress incontinence symptoms. both assessment and training. • \"Bladder neck-supportive devices\" like spe- Intravaginal-resistance devices consist mostly cial continence tampons, the Conveen conti- of perineometers, which are modified from nence guard, and urethral pessaries brace the Arnold Kegel's original design (Fig. 3.5.1.); these bladder neck during increased intraabdominal devices are inserted into the vagina and provide pressure. a visual display of pelvic floor contraction strength. A perineometer is essentially a simple • Intraurethral inserts and urethral suction caps pressure gauge that measures vaginal pressure, can be used to prevent urinary leakage , but it cannot dist inguish between pressure gener- although efficacy data is scarce . ated by vaginal muscle s from pressure generated by abdominal pressure.' Some modifications • To control pelvic organ prolapse, supportive include EMG electrodes at the base of the probe and space-occupying pessaries can be inserted to isolate pelvic floor muscle activity. They are vaginally. available directly to patients on the internet through a variety of sources. Although some Introduction patients will find the visual display helpful, a recent study found digital examination worked There are a variety of devices that can be used well with a per ineometer device in assessing to train pelvic floor muscles and to treat pelvic pelvic floor strength.' Several groups have floor disorders. Those used for pelvic floor train- reported a vaginal speculum designed to assess ing are an important source of biofeedback and pelvic floor muscular strength.' objective out come measurement for pelvic floor rehabilitation. Devices worn in the vagina are Vaginal weighted cones were designed to both non-surgical options in the treatment of pelvic assess PFMS and to further train the pelvic floor organ prolapse and stress urinary incontinence with a set of increasing weights .' :\" When placed that can be used in many clinical settings. In this in the vagina, the sensation of losing the cones chapter, we will outline the indication and use of these devices. 201

202 I. Nygaard and P.A. Norton Devices used to Treat Pelvic Floor Disorders Surgery for pelvic floor disorders such as stress urinary incontinence and pelvic organ prolapse is functional surgery; instead of removing a dis- eased organ, these procedures are aimed at restoring or improving the function of the pelvic organs. By its nature, such functional surgery cannot be guaranteed to restore continence and support to its original state. Given that a third of surgeries for pelvic floor disorders fail,\" alterna- tives to surgery may offer less risk and expense to many women for the management of pelvic floor disorders. Devices are widely available, but require some professional intervention to deter- mine the correct use and fit, similar to a contra- ceptive diaphragm. Little has been published on their use, possibly because there is no industry support for (or profit from) conducting properly controlled clinical trials. FIGURE 3.5.1. Original Kegel perineometer as sold in 1949. Intravaginal Devices for Pelvic Organ Prolapse prompts a pelvic floor contraction so as to retain the cone. No fitting is required, and patients Vaginal pessaries have been used for many cen- insert the device for a prescribed period of time turies, but improvements in materials and design daily. They are available to professionals have increased the usefulness of these devices for and through direct marketing to patients prolapse. themselves. A recent Cochrane review of vaginal cones concluded that vaginal weighted cones Indications for a pessary in the management of are better than control treatments (level 1 evi- pelvic organ prolapse (POP) include patients who dence) for self-reported cure or efficacy in women desire nonsurgical management of the condition. with proven stress urinary incontinence.' Although a few women are unable to undergo However, several randomized trials' \" have found surgical management because of medical prob- equal efficacy in women using vaginal cones and lems, a larger number of women might be inter- those doing pelvic muscle training without ested in a pessary because it manages the prolapse devices; in some trials, pelvic muscle training without the need to undergo surgery. In our prac- performed without cones was more effective.\" tices, pessaries are used successfully in women There is no information available to determine who cannot take time off for surgery, such as which women are more likely to benefit from mothers with small children at home and women vaginal cones. with busy careers outside the home. Willingness to use a vaginal device may be cultural, especially in areas where contraceptive diaphragms are used. An Australian study\" found that only 21% of 104women who presented to a community continence clinic stated that they felt very comfortable about inserting a device into the vagina and half felt uncomfortable. At the University of Iowa, two thirds of 190 women

3.5. Devices 203 (mean age 57.4 years, range 15-89) who were ~oo offered a trial of pessary to manage stress or r mixed incontinence were interested in trying !\\ • one.\" FIGURE 3.5.3. Space-occupying pessaries used to treat pelvic The best clinical scenario for pessary use in organ prolapse. Top row: left, cube; middle, doughnut; right, prolapse is an anterior and/or apical defect (cys- Gelhorn (all three by Milex). Bottom row:left, cube with drainage tocele, uterine prolapse, vaginal vault prolapse) in holes (Mentor); middle, inflatoball (Milex); right, Mar-land a woman with a narrow pubic arch and good (Mentor) . pelvic floor strength. Obstetricians are familiar with the assessment of the angle at which the defects.IS In the remainder that tailored the pubic rami meet at the symphysis; a wide arch in pessary to the defect, a ring pessary was more which three or more fingers can be placed is less common for anterior and apical defects, a Gelhorn likely to hold the ventral/caudal edge of a pessary. was more common for complete procidentia, and The pelvic floor braces the dorsal edge of many a doughnut was more common for posterior pessaries, and in the absence of intact pelvic floor defects. A similar management strategy was muscles one must consider the use of pessaries employed by Wu et al.,\" who always used a flexi- that utilize suction or inflation (\"space-occupying ble ring pessary as the first pessary tried. Seventy pessaries\"). If the vaginal capacity is reduced percent of women were successfully fitted with a after surgery, a narrower pessary may be needed size 3, 4, or 5 ring pessary. In one questionnaire (oval, Hodge, cube.) Reported risk factors for surve y,\" physicians reported that ring and pessary failure include a shortened vagina and a doughnut pessaries were the most common pes- wide levator hiatus. \" saries used . However, other centers use different strategies; Sulak et ali used a Gelhorn pessary in Supportive pessaries (which depend on some 96 out of 107 women with symptomatic pelvic levator muscle support to stay in place) include organ prolapse. \" the Gehrung, Hodge, Shaatz, and rings and ovals with support (Fig. 3.5.2). The pessary we use the Supportive pessaries generally allow coitus most is the ring with support, in sizes 3 and while wearing the device. They are the easiest 4 (refers to diameter in centimeters .) In a survey pessaries to use because they fold to a smaller of members of the American Urogynecologic dimension for insertion, but may not be sufficient Society, 22% of respondents used the same to support large prolapses. Pessaries are easiest pessary, usually a ring pessary, for all support to insert lying down, easiest to remove standing up, and may require digital bracing per vaginam ~· . 0 e during bowel movements. Some women have dif- ficulty removing the pessary; in such cases, we • 48 recommend tying a strand of dental floss around the ring so that the pessary can be pulled out by FIGURE 3.5.2. Support pessaries used to treat pelvic organ pro- the floss. lapse.Top left, Gehrung (Milex);topright, Hodge (Milex); middle, Shaatz (Mentor); bottom left, ring with support (Milex); bottom Space-occupying pessaries include the cube, right, oval with support (Mentor). doughnut, Gelhorn , and inflatoball (Fig. 3.5.3).

204 I.Nygaard and P.A. Norton These pessaries are more difficult to insert and covaginal fistulae caused by pessaries; in all cases remove, but work when the device would other- they were undergoing regular examinations by a wise be extruded, such as with larger prolapse, physician. It is possible that unseen erosions poor pelvic floor strength, or wider pubic arch. under the speculum blades may have heralded Of these, we use the doughnut and the Gelhorn the beginnings of such pressure ulcers . with the most frequency. The doughnut is simply pushed into the vagina (a difficult task if the Several series have demonstrated that pessa- introitus is scarred or atrophic), whereas the disk ries are useful. In one study, 74% of 110 women of the Gelhorn is fitted behind the symphysis, were fitted successfully,\" Of the 62 women who similar to a ring pessary, but the knob is aligned used a pessary for more than one month, 66% parallel to the axis of the vagina and facilitates were still using it after 12 months. In another placement and removal. The cube has a relative series, half of 107 women fitted with a pessary suction effect and may be effective in the case of continued to use the device at the time of manu- lax vaginal walls, but generates significant dis- script preparation (average length of use was 16 charge and, in our experience, is more prone to months).\" excoriation and ulceration than other pessaries. The inflatoball is pumped up with a small bulb In a prospective study, 73 of 100 women with and is similarly prone to excoriation, unless care symptomatic POP were fitted successfully with a is taken. pessary,\" Two months after fitting, only 3% of women reported a bulge, compared to 90% at Werecommend that women remove the pessary baseline. Other symptoms that improved with at least weekly, leave it out overnight, and then pessary use included pressure, discharge, and reinsert in the morning. In our experience, splinting. One third of women had urge inconti- women rarely encounter excessive or malodorous nence at baseline; this improved by 54%. Twenty- vaginal discharge using this approach and, thus, three percent had voiding difficulty at baseline, have little use for creams other than estrogen. which improved by 50%. At 2 months, 92% were Space-occupying pessaries are sometimes diffi- either very or somewhat satisfied with their cult for a woman to remove on her own. In such pessary. a case, we try to estimate the appropriate interval between pessary removals in the following Intravaginal Devices for Stress manner. We first examine women two weeks Urinary Incontinence after initial pessary insertion. If discharge is minimal and no erosions are present, we examine Devices in this category are worn in the vagina next at four weeks. Similarly, if the examination and work as a \"back-stop\" to brace the bladder is reassuring, we examine again after six weeks, neck during increased intraabdominal pressure. and so on. The appropriate pessary interval is The vaginal pessary has undergone some modi- either a maximum of three months or the inter- fications for use in women with stress inconti- val at which we see foul-smelling discharge or nence , but there are other devices for this early erosions. indication that are not pessaries. Many women report use of their contraceptive diaphragm After an initial 2-week and 3-month check, we as being effective.F:\" A short menstrual tampon examine women who manage their own pessary may be inserted just comfortably inside the without difficulty yearly. In women who retain introitus; patients need to be instructed to use the the pessary for several months at a time, we tampon under dry conditions, which improves believe that a visual inspection of the vagina the adherence of the tampon. We instruct patients should occur at least twice yearly. It is important to use this \"tampon trick\" with a super tampon, to examine the anterior and posterior vaginal and only on an occasional basis . The Conveen walls during the examination (by turning the Continence Guard is available in some countries, speculum 90 degrees), as well as the obvious and is a polyurethane foam cushion that is folded lateral walls that are visible when the speculum on its long axis and placed in the vagina. When is placed in the usual fashion. We have seen moistened and partially unfolding, it acts as a several women with large recto-vaginal or vesi- backstop under the bladder neck . The device is

3.5. Devices 205 available in three sizes and is worn for up to 18 FIGURE 3.5.5. Incontinence pessaries.Clockwise from top:Incon- hours then discarded. Several studies have docu- tinence dish with support (Mentor), Incontinence dish (Milex), mented good tolerance and significant reductions PelvX ring (DesChutes Medical Products), Suarez ring (Cook Uro- in urine loss with use. 22,23 logic), Incontinence ring with support (Milex), Incontinence dish withsupport (Milex); middle: Introl prosthesis (was Johnson and Non-supportive devices include a urethral Johnson; currently notavailable). insert (Rochester Medical, Inc.) and urethral suct ion caps, 24-26(Uromed, not currently avail- amount of bother with insertion, need for contin- able.) Such urethral plugs and caps have been ued use) associated with these devices. studied with some success , but do not seem to be popular in clinical practice. Examples of non- Most studies evaluating the effectiveness of pessary devices for incontinence are shown in devices for stress incontinence are small in Figure 3.5.4. numbers and short in duration. In a prospective, randomized laboratory-based study,\" 6 of 14 Pessaries modified for use in incontinent women were cured and 2 out of 14improved while women essentially are \"bladder neck-support- exercising wearing a super tampon in the vagina. ive\" during increased intraabdominal pressure. Nine of 12 women had resolution of stress incon- They include rings with knobs placed at the tinence while wearing a contraceptive diaphragm bladder neck, the Hodge pessary inserted back- during urodynamic testing\" and 4 of 10 women wards and upside down, the incontinence dish wearing a contraceptive diaphragm for 1 week with support, PelvX ring, and the Suarez ring had improved continence.\" (Cook Urologic) (Fig. 3.5.5). Some women may wear these devices for activities only, whereas Of 190 women presenting to a tertiary care others need to wear them on a daily basis . Care center with symptoms of stress or mixed UI who of these pessaries is similar to that for supportive were offered pessary management.P 63% chose to pessaries. undergo fitting and 89% achieved a successful fit in the office. Of the 106 women who took a pessary Although use of a short super tampon may be home, follow-up was available on 100. Fifty-five suggested on a temporary bas is, we use the incon- women used the pessary for at least 6 months as tinence dish as our main incontinence pessary. their primary method of managing urinary Patients will immediately see the advantages incontinence (median duration 13 months). Of (effective, no surgery) and disadvantages (small the remaining 45 women who discontinued use before 6 months, most did so by 1 month. FIGURE 3.5.4. Examples of devices used to treat stress inconti- nence that are not pessaries. Top row: left, contraceptive dia- Studies of intraurethral inserts showed that phragm; right-urethral suction cap (was marketed by Uromed, most women who use intraurethral devices are currently not available). Bottom row: left, menstrual tampon; dry or improved (66%-95%) when the device is right-urethral insert (Rochester Medical, Inc). in place.\" :\" Not surprisingly, urinary tract

206 I.Nygaard and P.A. Norton infections are a common adverse event; however, 9. Peattie AB, Plevnik S, Stanton SL. Vaginal cones: the incidence of infections decreases after the a conservative method of treating genuine stress first several months of use. In our practices, few incontinence. Br J Obstet Gynaeco1. 1988;95(10): women choose inserts as first line therapy, but 1049-1053. some are very satisfied with them as an option when other therapies are unsuccessful. 10. Bo K, Talseth T,Holme 1.Single blind, randomised controlled trial of pelvic floor exercises, electrical Conclusion stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in Pessaries and other devices are an important part women. BMJ. 1999;318(7182):487-493. of the treatment armamentarium for POP and stress urinary incontinence. Further research is 11. Olsen AL, Smith VJ, Bergstrom JO, et a1. Epidemi- needed to determine which women are most ology of surgically managed pelvic organ prolapse likely to respond to devices. Long-term studies of and urinary incontinence. Obstet Gyneco1. both effectiveness and adverse events associated 1997;89(4):501-506. with various devices are essential to better under- stand the risk-benefit ratio. 12. Prashar S, Simons A, Bryant C, et a1. Attitudes to vaginal/urethral touching and device placement References in women with urinary incontinence. Int Urogy- necol J Pelvic Floor Dysfunct. 2000;11(1):4-8. 1. Peschers UM, Gingelmaier A, Jundt K, et a1. Evalu- ation of pelvic floor muscle strength using four 13. Donnelly MJ, Powell-Morgan S, Olsen AL, et a1. different techniques. Int Urogynecol J Pelvic Floor Vaginal pessaries for the management of Dysfunct. 2001;12(1):27-30. stress and mixed urinary incontinence. Int Uro- gynecol J Pelvic Floor Dysfunct. 2004;15(5):302- 2. Isherwood PJ, Rane A. Comparative assessment 307. of pelvic floor strength using a perineometer and digital examination. BJOG. 2000;107(8):1007- 14. Clemons JL, Aguilar VC,Tillinghast TA,et a1. Risk 1011. factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. 3. Dumoulin C, Gravel D, Bourbonnais D, et a1. Reli- Am J Obstet Gyneco1. 2004;190(2):345-350. ability of dynamometric measurements of the pelvic floor musculature. Neurourol Urodyn . 15. CundiffGW, Weidner AC,Visco AG, et a1. A survey 2004;23(2):134-142. of pessary use by members of the American uro - gynecologic society. Obstet Gyneco1. 2000;95(6 Pt 4. Wilson PD, Borland M. Vaginal cones for the 1):931-935. treatment of genuine stress incontinence. Aust N Z J Obstet Gynaeco1. 1990;30(2):157-160. 16. Wu V, Farrell SA, Baskett TF, et a1. A simplified protocol for pessary management. Obstet Gyneco1. 5. Olah KS, Bridges S, Denning J, et a1. The conserva- 1997;90(6):990-994 . tive management of patients with symptoms of stress incontinence: a randomized, prospective 17. Pott-Grinstein E, Newcomer JR. Gynecologists' study comparing weighted vaginal cones and patterns of prescribing pessaries. J Reprod Med. interferential therapy. Am J Obstet Gyneco1. 2001;46(3):205-208. 1990;162(1):87-92. 18. Sulak PJ,Kuehl TJ, Shull BL.Vaginal pessaries and 6. Versi E, Mantle J. Vaginal cones: a conservative their use in pelvic relaxation. J Reprod Med. 1993; method of treating genuine stress incontinence. 38(12):919-923. Br J Obstet Gynaeco1. 1989;96(6):752-753. 19. Clemons JL, Aguilar VC, Sokol ER, et al. Patient 7. Herbison P, Plevnik S, Mantle J. Weighted vaginal characteristics that are associated with continued cones for urinary incontinence. Cochrane Data- pessary use versus surgery after 1 year. Am J base Syst Rev. 2002(1):CD002114. Obstet Gynecol. 2004;191(1):159-164. 8. Arvonen T, Pianu-Ionasson A, Tyni-Lenne R. 20. Suarez GM, Baum NH, Jacobs J. Use of standard Effectiveness of two conservative modes of physi- contraceptive diaphragm in management of stress cal therapy in women with urinary stress inconti- urinary incontinence. Urology. 1991;37(2):119- nence. Neurourol Urodyn . 2001;20(5):591-599. 122. 21. Nygaard 1. Prevention of exercise incontinence with mechanical devices. JReprod Med. 1995;40(2): 89-94 . 22. Hahn I, Milsom 1. Treatment of female stress urinary incontinence with a new anatomically shaped vaginal device (Conveen Continence Guard). Br J Urol. 1996;77(5):711-715.

3.5. Devices 207 23. Mouritsen 1. Effect of vaginal devices on bladder 28. Nielsen KK, Walters S, Maegaard E, et al. The ure- neck mobility in stress incontinent women. Acta thral plug II: an alternative treatment in women Obstet Gynecol Scand. 2001;80(5):428-431. with genuine urinary stress incontinence. Br J Urol. 1993;72(4):428-432. 24. Brubaker L, Harris T, Gleason D, et al. The exter- nal urethral barrier for stress incontinence: a mul- 29. Peschers U, Zen Ruffinen F, Schaer GN, et al. [The ticenter trial of safety and efficacy. Miniguard VIVA urethral plug: a sensible expansion of the Investigators Group. Obstet Gynecol. 1999;93(6): spectrum for conservative therapy of urinary 932-937. stress incontinence?). Geburtshilfe Frauenheilkd. 1996;56(3):118-123 . 25. Bellin P, Smith J, Poll W, et al. Results of a multi- center trial of the CapSure (Re/Stor) Continence 30. Staskin D, Bavendam t, Miller J, et al. Effective- shield on women with stress urinary incontinence. ness of a urinary control insert in the management Urology. 1998;51(5):697-706. of stress urinary incontinence: early results of a multicenter study. Urology. 1996;47(5):629- 26. Tincello DG, Adams EJ, Sutherst JR, et al. A 636 . urinary control device for management of female stress incontinence. Obstet Gynecol.2000;95(3):417- 31. Sirls LT, Foote JE, Kaufman JM, et al. Long-term 420. results of the FemSoft urethral insert for the man- agement of female stress urinary incontinence. Int 27. Realini JP, Walters MD. Vaginal diaphragm rings Urogynecol J Pelvic Floor Dysfunct. 2002;13(2):88- in the treatment of stress urinary incontinence. 95. J Am Board Fam Pract. 1990;3(2):99-103.

3.6 Alternative Methods to Pelvic Floor Muscle Awareness and Training Kaven Baessler and Barbara E. Bell Key Messages other treatment or training regimes has gained popularity and recognition. Pelvic floor muscles are increasingly incor- porated into Yoga and Pilates classes and for Pelvic Floor Incorporation in Yoga lower back pain physiotherapy. Other techni- and Pilates Classes and Lower Back ques , including Feldenkrais physiotherapy, which Pain Therapy develops pelvic floor awareness through move- ment and functional integration, and Cantienica, In some Yoga classes, the pelvic floor plays an whereby a pelvic floor contraction is palpated active role, and Pilates schools have adopted the externally after movements between the ischial pelvic floor into their program, too. Programs tuberosities, greater trochanters, and the coccyx. based on the Pilates concept have been very suc- Whole-body vibrations through biomechanical cessful with dancers and athletes as they focus stimulation of the muscles increases metabolic on stability, balance, body alignment and aware- power, might target type II muscle fibers, and is ness, and breathing and involve the deep abdom- increasingly used in the training of athletes and inal muscles and the pelvic floor.':' Pilates the management of women with osteoporosis. incorporates cognitive activation of the deep Theoretically, this may lead to a more powerful abdominal muscles before the performance of a muscle contraction. task. As the transversus abdominis and the pelvic floor muscles (PFM) are part of the local stability Introduction system of the lumbopelvic region, certain move- ments and exercises will result in increased pelvic This chapter will give an overview of different floor activity. A study using electromyographic approaches to pelvic floor awareness and train- (EMG) surface electrodes attached to the oblique ing that have not been mentioned before. Aware- and rectus abdominis muscles, and an intravagi- ness and voluntary control of the pelvic floor are nal EMG probe to record pelvic floor muscle the basis of any pelvic floor training. How a activity, demonstrated that, especially during the woman accomplishes this awareness may be indi- Pilates \"clam\" exercise, the pelvic floor muscles vidually different and may require the utilization are activated (Fig. 3.6.1}.3 Pilates movements of different techniques. Personal preferences on incorporating eccentric activity of the abdominal the woman's and the therapist's side will be a muscles generated greater PFM activity than con- factor and will vary between therapists. The con- centric abdominal activity,' scious, positive integration of the pelvic floor in 208

3.6. Alternative Methods to Pelvic Floor Muscle Awareness and Training 209 FIGURE 3.6.1. Pilates \"Clamexercise.\"The pelvic floor is activated concurrently. The integration of the pelvic floor into Yoga the brain to bring body movements into aware- and Pilates may range from simple coactivation ness.\" This is especially effective in muscle pain to voluntary and active incorporation of the and tension after prolonged misuse, e.g. as in pelvic floor. It is not necessarily pelvic floor train- neck and shoulder tensions of surgeons or typists ing, as it is likely to lack specificity and overload and in pelvic floor re-education. The Feldenkrais (see Chapter 3.1). With the changing view on how approach offers benefits not only with increased the pelvic floor and the abdominal and multifidi pelvic floor awareness but also with the con- muscles work synergistically together, trunk sta- sciousness of how fun ctional tasks such as weight bilization exercise programs for lower back pain lifting or coughing can be modified in order to or sacroiliac joint dysfunction now increasingly minimize the unfavorable effects on the pelvic include the pelvic floor muscles . There is also floor. In contrast to conventional physiotherapy, evidence that mind-body therapies like relax- the Feldenkrais method does not directly ation techniques, cognitive behavioral therapy, approach the tensed muscles, but offers aware - and biofeedback can be used as effective adjuncts ness of alternative body positions, which will be to conventional medical treatment in the man- able to replace former habits. Although compara- agement of chronic lower back pain and osteoar- tive literature is scarce , the Feldenkrais method thritis, for example.\" was superior to conventional physiotherapy in non -specific musculoskeletal disorders.' The The Feldenkrais Approach to the Feldenkrais method cannot replace conventional Pelvic Floor physiotherapy in general, but can be applied suc- cessfully in some individuals and might supple- \"Awareness through movement\" is the goal of the ment physiotherapy. so-called Feldenkrais method.\" Moshe Felden- krais (1904-1984) worked as a physicist and engi- Judy Pippen and Barbara Bell are trained phys- neer. When he suffered from a knee-injury and iotherapists in the Feldenkrais method and intro- adequate rehabilitation was not available, he duced the usefulness of this framework with developed a concept that enables a human being pelvic floor education (www.pelvicpower.com). not only to feel but also to analyze even complex Initially, during \"differentiation,\" one learns to muscular-skeletal body movements, which sense the movement of the PFM more clearly. subsequently leads to an increase in awareness. Lessons are organized in a slow progressive way Based on th is awareness, the individual can select so that attention is drawn to the ability to move the appropriate muscle action by optimizing the the pelvic floor in parts. The front section may be coordination between nervous system , muscles, differentiated from the back section, the right and the skeleton. The Feldenkrais method is a part of th e pelvic floor from the left. Attention is pedagogical concept with the intention to train also directed at sensing the difference between the pelvic floor tightening and that of the sur- rounding muscles , and then encouraging the

210 K. Baessler and B.E. Bell integration/synergism with them. \"Integration\" can learn in a graded way to breathe outwards is the second part of the Awareness Through and to organize the recruitment of the pelvic Movement classes. It involves combination of floor. movement of the whole body in an integrated way to support the functions of the pelvic floor. Moshe Breathing is also a focus because it can easily Feldenkrais said, \"Awareness fits action to inten- be brought under voluntary control, but is usually tion.\"\" The pelvic floor is recruited in various under involuntary control. Voluntary actions degrees when a movement is intended (e.g, can change the state of overall \"tonus\" or tension walking, breathing, singing, coughing) to keep and can change the subsequent rate, depth , continence, to keep our organs supported, and to and rhythm of the breath. In this meditative be able to allow for relaxation and tightening state between voluntary and involuntary where during sexual activities. The third step is to someone is very conscious and extremely focused, include the pelvic floor in many activities it can be sensed that breathing can be performed throughout the day when needed, consciously or by the abdomen and the pelvic floor with unconsciously, and to \"empower\" people to take coordination. control of improving function . \"Cantienica\" Within the Feldenkrais method, there is a par- ticular focus on breathing. While trying to hold Benita Cantieni in Switzerland developed the on to urine rushing to a toilet many people concept of \"sensual pelvic floor training\" to exer- breathe in. The patient has to learn to breathe out cise the \"most important storey in the human while holding on; this helps negate the panic building.\" Many of her claims are questionable, response , which only makes urgency more urgent. and the efficacy of the method has not formally The forceful \"out\" breath (e.g, laughing, vomit- been researched, but the approach to achieve a ing, coughing , or sneezing) is a challenging pelvic floor contraction and how to verify it is movement, especially for stress incontinent resourceful and practical (Fig. 3.6.2). Women are women. Using a functional approach, patients FIGURE 3.6.2. Three external ways to palpate activation ofthe muscle pull at theinferior edge ofthesymphysis and movement pelvic floor: medial shift oftheischialtuberosities, muscle action ofthecoccyx. over the major trochanters with slight external rotation and

3.6. Alternative Methods to Pelvic Floor Muscle Awareness and Training 211 asked to bend forward, palpate their ischial tuber- osities and try and pull them together. A subtle shift of the ischial tuberosities can be felt exter- nally, which probably is the action of the iliococ- cygeus and coccygeus muscles. A second method is to feel the gentle movement of the greater tro- chanters with a pelvic floor contraction, a move- ment that is probably generated by the obturator internus and piriformis muscles, which are inner- vated by the obturator nerve and pelvic branches from 51-52, respectively. The third method to confirm a pelvic floor contraction is the palpation of a movement underneath the fingers on the pubic bone and the coccyx. The integration of the pelvic floor into daily life is encouraged and taught with numerous exercises . Biomechanical Stimulation Biomechanical stimulation or whole-body vibra- FIGURE 3.6.3. Whole-body vibration therapy:The patient stands tion therapy is a new neuromuscular training ona platform thattilts onacentral axis with different frequencies method that increases metabolic power and and amplitudes.The musculature has to keep thebody initsposi- might specifically target type II muscle fibers. \" It tion andis forced to react to theoscillatory movements. is thought to elicit muscular activity via stretch reflexes and allows the combination of voluntary it lacks specificity. Women will still have to learn and involuntary muscle work.\" It has been used how to activate the PFM at the appropriate time, in the training of athletes \" and in the manage- but after whole-body vibration they might be able ment of women with osteoporosis\" and lower to do so with a more powerful contraction. back pain. \" It has been shown to improve vertical jumping,\" :\" bone density,\" and leg extension Acknowledgment. The part on the Feldenkrais strength,\" and to increase testosterone and growth hormone levels in men.\" Standing with method was finalized by the assistance of Mrs. the knees slightly bent on a platform that vibrates Erna Alig, Feldenkrais instructor, Switzerland. between 5 and 30 Hz at an amplitude of up to 13mm, all muscles that keep the body erect have References to work (Fig. 3.6.3). The typical frequency is 25- 30 Hz, forcing the muscle to contract and relax 1. LakeB.Acute back pain. Treatmentbythe applica- 25-30 times per second. Changing the position tion of Feldenkrais principles. Aust Fam Physi- on the platform changes the focus of muscle cian. 1985;14(1l):1l75-1178. work. Lower frequencies are supposed to be ideal for balance control, bone strengthening, and 2. Hutchinson MR, Tremain L, Christiansen J, et al. weaker individuals, whereas higher frequencies strengthen the muscles and are suitable for stron- Improving leaping ability in elite rhythmic gym- ger individuals. Theoretically, this training can nasts. Med Sci Sports Exerc 1998;30(10):1543- also improve the tone and strength of the PFM. Although this theory is currently being tested, no 1547. studies have been published yet. Without parallel pelvic floor education, it seems unlikely to prove better than current pelvic floor regimes because

212 K. Baessler and B.E. Bell 3. Sapsford R. Pilates and the pelvic floor. Pro- 10. Bosco C, Colli R, Introini E, et al. Adaptive ceedings , 2nd Biennal Excellence Down-under. responses of human skeletal muscle to vibration School of Pysiotherapy, University of Melbourne, exposure. Clin Physiol. 1999;19(2):183-187. Australia; 2005. 11. Rubin C, Recker R, Cullen D, et al. Prevention of 4. Sapsford R, Kelly S, C.R. Pilates and the pelvic bone loss in a post-menopausal population by low- floor. Abstract Physiotherapy Conference; 2004. level biomechanical intervention. Bone Min Res. 1998;23:1126. 5. Astin JA, Shapiro SL, Eisenberg DM, et al. Mind- body medicine : state of the science, implications 12. Rittweger J, Just K, Kautzsch K, et al. Treatment for practice. JAm Board Fam Pract. 2003;16(2):131- of chronic lower back pain with lumbar exten- 147. sion and whole-body vibration exercise - a rand- omized controlled trial. Spine. 2002;27:1829- 6. Feldenkrais M. Awareness through movement. 1834. Health exercises for personal growth. Hammond- sworth, UK: Penguin Books; 1977. 13. Torvinen S, Kannu P, Sievanen H, et al. Effect of a vibration exposure on muscular perfor- 7. Malmgren Olsson EB,Branholm lB. A comparison mance and body balance. Randomized cross-over between three physiotherapy approaches with study. Clin Physiol Funct Imaging . 2002;22:145- regard to health-related factors in patients with 152. non -specific musculoskeletal disorders. Disabil Rehabil. 2002;24(6):308-317. 14. Bosco C, Iacovelli M, Tsarpela 0 , et al. Hormonal responses to whole-body vibration in men. Eur J 8. Cantieni B. Tiger feeling. The sensual pelvic floor Appl Physiol. 2000;81:449-454. training for her and him . 2000. 15. Rubin C, Turner AS,Bain S, et al. Anabolism . Low 9. Rittweger J, Beller G, Felsenberg D. Acute physio- mechanical signals strengthen long bones. Nature . logical effects of exhaustive whole-body vibrat ion 2001;412 :603-604 . exercise in man. Clin Physiol. 2000;20:134-142.

Part IV Treatment: Condition-Specific Assessment and Approaches

4.1 Behavioral Treatment Kathryn 1. Burgio Key Messages and Research.' Although the majority of women are not cured with this approach, most can achieve • Behavioral treatments are usually comprised of significant improvement in continence status. several components and tailored to the needs of the individual woman. The Bladder Diary (See Chapter 2.6) • Active use of PFM is a key continence skill for The bladder or voiding diary is a valuable clinical avoiding both stress and urge incontinence. tool, both for the clinician and the woman. In the diagnostic phase , it provides information on the • Altering voiding habits, fluid intake, and other type and severity of urine loss and helps to plan aspects of life style promote improved conti- appropriate components of behavioral interven- nence status. tion. During treatment, the diary can be moni- tored to determine the efficacy of various • Using a bladder diary enhances women's aware- treatment components and guide the interven- ness of their incontinence and guides behav- tion. In addition to the value for the clinician, the ioral intervention. self-monitoring effect of completing the diary enhances the patient's awareness of voiding Introduction habits and patterns of incontinence. It facilitates a woman's recognition of how her incontinence is Behavioral interventions are a group of treat- related to her activities. In particular, clearly ments that improve incontinence by changing understanding the precipitants of urine leakage women's habits or teaching them continence optimizes the woman's readiness to implement skills. Behavioral interventions include self-mon- the continence skills learned through behavioral itoring with a bladder diary, PFM training and treatment. exercise, active use of PFMs to prevent urine loss, urge suppression strategies, urge avoidance, Before initiating treatment, it is advisable to scheduled voiding, delayed voiding, fluid man- have the woman complete a bladder diary for 5 to agement, weight loss, and other lifestyle changes . 7 days.' At a minimum, the woman should record In general, these treatments are safe and without the time and volume of micturition, the time of the risks and side effects of some other therapies. each incontinent episode, its size, and the circum- However, they require the active participation of stances or reasons for the accident (Fig. 4.1.1). a motivated woman and usually take some time Through the process of reviewing the bladder and persistence to reach maximum benefit. diary, women can identify certain times when Behavioral treatments have been recognized for they are more likely to have incontinence and the their efficacy by the 1988 Consensus Conference activities that seem to trigger incontinence. on Urinary Incontinence in Adults' and the Guideline for Urinary Incontinence in Adults developed by the Agency for Health Care Policy 215

216 K.L. Burgio Date:1-20-2006 TIME TIME OF TIME OF REASON FOR URINATED SMALL LARGE LEAKAGE IN TOILET LEAK LEAK 2:10am 6:40am Coughed in bed 4:30am 8:45 am 10:10 am Urge - Taking a shower 8:09am 3:32pm Urqe - Taking a walk 10:50 am Sneezed 3 times 1:35 pm 7:20pm Watching TV 5:55pm 9:25 pm 10:30 pm TIME UP FOR THE DAY: 8:00am TIMETO BED FOR THE NIGHT: 10:00 pm # OF PADS USED TODAY:-A.,. NUMBER OF LEAKAGES: ....5..... FIGURE 4.1.1. Sample bladder diary. PFM Training and Exercise The goal of behavioral intervention for stress incontinence is to teach the patient how to Pelvic floor muscle training and exercise are the improve urethral closure by voluntarily contract- foundation of behavioral treatment for stress ing her PFMsduring physical activities that cause urinary incontinence. This intervention has urine leakage, such as coughing, sneezing, or evolved as both a behavioral and a physical lifting. The first step in training is to assist the therapy, combining principles from both fields woman to identify her PFMs and to contract and into a widely accepted conservative treatment for relax them selectively. It is essential to confirm stress incontinence. that patients have identified and isolated the correct muscles. Failure to find the correct

4.1. Behavioral Treatment 217 muscles is perhaps the most common reason for Using Muscles to Prevent Urge failure of this treatment modality. Basics and Accidents: Urge Suppression advice on this subject are presented in Chapters Strategies 3.1 and 3.2. In addition to its value in treating stress inconti- It is best to begin treatment by ensuring that nence, this technique is now frequently used as a the woman understands which muscles to use. component in the treatment of urge incontinence This can be accomplished by palpating the pelvic as well.' In addition to using the PFMs to occlude floor during pelvic examination and guiding her the urethra, the woman learns to use PFM con- with verbal feedback to find the proper muscles. traction and other urge suppression strategies to Pelvic floor muscle control can also be taught inhibit bladder contraction. Furthermore, the using biofeedback or by applying electrical woman is taught a new way to respond to the stimulation. sensation of urgency; instead of rushing to the toilet, which increases intraabdominal pres- Once the woman learns how to properly con- sure and exposes her to visual cues that can trigger tract and relax the PFMs selectively, a program of incontinence, she is encouraged to pause, sit down daily practice and exercise is prescribed. The if possible, relax the entire body, and contract the purpose of the daily regimen is not only to PFMs repeatedly to diminish urgency, inhibit increase muscle strength but also to enhance detrusor contraction, and prevent urine 10ss.5 motor skills through practice. The optimal exer- When urgency subsides, she can to proceed to the cise regimen has yet to be determined; however, toilet at a normal pace. Behavioral training for good results are generally achieved using 45 to 50 urge incontinence has been tested in several clini- exercises per day, over 2 to 3 sessions per day. It cal series utilizing prepost designs and in con- is important to encourage the woman to practice trolled trials using intention-to-treat models. in various positions, so that she becomes com- Mean reductions of incontinence range from 60% fortable using her muscles to avoid accidents in to 80%.7-10 (See Chapter 4.6 for more detail on any position. (See Chapter 4.2 for more detail on urge suppression.) PFM training.) Using Muscles to Prevent Stress Adherence and Maintenance Accidents: Stress Strategies Although exercise alone can improve urethral Exercising and using the PFMs requires the active support and continence status, optimal results participation of a motivated woman. It is often depend on the woman learning to use her muscles challenging to remember to use muscles strategi- actively to prevent urine loss during situations of cally in daily life, as well as to persist over time in physical exertion. With practice and encourage- a regular exercise regimen to maintain strength ment, the woman can develop the habit of first and skill. This reliance on a woman's behavior consciously and then automatically contracting change represents the major limitation of this PFMs to occlude the urethra before and during treatment approach. In addition, progress with coughing, sneezing, or any other activities that behavioral treatment is often gradual and pro- have caused urine loss. This skill has been referred gressive, usually evident by the fourth week of to varyingly as the stress strategy.t\" counterbrac- training and continuing for up to 6 months. Herein ing, perineal blockage, precontraction and the lies the challenge for behavioral treatment - \"Knack.,,6 Some women will benefit simply from to sustain the woman's motivation for a long learning how to control their PFMs and to use enough time that she will experience noticeable them to prevent accidents. Others will need a change in her bladder control. more comprehensive program of PFM rehabilita- tion to increase strength, as well as skill. It is important in initiating behavioral treat- ment to make it clear to the woman that her

218 K.L. Burgio improvement will be gradual and will depend on clinical trial of bladder training demonstrated an consistent practice and use of her new skills. average 57% reduction of incontinence in older Clinicians can provide support by scheduling women.\" follow-up appointments to track and reinforce her progress, make adjustments to the exercise Lifestyle Changes regimen, and encourage persistence. Voiding Habits and Schedules Fluid Management Increasing Voiding Frequency Many behavioral clinicians recommend altera- tions in the volume or type of fluids that a woman Many women have been advised by health care consumes as a way to optimize her outcomes. It providers to increase frequency of urination as a is not only helpful for bladder control but also way to prevent urgency and incontinence by good health advice to ensure that the woman is avoiding a full bladder. Although immediate consuming an adequate amount of fluid each day. benefit can be observed, the long-term result is In an effort to cut down on urine loss, some most likely counterproductive, because it removes patients restrict their fluid intake in general, or opportunities for the bladder to be full, and the at particular times of day when they consider woman can lose the ability to accommodate themselves to be at risk of incontinence. In some bladder fullness. In addition, it feeds the cycle of cases, this results in an inadequate intake of fluid urgency and frequency thought to perpetuate and places them at risk of dehydration. overactive bladder and urge incontinence in the long run. Fluid restriction is often appropriate in women who consume an abnormally high volume of fluid Increasing the frequency of urination is gener- (e.g. >2,100ml of output per 24 hours) . Some ally reserved for women who clearly void below people increase their fluid intake deliberately in what is normal or in patients with dementia or an effort to \"flush\" their kidneys, lose weight, or who are otherwise cognitively impaired and inca- avoid dehydration. In others it is simply a habit. pable of learning new skills for bladder control. In these cases, reducing excess fluids can relieve Women who have reduced bladder sensation may problems with sudden bladder fullness and also benefit. resulting urgency. Reducing or eliminating fluids in the evening hours is often helpful for reducing Decreasing Voiding Frequency: Bladder nocturia. Training and Delayed Voiding Caffeine, in addition to being a diuretic, has Bladder training is a behavioral intervention also been shown to be a bladder irritant for many originally developed for the treatment of urge people. It is very difficult for most coffee drinkers incontinence. The belief behind the bladder to completely eliminate their morning coffee, but training method is that habitual frequent urina- many will be willing to reduce caffeine intake at tion can reduce bladder capacity and lead to over- least partially. Though there is little data on the active bladder (OAB), which in turn causes urge role of sugar substitutes in incontinence, there Incontinence.\" The goal of the training is to are clinical cases in which these substances break this cycle using consistent voiding sched- appear to be aggravating incontinence, and ules. The woman voids at predetermined inter- reduction has provided clinical improvement. vals, and over time, the voiding interval is gradually increased (see Chapter 4.6). Weight Loss Clinical series studies have demonstrated cure Obesity is a common health problem that has also rates ranging from 44% to 90% using outpatient been established as a risk factor for urinary bladder training or a mixture of inpatient and incontinence. Women with high body mass index outpatient intervention. The first randomized are not only more likely to develop incontinence but they also tend to have more severe inconti- nence than women with lower body mass index.\"

4.1. Behavioral Treatment 219 A small amount of literature exists showing can be very bothersome when it results in sleep significant improvement in continence status disruption or daytime fatigue, or increases the accompanying weight loss of 45-50 kg after bar- risk of falls. One practical approach to nocturia iatric surgery\" and of as little as 5% weight reduc- is to restrict fluid for 3 to 4 hours before bedtime. tion with conventional weight loss programs.IS In patients who reta in fluid during the day and Because this is an achievable goal for many over- have nocturia caused by fluid mobilization at weight or obese women, it is reasonable to recom- night, interventions focus on managing daytime mend weight loss as part of a comprehensive accumulation of fluid. This can be facilitated by program to treat incontinence in overweight wearing support stockings, elevating the lower women. extremities in the late afternoon, or using a diuretic. For patients who are already taking a Smoking diuretic, nocturia can often be improved by alter- ing the timing of the diuretic (so that most of the Smoking, adversely affects the continence mech - effect has occurred before bedtime) or by using a anism and aggravates stress urinary incontinence long-acting diuretic. by reducing lung function and vital capacity and producing a chronic cough with a corresponding In addition to the medical management of noc- rise in abdominal pressure. Therefore, it can be turia, behavioral training for urge incontinence helpful to interrupt this cycle by stopping smok- has also been shown to reduce nocturia.\" The ing and directing treatment toward the chronic woman is instructed to use the urge suppression cough. strategy when she wakes up at night . If the urge subsides, she is encouraged to go back to sleep. If Bowel Management after a minute or two the urge to void has not remitted, she should get up and void so as not to interfere unnecessarily with her sleep. Constipation and fecal impaction have been sited References as contributory factors to urinary incontinence, particularly in institutionalized populations. In 1. Consensus conference. Urinary incontinence in severe cases, fecal impaction can obstruct normal adults . JAMA. 1989;261:2685-2690. voiding, precipitate overflow incontinence, or be an irritating factor in OAB. Disimpaction can 2. Fantl JA, Newman OK, Colling J, et al. Urinary resolve symptoms for some women, but it can incontinence guideline panel. March 1996. Urinary recur unless a bowel management program is incontinence in adults : acute and chronic manage- implemented. Bowel management may consist of ment. Clinical practice guideline. Rockville, MD: instructions in normal fluid intake and dietary Agency for Health Care Policy and Research, fiber (or supplements) to maintain normal stool Public Health Service, US Department of Health consistency and regular bowel movements. When and Human Services. these measures are not adequate, enemas can be used to stimulate a regular daily bowel move- 3. Locher JL, Roth DL, Goode PS, et al. Reliability ment. Enemas should be timed after a regular assessment of the bladder diary for urinary incon- meal such as breakfast to capitalize on postpran- tinence in older women. J Gerontol: Med Sci. 2001; dial motility. 56A:M32-M35. Nocturia 4. Goode PS, Burgio KL, Locher JL, et al. Effect of behav ioral training with or without pelvic floor Urinary incontinence is often accompanied by electrical stimulation on stres s incontinence in nocturia, which is waking up at night to void. women:a randomized controlled trial. JAMA.2003; Although getting up once per night is widely 290:345-352. regarded as normal, getting up 2 or more times 5. Burgio KL, Pearce KL, Lucco A. Staying dry: a practical guide to bladder control. Baltimore: The Johns Hopkins University Press; 1989. 6. Miller JM, Aston-Miller JA, DeLancey 01. A pelvic muscle contraction can reduce cough-related urine loss in selected women with mild SUI. JAGS. 1998;46:870-874.

220 K.L. Burgio 7. Burgio KL, Whitehead WE, Engel BT. Urinary 12. Fantl JA, Wyman JF, McClish DK, et al. Effi- incontinence in the elderly: bladder/sphincter bio- cacy of bladder training in older women feedback and toileting skills training. Ann Intern with urinary incontinence. JAMA 1991;265:609- Med 1985;103:507-515. 613. 8. Burton JR, Pearce KL, Burgio KL, et al. Behavioral 13. Brown J, Grady D, Ouslander J, et al: Prevalence of training for urinary incontinence in elderly ambu- urinary incontinence and associated risk factors latory patients. J Am Geriatr Soc. 1988;36:693- in postmenopausal women. Heart & Estrogen/ 698. Progestin Replacement Study (HERS) Research Group. Obstet GynecolI999;94:66 . 9. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence 14. Bump R, Sugerman H, Fantl J, et al. Obesity and in older women. A randomized controlled trial. lower urinary tract function in women: effect of JAMA. 1998;280:1995-2000. surgically induced weight loss. Am J Obstet GynecolI992;166:392. 10. Burgio KL, Goode PS, Locher JL, et al. Behavioral training with and without biofeedback in the 15. Subak LL, Johnson CEW, Boban D, et al. Does treatment of urge incontinence in older women: weight loss improve incontinence in moderately a randomized controlled trial. JAMA 2002;288: obese women? Intl J Urogyn 2002;13:40. 2293-2299. 16. Johnson TM, Burgio KL, Goode PS, et al. Effects 11. Frewen WK. Role of bladder training in the treat- of behavioral and drug therapy on nocturia in ment of the unstable bladder in the female. Uro- older incontinent women. J Am Geriatr Soc. 2005; logic Clinics of North America. 1979;6:273-7. 53(5):846-850 .

4.2 Stress Urinary Incontinence Jo Laycock Key Messages continence mechanism should respond to muscle training. • The knowledge of pelvic anatomy and physiol- ogy and causes of incontinence are necessary Assessment to facilitate pelvic floor re-education. Stress urinary incontinence has several causes • The assessment of pelvic floor muscles (PFMs) (see Chapters 1.3, lA, and 1.5). In many cases, it includes their co-ordination, contraction, does not occur in isolation, and women present timing, and function during coughing. with coexisting urological symptoms, such as urge incontinence, frequency, elevated postvoid • If there is no voluntary contraction, then teach- residual urine, or urinary tract infection. Conse- ing must be directed toward increasing pelvic quently, a holistic assessment is needed to iden- floor awareness . tify and address all symptoms. In addition to the standard history and physical examination (see • If there is a weak pelvic floor contraction, then Chapter 2.1), the assessment should include a a strengthening program is necessary, and if pain assessment of the pelvis, lower back, and PFMs are easily fatigued, then an endurance pelvic floor, as pain in these regions may inhibit program is needed . PFM recruitment (see Chapter 3.1). • Progression in the pelvic floor reeducation A woman with SUI may have a defect in the program involves teaching the active use of fascial supportive tissues, but still have an intact PFM exercises and stress strategies, combined urethral sphincter and PFMs, or, conversely, she - if necessary - with drug therapy such as may have weak muscles with intact fascial sup- estrogen or duloxetine. ports, or a combination of these deficits. Further- more, inadequate muscular activity and weakness Introduction may be caused by disuse, which can be addressed by PFM exercises. However, weakness caused by Stress urinary incontinence (SUI) is the involun- partial denervation or muscles torn from their tary loss of urine associated with an increase in attachment is less likely to respond to muscle intraabdominal pressure, such as with coughing training (Fig. 4.2.1). or other physical activity (see Chapter 1.5). Con- tinence during raised intraabdominal pressure is Pelvic Floor Muscle Re-education attributable to an integrated system of muscles, fascia, ligaments, and neural control (see Chap- Pelvic floor muscle re-education is an effective, ters 1.1 and 1.2). The connection of the levator ani low-risk intervention that can reduce inconti- to the arcus tendineus fascia pelvis permits active nence significantly in varied populations, and contraction of the PFMs to elevate and support should be considered as a first approach. The the anterior vaginal wall.' In addition, continence principles underlying this therapy are discussed also requires a competent urethral sphincter in Chapter 3.1, and the effectiveness of treatment mechanism. Evidence suggests that a voluntary is described in Chapter 4.3. The following PFM contraction is accompanied by synergistic contraction of the urethral sphincter mecha- nism,' indicating that both components of the 221

222 J.Laycock Endopelv ic fascia with Bladder be facilitated by the use of anatomical models attachment at arcus and pictures. Realistic goal setting (depending on tendineous fasc iae pelvis severity), and the need for the woman to partici- pate actively in her treatment, is discussed. In Bladder neck this context, motivation and adherence to an Urethra exercise program lasting several months should be emphasized, and the consequences of non- A compliance clearly stated . The importance of good posture and the avoidance of heavy lifting Endopelvic fascia detached from and activities that produce a great increase in arcus tendlneous fasciae pelvis intraabdominal pressure should be explained. result ing in paravag inal defect Many women find it difficult to exercise in B general, and need to be convinced and motivated to adhere to their exercise regimen. Other women FIGURE 4.2.1. (A) With a sufficient pelvic floor contraction become excessive in their efforts and overexer- (orange arrows). theattached endopelvic fascia (via arcus tendi- cise in the early days. Therefore, all women neous fasciae pelvis; green) iselevated resulting in an elevation should be informed of the possibility of muscle ofthebladder neck (red arrow). (8)Detachment oftheendopelvic soreness, which usually occurs the day after they fascia from the levator ani muscle precludes transmission of a begin . This soreness applies to both the PFMs pelvic floor contraction (orange arrows) onto the bladder neck and the lower abdominal muscles. (small red arrow). Many women will be wearing incontinence step-by-step guide is recommended for the treat- pads to avoid embarrassment and allow freedom ment of SUI. of activities. Although necessary initially, the size and number of pads used should be moni- Education tored, and women should be encouraged to reduce pad use as symptoms improve. To optimize the usefulness of PFM training, the woman should understand the anatomy and All the above information can be provided in physiology of the lower urinary tract. ' This can a group setting.\" which can be both enjoyable and cost-effective, as well as enable women to realize that they are not alone with their problem. Finally, a simple handout explaining basic infor- mation should also be available to women. PFM Assessment Initially, the woman is told why the examination is to be carried out (to check whether she can contract the PFMs and how they perform), how the examination will be done (vaginal palpation), and alternative procedures if this is not accept- able (i.e. assessing the muscles by observation only or with a perineometer). The periurethral muscles are palpated by placing the distal pad of the gloved, lubricated index finger on the anterior vaginal wall just inside the introitus and asking the woman to con- tract her muscles as if stopping urination, and then to relax the pelvic floor. The activity of the external urethral sphincter can thus be detected. The finger is moved to the right of the urethra

4.2. Stress Urinary Incontinence 223 and then to the left, and further contraction and assessed . Because many women have never used relaxation requested. This should detect the con- the PFMs during stress situations, this gives them tractility of the muscles lateral to the urethra (see immediate feedback, especially if urine leakage Chapter 1.1). The resting tone of the muscles was avoided. For the therapist, the response can should also be noted because some women present be utilized to guide the training program. In with hypertonic PFMs caused by embarrassment, addition, this information will reveal those anxiety, or other factors (see Chapter 1.8).In this women who have a good PFM contraction with situation, a further contraction might not be an initial elevation of the bladder neck, but possible or detectable, and an inexperienced cli- descent of the urethra during coughing, while the nician might misinterpret this as a weak or no levator ani is still contracted. This may be caused contraction. by fascial detachment, in which case the chance of success seems low, although there are no The index finger is then flexed and placed in the studies to corroborate this. 8 o'clock and then the 4 o'clock positions, to enable palpation of the levator ani at rest and during a Initial Exercise Program voluntary contraction. Once voluntary contrac- tions have been established, a simple patient-spe- If the woman cannot produce a voluntary con- cificexercise program is developed, depending on traction or produces simply a flicker (grade 1 muscle strength and endurance.\" (See Chapter 3.1 contraction), the techniques in Table 4.2.1 may be on Concepts of Neuromuscular Rehabilitation helpful. Women who can perform a voluntary and Pelvic Floor Muscle Training). PFMcontraction of grade 2 or higher on the mod- ified Oxford Scale are ready to embark on a While palpating the levator ani , the woman is muscle strength training program. If the maxi- also asked to cough, and the examiner mon itors mum voluntary contraction is weak, then the for the presence of cocontraction of the PFMs. woman is initially encouraged to squeeze harder The woman should then be instructed to tighten and harder over the following weeks, to increase the PFMbefore and during a cough. Whether the muscle awareness and improve contraction woman is able to contract her muscles before the cough and hold this contraction should be TABLE 4.2.1. Techniques toassist voluntary contraction ofthepelvic floor muscles 1. Apply firm pressureonthemuscles (through thevaginal wall) tostretch themuscles and increase awareness. Many women arenot aware of theirPFMs and cannot locate them. Muscles often work better ifstretched. 2. Use biofeedback via surface electromyography with a vaginal electrode (e.g. Perlform\": Fig. 4.2.2) orvaginal oranal manometry to show the muscles working, however small theresponse. Thishelps thewoman become aware of, andconcentrate on, theappropriate muscles. Itprovides thefeedback needed for operant conditioning (trial and error learning) and can inspire thewoman togreater effort. 3. Teach contraction oftransversus abdominis(TrA) (see Chapter 3.1).Thismay help to recruitthePFMs. The woman then tries to\"join in\" with her PFMs. Again, biofeedback ishelpful.Ifbiofeedback isnotavailable, verbal feedback based ondigital palpation is used to re-enforce thecorrect response. At this stage, thewoman isrequested to perform only short, gentle contractions. All toooften, a woman will trytoohard anduse muscles notconnected withthepelvic floor (e.g. tightening theshoulders orholding theirbreath). Exercising onanexercise ball orinflated cushion will introduce theimportance ofintegrated muscle work for stability. Again, biofeedback can beused concurrently to demonstrate the effect onthe PFMs. 4. If there isstill noresponse, electrical stimulation can beused, providinq there arenocontraindications.This can bedone withthePeriform electrode (Fig. 4.2.2), asthemovement oftheindicator will help thewoman to understand theaction ofa PFM contraction.The current is gradually increased until theindicator moves downwards (posteriorly). Withsubsequent electrically elicited contractions, thewoman is instructed to\"join in\"and seetheindicator move down further.The author uses thefollowing electrical parameters: a. Frequency: 35 Hz b. Pulse-width (phase duration): 250/.ls c. Duty cycle: 5son/10 soff d. Current intensity:Sufficient to produce maximum posterior movement oftheindicator. The woman isencouraged totake themaximum current intensitythatshecan tolerate. Alternate electrical stimulation andbiofeedback isuseful to re-enforce thecorrect action.The useofa home muscle stimulator, with thewoman \"joining in\" with each contraction, may help toactivate themuscles. Once thewoman has located her PFMs, sheshould perform several voluntary contractions (l.e. without thestimulator) every hour, untilshe isready for anexercise program.

224 J.Laycock FIGURE4.2.2. Periform vaginal electrode with indicator.Acorrect concentrate on increasing strength by perform- voluntary contraction of the PFMs produces downward (poste- ing maximum short, 3 s contractions. However, a rior) movement of the indicator; an incorrect voluntary muscle woman with a strong Mve and poor endurance, contraction or cough produces upward (anterior) movement of e.g. 2-s hold and repeated 3 times, should concen- the indicator. trate initially on increasing endurance (hold time) and then the number of repetitions. This is strength. If the woman demonstrates fatigue best done by encouraging submaximal contrac- (short hold time and few repetitions), then the tions and gradually increasing the hold time to number of repetitions is increased and longer 10s. On subsequent visits to the clinician, the submaximal contractions are prescribed. The muscle contractility is assessed and the exercise goal is to eventually hold a maximum voluntary program advanced to satisfy overload. contraction (MVC) for 10s and repeat 10 times, while breathing normally. All exercises should be Many women have difficulty in maintaining a done sitting and standing, or lying if the muscles normal breathing pattern during voluntary PFM are very weak . exercises. When this occurs, biofeedback is a useful tool to help both the woman and the clini- Published trials have shown successful treat- cian to understand how the PFMs are behaving. ment of SUI by PFM exercise using a variety of First the woman is asked to breathe in; then, as exercise regimens. Therefore, it is advantageous she breathes out, she is instructed to gently to negotiate an individual regimen tailored to the tighten the PFMs (and transversus abdominis). circumstances and needs of each woman. For This contraction is held while continuing to example, a woman in full-time employment may breathe in and out. As the technique is learned, be limited to doing her exercises before and after which may take several days or weeks, the woman work. It is best to be realistic in planning the is encouraged to perform a stronger PFM con- exercise program, as too difficult a schedule may traction while maintaining normal breathing. result in noncompliance. Exercise Progression and Active Use To satisfy overload, it is necessary to evaluate ofMuscles the strength of a MVe, the endurance (hold time) , and the number of repetitions the woman is As PFM control improves, contractions generally capable of performing before the muscle output become stronger and longer. Once a woman can drops to below 50% of the MVC. This can be done sustain a PFM contraction for 5 s, fast, I-s Mves via the aforementioned digital palpation using may be added to the exercise program. In addi- the P.E.R.F.E.e.T. scheme\" or a perineometer tion, when breathing control has been estab- (manometric or electromyographic). To keep the lished, the woman can progress to holding a PFM home exercise program simple, one should con- contraction while balancing on an exercise ball centrate initially on either strength or endurance, and/or walking. Finally, the woman is taught how whichever is the weakest component. For example, to prevent urine loss using a voluntary contrac- a woman with a weak PFM contraction, which she tion of the PFMs before and during a cough or can hold for 5 s and repeat 6 times, would initially any increase in intraabdominal pressure that has precipitated an incontinent episode. This tech- nique has been called counter-bracing, \"The Knack,'\" and the \"stress strategy.\" Review and Follow-Up Although the woman follows a home practice regimen, it is best to have regular follow-up visits to ensure that she is progressing, and to encour- age her to adhere to her program. The number of treatment sessions depends on resources and the woman's progress. Published trials have used various protocols, and there is no agreement

4.2. Stress Urinary Incontinence 225 amongst clinicians regarding the minimum or who only leak urine during occasional physical optimum number of treatment sessions required. activities, such as tennis, and many report that One approach is to see the woman once per week they prefer to use a special continence tampon for 4 weeks and once per month for the next 3 than to wear an incontinence pad. The studies months, with a final review visit after another 2 quoted suffer from several problems, including months. This entails a total of 8 treatment ses- the lack of blinding, lack of randomized design, sions over a period of 6 months. and use of patients as their own controls; thus, further research is needed to ensure the safety A less expensive method is to see the patient in and efficacy of these devices. a group of women with similar problems. In the group model, the initial session includes educa- Pharmacological Therapy tion (see Education), followed by an individual session for PFM assessment. After this, if the Stress urinary incontinence is not a dichotomous woman has a voluntary PFM contraction, she condition; that is to say, a woman does not wake attends a series of group sessions to strengthen up one morning to find that she is suddenly the PFMs over a 4-month period. This is followed leaking with every movement and every cough. by an individual review 2 months later to assess In most cases, the incontinence begins with both symptoms and muscle strength. minor occasional loss of urine and increases in frequency and volume until it becomes a problem If there is no response after 6 months of treat- and she wishes treatment. Thus, there is a ratio- ment, despite convincing compliance, then a dif- nale for step -wise treatment of stress inconti- ferent approach may be needed. Perhaps the nence with medication and pelvic floor education, addition of biofeedback or electrical stimulation increasing to higher-risk treatments, such as (if not given previously) may be warranted. If the surgery, only for those whose incontinence pro- woman admits to not doing sufficient exercises, gresses in severity despite other treatments. alternative treatment or management should be sought. Alpha-Agonists One such technique is the use of an intravagi- The rationale for the pharmacological treatment nal tampon-like device, or a urethral insert. The of stress urinary incontinence has focused on vaginal devices are generally easier to use; they increasing the smooth muscle and striated have been developed to produce upward pressure sphincter muscle of the urethral closure mecha- around the bladder neck, reducing mobility. nism. Alpha-agonists are a class of drugs that Several urethral inserts have been tested/but dis - stimulate and increase the smooth muscle tone in comfort, hematuria, and urinary tract infections all parts of the body. Phenylpropanolamine has have questioned the long-term safety of these the best data, and was found to cure SUI in 0-14% devices. An example of a vaginal device - the and reduce SUI in a further 19-60% of subjects Conveen Continence Guard - is a shaped foam (summary data from eight randomized con- tampon with a plastic applicator. The tampons trolled trials [RCTs], AHCPR 1005).13 are available in three sizes, and before use they are soaked in water, which doubles their size. The Cochrane Collaboration recently reviewed Twenty-six women tested the Continence Guard,\" 15 randomized trials of alpha-agonists, including with 41% reporting continence with the device phenylpropanolamine (11 trials), midodrine (2 in situ, and a further 45% reported significant trials), and clenbuterol (2 trials), and found only improvement. After a further 12 months use by weak evidence to suggest that adrenergic ago- 19 women, 68% were subjectively dry and 26% nists were better than placebo . However, phenyl- were improved; furthermore, 86% were objec- propanolamine was removed from the market in tively improved on repeat pad testing and there 2000 after it was recognized that there was an were no serious complications reported.\" These increased risk for hemorrhagic stroke.\" Although data have been confirmed in a larger study (n = the use of alpha-agonists for SUI is theoretically 126) which demonstrated that 75% were conti- attractive, we await the development of more nent or improved.\" In addition to reducing/elim- \"uroselective\" drugs. inating daily urine loss in women with moderate to severe SUI, these tampons are useful for women

226 J.Laycock Hormone Therapy stress and mixed incontinence. It has systemic anticholinergic side effects, which are not bladder Estrogen therapy has been suggested for SUI specific, and also seems to inhibit the reuptake because estrogen receptors do exist in the urethra. of norepinephrine and serotonin. There are no Thus, the hormone should improve mucosal RCTs, and two open studies have demonstrated coaptation, increase vascular tone, and maintain mild positive effects.V\" Imipramine should be collagen content of the urethra. The Cochrane used with caution in the elderly because of its Collaboration recently reviewed estrogen therapy well-known potential for arrhythmias.\" for incontinence. The analysis is made difficult by the small number of women included in trials Selective Serotonin-Norepinephrine specifically designed to look at incontinence, and Reuptake Inhibitors the small number of RCTs with placebo . They concluded that estrogen had a positive effect on Duloxetine is a potent inhibitor of norepineph- UI overall, with 50% cure or improvement seen rine and serotonin reuptake that has been inves- in the 28 clinical trials compared to 25% seen tigated for the treatment of stress incontinence.\" with placebo, but that the effect was greater for In theory, both duloxetine and imipramine urge than for stress incontinence. However, these increase the activity of the urethral rhabdo- conclusions are based on 374 women on estrogen sphincter at the spinal cord level (Onuf's nucleus), versus 344 on placebo, including some studies thus, augmenting storage properties of the with as few as 16 subjects in each arm. Two large urethra without compromising emptying prop- American studies found that hormone replace- erties. The drug has been shown to have a moder- ment (HR) increased the risk of stress inconti- ate effect on improving stress incontinence when nence, but both were designed to study HR in compared to placebo, regardless of the severity of relation to heart disease. Jackson and colleagues the incontinence.\" :\" Duloxetine is the only drug analyzed data from a large cohort of 1,584 white approved for use in stress incontinence in Europe, and black women, aged 70-79 years, and found a but is not approved in the U.S. two-fold increased risk of stress incontinence in estrogen users (odds ratio (OR) 2.0, 95% confi- Summary dence interval (CI) 1.3_3.1).15 In a large RCT of combined estrogen/progesterone HR in over There is a need for pharmacological treatment of 2,700 women less than 80 years of age, inconti- stress urinary incontinence, as it offers an alter- nence improved in 26% of the women assigned to native to other conservative treatments that may placebo compared with 21% of those on HR. be more acceptable in some individuals. However, Incontinence worsened in 27% of the placebo only duloxetine has been shown to be effective in group versus 39% of the HR group. \" randomized trials, and is the only medication approved for use in stress incontinence. A major difficulty with the Cochrane analysis is that so few studies of topical estrogen therapy References versus placebo were available. Now that it would appear that systemic HR is not useful to treat 1. DeLancey JOL, Starr RA. Histology of the connec- incontinence, more data are needed about the tion between the vagina and levator ani muscles. efficacy of vaginal estrogens. Most continence J Reprod Med. 1990;35:765-771. clinicians use local estrogens to improve atrophic symptoms, so that evidence is urgently needed 2. BoK, SteinR. Needle EMG registration ofstriated regarding the effect of this therapy upon stress urethral muscle walland pelvic floor muscle activ- incontinence. The Cochrane report does not ity patterns during cough, valsalva, abdominal, provide this subset analysis. hip adductor and gluteal muscle contractions in nulliparous healthy females. Neurourol Urodyn. Tricyclic Antidepressants 1994;13:35-41. Imipramine is a tricyclic antidepressant that has been used for many years in the treatment of 3. Laycock J, Standley A, Crothers E, et al. Patient education and management. In: Clinical guide-

4.2. Stress Urinary Incontinence 227 lines for the physiotherapy management of females 13. Fantl JA, Newman DK, Colling J, et al. Urinary aged 16 to 65 years with stress urinary inconti- incontinence in adults: acute and chronic manage- nence . London: Chartered Society of Physiother- ment. Clinical practice guidance, No.2. 1996. apy; 2001:19. Update; Rockville, MD: U.S. Department of Health 4. Bo K, Hagen RH. Pelvic floor muscle exercise in and Human Services. Public Health Service, the treatment of female stress urinary inconti- Agency for Health Care Policy and Research. nence; effects of two different degrees of pelvic AHCPR Publication No. 96-0682 floor muscle exercises . Neurourol Urodyn. 1990;9: 489-502. 14. Kernan WN, Viscoli CM, Brass LM, et al. Phenyl- 5. Demain S, Fereday Smith J, Hiller L, et al. Com- propanolamine and the risk of hemorrhagic parison of group and individual physiotherapy for stroke. N Engl J Med. 2000;343(25):1826-1832. female urinary incontinence in primary care . Physiotherapy 2001;87(5):235-242 . 15. Jackson RA, Vittinghoff E, Kanaya AM, et al. 6. Laycock J, Ierwood D. 2001. Pelvic floor assess- Urinary incontinence in elderly women: findings ment : the P.E.R.F.E.C.T. scheme. Physiotherapy. from the Health, Ageing, and Body Composition 2001;87(12):631-642. Study. Obstet Gynecol. 2004;104(2):301-307. 7. Miller JM, Ashton-Miller JA, DeLancey J. 1998. A pelvic muscle pre-contraction can reduce cough- 16. Grady D, Brown JS, Vittinghoff E, et al. HERS related urine loss in selected women with mild Research Group. Postmenopausal hormones and SUI. J Am Geriatr Soc. 1998;46:870-874. incontinence: the Heart and Estrogen/Progestin 8. Burgio KL, Whitehead WE, Engel BT. Urinary Replacement Study. Obstet Gynecol. 2001;97(1): incontinence in the elderly: bladder/sphincter bio- 116-120. feedback and toileting skills tra ining. Ann Intern Med. 1985;103:507-515. 17. Gilja I, Radej M, Kovacic M, et al. Conservative 9. Tincello D. Prosthetic devices , inserts and plugs treatment of female stress incontinence with imip - for the management of stress incontinence. In: ramine. J Urol. 1984;132(5):909-911. Therapeutic management of incontinence and pelvic pain. Laycock J, Haslam J, editors. London: 18. Lin HH, Sheu BC, Lo MC, et al. Comparison of Springer-Verlag; 2002:91-94. treatment outcomes for imipramine for female 10. Thyssen H, Lose G. New disposable vaginal device genuine stress incontinence. Br J Obstet Gynaecol. (continence guard) in the treatment of female 1999;106(10):1089-1092. urinary stress incontinence. Design, efficacy and short term safety. Acta Obstet Gynecol Scand . 19. Glassman AH. Cardiovascular effects of tricyclic 1996;75:170-173. antidepressants. Annu Rev Med. 1984;35:503-511. 11. Thyssen H, Lose G. Long term efficacy and safety of a disposable vaginal device (continence guard) 20. Thor KB. Serotonin and norepinephrine involve- in the treatment of female urinary stress inconti- ment in efferent pathways to the urethral rhabdo- nence. Int Urogynecol J. 1997;8(133):130-132. sphincter: implications for treating stress urinary 12. Hahn I, Milson I. Treatment of female urinary incontinence. Urology. 2003;62(4 Suppl 1):3-9. stress incontinence with a new anatomically shaped vaginal device (Conveen Continence 21. Dmochowski RR, Miklos JR, Norton PA, et al. Guard) . Br J Urol. 1996;77:711-715. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170(4 Pt 1):1259- 1263. 22. van Kerrebroeck P, Abrams P, Lange R, et al. Duloxetine versus placebo in the treatment of European and Canadian women with stress urinary incontinence. BJOG. 2004;111(3):249 - 257.

4.3 Evidence for the Effectiveness of Pelvic Floor Muscle Training in the Treatment and Antenatal Prevention of Female Urinary Incontinence E. Jean C. Hay-Smith and Kate H. Moore Key Messages during pregnancy can prevent antepartum or postpartum urinary incontinence in women • Pelvic floor muscle training (PFMT) can cure without prior symptoms, and whether PFMT or improve incontinence symptoms and reduce during pregnancy is an effective treatment for voiding frequency, leakage frequency, and existing urinary incontinence. Because questions amount of leakage. about the effectiveness of an intervention are best addressed in randomized controlled trials (RCTs), • Women of all ages with stress, urge, or mixed the chapter summarizes the evidence from exist- incontinence can all benefit from PFMT. ing systematic reviews of RCTs of PFMT. • Clinicians should provide the most intensive Treatment ofUrinary Incontinence PFMT supervision available. This section summarizes evidence from existing • Supervision can be provided in individual or systematic reviews' r' that recruited women with group settings. existing stress, urge, or mixed urinary inconti- nence and used a PFMT program (but not PFMT • There is no additional benefit of adding bio- in conjunction with a scheduled voiding regimen) feedback (BF) in the initial PFMT program. in one or more branches of the study. • Antepartum PFMT can prevent postpartum incontinence, especially in women with in- creased bladder neck mobility. Introduction The purpose of the first part of this chapter is to Is PFMT Better than No Treatment or review the evidence for the effectiveness ofPFMT Control Treatments? as a treatment for urinary incontinence in women, and discuss the implications for clinical practice. PFMT has been compared to no treatment in 5 It is questioned whether PFMT is better than published, peer-reviewed trials.\"? Single trials no treatment or control treatment, whether one found that women who received PFMT had sig- approach to PFMT is better than another, and nificantly fewer leakage episodes and voids in 24 what the factors are that might affect treatment hours.Y Data from a variety of pad tests suggest outcome. The second part of this chapter reviews that the proportion of women who were cured or the evidence for the effectiveness of antepartum improved was greater, or the mean amount of PFMT for the prevention and treatment of urinary leakage was less, in the PFMT group.3-5.7 Most of incontinence. It is considered whether PFMT the training parameters suggest that the PFMT 228

4.3. Evidence for the Effectiveness of Pelvic Floor Muscle Training 229 programs were intended to increase muscle or improved, and that voiding frequency, leakage frequency, and amount of leakage were signifi- strength or endurance, although in one trial the cantly reduced. Women of all ages with stress , urge, or mixed incontinence showed benefit. aim was to improve the timing of a contraction Effect size was greater in some trials than others, but with so little data, it was not clear if the in response to a rise in intraabdominal pressure differences reflected methodological rigor, the sample characteristics (e.g, diagnosis and age), (Table 4.3.1). the training program, or other factors. Six trials compared PFMT with control treat- Is One Approach to PMFT Better than Another? ments, including placebo drug,\" sham electrical Trials have investigated the differences in exer- stimulation,\" offer of an anti-incontinence cise parameters, the amount of contact with health care professionals, the type of supervision, device,\" advice on use of incontinence pads,\" and the addition ofBF, intravaginal resistance, or a cue to exercise. and written information about bladder function The two studies that addressed differences and PFMT. 12 13 Pooled data suggested that patients in exercise parameters compared strength • with endurance training,\" and motor learning/ strength training with motor learning alone, IS in who received PFMT were about one and a half women with stress urinary incontinence. Neither found significant differences between the groups times more likely to report that they were cured for leakage episodes; nor were there differences in self-reported cure or improvement in the latter or improved with treatment and had significantly study. These studies challenge the idea that the primary purpose ofPFMT should be to strengthen fewer leakage episodes in 24 hours (approxi- mately 2 less every 3 days). The studies recruited younger women with urodynamic stress inconti- nence (mean ages between 40 and 50 years) and older women with detrusor overactivity or mixed urinary incontinence (average age 50 to 70 years). All of the PFMT programs had characteristics of strength and/or endurance training, and two included the advice to contract the pelvic floor muscles to prevent leakage with raised intraab- dominal pressure or with urgency (Table 4.3.1). In summary, the data favored PFMT and sug- gested that women who received PFMTwere more likely to report that their symptoms were cured TABLE 4.3.1. Description ofPFMT programs PFMT program Trial Diagnosis 10 VPFMC (S second hold, 10second rest), 3times aday, daily for8weeks. Progressed to 10second hold and 20second rest. Aksac et al.2003 USI 8to 12 high intensity VPFMC (6to 8 second hold, 6 second rest), 3 times a day, daily at Bo et al.1999 USI home, and aweekly PFMT exercise class for6 months. Burgio et al.1998 DO±USI 15 VPFMC (10 second hold), 3 times a day, daily for8 weeks. VPFMC with activities and 2002 USI±DO likely to cause leakage (e.g. urgency). Burns et al. 1993 20VPFMC (10 fast with 3 second hold, 10sustained with 10 second hold), 4times a day, daily for8 weeks. Progressed by10 VPFMC perset, to amaximum of 200 contractions Goode et al.2003 USI ± DO per day. Henalla et al.1989 USI 15 VPFMC (2to 4 second hold, equal period ofrest) , 3times aday for 8 weeks Lagro-Janssen et al.1991 SUI Progressed to 10second hold and 10 second rest. VPFMC withactivities likely to cause Miller et al.1998 SUI Yoon et al.2003 UI leakage (e.g. cough). 5VPFMC (5second hold), 5 times an hour, daily for 12 weeks. 10VPFMC (6second hold), 5 to 10times aday for 12 weeks. VPFMC before cough and held until abdominal wallrelaxed, forone week. 30 VPFMC (strength and endurance) daily for8 weeks. DO, detrusor overactivity; PFMT, pelvic floormuscle training; SUI, stress urinary incontinence; UI, urinary incontinence; USI, urodynamic stress inconti- nence; VPFMC, voluntary pelvic floormuscle contraction.

230 E.J.C. Hay-Smith and K.H. Moore the muscles, but the width of the confidence Summary intervals in these trials did not rule out poten- tially important differences. There is evidence that PFMT is an effective treat- ment for female urinary incontinence. Women In two small trials, women with stress urinary with stress, urge, or mixed incontinence seem to incontinence received PFMT, but women in one benefit. Because follow up data (not presented study arm had much more contact with the here) are sparse and difficult to interpret, the supervising physiotherapist.I':\" Pooled data longer-term benefits are less clear. found that women in the intensive supervision group were 4 times more likely to report improve- The limited evidence defining the best PFMT ment. Two further studies compared 3 to 4 ses- program suggests that: (a) clinicians should sions of individual PFMT instruction with provide the most intensive PFMT supervision standard care (e.g, information on PFMT during possible within service constraints, (b) supervi- postnatal class) in postnatal women with urinary sion can be provided in individual or group set- incontinence symptoms 3 months after deliv- tings, (c) there is no additional benefit of adding ery.18.19 Pooled data showed women receiving BF in the initial PFMT program. Although Table individual instruction were about a third more 4.3.1 describes a range of programs that have likely to report continence at 12 months postpar- demonstrated effect, much more research is tum than women receiving standard care. One required to determine which type of exercise large trial compared group versus individual program or parameters are most beneficial, and supervision of PFMT in women with symptoms for which groups of women. This review is of urinary incontinence.\" There were no signifi- restricted to RCTs, which provide the best evi- cant differences in the number of women report- dence of effectiveness. In addition, there is also a ing cure or the number of leakage episodes in 24 large literature, which does not meet the strict hours at neither 12 weeks nor 9 months later. In criteria for this review, but which also helps summary, it is possible that more supervisory establish the effectiveness ofPFMT. Clearly, there contact with a health care professional is better is a growing body of evidence supporting PFMT than less, but it might not matter whether this and enough evidence to justify the recommenda- contact is given individually or in a group tion that supervised PFMT is included in the setting. treatment choices offered to women with urinary incontinence. Four trials investigated the addition of home- based\" or home- and clinic-based biofeed- Antepartum Pelvic Floor Muscle back7,22.23 to a PFMT program for women with Training to Prevent Postpartum stress urinary incontinence. Pooled data found Urinary Incontinence no significant difference between the BFand non- BF groups for self-reported cure or improve- This section summarizes the evidence from merit.\":\" Five trials compared PFMT and clinic existing systematic reviews of RCTs of PFMT in BFwith PFMTalone in women with stress urinary pregnant women.v\" :\" Studies that were included incontinence' P':\" or urge urinary incontinence.27 in these systematic reviews recruited pregnant women, with or without existing urinary incon- There was no significant difference between the tinence, and used a PFMT program in one or BF and non-BF groups for self-reported cure in more arms of the study. pooled data (from 2 trials) or leakage episodes in 24 hours (from 3 trials) . From these data, it There are three grades of prevention: primary appeared that PFMT with adjunctive home or (to remove the cause of a disease), secondary (to clinic-based BFwas no more effective than PFMT detect asymptomatic dysfunction and intervene alone in the short term. to stop progression), and tertiary (treatment of existing symptoms to stop progression).\" In this Finally, there were too few data from the 2 small trials investigating the effect of intravagi- nal resistance\" or electronic cue to exercise\" to draw any conclusions about the effects of either approach.

4.3. Evidence fortheEffectiveness of Pelvic Floor Muscle Training 231 chapter, any study that recruited only pregnant gestation, respectively. The training parameters women without existing urinary incontinence suggest that the purpose of the PFMT programs symptoms was considered to be a primary or sec- was to increase muscle strength, rather than ondary prevention study; these studies addressed endurance or the timing of a contraction (Table the question of whether PFMT during pregnancy 4.3.2). In all three trials, the controls received can prevent antepartum or postpartum inconti- usual antepartum care, which may have included nence. However, most studies to date have advice on PFMT. recruited pregnant women (some with and some without existing urinary incontinence), so they With regard to the effect of antepartum PFMT cannot answer questions about prevention. on preventing antepartum incontinence, one Although such studies have mixed prevention trial\" found that women in the PFMTgroup were and treatment effects, they can address the ques- about half as likely to be incontinent at 36 weeks tion of whether PFMT during pregnancy reduces gestation. In contrast, another trial\" found that the prevalence of antepartum or postpartum urinary incontinence severity was not signifi- urinary incontinence. cantly different between the groups at 35 weeks. Can PFMT During Pregnancy Prevent Similarly, there was a mixed picture for the Antepartum and/or Postpartum preventive effect of antepartum PFMT on post- Urinary Incontinence in Women partum incontinence. One study\" found that Without Prior Symptoms? women receiving PFMT were about half as likely to report urinary incontinence at 3 months post- Three published, peer-reviewed trials compared partum, whereas another\" did not find any sig- supervised PFMTwith standard antenatal care.\":\" nificant difference. The third\" found significantly Although Merkved and colleagues\" and Samp- less incontinence severity in the PFMT group at selle and coworkers\" included women with prior 6 weeks postpartum. incontinence symptoms, data were also available for the subgroup of women without existing Medium- to long-term effects also varied. symptoms. Sampselle et al. did not find any significant dif- ference in incontinence severity between the Reilly and colleagues\" recruited primigravid groups at 6 or 12months (the primary endpoint).35 women without a prepregnancy or current history At four years, Reilly and colleagues\" found that of urinary incontinence, but with bladder neck women from the training group were still less hypermobility (more than 5 mm linear move- likely to report urinary incontinence, although ment on perineal ultrasound) at 18to 20 weeks of only 100 of the original sample of 268 women gestation. Merkved et al. 33 and Sampselle et al. 35 responded.\" also recruited primigravidae at 18 and 20 weeks In summary, 3 trials of moderate to good quality, have addressed the effect ofPFMT during pregnancy for prevention of antepartum and postpartum urinary incontinence. The findings suggest that women who are potentially at greater TABLE 4.3.2. Description of antepartum PFMT programs* PFMT program Trial Sample 8 to 12 near maximal VPFMC (6to 8 seconds hold with3to 4fast Morkved etal.2003 Primigravid women at 18 weeks gestation contractions attheend of each contraction, followed by6 seconds rest), twice aday, and weekly exercise class (including Reilly et al. 2002 Primigravid women, withbladder neck PFMT) from weeks 20 to 36. Sampselle etal.1998 hypermobility, at18to 20 weeks gestation 8 to 12 VPFMC (6second hold, 2second rest), twice aday. Primigravid women at 20 weeks gestation Up to 30near maximal VPFMC perday. PFMT, pelvic floormuscle training; VPFMC, voluntary pelvic floormuscle contraction. * Hughes etaldoes notappear here as theirPFMT program was notdescribed intheabstract.

232 E.J.C. Hay-Smith and K.H. Moore risk of developing urinary incontinence (i.e. third sudy\" found no significant differences in those with bladder neck hypermobility at 18 incontinence severity between the groups at 6 weeks of gestation) benefit from antepartum weeks, 6 months, or 12 months postpartum. PFMT with half the risk of urinary incontinence at 3 months postpartum. This effect might last as Of these three trials in samples of pregnant long as 4 years. The findings from the other two women (with and without incontinence symp- trials are conflicting; it is not clear if antepartum toms when PFMT began), only one\" found the PFMT reduces prevalence of urinary inconti- prevalence of antenatal and postnatal inconti- nence or incontinence severity (antepartum or nence to be significantly reduced in the women postpartum) in pregnant women without incon- who received PFMT; the 95% confidence intervals tinence symptoms at the onset of PFMT. suggested reduction in prevalence of 10-50% for antepartum incontinence and 10-60% for post- Can PFMT in Pregnant Women partum incontinence. Based on the description of (Regardless ofContinence Status) PFMT, women in this positive trial had more Reduce the Prevalence of regular contact with a health care professional Antepartum and/or Postpartum while training because they attended a weekly Urinary Incontinence? exercise class in addition to PFMT at home. It might be that to reduce the prevalence of urinary Two published trials (see previous sectionl.P:\" incontinence in antepartum and postpartum and one that, so far, has only appeared as a pub- women, intensively supervised programs and/or lished abstract of the International Continence regular exercise classes, in addition to home Society,37 were included. The trial by Hughes and training, are necessary. co-workers recruited nulliparous women at 20 weeks gestation and randomized them to super- Conclusion vised antepartum PFMT (individual appoint- ment with physiotherapist followed by one group Based on the limited evidence to date, it seems session) or the usual community antenatal care.\" that antepartum PFMT can prevent postpartum There was no description of the PFMT program urinary incontinence (at 3 months) in primipa- in the abstract. rous women with increased bladder neck mobil- ity but no incontinence symptoms. This effect Regarding the effect of PFMT during preg- might last as long as 4 years. Furthermore, an nancy on the prevalence of antepartum urinary antepartum PFMTprogram comprising a weekly incontinence, one trial\" found that the PFMT exercise class, in addition to home training, group was approximately 30% less likely to expe- might reduce the prevalence of antepartum (at 36 rience urinary incontinence at 36 weeks gesta- weeks) and postpartum urinary incontinence (at tion. Another\" reported no statisticallysignificant 3 months) . difference in the odds of stress, urge, or \"sponta- neous\" incontinence (not associated with exer- Thus, clinicians who are caring for childbear- tion or urgency) between the groups. The third \" ing women should consider first whether their did not find any significant difference in inconti- current approach is targeting women who might nence severity at 35 weeks. benefit most (i.e. women with bladder neck hypermobility at 18 weeks of pregnancy, but no The effect on prevalence of postpartum incon- urinary incontinence), and second, whether it is tinence also varied. One trial\" reported that sufficiently intensive. women in the PFMT group were approximately 40% less likely to be incontinent at 3 months References postpartum, whereas another\" did not find any difference in the odds of stress, urge, or unex- 1. Wilson PO, Hay-Smith }, Nygaard I, et al. Adult plained urinary incontinence at 6 months post- conservative management. In: Incontinence. Vol. partum. Analysis of unpublished data from the 2. Management, Abrams P, Cardozo L, Khoury 5, Wein A, editors . Health Publication, Ltd.; 2005: 855-964.

4.3. Evidence for theEffectiveness of Pelvic Floor Muscle Training 233 2. Hay-Smith EJC, Bo K, Berghmans LCM, et al., 14. Johnson VY. Effects of a submaximal exercise pro - 2001. Pelvic floor muscle training for urinary tocol to recondition the pelvic floor musculature. incontinence in women. (Cochrane Review) In: Nurs Res. 2001;50:33-41. The Cochrane Library, Issue 1. Update Software: Oxford. 15. Hay-Smith EJC. Pelvic floor muscle training for female stress urinary incontinence. Dunedin 3. Henalla SM, Hutchins CJ, Robinson P, et al. Non- School of Medicine. Dunedin, New Zealand: Uni- versity of Otago; 2003. operative methods in the treatment of female genuine stress incontinence. J Obstet Gynaecol. 16. Bo K, Hagen RH, Kvarstein B, et al. Pelvic floor 1989;9:222-225. muscle exercise for the treatment of female stress 4. Miller JM, Ashton-Miller JA, DeLancey JOL. A urinary incontinence: III. Effects of two different pelvic muscle precontraction can reduce cough- degrees of pelvic floor muscle exercise. Neurourol related urine loss in selected women with mild Urodyn . 1990;9:489-502. SUI. J Am Geriatr Soc. 1998;46:870-874. 5. Yoon HS, Song HH, Ro YJ. A comparison of effec- 17. Wilson PD, Al Samarrai T, Deakin M, et al. An tiveness of bladder training and pelvic muscle objective assessment of physiotherapy for female exercise on female urinary incontinence. Int J genuine stress incontinence. Br JObst Gynaecol. Nurs Stud. 2003;40:45-50. 1987;94:575-582. 6. Burns PA, Pranikoff K, Nochajski TH, et al. A comparison of effectiveness of biofeedback and 18. Glazener CM, Herbison GP, Wilson PD, et al. Con- pelvic muscle exercise treatment of stress inconti- servative management of persistent postnatal nence in older community dwelling women. J urinary and faecal incontinence: randomised con- Gerontol. 1993;48:M167-M174. trolled tria l. BMJ. 2001;323:593-596. 7. Aksac B, Aki S, Karan A, et al. Biofeedback and pelvic floor exercises for the rehabilitation of 19. Wilson PD, Herbison GP. A randomized controlled urinary stress incontinence. Gynecol Obst Invest. trial of pelvic floor exercises to treat postnatal 2003;56:23 -27. urinary incontinence. Int Urogynecol J Pelvic 8. Burgio KL, Locher JL, Goode PS, et al. Behavioral Floor Dysfunct. 1998;9:257-264. vs. drug treatment for urge urinary incontinence in older women: a randomized controlled trial. 20. Janssen CC, Lagro-Ianssen AL, Felling AJ. The JAMA. 1998;280:1995-2000. effects of physiotherapy for female urinary incon- 9. Hofbauer VJ, Preisinger F,Nurnberger N. Der stel- tinence: individual compared with group treat- lenwert der physikotherapie bei der weiblichen ment . BJU Int. 2001;87:201-206. genuinen streB-inkontinenz. Zeitschrift fur Urol- ogie und Nephrologie. 1999;83:249-254. 21. Shepherd A, Montgomery E, Anderson RS. A pilot 10. Bo K, Talseth T, Holme I. Single blind, randomised study of a pelvic exerciser in women with stress controlled trial of pelvic floor exercises, electrical incontinence. J Obstet Gynaecol. 1983;3:201-202. stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in 22. Aukee P, Immonen P, Penttinen J, et al. Increase women. BMJ. 1999;318:487-493. in pelvic floor muscle activity after 12 weeks' 11. Lagro-Janssen TLM, Debruyne FMJ, Smits AJA, training: a randomized prospective pilot study. et al. Controlled trial of pelvic floor exercises Urology. 2002;60:1020-1023. in the treatment of urinary stress incontinence in general practice. Br J Gen Pract. 1991;41:445- 23. Merkved S, Bo K, Pjertoft T. Effect of adding bio- 449. feedback to pelvic floor muscle tra ining to treat 12. Burgio KL, Goode PS, Locher JL, et al. Behavioral urodynamic stress incontinence. Obstet Gynecol. training with and without biofeedback in the 2003;100:730-739. treatment of urge incontinence in older women: a randomized controlled trial. JAMA. 2002;288: 24. Berghmans LCM, Frederiks CMA,de BieRA, et al. 2293-2299. Efficacy of biofeedback, when included with pelvic 13. Goode PS, Burgio KL, Locher JL, et al. Effect of floor muscle exercise treatment, for genuine stress behavioral training with or without pelvic floor incontinence. Neurourol Urodyn . 1996;15:37-52. electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA. 25. Glavind K, Nohr SB, Walter S. Biofeedback and 2003;290:345-352. physiotherapy versus physiotherapy alone in the treatment of genuine stress urinary incontinence. Int Urogynecol J. 1996;7:339-343. 26. Pages I, [ahr S, Schaufele MK, et al. Comparative analys is of biofeedback and physical therapy for treatment of urinary stress incontinence in women. Am J Physical Med Rehabil. 2001;80: 494-502 . 27. Wang AC, Wang Y-Y, Chen M-C. Single-blind, ran- domized trial of pelvic floor muscle training,

234 E.J.C. Hay-Smith and K.H. Moore biofeedback-assisted pelvic floor muscle training, 33. Merkved S, B0 K, Schei B, et al. Pelvic floor muscle and electrical stimulation in the management of training during pregnancy to prevent urinary overactive bladder. Urology. 2004;63:61-66. incontinence: a single-blind randomized con- 28. Ferguson KL, P.L. M, Bishop KR, et al. Stress trolled trial. Obstet Gynecol. 2003;101:313-319. urinary incontinence: Effect of pelvic muscle exer- cise. Obstet Gynecol. 1990;75:671-675. 34. Reilly ET, Freeman RM, Waterfield MR, et al. Pre- 29. Sugaya K, Owan T, Hatano T, et al. Device to vention of postpartum stress incontinence in pri- promote pelvic floor muscle training for stress migravidae with increased bladder neck mobility: incontinence. Int. J Urol., 2003;10:416-422. a randomised controlled trial of antenatal pelvic 30. Harvey MA. Pelvic floor exercises during and after floor exercises. BJOG. 2002;109:68-76. pregnancy: a systematic review of their role in pre- venting pelvic floor dysfunction. JOGC. 2003;25: 35. Sampselle CM, Miller JM, Mims BL, et al., Effect 487-498. of pelvic muscle exercise on transient inconti- 31. Hay-Smith J, Herbison P, Morkved S, 2002. Physi- nence during pregnancy and after birth. Obstet cal therapies for prevention of urinary and faecal Gynecol. 1998;91:406-412. incontinence in adults. (Cochrane Review.) In: The Cochrane Library. Issue 3. Update Software: 36. Udayakankar V,Steggles P,Freeman RM, et al. Pre- Oxford. vention of stress incontinence by antenatal pelvic 32. Hensrud DD. Clinical preventive medicine in floor muscle exercises (PFE) in primigravidae with primary care: background and practice: 1. Ratio- bladder neck mobility: A four year follow up nale and current preventive practices. Mayo Clinic [Abstract 219]. Int Urogynecol J. 2002;13:S57-58. Proceedings. 2000;75:165-172. 37. Hughes P, Jackson S, Smith P, et al. Can antenatal pelvic floor exercises prevent postnatal inconti- nence [Abstract 49]. Neurourol Urodyn . 2001;20: 447-448 .

4.4 Postpartum Management of the Pelvic Floor Pauline E. Chiarelli Key Messages plinary approach, which is described in this chapter. Continence promotion in the postpartum period involves a multicomponent approach. Postpartum Perineal Management • Postpartum perineal management includes wound care, preparing for the first bowel move- In addition to trauma affecting the deeper struc- ment, and minimizing perineal descent. tures of the pelvic floor, many women suffer • Pelvic floor muscle (PFM) rehabilitation painful trauma to the superficial structures of the should be routine for all postpartum women, perineum. Evidence supporting the morbidity and should be tailored for those with associated with per ineal repair includes wound i n co nt in en ce. breakdown, which is reported in 6% of women • Continence promotion includes patient educa- while in hospital and 12% at home up to 8 weeks tion, good bladder habits, PFM assessment and postpartum.' Other morbidity, such as mild or exercises, compliance aids, and follow-up moderate edema at 3 to 4 days postpartum, has contact. been reported in 59% of women.' Introduction In the presence of perineal discomfort, PFM contraction can be painful, and there is little like- One of the most socially devastating sequelae of lihood that women might feel motivated to vaginal delivery is PFM damage and the subse- undertake PFM exercises routinely in the post- quent loss of bladder or bowel control. The expul- partum. Pain is known to inhibit muscle contrac- sive forces of the fetal head as it descends through tion and alter the timing of the onset of reflex the birth canal lead to overstretching of both muscle contractions .51n view of the prevalence of nerve and muscle tissues, which do not always perineal trauma (sutured or otherwise) and its undergo full recovery. Such trauma can result perceived impact on PFM exercise, it is reason- in symptoms of urinary incontinence or anal able to routinely inform women about the best sphincter incompetence, including incontinence management practices related to postpartum of feces or flatus and fecal urgency,' Symptoms perineal trauma. Suggested care practices are such as these are both embarrassing and debili- shown in Table 4.4.1. tating, and although they may be transient following a first vaginal delivery, subsequent The discomfort of perineal suturi ng and PFM deliveries are likely to cause further deteriora- trauma might also have wider implications for tion.! Continence promotion in the postpartum women in the postpartum, and information period involves a multicomponent, multidisci- about constipation and perineal support to mini- mize perineal descent during defecation might need to be included within any postpartum con- tinence promotion program. 235

236 P.E. Chiarelli TABLE 4.4.1. Outline ofsuggested postpartum perineal care practices Suggested Practice PracticeDetails Wound care Point out: Familiarization • the incision line Use a hand mirror to view the perineum • any visible sutures togetherwith the woman • lacerations • bruising • hemorrhoids Does the woman admit to the presence of perineal swelling? Wound hygiene Soap and water as preferred wound hygiene Management of swelling /bruising Rinse down following urination or bowel motion while sitting on the toilet. Suggestthe use of a water-filled sports drink bottle. Pat dry with toilet paper or tissue. Preparing the woman for her first Cryotherapy postpartum bowel motion Ice preferred and applied: • in a dampened cover Management of hemorrhoids where • for maximum of 20 minutes present • repeated fourth hourly Minimizing perineal descent: Avoid constipation Pelvic floor muscle exercise • Explain their role in reducing swelling (muscle pump action) • exercises started after 24 hours • performed within the limits of discomfort Allay her fears relatedto \"stitches bursting\" during a bowel motion. Demonstrate the following while looking in the mirror: • gently supportthe perineum in an upwarddirection as she bears down to open her bowels. Advise her to cover her hand with paper tissue or a pad. • Her fingers can be parted to accommodate any suture line. Explain the need to protect any visible hemorrhoids from laceration during defecation using the above technique. Inquireabout the: • time since her last bowel motion • usual frequency of her bowel motions • current fluid intake If the normaltime between bowel motions has

4.4. Postpartum Management ofthePelvic Floor 237 TABLE 4.4.1. Continued been exceeded encourage her to seek such help as is routine/standard laxative care practice within the postnatal unit. Explain: • likely effect of increased fluid loss on her bowels • the need to increase her fluid intake • fluid loss is from the combined effects of lochia, breast milk production, and night sweats. Use of correct toileting position The Body Positionand Functional Pattern I!!/!!i:-lf.,,,,,e Defecation ~ ------~ Teach ''The Knack\" Using the mirror, check that the woman can contract her PFMs in an upward movement, away Explain the protective effect of from the mirror. precontracting the PFMs before coughing, sneezing or lifting To activate TrA ask the woman to pull her belly button and bikini line toward her backbone. Teach cocontraction of TrA with PFMs using the following suggested instructions: \"Breathe in, and as you let your breath out, pull up your PFM and pull in your belly button toward your backbone. Don't hold your breath .\" Demonstrate the effectiveness of the knack by asking the woman to cough. This is likely to be quite uncomfortable. Follow by asking the woman to precontract PFM and TrA and to repeat the cough. Advise the woman to use the knack before coughing or sneezing, as well as using it before ANY form of lifting, especially lifting the baby .

238 P.E. Chiarelli Postpartum PFM Rehabilitation Components ofa Successful Postpartum Continence It is widely held that healthy PFMs make an Promotion Program important contribution to continence, and pelvic Although PFXsare an important part of postpar- tum continence promotion, it is important to floor exercises (PFXs) should have top priority emphasize that continence promotion is more than PFX. Successful continence promotion is within any postpartum continence promotion optimized by a comprehensive program. The author polled leading experts, including urolo - program. Continence promotion should rou- gists, obstetricians, gynecologists, nurses, and physiotherapists, and designed such a program\" tinely include PFX for any woman who has had a (Fig.4.4.1).Arandomized controlled trial explored the continence promotion in postpartum women.\" baby. For women identified as having inconti- The components of this program were shown to be acceptable to women, and overall, the informa- nence of urine, feces, or flatus, the PFX program tion components of the intervention were well received. Over 80% of women reported that they should be individually tailored. read the information booklet, and more than 30% used the stick-up dots as an aid to compliance. In view of the enormous demands and time The intervention required 15-20 minutes to implement in the hospital and approximately 30 constraints placed upon new mothers, it is often minutes for the postpartum intervention. It would appear that this postpartum continence promo- unrealistic to expect regular attendance at post- tion program is feasible for women who deliver in hospitals. In view of the costs to the healthcare partum classes. It is important that any exercise system of female urinary incontinence, the costs of delivering this intervention might be seen as program be simple, quick, and incorporated into the activities of daily living. To encourage wide- spread routine adoption of PFX by postpartum women, the exercise program needs to be carried out by the women unsupervised, without exercise adjuncts (such as cones, biofeedback, or electrical stimulation), and without ongoing input from healthcare professionals. Although many proto- cols include such adjuncts, they have not been shown to be necessary components of treatment. An evidence-based protocol for the rehabilita- tion of the muscles of the pelvic floor following childbirth is presented in Table 4.4.2. 6 8 - TABLE 4.4.2. Summary of evidence-based exercise parameters for improving thefunctional capacity of striated pelvic floormuscles adapted for postpartum women Exercise Suggestion supported bytheliterature Adaptation forthe parameter postpartum intervention Type ofexercise Isometric Contraction ofthePFMs withhold atend of range Force Maximum Maximum ormaximum against acough Number of repetitions 3 to9 Starting number to beassessed from theper vaginam per session 5 seconds assessment ofeach woman, increasingasindicated byher own testing of her PFMs upto six repetitions Length of hold No Starting length of hold to beassessed from theper vaginam To address fast and slow twitch fibers assessment of each woman from one second orone hard Rest between Use thetask usually performed bythemuscle group cough upto five seconds orfive hard, successive coughs contractions One ormore No Minimum ofthree Speed Squeeze and hold (slow) as well as squeeze, hold and cough (fast) 5pecificity Sessions per day Addressed byusing \"theknack\" Conducted individually witheach woman, butaimingfortwo Sessions perweek sessions per day Daily tofacilitate remembering

4.4. Postpartum Management ofthe Pelvic Floor 239 FIGURE 4.4.1. Components of the post- The int er vention in hospital partum continence promotion program. Discussion from booklet Act ive int er vention .l Ur inary incontinence View per ineum using hand .lPelvic floor functionldysfunctlo mirror: .lPelvic floor exercises .l per ineal trauma (if any) - three times a day .I hemorrhoids - every day .I practice perineal splinting - hold for 3 seconds .IGood bladder habits to use during defecation .lGo 6-8 times/day & Pr actice: once at night .I pelvic floor muscle contraction .I Drink plenty of fluids .l\"t he knack\" .I Avoid caffeine .l Per inea l care versus abdominus co - ontraction Compliance aids .I Red stick-u p dots .I Posters (opt'onol) .I Partner information shee t (opt,onol) Eight weeks postpartum Choice of home visit or hospital outpatient visit ( rovide parking voucher) Discussion Act ive int er vent ion .I Continence sta tus .I Pelvic floar assessment .l Exercise adherence .l Per ineal elevcnen measure .I Barriers to exercise .lPer ineomet er measure .I Exercise progress ion .I Wound healing of pelvic floor .I Urinary incontinence .l Exercise prescription .I Constipation .l Tailor and contract .I Hemorrhoids .l Pelvic organ prolapse exercise program .I Vaginal self assessment (If agreeable) .I 0 The knack' ck defecation dynamics ;( Ongoing referral if necessary money well spent. In some cases, it might be nec- postpartum continence promotion examined the essary to prioritize interventions and limit them efficacy of PFX among postpartum women (not to members of a target group to achieve maximum using exercise adjuncts) and measured conti- impact with minimal resources. nence outcomes.\":\" Effectiveness of Three studies assessed urinary incontinence as Postpartum Intervention well as PFM function as an outcome measure. Two studies found significant reductions in The evidence for effectiveness of PFM training urinary incontinence postpartum, but no signifi- during pregnancy has been explored in Chapter cant difference in measured PFM strength.\":\" 4.3. Five studies relating to the efficacy of PFX for The study by Morkved and colleagues found sig- nificant improvement in both groups at 16weeks postpartum.':'Some improvement in measures of

240 P.E. Chiarelli PFM function were also noted in the control period,\" and up to 52%for postpartum women.\" group (assumed to be the natural recovery of Adherence to a treatment program cannot be muscle function after childbirth), but measured assumed, and potential strategies for enhancing changes in PFM function were significantly a woman's adherence to PFX regimens during greater in the intervention group . and beyond the postpartum year must be consid- ered an important component in any continence Chiarelli and colleagues adapted the protocol promotion program. used by Bo,8 and incorporated the precontraction of the PFMs in anticipation of a cough, as well as Studies of adherence to general exercise therapy cocontraction of the transversus abdominis (TrA) show programs that include motivational strate- and PFM during any activities likely to increase gies to be more effective. Key components of intraabdominal pressure (Table 4.4.1). This treat- success include goal setting, negotiating treat- ment consisted of a single visit by a physiotherapist ment goals, formulating plans that are tailored to to all eligible women (continent and incontinent) . the individual needs of the woman's situation and Women were given a continence promotion inter- daily routine, and finding specific events in a vention, including a specificallydesigned informa- woman's daily routine to which program compo- tion booklet. A single follow-up visit for further nents might be anchored.I? Lack of time is among PFM assessment and exercise prescription fol- the reasons given by postpartum women for diffi- lowed. Although the program was effective in pro- culties in adhering to prescribed PFXprotocols,\" moting PFXs and continence at three months and women find it easier to adhere to programs postpartum/a there was no significant difference that involve fewer lifestyle changes (Fig. 4.4.1). in continence status among the women in the intervention group at 12 months postpartum.\" Studies show that adherence levels deteriorate Further, continued adherence to PFXsat 12months when any effective adherence-aiding strategy is was predictive of continence at that time. withdrawn. Furthermore, women are more likely to comply with treatment programs that include In another trial, incontinent postpartum specific positive-feedback program adherence. women were seen initially at 3 months with It is therefore important to check adherence follow-up visits at 6 months and 9 months post- at every consultation and maintain adherence partum. Significant improvements in continence interventions. status were noted, along with significantly higher reported performance of PFX.IS Although one Integrating Continence Promotion study tested continence promo tion, while the into Routine Health Care other examined an intervention for incontinent women, the following observations might be Continence promotion programs have been made from these studies. First, extending the found to be acceptable to postpartum women.I? follow-up visits to 3, 6, and 9 months postnatally The information components of the program are would seem more likely to provide consistent well utilized and there is good adherence with results in terms of continence. Second, PFX are the recommended PFX regimen. Yet, in general, significantly more likely to be performed at 12 opportunities for continence promotion during months postpartum with even a minimal inter- pregnancy are not being utilized,\" and studies of vention, and continence status at 12 months is continence promotion programs show dropout associated with the regular performance of PFX. rates of up to 52% for postpartum women.\" Adherence to PFX Programs Because women's perceptions about their ability to contract these muscles are not always In the case of PFXprograms, the most significant correct, well-designed PFX programs include prognostic factor for success is the woman's vaginal preassessment of PFMs to ensure correct adherence to the exercise program.\" Studies of contraction.\" Women appear to be receptive to continence promotion programs show problems such PFMfunction assessment in the postpartum with adherence, with dropout rates of 15% for period. The continence promotion study in post- women who are not within the peripartum partum women revealed that 74.5%of the women had attended their routine postnatal checkup and

4.4. Postpartum Management ofthe Pelvic Floor 241 that 79.8% of these women had undergone a 6. Hay-Smith E, Bo K, Berghmans L, et al. Pelvic pelvic examination.' Moreover, few reported floor muscle training for urinary incontinence in feeling embarrassed about PFM function testing women. The Cochrane Library 2003(1):Oxford: during the examination. Update Software . Although opportunistic assessment of correct 7. Chiarelli P. Female urinary incontinence in PFM contraction might seem to be a rational inclusion within a routine postnatal examina- Australia: prevalence and prevention in postpar- tion, only 27.5% of the women reported having tum women. [doctoral thesis]. Newcastle, Austra- their muscles tested in this manner.' Health pro- lia: University of Newcastle; 2001. fessionals need to be informed and reassured that 8. Bo K. Pelvic floor muscle exercise for the treat- postpartum women are receptive to PFM func- ment of stress urinary incontinence: an exercise tion testing, and that postpartum visits present an ideal opportunity for such a procedure. Efforts physiology perspective. Int Urogynecol J Pelvic should be made to ensure that all relevant health- care professionals possess adequate knowledge Floor Dysfunct. 1995;6:282-291. about PFX. 9. Chiarelli P. What the experts said: developing a Conclusion postpartum continence promotion programme. There is little doubt that the conservative man- Aust Continence J. 1999;5(2):41-42. agement of urinary and fecal incontinence is effi- 10. Chiarelli P, Cockburn J. Promoting urinary conti - cacious. Further, continence promotion among women in the early postpartum has been shown nence in women following delivery: randomised to prevent the development of urinary inconti - nence. Women benefit from education within a controlled trial. Br Med J. 2002;324(25May):1241- continence promotion program, and health care professionals should use the opportunity post- 1247. partum to assess the pelvic floor, to inform about pelvic floor dysfunction, and to encourage and 11. Sampselle C, Miller J, Mims B, et al. The effect of instigate PFXs. pelvic muscle exercise on transient incontinence References during pregnancy and after birth. Obstet Gynecol. 1998;91:406-412. 1. Sultan A, Kamm M, Hudson C, et al. Anal sphinc- 12. Wilson P, Herbison G. A randomised control trial of pelvic floor muscle exercises to treat postnatal ter disruption during vaginal delivery. N Eng J urinary incontinence. Int Urogynecol J Pelvic Med. 1993;329:1905-1911. 2. Fynes M, Donnelly V, Behan M, et al. Effect of Floor Dysfunct. 1998;9:257-264. 13. Morkved S, Bo K, Schei B, et al. Pelvic floor muscle second vaginal delivery on anorectal physiology and faecal incontinence: a prospective study. training during pregnancy to prevent urinary Lancet. 1999;354:983-986. incontinence: A single-blind randomised con- 3. Glazener C, Abdalla M, Stroud P, et al. Postnatal trolled trial. Obstet Gynecol. 2003;101(2):313-319. maternal morbidity: extent, causes, prevention and 14. Chiarelli P, Murphy B, Cockburn J. Promoting treatment. Br JObstet Gynaecol. 1995;102:282-287. urinary continence in postpartum women:12 4. Abraham S, Child A, Ferry 1, et al. Recovery after month follow-up data from a randomised con- childbirth: a preliminary prospective study. Med trolled trial. Int Urogynecol J Pelvic Floor Dys- JAust. 1990;152:9-12. funct. 2004;15:99-105. 5. Petty N, Moore A. Function and dysfunction of 15. Glazener C, Herbison G, Wilson P, et al. Conserva- muscle. In: Petty N, Moore A, editors. Principles of neuromusculoskeletal treatment and manage- tive management of persistent postnatal urinary ment. Edinburgh: Churchill Livingstone; 2004: and faecal incontinence: Randomized controlled 139-220. trial. Br Med J. 2001;323:1-5. 16. Lagro-Ianssen T, Debruyn F, Smits A, et al. Con- trolled trial of pelvic floor exercises in the treat - ment of urinary stress incontinence in general practice. Br JGen Pract . 1991;9(3):284-289. 17. Hallberg J. Teaching patients self care. Nurs Clin North Am. 1970;5:223-231. 18. Chiarelli P, Campbell E. Incontinence during pregnancy. Prevalence and opportunities for con- tinence promotion. Aust New Zealand J Obstet Gynaecol. 1997;37(1):66-73. 19. Morkved S, Bo K. The effect of postpartum pelvic floor muscle exercise in the prevention and treat- ment of urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1997;8:217-222.

4.5 Role of a Perineal Clinic Ranee Thakar Key Messages childbirth can leave women feeling inadequate and distraught. As these problems are usually of • The perineal clinic offers access to multidisci- a sensitive nature, women should ideally be seen plinary care for a variety of postpartum prob- in a dedicated clinic instead of a busy general lems, including dyspareunia, perineal pain, clinic. Furthermore, this environment facilitates wound breakdown, and anal and urinary childcare and breastfeeding. The establishment incontinence. of a dedicated one-stop clinic enables provision of evidence-based quality care by experienced • Women who sustain obstetric anal sphincter professionals. A dedicated perineal clinic also injury should be seen within 3 months provides women an opportunity to be given an postpartum. explanation of the circumstances under which the perineal injury occurred and counseled • Pregnant women with a prior injury can be appropriately regarding modes of subsequent evaluated and counseled regarding mode of delivery. Women attending such a dedicated delivery. clinic have reported high satisfaction rates and found the service very valuable. Introduction More than 85% of women sustain perineal Structure ofthe Clinic trauma,' and up to two thirds of women need suturing. This can have a devastating effect on The perineal clinic should be staffed by a consul- family life and sexual relationships.' Perineal tant urogynecologist (competent at urodynamics, pain and discomfort affects up to 42% of women anal manometry, and ultrasound) and a trained 10days postpartum, and in 10% of women these nurse/midwife. There should be easy access to problems persist at 18 months.' Fifty-eight a physiotherapist, a continence nurse specialist, percent of women experience superficial dyspa- colorectal nurse specialist, colorectal surgeons, reunia 3 months after delivery,' Urinary inconti- and psychosexual counselor. Integration of multi- nence affects 32% of women 3 months post- disciplinary professionals promotes a holistic partum,\" although this improves in two thirds approach to pelvic floor and perineal problems. within 1 year.\" Incontinence to flatus and feces Furthermore, this clinic should accept self-refer- affects 45% and 10% of women, respectively, rals and should be easilyaccessibleto general prac- within 3 months of delivery.' titioners and midwivesto allow fast tracking . Although there have been great advances in This clinic should be restricted to childbirth- antenatal and intrapartum care, postnatal mater- related problems and include conditions such as nal morbidity has remained largely neglected. dyspareunia, perineal pain, wound breakdown, Encountering such unexpected problems after 242

4.5. Role ofa Perineal Clinic 243 FIGURE 4.5.1. Pathway for management I IClinical diagnosis of anal fissure ofanal fissure. 1 Lactulose 15mls bd , Isphagula Husk (FybogeJ®lone sachet bd 1 I Severe headache I Glyceryltrinitrate 0.2% ointment I I Apply perianaly tds I I 1Hydrocortisone 1%, pramocaine 1% I 1 I (Anusol-HC® )ointment bd I I I Follow up in 8 weeks 1 Ilf problems persist refer to colorectal surgeons I Ito cons ider lateral sphincterotomy infection, prolapse, and anal and urinary incon- Treatment for Conditions Encountered tinence. Women who have sustained obstetric in the Perineal Clinic anal sphincter injury (GASI) should be seen within 3 months postpartum. In addition, preg- Anal fissures, perineal pain , and GASI can be nant women with previous GASI can be evaluated managed according to the pathways in Figures and counseled regarding mode of delivery. 4.5.1, 4.5.2, and 4.5.3.8 All women with urinary Ideally, the clinic should be equipped with facili- and anal incontinence should be instructed to do ties for endoanal ultrasound scans and for anal pelvic floor muscle exercises and/or biofeedback manometry, to facilitate a one-stop approach. Detailed perineal examination looking specifically for: scar tissue elicit scar tenderness other causes of perineal pain including abscess & irritant non dissolved suture material Specific pathology for example: No obvious pathology : Abscess - drain lidocaine hydrochloride gel 2% advise to commence sexual intercourse Irritant suture material - remove follow up in three months. if pain persists give the following into the site of maximal tenderness : 10ml 0.5% Bupivicaine 1500iu Hyaluronidase 1mt of depotmedrone Follow up in 1 month if pain continues repeat the three injections as described above Follow up in 1 month If perineal pain still persists consider other treatments including vaginal dilators and psychosexual counselling FIGURE 4.5.2. Pathway for management ofperineal pain.