244 R. Thakar Management after a 3j/4 j tear Avoid traumatic delivery Experienced person Prophylactic episiotomy unproven benefit Traumatic delivery anticipated Conservative matrix Big baby Dietary advice Occipito-posterior position Slow progress in labour Regulate bowel action Bulking allents Constipating agents - Codeine phosphate - loperamide PFE and biofeedback FIGURE 4.5.3. Pathway for management after3°W anal tear. should be initiated. Women with perineal wound period, between September 2002 and May 2004, breakdown should have careful inspection of 249 new referrals were seen. The mean age was 30 their perineum, swabs taken, antibiotics given years (range 16-42) with a median parity of 1 as appropriate, and advice given on perineal (range 1-5). The reasons for referral are shown in hygiene. Table 4.5.1. Our Experience All women with anal fissures, perineal pain, and dyspareunia had resolution of symptoms In Mayday University Hospital, Croydon, UK, we when managed by protocol. On direct question- have a one-stop perineal clinic. Over a 21-month ing, 7 (5.2%) with OASI had symptoms of anal incontinence. Twenty (15.6%) had ultrasound TABLE 4.5.1. Reasons for referral n % defects at follow-up. Nineteen (7.6%) women attending the clinic required directed pelvic floor OASI follow up 134 54.0 muscle exercises and 24 (9.6%) had biofeedback. Dyspareunia 8 3.2 Five women have subsequently had surgery, two Perineal pain 12 4.8 for urinary incontinence and prolapse, and 3 had Wound breakdown 2 4.8 secondary anal sphincter repairs. Prolapse 9 3.6 Urinary incontinence 20 8.0 Conclusion Vulval hematoma 3 1.2 Anal incontinence 16 6.4 Postpartum problems are clearly an integral part Previous OASI 15 6.0 of care of childbearing women, and such clinics Vaginal discharge 7 2.8 should be available to mothers. This kind of Traumatic vaginal delivery 7 2.8 service would lead to women being seen promptly Miscellaneous 6 2.4 and to the development oflocal expertise in man- aging perineal problems . More research is needed n=249.
4.5. Role ofa Perineal Clinic 245 in the management of perineal problems, includ- 4. Barrett G, E Pendry, J Peacock, C, et al. Women's ing the management of women with OASI in sub- sexuality after childbirth: A pilot study. Arch Sex sequent pregnancies, and a perineal clinic is an Behav. 1999; 28(2):179-191. ideal setting for this. 5. Morkved S, Bo K, Schei B, et al. Pelvic floor muscle References training during pregnancy to prevent urinary incontinence: A single-blind randomised con- 1. Sleep J, Grant A, Garcia J, et al. West Berkshire Peri- trolled trial. Obstet Gynecol. 2003;101:313-319. neal Management Trial. BMJ. 1984;289:587-590. 6. Arya L, Jackson N, Myers DL, et al. Risk of 2. Kettle C, Hills RK, Jones P, et al. Continuous versus new-onset urinary incontinence after forceps and interrupted perineal repair with standard or rapidly vacuum delivery in primiparous women. Am J absorbed sutures after spontaneous vaginal birth: Obstet Gynecol. 2001;185:1318-1324. arandomisedcontrolledtrial. Lancet.2002:359;2217- 2223. 7. MacArthur C, Glazener CMA, Wilson PD, et al. Obstetric practice and faecal incontinence three 3. Carroli G, Belizan J, Stamp G. Episiotomy policies months after delivery. BJOG. 2001;108:678- in vaginal births. (Cochrane Review).In: Cochrane 683. Library. Issue 2. Oxford; Update Software; 1998. Updated quarterly. 8. Thakar R, Sultan AH. Management of obstetric anal sphincter injury. Obstet Gynaecol. 2003;5(2): 72-78.
4.6 Overactive Bladder Kathryn 1. Burgio, Dudley Robinson, and Linda Cardozo Key Messages OAB symptoms. However, over time they have also proven useful for reducing the symptoms of • Two main approaches to OAB are behavioral urgency, frequency, and nocturia. Several behav- interventions and pharmacologic therapies. ioral techniques have been described, includ- ing scheduled toileting (timed voiding, delayed • Bladder training focuses on reducing voiding voiding, bladder drill, bladder training, and frequency using incremental voiding schedules prompted voiding), PFM training and exercise, and techniques for coping with urgency. biofeedback, use of PFMs for urethral occlu- sion, urge inhibition training, urge suppres- • Behavioral training focuses on teaching sion strategies, urge avoidance , self-monitoring patients a new response to urgency and urge with bladder diaries, and fluid and diet mod i- suppression strategies, including how to use fication. The goal of each of these methods pelvic floor muscle (PFM) contractions to vol- is to reduce urinary incontinence by changing untarily suppress detrusor contraction. patient behavior or by teaching continence skills. • Pharmacological therapy includes oxybutynin, propiverine, tolterodine, trospium, solifenacin, In clinical practice, the most successful behav- darifenacin, imipramine, and desmopressin. ioral programs appear to be multicomponent programs that combine various behavioral ele- • Combining behavioral and drug therapy can ments into a program individualized to the optimize patient outcomes. patient. There are two fundamentally distinct approaches to behavioral management of urge Introduction incontinence and OAB that incorporate one or more of these techniques: bladder training, which Overactive bladder (OAB) is defined as urgency, targets voiding habits, and behavioral training, with or without urge incontinence, usually with which focuses on teaching patients new skills frequency and nocturia.' It is a common condi- using methods such as PFM training and urge tion with a significant impact on the quality of suppression strategies to control detrusor life.' There are two primary approaches to the contraction. treatment of OABj behavioral interventions and pharmacologic therapies. Both have been shown Bladder Training to produce significant reduction of OAB symp- toms in large numbers of patients. First described in the 1970s,bladder training has long been viewed as a standard behavioral treat- Behavioral Interventions ment for urge incontinence.' The goal of bladder training is to modify bladder function by altering Historically, behavioral interventions have voiding habits. The training focuses on reducing focused on the treatment of urge urinary incon- tinence, rather than the broader spectrum of 246
4.6. Overactive Bladder 247 Cycle of Urgency and Frequency ity are thought to contribute to detrusor over- activity. Uncontrolled detrusor contraction pro - ~ Urgency Incontinence duces incontinence and contributes to urgency, completing a self-perpetuating cycle of OAB I symptoms. Bladder Detru;or_ Behevioral Bladder training breaks the cycle of urgency Training - F requency and frequency using consistent incremental Overa clivity Trelnlng voiding schedules. It begins with the patient com- pleting a voiding diary, which shows the clinician Reduced \"\" when and how often the patient is voiding. The Capac ity diary is reviewed with the patient to determine the longest time interval between voids that is FIGURE 4.6.1. Cycle of urgency and frequency, depictingthetwo comfortable, and this baseline interval becomes the starting point. Patients are given instructions points where bladder trainingand behavioral trainingare thought to void according to this schedule rather than in to break the cycle. (Source: Burgio KL. Current perspectives on response to urgency. Their daily schedule includes management of urgency using bladder and behavioral training. voiding upon waking, each time the interval passes during the day, and just before bed. To Supp J Am Acad Nurs Pract. 2004;16:4-7.) comply with this regimen, patients must resist the sensation of urgency and postpone urination. voiding frequency to increase bladder capacity To help the patient cope with their urgency, they and eliminate detrusor overactivity. can be instructed to use distraction or relaxation techniques or self-affirming statements to get Figure 4.6.1 presents a model of OAB in which them to the next scheduled voiding time . Over urgency is a sensation that drives frequency. time , the voiding interval is increased at comfort- Unlike the ordinary sensation of fullness , urgency able intervals to a maximum of every 3 to 4 hours. is a strong sensation that is difficult to defer. In See Figure 4.6.2 for guidelines for implementing this model, urgency promotes the increased fre- bladder training. quency, which over time, can lead to reduced bladder capacity. In turn, the habit of frequent voiding and a smaller funct ional bladder capac- Guidelines for Bladder Training Step 1: Reviewbladder diary with the patient and identify varyingvoiding intervals. Step 2: With the patient, select the longestvoiding interval that is comfortable for Step 3: her. Step 4: Providewritten patient instructions: Step 5: Emptyyour bladder... FIGURE 4.6.2. Guidelines for o First thing in morning bladder training. o Every time your voiding interval passes during the day o Just before you go to bed Teach patient coping strategiesthat she can use when she has an urge to void before her interval has passed: ~ Self-statements (e.g., \"I can wait until it is time to go.\") ~ Distraction to another task ~ Deep breathing and relaxation ~ Urge suppression using pelvic floor musclecontraction Graduallyincreasethe voiding interval... ~ When patient is comfortable on her schedule for at least 3 days ~ By 3D-minute intervals, more or less as determined by the patient's confidenceand clinician judgment
248 K.L. Burgio et al. The effectiveness of bladder training for reduc- vaginal or anal palpation.\" Once patients have ing incontinence has been demonstrated in learned to properly control the PFM in the clinic, several studies.':\" The most definitive is a ran- they are given instructions for daily progressive domized controlled trial demonstrating in older exercises to strengthen their motor skills, as well women an average 57% reduction in incontinent as muscle strength (see Chapter 4.2). episodes and 54% reduction in the quantity of urine loss.\" One exercise found to be helpful for patients with urge incontinence is to interrupt or slow the Behavioral Training with PFM Rehabilitation urinary stream during voiding once per day. Not only does this provide practice in occluding the The second basic approach to the behavioral urethra and interrupting detrusor contraction, it treatment of urge incontinence and OAB is behav- does so in the presence of urge sensation, when ioral training. The goal of behavioral training is patients with OAB need the skill most . Some cli- to improve bladder control by teaching the patient nicians have concerns that repeated interruption how to voluntarily suppress detrusor contrac- of the stream may lead to incomplete bladder tions . This involves a new response to urgency emptying in certain groups of patients. There- and learned use of the PFM to control urgency fore, caution should be used when recommend- and detrusor contraction (Fig. 4.6.3). ing this technique for patients who may be susceptible to voiding dysfunction. PFMtraining is a central element of behavioral training. Its use is based on the premise that vol- Another cornerstone of behavioral training untary contraction of the PFM not only can is teaching patients a new way to respond to occlude the urethra, but also can inhibit or abort urgency: the urge suppression strategy,\"Ordinar- detrusor contractions. It is a skill that can be ily, OAB patients feel compelled to rush to the accomplished by most patients and provides sig- nearest bathroom when they feel the urge to void. nificant reduction of incontinence. In behavioral training, they learn how th is natural response is actually counterproductive, The first step in behavioral training for OAB is because it adds physical pressure on the bladder, to assist patients to identify the PFMsand to con- enhances the sensation of fullness, exacerbates tract and relax them selectively without increas- urgency, triggers detrusor contraction, and ing pressure on the bladder or pelvic floor. Among increases the risk of an incontinent episode. the techniques shown to be successful for this Although the new response is counterintuitive at step are biofeedback/ and verbal feedback using first, patients can learn instead to stop what they are doing , sit down if possible, and contract the Detrusor Inhibition PFMrepeatedly to suppress the detrusor contrac- tion . They concentrate on voluntarily inhibiting Anal Sphincte r I the urge sensation and wait for the urge to subside before they walk at a normal pace to the toilet. 1~\\ See Figure 4.6.4 for patient instructions for using the urge suppression strategy. ~~-- The effectiveness of behavioral training has FIGURE 4.6.3. Polygraph tracings showing themechanism ofthe been established in several studies.Y\":\" In the urge suppression strategy: immediate suppression of detrusor first randomized controlled trial, behavioral contraction using active, voluntary contraction of PFMs (anal training reduced incontinence episodes signifi- sphincter). cantly more than drug treatment, and patient perceptions of improvement and satisfaction with their progress were higher,\" A subsequent study demonstrated that the results of behavioral training using biofeedback versus verbal feed- back based on vaginal palpation did not differ significantly,\" indicating that careful training with either method can achieve good results.
4.6. Overactive Bladder 249 FIGURE 4.6.4. Patient Patient Instructions for the Urge Suppression Strategy instructions for the urge suppression strategy. (Source: When you experience a strong urgeto urinate... Burgio KL, Pearce KL, Lucca A. Staying Dry: A Practical Guide Step 1: Stopand staystill. Sit downif you can. to Bladder Control. Baltimore: Step 2: Squeeze your pelvicfloor muscles quickly 3 to Stimes and repeat as Johns HopkinsUniversity needed . Press, 1989.) Step 3: Relaxthe restof your body. Take several deepbreaths. Step 4: Concentrate on suppressing the urgefeeling. StepS: Wait until the urge subsides. Step 6 Walkto the bathroom at a normal pace. Urgency, Frequency, and Nocturia receptors in the bladder and a higher affinity for MI and M3 receptors over M2• Because most research on bladder training and behavioral training has been conducted with The effectiveness of oxybutynin in the man- incontinence as the primary outcome measure, agement of patients with OAB is well documented less is known about their effects on urgency or in placebo controlled trials, although as many as daytime frequency and nighttime urination. In 80% of patients complain of significant adverse studies of bladder training, frequency is not effects, principally dry mouth or dry skin .\" :\" usually viewed as an outcome measure because it Oxybutynin has been shown to be more effective is the mechanism by which incontinence is than previous ant imuscarinic agents, such as reduced. In studies of behavioral training, reduc- propantheline, and as efficacious as propiverine. tions in daytime and nighttime urination have However, the ant imuscarinic adverse effects of been observed incident to treatment for urinary oxybutynin are often dose limiting.P:\" Using an incontinence.\":\" Thus, there is evidence that intravesical or intrarectal route of administra- both bladder training and behavioral training tion , higher local levels of oxybutynin can be can be used to successfully to treat the broad achieved while limiting the systemic adverse spectrum of OAB symptoms. effects. Pharmacological Therapy More recently, controlled release oxybutynin (Ditropan XL) preparations using an osmotic Pharmacological therapy continues to play an system (OROS) have been developed and shown important role in the management of women to have efficacy comparable to immediate release with an overactive bladder. oxybutynin, although with fewer adverse effects.\" In one study, incidence of moderate to severe dry Drugs with Mixed Actions mouth was 23%, and only 1.6% of participants discontinued because of adverse effects.IS Oxybutynin An oxybutynin transdermal delivery system Oxybutynin is a tertiary amine with a mixed has also been developed and compared with action consisting of both an antimuscarinic and extended release tolterodine. Both agents signifi- a direct muscle relaxant effect. In addition it has cantly reduced incontinence episodes, increased local anesthetic properties, which is important volume voided and improved qual ity of life in when given intravesically. Oxybutynin has been patients with mixed incontinence. The most shown to have a high affinity for muscarinic common adverse event with the oxybutynin patch was application site pruritis in 14%. The incidence of dry mouth was lower (4.1%) com- pared to tolterodine (7.3%).19
250 K.L. Burgio et al. Propiverine P = 0.03), although they experienced significantly more dry mouth.\" Propiverine has been shown to combine anticho- linergic and calcium channel-blocking actions Trospium and is the most popular drug for OAB in Germany, Austria, and Japan. Efficacy has been demon- Trospium chloride is a quaternary ammonium strated in open studies and in a placebo - compound that is nonselective for muscarinic controlled trial of its use in neurogenic detrusor receptor subtypes and shows low biological overactivity, it was shown to significantly increase availability. It has produced significant clinical bladder capacity and compliance. Dry mouth was improvement, as well as increases in maximum experienced by 37% in the treatment group com- cystometric capacity and threshold volume for pared to 8% in the placebo group, with dropout detrusor contraction. The frequency of adverse rates of 7% and 4.5%, respectively,\" events was similar to placebo.\" Compared to oxybutynin, both agents showed significant Antimuscarinic Drugs improvement in bladder capacity and compliance and were not significantly different from each Tolterodine other. Those taking trospium had a lower inci- dence of dry mouth (4% vs. 23%) and were less Tolterodine is a competitive muscarinic receptor likely to withdraw (6% vs. 16%),21 antagonist with relative functional selectivity for bladder muscarinic receptors, and although it Solifenacin shows no specificity for receptor subtypes, it does appear to target the bladder over the salivary Solifenacin is a potent M3 receptor antagonist glands. Several controlled trials on patients with that has selectivity for the M3 receptors over M2 idiopathic or neurogenic detrusor overactivity receptors and has much higher potency against have demonstrated significant reductions in M3 receptors in smooth muscle than in salivary incontinent episodes and frequenc y\" and con- glands. Despite expressing a higher potency than firmed the safety of tolterodine, with an in- darifenacin in a model of inhibition of M3 recep- cidence of adverse events no different than tor-mediated calcium ion mobilization in guinea placebo.\" Data from several trials indicate that pig colonic smooth muscle cells,\" it has been the clinical efficacy of tolterodine is comparable shown to be 40-fold less potent than oxybutynin to that of oxybutynin, and is associated with and 79-fold less potent than tolterodine in its fewer adverse events, dose reductions, and patient inhibition of salivary secretion. \" In the S.T.A.R. withdrawals.\" study (Solfenacin in a flexible dose regime with tolterodine XL as an active comparator in a More recently, tolterodine has also been devel- double-blind, double-dummy, randomized OAB oped as an extended release once daily pre- symptom trial) on 1,177 patients, solifenacin was paration (Detrusitol XL). When compared to more effective than tolterodine in producing immediate release tolterodine and placebo, this continence (59% vs. 49%) using a three-day preparation was found to be significantly more diary. There was a 31% greater reduction in effective for reducing urge incontinent episodes pad usage with solifenacin than tolterodine (P = and had better tolerability, with a 23%lower inci- 0.0023) and symptoms of urgency were also dence of dry mouth.\" decreased. The suggested dosage is 5 mg daily, with an increased dose to 5mg bd if required.\" Extended release oxybutynin and extended release tolterodine were compared in the OPERA Darifenacin trial (Overactive bladder: Performance of Extended Release Agents), which involved 71 Darifenacin is a highly selective M3 receptor centers in the United States. Improvements in antagonist that has been found to have a 5-fold episodes of urge incontinence were similar for higher affinity for the human M3 receptor, rela- the two drugs, but oxybutynin was significantly tive to the M1 receptor. Darifenacin is equipotent more effective for reducing frequency of micturi- with atropine in the ileum and bladder and 6- tion. Significantly more women taking oxybu- times less potent at inhibiting muscarinic recep- tynin were also completely dry (23% vs. 16.8%;
4.6. Overactive Bladder 251 tors in the salivary gland. Salivary responses are nificantly over those achieved with the single inhibited at doses 6-1O-fold higher than those therapy,\" Thus, combining behavioral and drug required to inhibit bladder responses. Further- therapy may be one way to optimize outcomes for more, a pilot study has demonstrated its ability patients with OAB. to reduce the number, maximum amplitude, and duration of uninhibited bladder contractions.\" References Antidepressants: Imipramine 1. Abrams P, Cardozo L, Fall M, et al. The standardi- sation of terminology of lower urinary tract Imipramine has been shown to have systemic function. Report from the standardisation sub - anticholinergic effects and blocks the reuptake of committee of the International Continence serotonin. Some authorities have found a signifi- Society. Urology. 2003;61:37. cant effect in the treatment of patients with OAB32 although others report little effect. In light of this 2. Stewart WF, Van Rooyen JB, Cundiff GW, et al. evidence and the adverse effects associated with Prevalence and burden of overactive bladder in tricyclic anti-depressants, their role in OAB the United States. World J Urol. 2003;20:327 remains of uncertain benefit although they are often useful in patients complaining of nocturia 3. Frewen WK. Role of bladder training in the treat- or bladder pain. ment of the unstable bladder in the female. Urol Clin North Am. 1979;6:273-277. Antidiuretic Agents: Desmopressin 4. Jarvis GJ, Millar DR. Controlled trial of bladder Desmopressin (l-desamino-8-D-arginine vaso- drill for detrusor instability. Br Med J. 1980;281: pressin; DDAVP) is a synthetic vasopressin ana - 322-1323. logue. It has strong antidiuretic effects without altering blood pressure. The drug has been used 5. Pengelly AW, Booth CM. A prospective trial of primarily in the treatment of nocturia and noc- bladder training as treatment for detrusor insta- turnal enuresis in children and adults. More bility. Br J Urol. 1980;52:463-466. recently, nasal desmopressin has been reported as a \"designer drug\" for the treatment of daytime 6. Fantl JA, Wyman JF, McClish DK,et al. Efficacy of urinary incontinence.\" Desmopressin is safe for bladder training in older women with urinary long-term use, however it should be used incontinence. JAMA. 1991;265:609-613. with care in the elderly because of the risk of hyponatremia. 7. Burgio KL, Whitehead WE, Engel BT. Urinary incontinence in the elderly: bladder/sphincter bio- Combining Behavioral and Drug Therapy feedback and toileting skills training. Ann Intern Med 1985;103:507-515. One of the drawbacks of both behavioral treat- ment and pharmacological therapy is that the 8. Burgio KL, Goode PS, Locher JL, et al. Behavioral majority of patients do not achieve full conti- training with and without biofeedback in the nence. On average, only 20% to 30% become dry. treatment of urge incontinence in older women: a Considering that these therapies may work by randomized,controlledtrial. JAMA. 2002;288:2293- different mechanisms, combining them may be 2299. one strategy to enhance outcomes . Early studies provide evidence for the effectiveness of com- 9. Burgio KL, Pearce KL, Lucco A. Staying dry: A bined therapy. In one study, bladder training sig- practical guide to bladder control. Baltimore: The nificantly increased the effects of tolterodine Johns Hopkins University Press; 1989. for reducing voiding frequency and increasing volume voided.\" In another study of women 10. Burton JR, Pearce KL, Burgio KL, et al. Behavioral treated initially with behavioral training or training for urinary incontinence in elderly ambu- immediate-release oxybutynin alone, crossover latory patients. J Am Geriatr Soc. 1988;36:693- to combined treatment improved outcomes sig- 698. 11. Burgio KL, Locher J1. Goode PS, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA. 1998;280:1995-2000. 12. Johnson TM, Burgio KL, Goode PS, et al. Effects of behavioral and drug therapy on nocturia in older incontinent women. J Am Geriatr Soc. 2005; 53:846-850. 13. Moore KH, Hay DM, Imrie AE, et al. Oxybutynin hydrochloride (3mg) in the treatment of women with id iopathic detrusor instability. Br J Urol. 1990;66:479-485.
252 K.L. Burgio et al, 14. Tapp AIS, Cardozo LD, Versi E, et al. The treat- extended-release formulations of oxybutynin and tolterodine for overactive bladder: results of the ment of detrusor instability in post menopausal OPERA trial. Mayo Clin Proc. 2003;78:687-695. women with oxybutynin chloride: a double blind 26. Cardozo LD, Chapple CR, Toozs-Hobson P, et al. placebo-controlled study. Br I Obstet Gynaecol. Efficacy of trospium chloride in patients with 1990;97:479-485. detrusor instability: a placebo-controlled, ran - 15. ThuroffJW, Bunke B, Ebner A, et al. Randomized, domized, double-blind, multicentre clinical trial. double-blind, multicentre trial on treatment of BIU Int. 2000;85:659-664. frequency, urgency and incontinence related to 27. Madersbacher H, Stoher M, Richter R, et al. Tros- detrusor hyperactivity: oxybutynin versus prop- pium chloride versus oxybutynin: a randomized, double-blind, multicentre trial in the treatment of antheline versus placebo. I Urol. 1991;145;813- detrusor hyperreflexia. Br I Urol 1995;75:452- 817. 16. Madersbacher H, Halaska M, Voigt R, et al. A 456. 28. Ikeda K, Kobayashi S. Effects of YM905, Oxybu- placebo-controlled, multicentre study comparing the tolerability and efficacy of propiverine and tynin and Darifenacin on carbachol induced oxybutynin in patients with urgency and urge intracellular calcium mobilization by dispersed incontinence. BIU Int. 1999;84:646-651. longitudinal smooth muscle cells of guinea pig 17. Anderson RU,Mobley D, Blank B, et al. Once daily colon. Yamanouchi Pharmaceutical Co. (1998). controlled versus immediate release oxybutynin Registration No. 0199803320-02.00. International chloride for urge urinary incontinence. OROS Study 10: 905-PH-006. 29. Ikeda K, Kobayashi S. Effects of YM905, toltero- Oxybutynin Study Group I Urol. 1999;161:809- dine and Oxybutynin on M3 receptor mediated cytosolic free Ca2+ mobilization in acutely disso- 1812. ciated cells of guinea pig urinary bladder smooth muscle and murine submandibular gland. Yama- 18. Gleason DM, Susset I, White C, et al. Evaluation of nouchi Pharmaceutical Co. (l998). Registration No. 0199803217-02.000. International Study 10: a new once-daily formulation of oxybutynin for 905-PH-005. the treatment of urinary urge incontinence. Ditro- 30. Chapple C, Martinez-Garcia R Selvaggi L, et al A pan XL Study Group. Urology. 1999;54:420-423. comparison of the efficacy and tolerability of Soli- 19. Dmochowski RR, Sand PK, Zinner NR, et al. fenacin Succinate and extended release Toltero- Transdermal Oxybutynin Study Group. Compara- dine at treating overactive bladder syndrome: tive efficacyand safety of transdermal oxybutynin results of the S.T.A.R trial. Eur Urol. 2005; and oral tolterodine versus placebo in previously 48:464-470. treated patients with urge and mixed urinary incontinence. Urology. 2003;62;237-242 . 31. Rosario DI, Leaker BR, Smith DI, et al. A pilot 20. Stoher M, Madersbacher H, Richter R, et al. Effi- cacy and safety of propiverine in SCI-patients study of the effects of multiple doses of the M3 suffering from detrusor hyperreflexia: a double- muscarinic receptor antagonist darifenacin on blind, placebo-controlled clinical trial. Spinal ambulatory parameters of detrusor activity in Cord. 1999;37:196-200. patients with detrusor instability. Neurourol Urodyn. 1995;14:464-465. 21. Millard R, Tuttle I, Moore K, et al. Clinical efficacy 32. Castleden CM, Duffin HM, Gulati RS. Double- blind study of imipramine and placebo for incon- and safety of tolterodine compared to placebo in tinence due to bladder instability. Age Ageing. 1986;15:299-303. detrusor overactivity. I Urol. 1999;161:1551-1555. 33. Robinson D, Cardozo L, Akeson M, et al. Women take control; Desmopressin - A drug for daytime 22. Rentzhog 1. Stanton SL, Cardozo LD, et al. Effi- urinary incontinence. Neurourol Urodyn . 2002;21: cacy and safety of tolterodine in patients with 385-386. detrusor instability: a dose ranging study. Br I Urol. 1998;81:42-48. 34. Mattiasson AI, et al. Simplified bladder training 23. Abrams P, Freeman R, Anderstrom C, et al. Tolt- augments the effectiveness of tolterodine in erodine, a new antimuscarinic agent: as effective patients with an overactive bladder. BIU Int. but better tolerated than oxybutynin in patients 2003;91:54-60. with an overactive bladder. Br I Urol. 1998;81: 35. Burgio KL,Locher IL,Goode PS.Combined behav- 801-810. ioral and drug therapy for urge incontinence in 24. Van Kerrebroeck P, Kreder K, Ionas U, et al. Tolt- older women. I Am Geriatr Soc. 2000;48:370-374. erodine Study Group. Tolterodine once-daily: superior efficacy and tolerability in the treatment of overactive bladder. Urology. 2001;57:414-421. 25. Diokno AC, Appell RA, Sand PK, et al. OPERA Study Group. Prospective, randomised, double blind study of the efficacy and tolerability of the
4.7 Sexual Dysfunction and the Overactive Pelvic Floor Wendy F. Bower Key Messages Sexual arousal depends on an intact sympa- thetic nervous system and can be overridden by • Dyspareunia and overactive pelvic floor (OAPF): the expectation of pain. The anticipation of dis- stretching techniques of the pelvic floor muscle comfort induces anxiety and limits the sexual (PFM), stimulation of painful regions. arousal response, thus, preventing vaginallubri- PFM training may improve orgasmic cation.\" Pain medication, estrogen deficiency, response. alcohol, and antidepressant, anticholinergic, and antihistamine medications also have a negative • Sexual dysfunction, including coital inconti- effect on vaginal lubrication.2 Poor lubrication of nence, is common in incontinent women. vaginal tissues leaves them susceptible to trauma with penetration and subsequent pain. • Management of OAPF includes postural cor- rection, joint mobilization, and reduction of Symptoms and Findings strain on pelvic fascia. Dyspareunia • Subcutaneous restrictions, trigger points, or scar tissue are treated with deep massage and friction techniques, augmented by the use of ultrasound or heat . Introduction Dyspareunia, or pain on penile, digital, or other methods of vaginal penetration, ranges from Female sexual dysfunction is defined as a disor- localized introital tenderness to diffuse deep der of sexual desire, arousal, orgasm, and/or soreness and can be sustained for up to 3 days sexual pain.I Loss of arousal is marked by vaginal after sexual activity.' Common causes in women lubrication problems, whereas orgasmic dys- with pelvic pain include endometriosis, adhe- function includes infrequent or nonorgasmic sions, organ pathology, acute or chronic inflam- response.' Pain associated with sexual activity mation, contact with the cervix, vaginismus, may be either dyspareunia, vaginismus, or non- atrophy, and urethral or bladder wall trauma.i\" coital sex pain.' Up to 63% of community- Dyspareunia has been reported in up to 41% of dwelling women and 76% of women with pelvic patients with incontinence and 57% of patients pain may have some form of sexual dysfunc- with OAPF. It is generally attributed to stretch- tion.':':\" Personal distress, negative experience in ing of the shortened pelvic floor, stimulation sexual relationships, and adverse effects on of painful regions, or organ dysfunction/ quality of life are common in women with sexual adhesions .vY'\" dysfunction.\" Initially, treatment should involve the identifi- cation and management of associated pathologi- cal conditions of the bladder, urethra, and vagina. 253
254 W.F.Bower Sexual counseling is appropriate if psychological vagina while maintaining a lax introitus, even or relationship problems are evident or there is a breathing, and relaxation. Ifbiofeedback is used, disclosure of previous sexual abuse. When deep the woman has immediate visual feedback of dyspareunia is present, women should be edu- vaginal pressure and relaxation. At all times the cated to limit deep thrusting during intercourse patient is in control of the situation, and progres- until they are highly aroused, the vaginal apex sion to penetration will occur only when she has expanded, and the uterus has moved upward .' chooses, and when she has trust in her sexual Sexual positions that minimize discomfort in- partner. v\" clude the woman being astride, partners side by side, or vaginal entry from behind. Techniques to Orgasmic Dysfunction desensitize the introitus using the woman's own finger, her partner's fingers, or a dilator/vibrator Female orgasm follows sufficient sensory stimu- may prove helpful. lation and induces repeated l-s motor contrac- tions of the pelvic floor, succeeded by repeated Vaginismus uterine and vaginal smooth muscle contractions.I Poor pelvic floor positioning, tone, and strength Vaginismus is the involuntary contraction of are associated with decreased intensity of muscles in the outer third of the vagina, which orgasm.\" In women with pelvic pain, a lack of limit or prevent vaginal penetration. The muscle orgasm is frequently associated with a learned spasm is considered to be a conditioned response inhibitory elevation of the pelvic floor, based on to events that have previously caused pain or dis- prior painful encounters.' Low arousal, inade - comfort and may have its origin in prior vaginal quate stimulation, dyspareunia, anxiety, vaginis- infection, sexual trauma, or unresolved psycho- mus, and sexual inhibition can all be primary logical conflict.2.8.11 As vaginismus is situation factors driving a nonorgasmic response . Although specific, pelvic muscle spasm may not always be there is no correlation between sexual function evident on examination. However, in most such and PFM strength in the normative muscle,IS cases, careful palpation of the pelvic floor repro- one third of women who reported difficulty in duces the woman's pain.' reaching climax improved after pelvic floor re- habilitation treatment.\" To date, no studies have There is known to be a high prevalence of vagi- demonstrated improvement in pelvic pain with nismus in patients with both urethral syndrome pelvic floor rehabilitation. and vulvar vestibulitis,\" suggesting a link with impaired vasodilatory arousal response and dys- Sexual Dysfunction and Incontinence pareunia.' Although women with vaginismus would be expected to have altered muscle Sexual dysfunction, and particularly the aspects mechanics, van der Velde and Everaerd reported no difference in the quality of pelvic floor relax- of hypoactive desire and sexual pain, are signifi- ation or contraction when compared with healthy volunteers.\" cantly more common in women with inconti- Therapy is multimodal and involves explora- nence than in those who are continent.\":\" tion of physical causes, identification of signifi- cant psychological issues, and reconditioning of Although it is unclear whether urinary symp- the learned response to sexual contact. Patient education involves the woman looking at her toms may be the cause or result of sexual vulva and coming to understand the vaginismic response. This is followed by muscle awareness dysfunction, patients with mixed urinary incon- of contraction and relaxation in other regions of the body, with eventual progression to the peri- tinence appear more vulnerable than those with neal and PFM groups . The woman and/or her partner gradually and progressively introduce a isolated overactive bladder or stress inconti- finger, tampon, dilator, or EMGelectrode into the nence. 16 18 Women with an overactive bladder - report the need to void and fear of coital leakage as major causes of hypoactive sexual desire .\" The prevalence of incontinence during sexual activity ranges from 2% to 10% in a community sample and from 10% to 56% in women with lower urinary tract disorders.Y\";\" Coital leakage
4.7. Sexual Dysfunction and theOveractive Pelvic Floor 255 is more prevalent in women with severe rather of muscle imbalances around the trunk and hip than moderate symptoms and peaks around 50 joints is often necessary.\" If a woman has a years of age.20,21 Unless a clinician specifically significant diastasis of the rectus, optimal func- asks about incontinence during intercourse, tion of the pelvic floor cannot be achieved, and women are unlikely to volunteer the symptom.\" she should be taught to support the abdominal Aside from coital leakage, wetness during the wall and begin rehabilitation of the apposed night, the need to wear pads to bed, odor, and muscle.\": \" nocturnal enuresis have all been associated with a decrease in the frequency of sexual activity,\" Psychological Women with urinary incontinence or lower Because there is a known association between urinary tract symptoms have a significantly prior sexual and physical abuse and functional higher rate of sexual pain than women without disorders (e.g. dysfunctional voiding, defecation these symptoms.\" Women with an overactive difficulties) in women with pelvic pain, clinicians bladder are more likely to experience pain or should be sensitive to possible disclosures. Aside orgasmic difficulties during intercourse than are from showing calm concern and care, a referral women with isolated stress incontinence; however, for psychotherapy or other mental health inter- the latter group reported greater interference vention should be considered. Intervention may with sexual activity,\" :\" Women with recurrent be modified by the need to proceed more slowly cystitis and voiding dysfunction may be at the to techniques involving vaginal contact, and most risk for sexual pain disorders, possibly perhaps to substitute external therapies for inter- because of impaired blood flow to the pelvic nal techniques. region, inflammation, or underlying OAPF.1s Box #1 Surgical treatment of incontinence and uro- Assessment ofthe woman with an genital prolapse, although curative, may have OAPF muscle adverse effects on sexual function. Alteration of local blood flow, vaginal architecture, sensation, and connective tissue structure can diminish libido and arousal, cause dyspareunia, and inhibit orgasm.v\" Conservative Management of 1. Visualize the perineum at rest: note size theOAPF of genital hiatus and position of perineal body. Musculoskeletal 2. Observe PFM contraction, relaxation, and The basic premise behind any treatment of the bearing down; note movement, recruit- OAPF is that, as a consequence of its attachment ment patterning, timing, proprioception, to the bony pelvis and fascial structures, dys- fatigue, and accessory muscle activity. function often extends beyond the fibers of the levator ani. Accordingly, a holistic therapy 3. Check sensation/neurological integrity; approach begins with postural correction, joint note anal wink reflex. mobilization, and gait modification. Spinal and hip joints need full range of movement to reduce 4. Palpate the external tissues: note tissue strain on the pelvic fascia and its attachment to quality, variation in color, sensation, the OAPF. In particular, limitation of pelvic temperature, tenderness, possible trigger movement at the coccygeus or sacrum can impair points, and sites of pain referral. the rehabilitation of the PFMs.24 Because joints are anchored by their capsules and connective 5. Palpate the vagina/rectum with a single, tissue, stretching, strengthening, and correction well-lubricated digit; note presence of pain (site, localized or diffuse), PFM tone (com- pressibility); relaxation after a contraction (absent, partial, full), spasm, and con- tractile activity (+/- surface EMG or manometry).
256 W.F.Bower Box #2 effect the more complete relaxation and length- ening that follows muscle contraction. Adjunc- Point-form treatment ofdyspareunia patient tive neuromuscular electrical stimulation with short pelvic floor muscles (NMES) can be used to increase local circulation, thereby removing metabolites. This facilitates • Goal setting of 4-6 weeks before tissue optimal neural drive , allows greater tissue exten- normalization sibility, and provides a posttreatment analgesic effect.\" Resolution of trigger-point pain and res- • Home introital desensitization (+/- vagi- toration of tissue homogeneity may take from 6 nal dilator) and exploration of arousal to 10 weeks.\":\" techniques Muscle Rehabilitation • Connective tissue work on pelvic and abdominal region +/- heat and ultrasound Extensive muscle awareness training is imple- mented and may involve the use of perineal or • Treatment of any overactive bladder symp- vaginal biofeedback. Initially, the OAPF will have toms or bowel-emptying dysfunction a high resting tone and will be weak in its short- ened range. Therapy aims to retrain resting • Stretching and fascial release of vaginal wall muscle tension by bringing muscle tension to a and anomalies identified on palpation conscious level. Biofeedback is particularly useful for enhancing this awareness .\" Women may use • Contract-relax techniques immediately after fascial therapy • Posttreatment electrostimulation via surface or vaginal electrode for pain relief or muscle normalization • Explanation of sexual positioning to mini- mize discomfort General Box #3 Women are encouraged to initiate general fitness Point-form treatment ofpelvic pain patient with activities, such as walking or swimming, to stim- coexisting shortened pelvic floor ulate circulation, decrease stress and depression, and assist in pain relief,\" From the outset, activi- • patient education and counseling ties and postures (e.g, excessive posterior pelvic • lifestyle and physical stress reduction tilt in sitting) that increase tension on the short- ened OAPFor generate pain should be avoided. 25,27 techniques Vigorous PFM exercise is not an appropriate first- • postural correction to rectify imbalances line therapy for the woman with OAPF. generated by pain-protective postures Manual Therapy • spinal and pelvic mobilization to address Connective tissue of the pelvic and abdominal any secondary limitations in range of move- region may be noted to have subcutaneous restric- ment at hips, spinal or pelvic joints tions , trigger points, or scar tissue.\" Such limita- • general exercise regimen to combat physio- tions are treated with deep massage and friction logical de-conditioning techniques, augmented by the use of ultrasound • specific PFM awareness and relaxation or heat, until there is unrestricted mobility in training (+/- surface biofeedback) all directions.\":\" The PFMs are assessed by • deep friction or myofascial techniquesl digital vaginal palpation for fibrous bands, areas trigger point pressure of soreness, trigger points, and decreased tissue • active and passive stretching of PFM with mobility.\" Tissue abnormalities are treated with emphasis on achieving descent postcon- techniques to stretch and release fascia and elon- traction and restoring pain-free range of gate the underlying muscle.\" Women may volun- movement tarily contract the pelvic floor after stretching to • heat/NMES • home program of PFM awareness and active relaxation • strength training to regain normal contrac- tile capability
4.7. Sexual Dysfunction and theOveractive Pelvic Floor 2S7 home EMG biofeedback or neuromuscular elec- Eur J Obstet Gynecol Reprod BioI. 2002;10:105(1): trical stimulation to train proprioception and 67-70. functional recruitment, respectively, in the pelvic 12. Gibbons JM. Vulvar vestibulitis. In: Steege JF, floor rehabilitation phase. Metzger DA, Levy BS,editors. Chronic pelvic pain. Philadelphia: WB Saunders; 1998:181-187. A home program of PFM exercise should 13. Van der Velde J, Everaerd W. Voluntary control not be given until the muscle has resumed its over pelvic floor muscles in women with and normal length-tension ability. PFM exercise can without vaginismus. Int Urogynecol J. 1999;10: be accompanied by bladder tra ining, bowel man- 230-236 . agement, and defecation techniques to address 14. Shafik A. The role of the levator ani muscle in associated symptoms. Other techniques that evacuation, sexual performance and pelvic floor promote general body relaxation, such as focused disorders. Int Urogynecol J Pelvic Floor Dysfunct. breathing, ambient environment, visualization, 2000;11:361-376. and progressive active relaxation, are helpful for 15. Salonia A, Zanni G, Nappi RE, et al. Sexual dys- the woman with OAPF.29 function is common in women with lower urinary tract symptoms and urinary incontinence: Results References of a cross-sectional study. Europ Urol. 2004;45: 642-648. 1. Munarriz R, Kim NN, Goldstein I, et al. Biology 16. Walters MD, Taylor S, Schoenfeld LS. Psychosex- of female sexual function. Urol Clin N Am. ual study of women with detrusor instability. Obstet Gynecol. 1990;75:22-26. 2002;29:685-693. 17. Shaw C. A systematic review of the literature on 2. Bachmann GA, Phillips NA. Sexual dysfunction. the prevalence of sexual impairment in women with urinary incontinence and the prevalence of In: Steege JF, Metzger DA, Levy BS, editors. urinary leakage during sexual activity. Eur Urol. Chronic pelvic pain . Philadelphia: WB Saunders; 2002;42:432-440. 1998:77-90. 18. Gordon D, Groutz A, Sina i T, et al. Sexual function 3. Basson R, Berman J, Burnett A, et al. Report of in women attending a urogynecology clinic. Int the international consensus development con- Urogynecol J Pelvic Floor Dysfunct . 1999;10(5): ference on female sexual dysfunction: defin itions 325-328. and classifications. J Urol. 2000;163(3):888- 19. Amarenco G, Le Cocquen A, Bose S. Stress urinary 893. incontinence and genitor-sexual conditions. Prog 4. FitzGerald MP, Kotarinos R. Rehabilitation of the Urol. 1996;6:913-919. short pelvic floor: background and patient evalu- 20. Moller LA, Lose G, Jorgensen T. the prevalence ation. Int Urogynecol J. 2003;14:261 -268. and bothersomeness of lower urinary tract symp- 5. Laumann EO, Paik A, Rosen RC. Sexual dysfunc- toms in women 40-60 years of age. Acta Obstet tion in the United States: prevalence and predic- Gynecol Scand. 2000;79:298-305. tors . JAMA. 1999;281:1174. 21. Nygaard I, Milburn A. Urinary incontinence dur- 6. Marthol H, Hilz MJ. Female sexual dysfunction: a ing sexual activity: prevalence in a gynecologic systematic overview of classification, pathophysi- practice. J Women's Health. 1995;4(1):83-86 . ology, diagnosis and treatment. Fortschr Neurol 22. Hilton P. Urinary incontinence during sexual Psychiatr.2004;72(3):121-135. intercourse: a common, but rarely volunteered, 7. Salonia A, Munarriz RM, Naspro R, et al. Women's symptom. Br J Obstet Gynaecol. 1988;95(4):377- sexual dysfunction: a pathological review. BJU 381. Int. 2004;93:1156-1164. 23. Maaita M, Bhaumik J, Davies AE. Sexual function 8. Pauls RN, Berman JR. Impact of pelvic floor dis- after using tension-free vaginal tape for the surgi- orders and prolapse on female sexual function and cal treatment of genuine stress incontinence. BJU response. Urol Clin N Am. 2002;29:677-683. Int. 2002;90:540-543 9. Beji NK, Yalcin O. The effect of pelvic floor train- 24. Lukban JC, Whitmore KE. Pelvic floor muscle re- ing in sexua l function of treated patients. Int Uro- education treatment of the overactive bladder and gynecol J. 2003;14:234-238. painful bladder syndrome. Clin Obstet Gynecol. 10. Meadows E. Treatment for pat ients with pelvic 2002;45(1):273-285. pain. Urolog Nurs. 1999;19(1):33-35. 25. Shelly B, Knight S, King P, et al. Treatment of 11. Shafik A, EI-Sibai O. Study of the pelvic floor pelvic pain. In: Laycock J, Haslam J, editors. muscles in vaginismus: a concept of pathogenesis. Therapeutic management of incontinence and
258 W.F.Bower pelvic pain. London : Springer-Verlag; 2002:177- 28. Weiss JM. Pelvic floor myofascial trigger points: 189. manual therapy for interstitial cystitis and the 26. Costello K. Myofascial syndromes. In: Steege JF, urgency-frequencysyndrome.JUroI.2001;166(6):2226- Metzger DA,Levy BS, editors. Chronic pelvic pain. 2231. Philadelphia: WB Saunders; 1998:251-266. 27. FitzGerald MP, Kotarinos R. Rehabilitation of the 29. Baker PK. Musculoskeletal problems. In: Steege JF, short pelvic floor: treatment of the patient with the Metzger DA,Levy BS, editors. Chronic pelvic pain. short pelvic floor. Int Urogynecol J. 2003;14:269- Philadelphia: WB Saunders; 1998:215-240. 275.
4.8 Anal Incontinence and Evacuation Difficulties Christine Norton Key Messages getting more exercise, which should always be tried first. Anal incontinence will likewise often o Treatment often involves several conservative improve with attention to diet, bowel habits, and components tailored to the patient's needs. some retraining and exercises. o Patients often benefit from education about Patient Education normal bowel function and what has gone wrong in their case. Bowels are a mystery to most members of the public . From the time of mastery of control until o If possible, establish a consistent bowel pattern things go wrong, most people think little about with complete evacuation at the same time each their bowels - like any other skill which has day, preferably after meals. become \"incorporated,\" the body functions on a semiautomatic level, and little conscious thought o Proper diet, fluids, and physical activity faci- goes into either holding on when an urge or gas litate normal stool consistency and bowel is felt, or into evacuating once sitting in the habits. correct position. This can make it very difficult to regain control if FI or evacuation difficulties o Evacuation tra ining addresses regular habit, develop. Patients often benefit from education posture, breathing, pushing without straining, about normal bowel function and learning why it relaxing the back passage, and avoiding has gone wrong in their individual case. This can laxatives. be achieved verbally, by using diagrams or models, or through written information (www. o Pelvic floor muscle retraining, bowel retrain- bowelcontrol.org.ukj.l\" Often, a combination of ing, and biofeedback can improve bowel methods, tailored to each person's needs, will control. enable the best understanding. Introduction Bowel Routine Many patients with fecal incontinence (FI), anal If it is possible to establish a predictable bowel incontinence (AI), which includes loss of flatus or pattern, with complete evacuation at the same mucus, or evacuation difficulties can be helped time each day, then most bowel problems are by conservative measures.f This often involves much more manageable. For most people, the several different elements, rather than a single bowel is relatively inactive while asleep and definitive intervention, and in clinical practice it maximum motility occurs in the first few hours makes sense to combine approaches in a retrain- ing program to maximize patient benefit. Uncom- plicated mild-to-moderate constipation will often respond to simple measures, such as a regular habit, increasing fiber and fluid intake, and 259
260 C.Norton after getting up in the morning. Motility is content of their diet. If transit is slow, adding enhanced by stimulating the gastrocolic response fiber, particularly unrefined wheat bran, will by eating and drinking at breakfast. Approxi- simply add to what is sitting in the colon and is mately 20-30 minutes after eating is the most unlikely to promote peristalsis. More soluble likely time for mass movements in the colon to forms of fiber, such as in fruit and vegetables, result in propulsive waves of peristalsis, deliver- may be better tolerated. It is certainly worth it for ing a bolus of stool to the rectum. Unfortunately, each person to experiment, as some people seem with modern life styles, this is often the time of to have an intolerance, and to find that their con- day when we are traveling to work or taking the stipation worsens with certain food groups or children to school. If the urge to defecate is combinations. It is unwise to restrict whole food ignored, stool may be propelled away from the groups in the long term without good dietary anus by retrograde peristalsis. If this is done advice, as deficiencies can develop. repeatedly, the stool becomes harder as more water is absorbed through the colonic mucosa Standard advice for constipated people is to and the urge will fade and even disappear. Delib- drink more, and this may work well if the patient erately ignoring the call to stool slows colonic is clinically dehydrated and the body is trying to transit,\" and many constipated people report that preserve fluid by increasing colonic fluid uptake . they never feel an urge, possibly a result of a long- However, if already adequately hydrated, drink- term habit of ignoring this sensation. ing more will simply cause increased urine, not stool, production. Drinking fluids may have a This is why patients are advised very strongly limited effect on motility via the gastrocolic to make time for breakfast and their bowels in response, but it will not generally soften the the morning, even if this involves getting up 30 stool.\" minutes earlier or adjusting their morning routine. There is no evidence that it matters what People with incontinence are more prone to is eaten and drinking any type of fluid seems to leakage or accidents if the stool is soft or loose, be almost as effective as drinking caffeine in and many people modify their diets considerably stimulating motility/ in an attempt to avoid FL In these cases, the goal is to keep the stool formed, while avoiding hard Patients are instructed to eat something, stool or constipation. Diet has a major role in consume two drinks, and then attempt to use the this. Some patients need more fiber to bind stool toilet 20-30 minutes later, allowing 5-10 minutes together, and adding supplements such as psyl- of uninterrupted privacy for this, every day at the lium or gum arabic to the diet has been found to same time ifit is at all feasible. Ifthis proves impos- improve FLU Others achieve a firm stool by sible, an evening routine may be substituted. restricting their fiber intake. Physical Activity, Diet, and Fluids Evacuation Training Exercise is often recommended as a means of Patients with both slow transit constipation and promoting a regular bowel habit with complete evacuation difficulties respond equally well to evacuation, as it increases propulsive activity in retraining techniques, often described in the lit- the colon.\" The epidemiological literature is con- erature as \"biofeedback,\" whether or not feed- sistent in showing less constipation in people back equipment is utilized. \" Table 4.8.1 gives an who report that they exercise.\" Excessiveexercise example of the basic instructions given to patients can even cause diarrhea. However, there have on evacuation technique. The elements are out- been no studies evaluating the efficacyof increas- lined for all patients, but with different emphasis , ing exercise in people with long-standing or depending on the presenting problems and find- severe constipation.\" ings on assessment. Patients are advised that , although each element sounds simple, putting it Clinically, patients with slow-transit constipa- all together takes time, practice, and determina- tion often report less discomfort and bloating tion. Routine and daily practice is emphasized. when they reduce, rather than increase, the fiber
4.8. Anal Incontinence and Evacuation Difficulties 261 TABLE 4.8.1. An example ofthe basic instructionsgiven to patientson evacuation technique Getting intoa RegularHabit • Most people's bowels respond best toa regular habit. Some ofusaretoobusyto make time fo rourbowels. Others live a very irregular lifestyle, which makes a habit difficult. • Thebowel usually goes to sleep at night and wa kes upinthemorning. Eating, drinking, andmoving around all stimulate thebowel. The most likelytime for a bowel action is about 30minutes after thefirst meal of theday. • This makes it important nottoskipbreakfast. Try to eatsomething for breakfast and have two warm drinks. Tryto make S-10 minutes offree uninterrupted time about 30minutes later. This isnot always easy if your house isbusy inthemorning, soyou may need to plan ahead orgetupa littleearlierwhile you retrain you bowel. Sitting Properly • The way you sit onthetoilet can make a bigdifference toease ofopening your bowels. The \"natural\" position (before toilets were invented) is squatting. Countries wheresquat (hole inthefloor) toilets arestill common seem to have fewe r problems with constipation. • Whereas actually squatting is not very practical. many people find thatadopting a 'semisquat\" position helps a lot. One ofthefootstoo lsthat toddlers use to reach a sink isideal, 8-12inches high (20-30 em). Position this justinfront ofyour toilet and rest your feet flat onthestool, keeping your feetand knees about 1foot (30cm) apart. leanforward, resting your elbows onyour thighs. Try to relax. Breathing • Itisimportant not to hold your breath when trying to open your bowels. Many people aretempted totake a deep breath inand then hold their breath while trying to push. Try to avoid this. Sit onthetoilet asdescribed above, relax your shoulders, and breathe normally. You may find it easiest to breathe inthrough your nose and outthrough your mouth. • If you hold your breath and push, this is STRAINING, which tends to close your bottom more tightly. Also, when you holdyour breath, you are limited inhow long you can hold this, and when you have totake thepressure offand breathe you areback at square one. • If you find thatyou cannot help straining and holding your breath, trybreathing outgently orhumming orreciting a nursery rhyme. Pushing Without Straining • The bestway toopen yourbowels is by using yourabdominal (stomach) muscles to push. leaning forward, supporting your elbows onyour thighs andbreathing gently, relaxyour shoulders. Make your abdominal muscles bulge outwards to\"make your waist wide: Now, use these abdominal muscles asa pump to push backwards and downwards into your bottom. Keep upthegentle butfirm pressure. Relaxing theBack Passage • The final partofthejigsaw is torelax theback passage. Many people with constipation actually tighten theback passage when they aretrying to open thebowels, instead ofrelaxing, without realizing what they aredoing. This islike squeezing a tubeoftoothpaste while keeping thelid on! • To locate themuscles around theback passage, first squeeze asifyou aretrying to control wind. • Now imagine thatthemuscle around theanus isa lift. Squeeze totake your lift uptothefirst floor. Now relax, down totheground floor, down to thebasement, down tothecellar. Putting itall Together Thisisa bitlike learning to ridea bike. The above instructions tell you WHAT to do, butdonottell you HOW to doit.Itsounds simple, but coordinating everything takes practice, and you have towork itoutfor yourself. Some people find iteasier than others. • Sit properly • Breathe normally • Push from your waist downwards • Relax theback passage Keep thisupfor about 5 minutes, unless you have a bowel action sooner. If nothing happens, don't give up.Try again tomorrow. Itoften takes several weeks ofpractice until thisreally starts towork. Posture support the elbows on the knees, allowing the abdominal muscles to relax between the For some patients, posture on the toilet seems to knees. be very important, and evacuation difficulty is largely resolved by adopting a \"sernisquat\" Balloon Expulsion Training posture, with feet raised on a 20-30 -cm-high footstool placed in front of the toilet. Patients are If the patient has difficulty grasping the correct instructed to lean forward with the feet apart and technique, balloon expulsion can be used to teach
262 C. Norton the coordination of pushing. A rectal balloon, Laxatives filled with approximately 50 ml of air or water, has been found useful when teaching correct Many authors have recommended allowing technique.' Placed just inside the rectum near the no oral laxatives (prescribed or self-purchased) anal margin, this can give the patient the sensa- during the retraining period, even if previous tion of rectal fullness or the urge to defecate and, doses were high and dependence is long stand- if pushing correctly, they experience the proprio- ing.! The exception is in patients with neurologi- ception of stool moving in the right direction in cal disorders and children, who may need 6-12 response to pushing. If technique is good, the months of regular laxatives to establish a regular balloon may actually be expelled . Byholding the bowel habit. \" Many patients are frightened by the end of the balloon just outside the anus, the ther- prospect of coming off laxatives. However, if the apist can assess whether propulsive effort is purpose is to get the bowel functioning normally effective and improving. again then this habit must be broken. Clinical experience suggests that it is better to stop laxa- Success Rates tives completely than to attempt a gradual weaning. ! Glycerin suppositories may be used as Studies report that 50-80% of patients are a rescue if no stool has been passed for five days. improved with these techniques.' Patients may Often, abdominal discomfort and bloating are have unrealistic expectations, and it is important improved simply by stopping the use oflaxatives, to dispel myths about the necessity to have a as these can be side effects of the medication bowel movement every day. A more appropriate rather than a result of the constipation. goal is that evacuation will be comfortable and without straining. Patients with a symptomatic Some patients fail the retraining program and rectocele or intraanal intussusception often may need to use laxatives long-term. The logical achieve moderate symptom relief, and some laxative is a stimulant for slow transit constipa- symptoms even resolve completely. tion and a softener for evacuat ion difficulties. Table 4.8.2 gives a summary of laxative classes. TABLE 4.8.2. Laxatives and evacuants and their uses Ma in use Notes Class Examples Stool softening when diet Introduce slowly and withadequate fluidintake. nottolerated May cause bloating and discomfort. Bulking agents Ispaghula Avoid ifpatient isseverely constipated or Sterculia Methylcellulose impacted. Can take several days towork. Osmotic laxatives Magnesium salts Can adjust dose to produce Often work in8-12hours. Stimulant laxatives Lactulose desired stool consistency Can cause bloating (especially lactulose) . Macrogols Macrogols can also beused for disimpaction. Rectal agents Bisacodyl Stimulate peristalsisin slow Often work in12-24 hours. Senna transit constipation Can cause abdominal cramping. Sodium picosulfate No evidence ofharm with long-term use, but Docusate sodium To initiate defecation orto Danthron (terminal illness only) evacuate completely may cause discolouration ofcolonic mucosa Glycerol suppositories (melanosiscoli). Stimulant, toinitiate defecation Often work within 5-20 minutes. Bisacodyl suppositories ifglycerol does not work Can bemore predictable andcontrollable than oral preparations. Tap water enemas Can uselow volume to Not acceptable toall patients. initiate orhigher Patients with disabilities may find them Microenemas (e.g. sodium citrate) volume to irrigate difficultto use independently. Phosphate enemas Stimulate rectal contraction When micro enemas are ineffective
4.8. Anal Incontinence and Evacuation Difficulties 263 Unfortunately, there is very little research on be broken, but it requires considerable effort and which laxative is best , and there is really no sub- may take several months. It can be helped by rectal stitute at present for trial and error to find the balloon distension to help re-learn that the urge best preparation (most effect with least inconve- will wear off if resisted, or by loperamide to nience/side-effects) for each individual. Almost dampen motility (see next section). all oral laxatives seem to become less effective with time, so dependence on a single preparation Medication for Fecal Incontinence is best avoided . Rotating a few effective prepara- tions and keeping doses as infrequent and low as The aim of medication for AI is to firm the stool, possible is important for long-term users, as is making it less likely to leak, and to slow gut maximizing the use of nondrug interventions, motility. Loperamide is the drug of first choice such as diet and habit. Some patients find rectal for this as it has a rapid onset of action and is safe evacuants more predictable in the timing of effect in a range of doses. ' Up to 16mg per day is com- and, thus, more convenient. monly used, and is adjusted to achieve the desired formed, but not hard, stool. Syrup formulation is Exercises for Anal Incontinence available if tablets are too constipating. This allows for the accurate adjustment of dose to Pelvic floor muscle retraining is widely used for individual needs. It is most effective if taken treatment of AI. Yet, there is no consensus about about 30 minutes before eating, as it also dampens the optimum frequency or intensity for an exer- the gastrocolic response. Development of side cise program. Indeed, there are very few reports effects, tolerance, or addiction is unusual with of exercises being used without the additional use loperamide. Codeine phosphate is an alternative, of biofeedback.l' :\" In clinical practice, exercise but can be associated with drowsiness and even- instructions are very similar to those given for tual addiction. Early work with alpha-adrenergic urinary incontinence. Patient instructions are stimulants to raise anal resting pressure has not available at www.bowelcontrol.org.uk. One study so far lived up to early promise of clinical found no additional benefit of exercises, over that efficacy.IS which was gained from advice, information, and deferment techniques. \" However, other studies Biofeedback for Anal Incontinence have shown benefit, with women performing exercises for urinary incontinence after child- and Constipation birth reporting much less AI at 12 months postpartum.\" Biofeedback is often cited as the management of first choice for AI.I9 However, unlike the litera- Bowel Retraining ture on urinary incontinence, in the colorectal and gastrointestinal literature, several different Patients with urgency will often benefit from an interventions and complex packages of care have urge resistance program akin to bladder retrain- been grouped under the term \"biofeedback.\" ing for urge urinary incontinence. It may only Therefore, when reading the literature on success take a single episode of major FI in public to set up rates it is crucial to determine what intervention a vicious circle of anxiety, which stimulates colonic was actually used in the name of \"biofeedback.\" peristalsis, leading to urgency, which engenders panic, and a flight to the toilet with an accident As originally described, biofeedback was used on the way. Hypersensitivity to rectal contents to enhance rectal sensitivity to distension.\" By becomes a self-protective mechanism with con- using a rectal balloon, filling it to the threshold stant monitoring of sensation. Any arrival of stool of sensation, and then attempting to \"teach\" the or gas results in a sensation of urgency and patient to detect smaller and smaller volumes, running to the toilet \"just in case.\" This cycle can it was intended to enable the patient to detect rectal contents sooner. Patients were then taught to respond appropriately to resist the urge to defecate by squeezing the anal sphincter to resist
264 C.Norton the drop in anal pressure with rectal distension correct muscle, and/or inhibiting unwanted (the rectoanal inhibitory reflex). This technique rectal motility. Anal electrical stimulation has remains the most commonly used in the USA, been reported as helpful in a few case series, but particularly in gastroenterology settings. The was not helpful in others. In the absence of good same equipment, or a simpler manometric or randomized studies, it is impossible to determine EMG anal probe or surface electrodes can be if this is likely to be useful.30 used to teach anal sphincter exercises and to give the patient feedback about the progress of muscle Conclusion training. Conservative management for AI and constipa- Biofeedback for evacuation difficulties usually tion often yields clinically useful improvement. involves displaying sphincter activity and train- However, it is not clear which elements are most ing relaxation to coordinate with pushing. effective for which patients, and more research is needed to refine techniques. Does Biofeedback Make a Difference? Cases Clinical series have almost always reported posi- Patient 1:Ms. JD tive results using biofeedback for AI or consti- 26-year-old office worker with a history of severe pation, with two-thirds of patients reporting constipation, which she reports started when she left home at age 16, after prolonged disputes improvement ofFI. 14 There is also evidence that with her parents. Onset probably coincided with ,21 chaotic lifestyle and erratic eating habits, but symptoms persist now despite a settled lifestyle certain neurological patients (e.g., spina bifida, and a happy relationship with a supportive partner. Opens her bowels once in 10-14 days by multiple sclerosis) can benefit from retraining taking large doses of sodium picosulphate, with excessive straining and bloating. Hard pellet techniques.f-\" Some have reported a differential stool with bright red bleeding. response between constipation and FI, whereas Assessment others have found good responses in both. Useful An intelligent, motivated patient with no other health concerns, no medications, a balanced diet, clinical changes do not necessarily depend on good fluid intake and a reasonable level of exer- cise. Transit study showed slow colonic transit on changes in the physiological parameter being all 3 marker sets. Digital examination was normal. Attempted balloon expulsion showed no \"trained,'?' Improved bowel function has been paradoxical anal contraction, but no relaxation and poor propulsive effort with straining found to be associated with a measurable im- (Valsalva). provement in autonomic gut function.\" There is a small but growing body of evidence from controlled studies that the biofeedback may not be the crucial element, with equally good results obtained from well-supervised conven- tional management in children and adults. 16,26- 28 It has been shown that a computer display of sphincter EMG does not enhance the response of constipated patients when compared with balloon expulsion in the absence of visual feedback.\" This does not mean that biofeedback techniques are not helpful with individual patients, but it does mean that it is very feasible to set up a service for these patients without major capital investment. Intervention Electrical Stimulation Intervention included detailed patient education, demonstration of good evacuation posture and Electrical stimulation could in theory be helpful technique while breathing, and a daily routine for improving striated muscle function, improv- (Table 4.8.1). All laxatives were stopped and glyc- ing sensory function and ability to exercise the erine suppositories allowed only if no stool was
4.8. Anal Incontinence and Evacuation Difficulties 265 produced in 5 days. She was advised that symp- digital vaginal pressure to assist complete empty- toms might worsen initially, but the importance ing of the rectocele. Detailed advice was also of retraining the bowel to act without laxatives given on diet and avoidance of artificial sweeten- was stressed. ers and caffeine, and she was encouraged to join a weight reduction and exercise class. Her family Outcome doctor was contacted and her diabetic oral medi- cation was changed to one less likely to cause After 5 monthly sessions of advice, encourage- loose stool. She initially found the program chal- ment, and repeat balloon expulsion at sessions 2 lenging and was seen twice weekly to help main- and 3, she was opening her bowels once in 3-4 tain motivation. This was increased to monthly days with less effort, no laxatives, and no bleed- visits once she was progressing. ing. She was content with this outcome. Patient 2:Mrs. SF Outcome A 56-year-old woman with constipation, which After a total of 6 sessions she was improved, but she felt had started after her abdominal hysterec- symptoms were still troublesome. She was tomy 9 years previously. This changed 18months referred to a counselor to address apparent ago, and she developed frequency, with some depressive symptoms and motivation with weight bleeding and FI. Mrs. SF is obese (BMI 32), has loss and exercise. Another 6 months later she type 2 diabetes, and eats a nutritionally poor diet. was still making progress and had lost weight, She also reports stress urinary incontinence. She seeming a lot more confident. At this point, home currently opens her bowels 2-4 times per day to anal electrical stimulation (35Hz, 20 minutes a variable stool consistency with urgency, rare daily) was added and, after 4 months, she was urge FI, and soiling most days. Evacuation is fully continent. sometimes easy, but she often has to strain and has a feeling of incomplete evacuation. In the past References she has had 3 vaginal deliveries; the largest baby was 4.2kg and was delivered using forceps. 1. Norton C, Whitehead WE, Bliss DZ, et al. Conser- vative and pharmacological management of faecal Assessment incontinence in adults. In: Abrams P, Khoury S, Wein A, Cardozo L, editors. Incontinence (Pro- In view of her change in bowel habit, a full colo- ceedings of the Th ird International Consultation noscopy was ordered, which was normal. Anal on Incontinence). Plymouth: Health Books; 2004. ultrasound showed intact, but atrophic, anal sphincters. Manometry showed reduced resting 2. Horton N. Behavioural and biofeedback therapy and squeeze anal pressures and slightly blunted for evacuation disorders. In: Norton C, Chelvana- anorectal sensation. Proctogram showed a large yagam S, editors. Bowel continence nursing. Bea- (4em) rectocele, which did, however, empty consfield: Beaconsfield Publishers; 2004. completely. There was major pelvic floor descent with evacuation . Digital examination found 3. Chiarelli P, Markwell S. Let's get th ings moving : inability to localize anal squeeze and rapid overcoming const ipation. East Dereham: Neen fatigue. Inspection revealed no obvious atrophic Healthcare; 1992. vaginitis. 4. Norton C, Kamm MA. Bowel control - informa- Intervention tion and practical advice. Beaconsfield: Beacons- field Publishers; 1999. A combination of anal sphincter exercises to address perineal descent and sphincter weak- 5. Heaton KW. Understanding your bowels. London: ness, urge resistance training to combat urgency, Family Doctor Publications, British Medical Asso- with evacuation training and advice to try gentle ciation; 1995. 6. Klauser AG, Voderholzer WA, Heinrich CA, et al. Behavioural mod ification of colonic function - can const ipation be learned? Dig Dis Sci. 1990;35: 1271-1275 . 7. Brown SR, Cann PA, Read NW. Effect of coffee on distal colon function. Gut. 1990;31:450-453.
266 C. Norton 8. Cheskin LJ, Crowell MD, Kamal N, et al. The 20. Engel BT, Nikoomanesh P, Schuster MM. Operant effects of acute exercise on colonic motility. J Gas- conditioning of rectosphincteric responses in the trointest Motility. 1991;4:173-177. treatment of faecal incontinence. N Eng J Med. 1974;290:646-649. 9. Everhart JE, Go VL, Johannes RS, et al. A longitu- dinal survey of self-reported bowel habits in the 21. Heymen S, Jones KR, Ringel Y, et al. Biofeedback United States. Dig Dis Sci. 1989;34:1153-1162. treatment of fecal incontinence: a critical review. Dis Colon Rectum. 2001; 44:728-736. 10. Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic 22. Wald A. Biofeedback for neurogenic faecal incon- constipation. Am J Gastroenterol. 2005;100(1): tinence: rectal sensation is a determinant of 232-242 . outcome. J Pediatr Gastroenterol Nutr, 1983;2:302- 306. II. Bliss DZ, [ung H, Savik K, Lowry AC, et al. Supple- mentation with dietary fiber improves fecal incon- 23. Wiesel PH, Norton C, Roy AJ, et al. Gut focused tinence. Nurs Res. 2001;50(4):203-213. behavioural treatment (biofeedback) for constipa- tion and faecal incontinence in multiple sclerosis. J 12. Chiotakakou-Faliakou E, Kamm MA, Roy AJ, Neurol Neurosurg Psychiatry. 2000;69(2):240-243. et al. Biofeedback provides long-term benefit for patients with intractable, slow and normal transit 24. Ko CY, Tong J, Lehman RE, et al. Biofeedback is constipation. Gut. 1998;42:517-521. effective therapy for fecal incontinence and con- stipation. Arch Surg. 1997; 132(8):829-833. 13. Clayden GS, Hollins G. Constipation and faecal incontinence in childhood. In: Norton C, Chelva- 25. Emmanuel AV, Kamm MA. Successful response to nayagam S, editors. Bowel continence Nursing. biofeedback for constipation is associated with Beaconsfield: Beaconsfield Publishers; 2004. specifically improved extrinsic autonomic inner- vation to the large bowel. Gastroenterol. 1997;112: 14. Norton C, Kamm MA. Anal sphincter biofeedback A729. and pelvic floor exercises for faecal incontinence in adults - a systematic review. Aliment Pharma- 26. Solomon MJ, Pager CK, Rex J, et al. Randomised, col Ther, 2001;15:1147-1154. controlled trial of biofeedback with anal manom- etry, transanal ultrasound, or pelvic floor retrain- 15. Norton C, Hosker G, Brazzelli M. Biofeedback ing with digital guidance alone in the treatment of and/or sphincter exercises for the treatment of mild to moderate fecal incontinence. Dis Colon faecal incontinence in adults (Cochrane review). Rectum. 2003;46(6):703-710. The Cochrane Library; 2002 27. Loening-Baucke V, Desch L, Wolraich M. Biofeed- 16. Norton C, Chelvanayagam S, Wilson-Barnett J, et back training for patients with myelomeningocele al. Randomized controlled trial ofbiofeedback for and faecal incontinence. Dev Med Child Neurol. fecal incontinence. Gastroenterol. 2003;125:1320- 1988;30:781-790. 1329. 28. Whitehead WE, Parker L, Bosmajian L, et al. 17. Glazener CM, Herbison P, Wilson PD, et al. Con- Treatment of fecal incontinence in children with servative management of persistent postnatal spina bifida: comparison of biofeedback and urinary and faecal incontinence: randomised con- behavior modification. Arch Phys Med Rehabil. trolled trial. Br Med J. 2001; 323: 593-596. 1986;67(4):218-224. 18. Cheetham M, Kamm MA, Phillips RK. Topical 29. Koutsomanis D, Lennard-lones JE, Roy A, et al. phenylephrine increases anal canal resting pres- Controlled randomised trial of visual biofeedback sure in patients with faecal incontinence. Gut. versus muscle training without a visual display for 2001;48:356-359. intractable constipation. Gut. 1995;37:95-99. 19. Whitehead WE, Wald A, Norton N. Treatment 30. Hosker G, Norton C, Brazzelli M. Electrical stimu- options for fecal incontinence: consensus con- lation for faecal incontinence in adults (Cochrane ference report. Dis Colon Rectum. 2001;44:131- review). The Cochrane Library; 2002. 144.
4.9 Incontinence During Sports and Fitness Activities Alain P. Bourcier Key Messages Etiology • Pelvic floor disorders are a significant problem Repeated increases in intraabdominal pressure for women who exercise, especially those on the pelvic floor structures may overload and involved in high impact sports weaken pelvic floor muscles (PFM) over time and lead to loss of support to the bladder neck • Recommendations for exercise incontinence and urethra. Fatigue of the PFMs might be the include vaginal devices and pelvic floor muscle reason why women with symptoms of stress (PFM) training, with emphasis on PFM precon- incontinence often describe that leakage starts traction (perineal blockage) to prevent urethral only after several incidents, such as repetitive descent and leakage during exertion jumps, indicating that the continence control system weakens after repetitive stresses. • Techniques of biofeedback include training in different positions, simulation of daily activi- In add ition to this mechanical aspect, a com- ties, and PFM practice while performing real bination of weak connective tissue and/or partial physical activities pudendal denervation may worsen the problem.\" It has also been suggested that chronic repetition • The goal is to provoke a reflex PFM contraction of intraabdominal pressure may damage the car- in response to physical stress dinal and uterosacral ligaments and connective tissue, as well as neuromuscular structures, Introduction resulting in loss of neural control and weakness of the PFM.8 Pelvic floor disorders are widely regarded as problems affecting older, postmenopausal, mul- High-impact movements result in impact tiparous women. Many do not realize that it is forces up to 3 or 4 times a person's body weight. also a significant problem for female exercisers of Investigators have found that the flexibility of the all ages. The prevalence of urinary stress incon- foot arches in incontinent athletes was signifi- tinence in young female athletes and women who cantly lower than in the continent athletes,\" indi- exercise ranges from 8% to 47%.1-6 Physically cating that the way in which impact forces are active women are more likely than sedentary absorbed may be another etiological factor. women to experience incontinence,' and the problem is most common in high-impact sports. Pelvic Floor Rehabilitation Because stress incontinence occurs during physi- cal exertion, this condition represents a major For female athletes with \"exercise incontinence,\" problem for females participating in fitness or recommendations include vaginal devices - either sports activities. tampons or pessaries - to elevate the bladder 267
268 A.P. Bourcier neck and help avoid leakage during activity. But important in the control of urge incontinence even those who use such devices should also do associated with sports.\" (See Chapter 4.6). PFM exercises, which can dramatically relieve the problem. Techniques ofBiofeedback Most rehabilitation programs teach women to Urinary stress incontinence and pelvic organ contract PFMs before and during increased prolapse are primarily related to the erect posture. intraabdominal pressure, particularlywith stren- In the vertical position, the urethra leaves the uous effort.\" This technique is called the \"stress bladder at the point of maximum combined strategy,\" \"the perineal blockage before stress intraabdominal pressure and gravity force. technique,\" or \"the Knack.\" A quick, strong, well- Intraabdominal pressure in the standing posi- timed PFMcontraction can compress the urethra tion is two or three times greater than that in the (increasing urethral pressure), prevent urethral supine position. One technique of applied bio- descent, and prevent leakage during an abrupt or feedback uses electromyography (EMG) of the sustained increase in intraabdominal pressure. levator ani combined with synergistic and antag- Eventually, women will be conscious of a con- onistic muscle activity in a standing position stant contraction of the levator ani and can use (Fig. 4.9.1). The method consists of teaching PFM the technique of perineal blockage before physi- cal stress. PFM strength and control are also FIGURE 4.9.1. Multichannel system used for biofeedbock (LaborieInc.) Different vaginal probes are available for easy insertion and possibility ofstanding position for pelvic floor muscle training program.
4.9. Incontinence During Sports and Fitness Activities 269 contraction during the abrupt increasing intraab- FIGURE 4.9.2. Applied biofeedback during exercises. A short dominal pressure that occurs during standing vaginal sensor and electrodes wire set forabdominal muscles are and exercising.\" used forthe exercise program. The woman practices theperineal blockage technique while performing movement. Equipment is used that allows women to assume different positions as they learn to use Conclusion the PFM.10•12 The trainer helps women change their responses by establishing targets and Stress incontinence is surprisingly high in groups assisting them to develop new habits and modify of physically active women. More research is their physical activities. The simulation of needed to clearly understand how impact from daily activities is a very important stage, in different exercises affects pelvic organs and which selected \"home stresses\" or physical PFMs. Based on current knowledge, specific PFM task are used to access the woman's ability training programs are recommended as the first to perform a real-life activity. The woman is choice of treatment. The perineal blockage tech- asked to perform various tasks, very similar to nique is a very adjunctive modality and can be domestic activities, such as carrying a baby proposed for active women. basket or lifting items from the floor. In general, one should start with easy tasks and progres- References sively make the activities more difficult and more functional. 1. Nygaard IE, DeLancey JOL, Arnsdorf L, et al. Exercise and incontinence. Obstet Gynecol. 1990; Successful recovery of the ability to perform 75:848-851. daily activities without incontinence is most likely to occur when the PFM strength is com- bined with a refined control of the functional activity. For this purpose, equipment, such as a video monitor connected to a computerized unit, is used to monitor EMG activity of muscle groups (Fig. 4.9.2}.5 It is optimal for women to be standing when they perform these exercises, but if the woman has some difficulty in per- form ing the exercises, it is suggested that she practice in different positions, such as lying and sitting. Sportswomen should use a treadmill, which provides an opportunity to combine speed and endurance. The underlying concept is that the circumstances and precipitants of incontinence must be taken into account during treatment ses- sions to provoke a reflex PFM contraction in response to physical stress. Accuracy of speed (from 2.5 mph to 6 mph) and slope (from 5% to 12%) is assumed for a precisely controlled workout. The introduction of the treadmill or other sports equipment into the program for sportswomen is one way to allow the woman to perform real physical activities in a medical envi- ronment. Recently, another technique has been introduced with telemetry (wireless biofeedback), in which the infrared connection allows more freedom for the woman while practicing different physical activities.
270 A.P. Bourcier 2. Nygaard IE, Thompson FL, Svengalis SL, et al. 8. Nichols D Milley P. Functional pelvic floor Urinary incontinence in elite nulliparous athletes, anatomy: the soft tissue supports and spaces of Obstet Gynecol. 1994;84:183-187. the female pelvic organs. In: The human vagina . Amsterdam: Elsevier/North Holland Biomedical 3. Bo K, Maehlum S, Oseid S, et al. Prevalence of Press; 1978;21-37. stress urinary incontinence amongst physically 9. Nygaard IE, Glowaski C, Saltzman 1. Relationship active and sedentary female students. Scand I Med between foot flexibility and urinary incontinence in nulliparous varsity athletes. Obstet Gynecol. Sci Sports. 1989;11:113-116. 1996;87:1049-1051. 4. Bourcier AP, Iuras IC. Conservative treatment of 10. Bourcier AP, Iuras IC, Iacquetin B. Urinary incon- stress incontinence in sportswomen. Neurourol Urodyn . 1990;9:232-234. tinence in physically active and sportswomen. In: 5. Fall M, Frankenenberg S, Frisen M. 456 000 sven- Appell RA, Bourcier AP, La Torre F, editors. Pelvic skar kan ha urininkontinens. Endasr var fjaerde floor dysfunction: Investigations and conservative soker hjelp for besvaeren. Laekartidningen. 1985; treatment. Rome: CESI; 1999:9-17. 82:2054-2056. 11. Burgio KL, Locher IL, Goode PS, et al. Behavioral 6. Iacquetin B, Lambert T, Grumberg P, et al. Incon- versus drug treatment for urge incontinence in tinence urinaire de la femme sportive. In: Le Pelvic older women: A randomized clinical trial. lAMA. Peminin, Statistique et Dynamique. Paris : Masson; 1998;23:995-2000. 1993:142. 12. Bourcier AP, Burgio KL. Biofeedback therapy. In: 7. Norton P, Baker I, Sharp H, et al. Genito-urinary AP Bourcier, EI McGuire, P Abrams, editors. Pelvic prolapse. Relationship with joint hypermobility. floor disorders. Philadelphia: Sauders-Elsevier; Neurourol Urodyn. 1991;9:225-228. 2004:297-311.
4.10 Pelvic Organ Prolapse - Pessary Treatment Jane A. Schulz and Elena Kwon Key Message mild prolapse, those who are too frail or unwill- ing to have surgical management, or for those Pessary treatment of prolapse is one of the oldest who wish to have more children. However, remedies in medicine and is an important con- because evidence indicates that we still do not servative treatment that is particularly valuable have good durability of prolapse repairs, and for the physically frail. Pessaries can be used for with women living longer, conservative manage- diagnosis and treatment of prolapse, for voiding ment options must be considered for all as a dysfunction and urinary incontinence and for method of treatment. the management of incontinence or retention during pregnancy. The guidelines for pessaries Historical Perspective and the role of the woman in taking care of her pessary is emphasized. The main types of pessary Mechanical devices as a conservative manage- and the specific indications are reviewed - choice ment tool for POP have been used for many cen- will depend on the type of prolapse and the turies. They were described as far back as the vaginal anatomy. The success rate and the com- time of Hippocrates. Multiple variations have plications and their management are outlined. been described, such as pomegranates, bone, sea The role of pelvic floor exercises and supportive sponges, and various external braces (see Fig. garments are reviewed. The importance of future 4.10.1). Other conservative methods included randomized control trials and establishment of repositioning of the prolapse, leg binding, douch- clinical guidelines is emphasized. ing, herbal remedies, and the use of leeches. Introduction Pessaries gained popularity in the 1800s for the management of uterine retroversion. All were The lifetime risk for pelvic organ prolapse (POP) precursors to our current pessaries and were or incontinence surgery for a female by the age of used very frequently because of the high surgical 80 years old is 11.1%. Up to 30% of women will morbidity and mortality. However, with advances require repeat prolapse surgery, and up to 10%of in anesthesia and surgical techniques, they fell women will require repeat continence surgery.I out of favor. More recently, with newer pessaries, Treatment of prolapse depends on several factors, and a wide range of styles, the longer lifespan of including the patient's wishes for management, women, and the realization of the impermanence the severity of prolapse and its symptoms, the of surgery, mechanical devices for POP are expe- woman's general health, and whether childbear- riencing a rebirth in popularity of use.2 ing is completed. In the past, conservative treat- ment of prolapse has been reserved for those with Research in this area is still lacking. The recent Cochrane review of mechanical devices for POP in women found no eligible, completed, published 271
272 J.A. Schulz and E. Kwon agement. Pessaries can also be used as a diagnos- tic tool. Examples of their use for diagnosis include whether pessary insertion corrects the patient's symptoms of prolapse, and whether associated symptoms such as voiding dysfunc- tion and urinary incontinence are corrected by pessary insertion. Pessaries are believed to work by creating an artificial shelf of levator support to reduce the prolapse. Incontinence pessaries also work by elevating the bladder neck back to the normal anatomic position, and by some degree of obstructive effect on the urethra.' Pes- saries need to be fitted by a health care profes- sional. A nurse-run clinic for pessary fitting is a good option as a time- and cost-saving measure.' FIGURE 4.10.1. Cup and stem pessary with belt. (Source: Repro- Indications for Pessary Fitting duced with permission from Milex Products Inc., Chicago, Illinois.) Pessaries can be used for all types and all stages of POP.Pessaries can also be used for stress, urge, or unpublished randomized controlled studies; mixed, and overflow urinary incontinence. therefore, no data collection or analysis was Although, historically, incontinence type pessa- possible.' Types ofPelvic Organ Prolapse and Evaluation Conservative Management Options for POP Pessaries An extensive range of mechanical devices has FIGURE 4.10.2. Milex pessaries. (Source: Reproduced with per- been described for the management of pelvic mission from Milex Products Inc.,Chicago, Illinois.) floor disorders, and they are listed in Chapter 3.4. Because these devices are often underutilized, they are covered separately in this chapter, where we will consider their use for specific indications of POP. These mechanical devices consist mainly of pessaries. Pessaries are primarily made of medical grade silicone covering surgical steel. The advantages of silicone are that it has a longer lifespan for use, it can be autoclaved, it does not absorb odors or secretions, and it is an inert material. Pessaries come in a wide range of shapes and sizes (Fig. 4.1O.2). They may be used to prevent prolapse from becoming worse, to decrease the frequency or severity of symptoms of prolapse, and to avert or delay surgical man-
4.10. Pelvic Organ Prolapse - Pessary Treatment 273 ries have been used for stress urinary inconti- inserted and tilted up behind the pubic symphy- nence, there have been reports of success with sis (Fig. 4.1O.3). A fingerbreadth should fit between urge incontinence in 64-67% of patients.\" Pes- the pessary and the vaginal mucosa. Once the saries have been used for the diagnosis and man- pessary has been fitted, the patient should walk agement of latent stress urinary incontinence,\" around and exercise in the clinic to ensure it will Hextall et al. found stress incontinence was not immediately fall out. It is necessary to ensure unmasked in 27% of women in their unit with that patients are able to void and are given appro- prolapse that were being investigated with uro- priate education before leaving the clinic with dynamics.\" The use of a pessary before surgery is their new pessary. If possible, patients should also useful to predict whether women will achieve be taught to remove, clean, and replace their relief of their prolapse symptoms, and whether pessaries themselves. If pessaries are difficult to urinary symptoms, such as urgency and voiding remove, fishing wire or dental floss may be dysfunction, will resolve.\" Pessaries are a valu - attached to the pessary to aid in removal. There able tool for the management of the pregnant are few guidelines for pessary removal and clean- woman who has urinary incontinence, POP, or ing, and the recommendations that do exist are urinary retention secondary to uterine retrover- variable. Current Canadian practice advises any sion or incarceration. In pregnancy, the size of woman who is able to remove her own pessary to the pessary may have to be changed with advanc- remove, wash, and replace it once per week. The ing gestation. Hodge pessaries work best for patient is advised to wash the pessary in soap and uterine incarceration with associated voiding warm water. If she cannot remove her pessary, dysfunction. Once the pregnant uterus moves up she should have it removed, cleaned, and replaced out of the pelvis in the second trimester, symp- every 3 months by a health care professional.' toms often improve. Similar guidelines are followed by family physi- cians and gynecologists.\" :\" Women may have There are few contraindications to pessary intercourse with their pessary in place; however, fitting. Active infections of the pelvis or vagina, many elect to remove it . such as vaginitis or pelvic inflammatory disease, preclude the use of a pessary until the infection has resolved. Allergies to the pessary are very uncommon, especially since now most are made of silicone. However, any allergic response to a vaginal pessary would be a contraindication to fitting. The only other caution is with patients who are not likely to be compliant with pessary care and follow-up; these patients should not be fitted with a device .\" Guidelines for Pessary Fitting An adequate amount of time should be allotted FIGURE 4.10.3. Pessary fitting. (Source: Reproduced with permis- for pessary fitting. A clinical setting in a nurse- sion from Milex Products Inc., Chicago, Illinois.) run pessary clinic is ideal. In postmenopausal women, pretreatment with local estrogen therapy for at least 6 weeks is helpful to optimize success- ful fitting.' A postvoid residual should be checked before pessary fitting, as pessaries can cause obstruction of urinary flow. To fit a pessary, size the vaginal vault by examining the vagina with two fingers. Start with a covered ring pessary, or the appropriate design for the diagnosis. The pessary should be lubricated on the end and then
274 J.A. Schulz and E. Kwon Proper pessary fitting may require trials of ficult to remove, and cannot be used if a patient several styles and sizes. Difficulty with pessary is sexually active, unless she is able to remove the fitting may arise if there is a large posterior wall pessary herself. To remove the Gellhorn, the defect, poor perineal body support, or a short- suction must be broken at the dish of the device; ened vagina.\" Many pessaries rely on good peri- occasionally, a Kelly clamp is requ ired to pull on neal support to remain in place. Patients that the stem and assist with removal. have had prior radiation or multiple pelvic sur- geries may also encounter difficulties with The cube or tandem cube pessaries are used pessary fitting because of a scarred or shortened when other pessaries are unsuccessful, or when vagina.\":\" Peri- or postmenopausal women with there is very poor pelvic tone . They work using significant vaginal atrophy may have significant suction to the vaginal walls, as all their sides are discomfort when pessary fitting is attempted. In concave. Older cube pessaries did not have drain- this situation, 4 to 6 weeks of local estrogen age holes and required daily removal and clean- therapy is often helpful to increase the success ing. However, newer versions do have some rate of pessary fitting. \" drainage holes that allow them to be left for up to a week. There is a string attached to the cube Types ofPessaries pessary; however, this is to assist with locating the pessary and is not for traction for removal. Ring pessaries are the most widely available and most commonly used:\" they are available in open There are now a variety of lever pessaries that and covered forms . The covered ring pessary has are all modifications of Hodge's original design drainage holes to allow the vaginal secretions to from the 1860s.15 These include the Hodge, the escape; it is useful in patients that still have a Smith-Hodge, the Risser, and the Gehrung. The uterus, to prevent the cervix from slipping Hodge pessary has been used traditionally for through the ring. Open and covered ring pessa- uterine retroversion and incompetent cervix. ries are best used in POPQ stage I and II pro- Variations of this pessary are for variations in lapse .\" The Shaatz pessary is a stiffer circular pubic arch anatomy. Traditionally, the Gehrung pessary that is used when more support is has been used for women with both a cystocele required for management of the prolapse. Shaatz and rectocele, although it is sometimes difficult pessaries can be used if the rings fall out, or if to keep this pessary in position.\" there is still protrusion of the prolapse beyond a ring pessary. Doughnut pessaries are shaped like Incontinence pessaries are variations on the their namesake; they are used for more signifi- other forms of pessaries with an elevated knob to cant uterine prolapse, especially if accompanied support the bladder neck. There are incontinence by anterior and posterior wall descent. A varia- ring and dish pessaries, and now also inconti- tion of the doughnut pessary is the Inflatoball; nence versions of some of the lever pessaries. If a this is made of latex and must be deflated daily patient with prolapse develops stress inconti- for removal and cleaning. The Inflatoball pessary nence after being fit with one of the other styles is used in patients with a narrow introitus but a of pessaries, switching to an incontinence pessary capacious upper vagina. The Regula is a newer may address both problems. pessary for mild prolapse. Its unique bridge- shaped design helps to prevent expulsion.\" Success Rates with Pessaries The Gellhorn, or stem, pessary is indicated for The reported success rates for pessaries vary by more advanced stage III or IV prolapse. It is often diagnosis. Vierhout reported a 63% subjective useful in reducing a complete procidentia or improvement or cure rate with pessary use for vaginal vault eversion. Like the other pessaries, stress urinary incontinence.\" In a prospective the Gellhorn creates an artificial levator shelf, but review by Clemons et al. of 100 women being also creates a suction to provide a little more fitted for a pessary for POP, 73% had a 2-week support. The stem helps to prevent the pessary successful pessary-fitting trial.I? Of the group from shifting position. The Gellhorn is more dif- that had successful pessary fitting, almost all had complete resolution of their prolapse symptoms, 50% had improvement of their urinary symp-
4.10. Pelvic Organ Prolapse - Pessary Treatment 275 toms, and 92% were satisfied with their pessary. ing or a change in discharge. If left untreated, Dissatisfaction with pessary fitting was associ- they may progress to ulcers. In patients with a ated with occult stress incontinence. uterus still in place, other causes of abnormal vaginal bleeding must be ruled out. These areas In a retrospective review of 1,216 women in a may also become secondarily infected, leading to tertiary care gynecology unit, 86% of women further tissue breakdown. Erosions occur in 2% were able to be fit with pessaries, and of these 71% to 8.9% of patients. v\" They usually respond well were able to wear them successfully. Successful fit to local estrogen therapy; addition of an antibi- was achieved in 83% of patients with uterine pro- otic cream may also be required if secondary lapse, 82% of patients with cystocele, 69% of infection has occurred. Diligent pessary care and patients with vault prolapse/enterocele, and 66% inspection of the vaginal tissues every 6 to 12 of patients with cystocele/rectocele.\" months helps to prevent erosions. Pessary size may also have to be adjusted to prevent further There is some suggestion that the use of a erosions from developing. pessary may prevent the progression of POP.IS However, there is still significant study required Fistulas in this area. One of the keys to long-term pessary care is Pessary Complications ensuring that the patient takes adequate precau- tions to prevent the more serious complications. Overall pessary complications are uncommon Fistulas, although very rare, are among the most and affect less than 10% of patients.Y serious complications of neglected pessaries.\" They can be rectovaginal, vesicovaginal, or ure- Vaginal Discharge throvaginal. An impacted pessary can develop erosions that break down, or get infected, leading Vaginal discharge is one of the more common eventually to fistula. It is very important that complaints with pessary fitting. With insertion of pessaries are regularly removed, washed, and a foreign body into the vagina, it is normal to see replaced, and that the vagina inspected for any an increase in the vaginal discharge, especially if signs of infection or erosion. In a cognitively local estrogen treatment is also being used, such impaired patient, it is imperative that a caregiver as in the postmenopausal population. However, be committed to ensuring ongoing pessary care if there is patient concern, or if there are other and cleaning. symptoms such as foul smell, bleeding, or pruri- tis, the discharge should be investigated. A Pelvic Floor Physiotherapy vaginal examination and culture can be com- pleted. If there is a yeast infection or bacterial Pelvic floor prolapse is an anatomical defect vaginosis, the pessary should be left out for a associated with functional changes. These may week while the appropriate antibiotic or antifun- include urinary incontinence (urge, stress, and gal treatment is used. Concern about recurrent overflow), defecatory dysfunction, and pelvic vaginal infections is a common patient concern. pressure. There is evidence that pelvic floor exer- However, this is unusual; in the postmenopausal cises are helpful for some of the resultant condi- population this is best prevented with local estro- tions and functional changes associated with gen use. The use of Trimosan cream, which is POP. These include pelvic floor exercises and provided with the Milex pessaries, has been rec- bladder retraining for urinary incontinence. i'r\" ommended to help decrease the amount of odor and discharge, although it has not been studied However, for the direct treatment of pelvic in clinical trials.\":\":\" floor prolapse as an anatomical defect, there is little documentation regarding the effect of pelvic Vaginal Erosions floor physiotherapy.\" For mild prolapse there is a perceived benefit,\" however, more severe pro- Erosions of the vaginal mucosa usually start as lapse is unlikely to be corrected by exercises an area of redness or abrasion where the pessary is resting. They may present with vaginal bleed-
276 J.A. Schulz and E. Kwon alone. Defects such as stress urinary inconti- reducing varicose veins on the vulva, as well as for nence and POP have been associated with elec- reducing hip, leg, or pelvic pain. tromyographic changes that may represent either motor unit loss or failure of central activation,\" Other Alternatives and this would certainly impact the potential success of pelvic floor therapy for these condi- Other options include the use of tight bicycle tions. Randomized clinical trials, and the estab - shorts as a perineal support in women that are lishment of clinical and referral guidelines, are unable to fit a pessary and unable to have surgery. required in this area. Some women have used their contraceptive dia- phragms or tampons to attempt to reduce their Fembrace26 prolapse, or to provide relief for their urinary incontinence. However, a common complaint of For many centuries, conservative management of women with moderate to severe prolapse is the POP relied primarily on the use of pessaries and inability to retain a tampon. Desperate patients pelvic floor exercises. Since the marketing of a new that have come to our clinic have also described V-brace\" support garment in NewYorkin the fall the use of sticky tape across the vaginal opening. of 2000, however, there exists an alternative for POP symptom relief in patients who cannot use a Summary pessary for various reasons (Fig. 4.10.4). The V- brace' garment is a panty with a padded double Pelvic organ prolapse is a prevalent condition crotch and cross elastic straps that acts to reduce that impacts quality oflife. As women live longer, the symptoms of pelvic organ prolapse by provid- further research is needed to study conservative ing support and pressure to the vaginal area. The options to treat prolapse. Pessaries are currently creators of the V-brace\" garment suggest that the main conservative management tool.27 Other even women who use a pessary can alternate and options that exist include pelvic floor physiother- also use the V-brace\" every other day when not apy and the Fembrace support. wearing the pessary, for ultimate relief of prolapse symptoms. The garment is also recommended for References FIGURE 4.10.4. The Fembrace support device for pelvic organ 1. Deval B, Haab F. What's new in prolapse surgery? prolapse. Curr Opin Urol. 2003; 13(4):315-323. 2. Davila GW. Vaginal prolapse: management with nonsurgical techniques. Postgrad Med. 1996; 99(4):171-81. 3. Adams E, Thomson A, Maher C, et al. Mechanical devices for pelvic organ prolapse in women (Cochrane Review). In: The Cochrane Library. Issue 2. Chichester, UK: John Wiley and Sons Ltd.; 2004. 4. Bhatia NN, Bergman A, Gunning JE. Urodynamic effects of a vaginal pessary in women with stress urinary incontinence. Am J Obstet Gynecol. 1983; 147(8): 876-884 . 5. Tam F, Schulz J, Flood CG, et al. Factors affecting the success of pessary fitting in a nurse-run clinic . Int Urogynecol J. 2000;11:S17. 6. Hanson L, Schulz JA, Flood CG, et al. Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient char- acteristics and factors contributing to success. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(2): 155-159. Epub 2005 Ju126.
4.10. Pelvic Organ Prolapse - Pessary Treatment 277 7. Wu V, Farrell SA, Baskett TF, et al. A simplified 17. Clemons JL, Aguilar VC, Tillinghast TA, et al. protocol for pessary management. Obstet Gynecol. Patient satisfaction and changes in prolapse and 1997; 90(6): 990-994. urinary symptoms in women who were fitted suc- cessfully with a pessary for pelvic organ prolapse . 8. Liang CC, Chang YL, Chang SD, et al. Pessary test Am J Obstet Gynecol. 2004;190:1025-1029. to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse. 18. Handa VL, Jones M. Do pessaries prevent the pro - Obstet Gynecol. 2004; 104(4): 795-800. gression of pelvic organ prolapse? Int Urogyne J. 2002;13:349-532. 9. Hextall A, Boos K, Cardozo L, et al. Videocysto- urethrography with a ring pessary in situ . A 19. Viera A, Lark ins-Pettigrew M. Practical use of the clinically useful preoperative investigation for pessary. Am Fam Physician . 2000; 61(9): 2719- cont inent women with urogenital prolapse ? Int 2726. Urogynecol J Pelvic Floor Dysfunct . 1998;9(4): 205-209. 20. Chow S, LaSalle M, Rosenberg G. Urinary incon- tinence secondary to a vaginal pessary. Urology. 10. Lazarou G, Scotti RJ, Mikhail MS, et al. Pessary 1997;49(3):458-459. reduction and postoperative cure of retention in women with anterior vaginal wall prolapse. Int 21. Proceedings of the international consultation on Urogynecol JPelvicFloor Dysfunct. 2004;15(3):175- incontinence. Abrams P, Cardozo L, Khoury S, 178. Epub 2004 Feb 14. Wein A, editors. 2004. 11. Clemons J, Aguilar V, Tillinghast T, et al. Risk 22. Borello-France D, Burgio K. Nonsurgical treat- factors associated with an unsuccessful pessary ment of urinary incontinence. Clin Obstet Gynecol. fitting trial in women with pelvic organ prolapse. 2004 ;47(l):70-82 Am J Obstet Gynecol 2004; 190: 345-350. 23. Wallace SA, Roe B, Williams K, et al. Bladder 12. Farrell SA, Singh B, Aldakhil 1. Continence pes- training for urinary incontinence in adults . saries in the management of urinary incontinence (Cochrane Review). In: The Cochrane Library. in women. J Obstet Gynaecol Can. 2004 Feb; 26(2): Issue 1. Chichester, UK: John Wiley and Sons Ltd.; 113-117. 2004 . 13. Pott-Grinstein E, Newcomer J. Gynecologists ' pat- 24. Hagen S, Stark D, Cattermole D. A United terns of prescribing pessaries. J Repro Med 2001; Kingdom-wide survey of physiotherapy practice 46(3): 205-208. in the treatment of pelvic organ prolapse . Physio- therapy. 2004;90:19-26. 14. Milex (Chicago, Illinois). Website. http://www. milexproducts.com/products/pessaries. Accessed 25. Cundiff G, Addison A. Management of pelvic January 1, 2005. organ prolapse . Obstet Gynecol Clin N America. 1998;25(4):907-921. 15. Miller D. Contemporary use of the pessary. In: 26. Weidner A, Barber M, Visco A, et al. Pelvic muscle Sciarra JJ, editor. Gynecology and Obstetrics: electromyography oflevator ani and external anal sphincter in nulliparous women and women with Clinical Gynecology. Vol 1. Philadelphia: Lippin- pelvic floor dysfunction. Am J Obstet Gynecol. cott; 1999:1-13. 2000;183:1390-1401. 16. Vierhout ME, Lose G. Preventive vaginal and intra-urethral devices in the treatment of female 27. Fembrace Support Garment. Advertisement. urinary stress incontinence. Curr Opin Obstet Website. http://www.fembrace.com/. Accessed 18 Gynecol. 1997;9:325-328. Aug 2004.
5.1 Stress Urinary Incontinence: Choice of Surgery Stuart 1. Stanton Key Messages Minimally Invasive Procedures After an adequate trial of physiotherapy, surgery Bulking Agents should be offered, which may either be minimally or majorly invasive. It is important to be aware of Urethral bulking agents (e.g, collagen, Uretex, the cure rates and complications, and an ade- Zuidex, Macroplastique, and Durasphere) act quate follow-up is always needed to assess either by preventing premature bladder neck these. opening or improving the urethral \"seal.\" Their success rate varies enormously - most clinicians Introduction accept 70% as a subjective improvement and 50% as an objective improvement, but only up to 1 When stress urinary incontinence, despite year. ' conservative treatment, remains an intrusive symptom, it is necessary to consider surgery. Pre - Because of these rather indifferent results, operative urodynamic studies, including an MSU bulking agents are used as follows: for culture and sensitivity (Chapter 2.3.1), are necessary to confirm the diagnosis and exclude 1. for mild SUI an overactive bladder and voiding. Cystometry 2. as an adjunct to enhance the cure rate of con- and uroflowmetry are the basic and most helpful studies, which may be combined with video cys- tinence surgery tourethrography (radiological control - VCU) to 3. where child bearing is incomplete and a pro- demonstrate urinary loss and any anatomical abnormality (Chapter 2.1.6). cedure is needed at the moment 4. where other continence surgery is Surgical treatment may be classified as follows: contraindicated. 1. Simple The procedure is simple and quick and can be - urethral bulking performed as a day case under local anesthetic - mid urethral tape with or without sedation. Complications include short-term voiding disorders, local (periurethral) 2. Complex abscess formation, systemic allergic reaction - colposuspension - open or laparoscopic with collagen and particle migration (Teflon, sili- - sling cone , and carbon-coated beads). - artificial urinary sphincter - urethral closure The bulking agent is conventionally injected at - urethral diversion the bladder neck , but recent studies have sug- gested bulking should be carried out more distally. ' 281
282 S.L. Stanton Midurethral Tape similar for both operations. More pain was expe- rienced by the open colposuspension. This innovative procedure was described by Petros and Ulmsten in 19903 as the intravaginal The colposuspension works by elevating the sling and was refined until it became commer- bladder neck and may lead to some outflow cially available as the tension-free vaginal tape in obstruction.Intraoperativecomplications include 199t: all subsequent tapes, whether retropubic or venous hemorrhage, bladder injury, and ureteric transobturator, are derived from this work. The injury, and, postoperatively, voiding difficulty tapes are polypropylene and may either be mono- and posterior compartmental prolapse. filament (preferably) or multifilament. There are now at least 20 commercially available varieties. At a mean follow-up of 12.1 years Alcalay et al. reported an objective cure rate of 94%. 8 Midurethral tape is believed to stabilize and support the midurethral segment on effort, when Sling the proximal and distal urethral portions of the urethra descend, leaving the midurethra sup- Sling procedures are now largely used as second- ported and leading to kinking at this point (rather ary continence operations - when other conti- similar to how a garden hose can be bent to inter- nence operations have failed and intrinsic rupt the flow). sphincter defect is present. First described in 1907 by von Giordano, and later modified by The indications are either primary or second- Goebell (1910), Frangenheim (1914) and Stoeckel ary SUI at any age. Contraindications include (1917), they were more popular in Central Europe previous tape or sling erosion of the midurethra until modified by Aldridge (1942) and Studdiford or a fistula. Previous irradiation is a relative (1944) in the USA9 and Moir (1968) in the United contraindication. Kingdom.'? Complications include short-term voiding The earliest slings were of autologous tissue difficulty (11%), retention requiring resection of (rectus sheath fascia and fascia lata) then syn- the tape (1-2.8%), retropubic hemorrhage, and thetic tissue (polyethylene and polypropylene), bladder perforation at the time of surgery (0.8- allograft tissue (cadaveric dura, fascia lata, etc.), 21%).2 Tape erosion into the urethra or vagina and, more recently, xenograft tissue (porcine and bowel injuries are uncommon. dermis, SIS, etc.); all require a combined abdorni- novaginal approach. The sling is inserted at the Complex Procedures bladder neck (not midurethra) without tension. Cure rates vary enormously, with a quoted mean Colposuspension of 85%. Complications of all slings include voiding difficulties and erosion. With xenografts The main continence operation in this group, there is the added potential risk of transmission which is still the gold standard for continence of viruses and DNA.2 surgery, is the Burch colposuspension, first described by Burch in 1961.5 Many papers have Artificial Urinary Sphincter since been published about the technique, com- plications, and success rates. In 1973, Scott, Bradley, and Timm described the artificial urinary sphincter (made by American The colposuspension can be performed either Medical Systems), which could be used in both open or laparoscopically - most traditional clini- men and women.\" In women, it is usually reserved cians prefer the former, which is more likely to be for recurrent incontinence after failed conven- accompanied by posterior compartmental pro- tional continence procedures. The device con- lapse and voiding difficulties.\" In a multicenter sists of a fluid-filled silastic-coated system with a prospective random controlled trial of open and cuff to be placed around the bladder neck, a pres- laparoscopic colposuspensions by Smith et al.,' sure-regulating balloon in the retropubic space, the subje ctive and objective cure rates, mean and an activating device or pump in the left length of hospital stay, and complications were labium majus.
S.l. Stress Urinary Incontinence: Choice ofSurgery 283 The sphincter allows controlled voiding via the recurrent urinary tract infection with renal dete- urethra. The patient must be carefully selected - rioration (caused by ureteric ileal stenosis) and she must be mentally alert and aware of the com- conduit obstruction at the skin surface. plexity and complications of the artificial urinary sphincter and have adequate hand movements Alternatively, the ureters can be implanted and coordination to operate the sphincter. She into a detubularized rectosigmoid pouch (Mainz should have sterile urine, normal upper urinary pouch), allowing the patient to void per rectum. tract, and a bladder capacity of >200ml with The complications include the potential of minimal residual urine. Urodynamic testing metabolic acidosis and malignant change . An- should confirm USIwithout an overactive bladder nual sigmoidoscopy is necessary to detect the or voiding difficulty. The sphincter is implanted latter. through a lower abdominal incision and acti- vated 6 weeks later to allow tissue healing. Continent urinary diversion is achieved by a The success rate for social continence may be Mitrofanoff procedure. The bladder continues to as high as 92%.2 Complications include mechani- be used as reservoir, but the bladder neck is cal failure, cuff erosion, and infection. Careful closed off and a new \"urethra\" is constructed follow-up is necessary. (using the appendix, ureter, or an isolated portion of ileum; Monti procedure), one end of which is Because of their complexity, sphincters should anastomosed to the bladder and the other end only be implanted in units (urological or gyneco- opens out as a small stoma on the anterior logical) with specialized experience and capable abdominal wall. The bladder is emptied by fre- of long-term follow-up. quent catheterization via the stoma. Complica- tions include revision (as high as 25%) because of The sphincter is the option for the woman with stenosis, urinary infection, stone formation, and intractable incontinence who wishes to be dry, to failure to catheterize.\" void through her urethra, and to avoid urinary diversion. Most patients agree that it improves Conclusion the quality of life. Urethral Closure There are many surgical options, and experi- enced advice from a urologist or urogynecologist This is a relatively simple procedure that is com- is necessary when considering any of them. bined with suprapubic catheterization. Closure may be carried out vaginally (with a Martius fat References pad) or suprapubically (with an omental interpo- sition); the latter is usually more successful, 1. Monga A, Robinson D, Stanton SL. Periurethral but has a higher morbidity. Recanalization and collagen injections for genuine stress inconti- fistula formation are known complications of both.\" nence: a two-year follow up. Brit J Urol. 1995;76: Urinary Diversion 156-60. 2. Smith A. Surgery for urinary incontinence in Urinary diversion is the final and most complex option for persistent urinary incontinence. Diver- women. In: Abrams P, Cardozo L, Khoury S, Wein sion may be carried out by several means. The A, editors. Incontinence - third international con- most common is the conduit, in which a loop of sultation. Plymouth, UK: Health Publications Ltd; small ileum is isolated and the ureters are reim- 2005:1297-1370. planted into one end, while the opposite end 3. Petros P, Ulmsten U. An integral theory of female opens out through a stoma onto the anterior urinary incontinence. Experimental and clinical abdominal wall, where urine collects in a bag. considerations. Acta Obstet Gynecol Scand . The disadvantages include upper tract reflux and 1990;153:7-31. 4. Ulmsten U, Falconer C, Johnson P, et al. A multi- centre study of TVT for surgical treatment of stress urinary incontinence. Int Urogynecol J. 1998:210-215. 5. Burch J. Urethro-vaginal fixation to Cooper's ligament for correction of stress incontinence,
284 S.L. Stanton cystocele and prolapse. Am] Obstet Gynecol. 1961; 9. Hohenfellner R, Petri E. Sling procedures. In: 81:281-290. Stanton SL,Tanagho E, editors. Surgery for female 6. Alcalay M, Stanton SL. Retropubic suspensions - incontinence. 2nd edition. Berlin: Springer-Verlag; open retropubic suspensions. In: Stanton SL, 1986:105-113. Zimmern P, editors. Female pelvic reconstructive surgery. London: Springer-Verlag; 2002:93-101. 10. Moir ]C. The gauze hammock operation. Br ] 7. Smith A, Kitchener H, Dundee G, et al. A prospec- Obstet Gynaecol. 1968;75:1-9. tive randomised controlled trial of open and lapa- roscopic colposuspension. Neuro Urol Urodyn . 11. Scott F, BradleyW, Timm G. Treatment of urinary 2005;24:422-423. incontinence by implantable prosthetic sphincter. 8. Alcalay M, Monga A, Stanton SL. Burch colposus- Urol. 1973;1:252-259. pension: a ten-twenty year follow-up. Brit] Obstet Gynaecol. 1995;105:740-745. 12. Venn S, Mundy T. Diversion and bladder neck closure. In: Stanton SL, Zimmern P, editors. Female pelvic reconstructive surgery. London: Springer-Verlag; 2002:261-269.
5.2 Genital Prolapse: Surgery for Failed Conservative Treatment Stuart 1. Stanton Key Messages 1. Continued childbearing. As with urinary stress incontinence, it is wisest to defer surgery Surgical treatment of prolapse can be deferred until childbearing is complete, as subsequent until symptoms become intrusive. Conditions pregnancies and vaginal delivery are likely to that raise the intraabdominal pressure should disrupt any reconstructive surgery and lead to be reduced . Sometimes a decision may have to recurrence of symptoms with a decreased rate of be made between a vaginal or an abdominal success for further surgery. approach, and whether to use a supportive bio- logical or synthetic tissue . More properly con- 2. Lifestyle. A job entailing heavy lifting or an trolled trials with a realistic follow-up are needed active sporting life will need discussion, and even to help decision-making. some curtailment, if a successful outcome is to be achieved . Advice will be needed to reduce excess Introduction or unnecessary physical activity. Management of prolapse depends on the symp- 3. Coincident pelvic conditions. An overall toms and their interference with quality of life, plan needs to be adopted if surgery is required the extent of physical signs of prolapse, and asso- for pelvic conditions, such as hysterectomy for ciated conditions. If the symptoms are mild, the fibroids, oophorectomy for ovarian pathology, or prolapse is stage I, and pelvic surgery is not urinary or fecal incontinence. required for any other condition (e.g, urinary incontinence, hysterectomy, or fibroids), surgical 4. Coitus. Care needs to be taken to avoid treatment may be deferred. vaginal narrowing or shortening so that coitus is not compromised. However, to prevent worsening of the prolapse, the following things should be minimized or The patient's choice needs to be considered avoided: weight gain, unnecessary heavy lifting, when informed consent is taken. Some women chronic cough, straining at stool, or anything with multiple prolapses may want only one else that raises the intraabdominal pressure. attended to and need to be warned that an incom- plete cure of prolapse may result with continua- Surgery is appropriate when the prolapse is a tion of prolapse symptoms. nuisance and conservative measures have failed or, rarely, when a stage 4 cystocele obstructs the Finally, the choice of operation for any pro- ureters, leading to renal failure . Any decision to lapse may be influenced by previous prolapse proceed to surgery should take the following into surgery or other pelvic operations (e.g, fistula account: repair), the expertise of the surgeon, and the fitness of the patient (e.g, vaginal surgery may be less traumatic to the patient, but may not have the same success rate as an abdominal operation). 285
286 S.L. Stanton Role ofMesh 2. Cervix and uterine prolapse: descent of the uterus First time surgery for prolapse may fail in 30% of women, and up to a further 10% may require 3. Vault prolapse: posthysterectomy prolapse in repeat surgery,' Some clinicians contest these which the top of the vagina descends and may figures and say that they are too high and that be indistinguishable from an enterocele . Both many women with prolapse may remain asymp- can contain small bowel. tomatic. Nevertheless, there is broad agreement that the success rate of prolapse surgery needs to 4. Posterior vaginal wall: rectocele be improved. The staging of severity or extent is fully explained Over the last 5 years, synthetic meshes, autolo- in Chapter 1.6. gous fascia, cadaveric fascia, and pig's small intestine have been used increasingly to streng- Surgery then prolapse repair. The most commonly used synthetic material is polypropylene, and of the Anterior Vaginal Wall Prolapse varieties available monofilament is usually pre- ferred because of the lower risk of infection The anterior repair, which was initially described caused by bacteria being trapped within its inter- simultaneously in 1888 by Donald in Manchester stices. Whether synthetic or biological, all meshes and Olshausen and Schroeder in Berlin, is the and grafts rely on host fibroblasts growing into conventional procedure, with success rates them to form a firm barrier and support. There varying between 31-85%; with mesh or other are complications - the most common being support this may rise to 40-100%.3 The proce- rejection with infection and erosion. Because of dure involves a vertical incision of the vaginal the concern about the durability of biological wall to expose the pubocervical fascia. Several grafts and the risk of infection caused by trans- nonpermanent sutures are then used to draw the mission of prions, synthetic meshes have become pubocervical fascia together from both sides to more popular, although many commercial prod- the midline, to buttress the urethra and bladder. ucts may have insufficient animal and human Usually, some excess vaginal mucosa is excised trial evidence to support the safety or efficacy and the remaining vaginal tissue is sutured in the of the mesh and the procedure, and these will midline. Care is exercised to avoid taking too need careful evaluation and discussion with the much mucosa, which may lead to vaginal con- patient. traction. Catheter drainage is used afterward. The main indications that meshes and grafts An alternative technique, the paravaginal should be used are (a) previous failed prolapse repair, is based on the principle that a cystocele surgery; (b) raised intraabdominal pressure, e.g. can occur when the pubocervical fascia is chronic obstructive airways disease, obesity, detached laterally from the white line (arcus unavoidable heavy lifting; and (c) poor wound tendineus). In this repair, which can be carried healing (e.g. coincident steroid therapy). Previ- out vaginally, abdominally, or laparoscopically, ous pelvic irradiation may be a contraindication several permanent sutures are inserted into the to synthetic meshes. white line and then into the pubocervical fascia. The success rate for this procedure varies between Classification ofProlapse 61% and 97%, but, to date, no randomized con- trolled trial has evaluated the paravaginal repair in isolation.Y The practical and anatomical classification of Uterine Prolapse prolapse is: Uterine prolapse can be managed either by a 1. Enterocele: anterior vaginal wall sacrohysteropexy, which leaves the uterus in Cystocele: bladder only place, or a hysterectomy, which can be carried out Cystourethrocele: bladder and urethra either vaginally or abdominally.
5.2. Genital Prolapse: Surgery forFailed Conservative Treatment 287 The sacrohysteropexy has a success rate of from the venous plexus over the sacrum and 92-100%.3 Either an abdominal or laparoscopic mesh erosion into the vagina . approach may be used. Polypropylene or Vypro mesh is attached to the junction of the cervix and Rectocele uterus and then to the anterior longitudinalliga- ment over the first sacral vertebra. Because mesh The posterior colporrhaphy is the standard pro- may shrink by up to 20%, the mesh is left quite cedure for rectocele correction and to \"tighten\" loose and follows the curve of the sacrum. It is the vagina in those women who complain of usually not peritonealized. vaginal laxity. The conventional approach is a posterior wall vaginal incision that displays the A hysterectomy is usually carried out vaginally fascia over the levator ani muscles, which are when the main indication is prolapse and the then approximated in the midline by absorbable uterus is not larger than 16 weeks. If there is sutures. Alternatively, a discrete fascial plication concern about the difficulty of the hysterectomy, that looks for breaks in the fascia can be used, the risk of intraperitoneal adhesions, or a large and then these breaks are sutured. The success uterus, it is wisest to carry out an abdominal rate for levator muscle plication is approximately hysterectomy. Either way, the vault has to be 70% and for discrete fascial plication it is between secured to the remnants of the broad and utero- 68% and 95%.3However, the follow-up for fascial sacral ligaments to prevent subsequent vault pro- plication at present does not exceed 18 months, lapse, which may occur in 10% of patients. so some judgment must be reserved about this procedure. Posterior colporrhaphy complications Vault prolapse may be managed by many oper- include dyspareunia and constipation. Kohli and ations, including vaginal sacrospinous fixation Miklos\" used dermal grafts and had a 93% surgi - and bilateral iliococcygeal fixation or abdominal cal cure, whereas Sand et aF found no difference sacrocolpopexy (either open or laparoscopic). in cure rate when comparing a standard posterior repair with a repair using Polyglactin 910 mesh Sacrospinous fixation is performed by attach- reinforcement. ing the vault to one of the sacrospinous ligaments using nonabsorbable sutures; care has to be taken Alternatively, colorectal surgeons prefer a to avoid trauma to the pudendal nerve and transanal repair, where the patient is placed vessels. This technique has the disadvantage of prone on the operating table and the anterior deviating the vagina to one side. Alternatively, a rectal mucosa is incised transversely, proximal to bilateral iliococcygeal fixation can be carried out, the dentate line, and dissected free of the under- which involves securing the vault to the fascia lying circular muscle. The circular muscle is then over the left and right iliococcygeal muscles at plicated longitudinally with 3 or 4 polypropylene the level of the ischial spine . There may be some permanent sutures, the excess mucosa is excised, shortening of the vagina in this operation. Maher and the defect then closed with a polydioxanone and colleagues' have shown a similar objective suture. Complications include prolonged wound success rate between the sacrospinous and ilio- healing of the perineum caused by infection and coccygeal fixation of 67% and 53%, respectively. failure to correct any associated enterocele. The success rate of the transanal repair varies between The sacrocolpopexy involves suturing either 23% and 70%. 8 Vypro or polypropylene mesh to the vault of the vagina using slowly absorbable sutures (PDS) and Conclusion then to the anterior longitudinal ligament of the first sacral vertebrum. The mesh may be perito- Many of the trials were neither randomized nor nealized and again is left loose to avoid the poten- controlled, nor did they have a follow-up of more tial shortening due to contraction. If there is a than 2 years. Thus, there is insufficient reliable concurrent rectocele the mesh can be extended data to make a positive recommendation for one down the posterior wall of the vagina and attached operation over another, or for a specific mesh to the perineal body. The cure rate for sacro- colpopexy, either open or laparoscopic, varies between 90% and 100%.3 The main complica - tions of sacrocolpopexy are venous hemorrhage
288 S.L. Stanton reinforcement. Surgeons have to be guided by the Khoury S, et al, editors. Incontinence. Paris: Health patient's requirement and characteristics, and Publication Ltd; 2005:1373-1401. their own expertise, success, and complication 4. Bent A, Yee A. Vaginal and abdominal paravaginal rates . repair. In: Stanton SL, Zimmern P, editors. Female pelvic reconstructive surgery. London: Springer- References Verlag; 2002:169-178. 1. Olsen A, Smith UG, Bergstrom J. Epidemiology of 5. Maher CF,Murray CJ, Carey MP,et al. Iliococcygeal surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gyneco1. 1997;89:501- or sacrospinous fixation for vaginal vault prolapse . 506. Obstet Gyneco1. 2001;98:40-44. 6. Kohli V, Miklos J. Dermal graft augmented recto- 2. Shaw F. Plastic vaginal surgery. In: Kerr JM, cele repair. Int Urogynecol J. 2003;14:146-149 . Johnstone R, Phillips M, editors. Historical review 7. Sand P, Koduri S, Lobel R, et al. Prospective ran- of British obstetrics and gynaecology. Edinburgh: domised trial of Polyglactin 910 mesh to prevent E.S. Livingstone Ltd; 1954:370-381. recurrence of cystocele and rectocele. Amer J Obstet Gyneco1. 2001;184:1357-1364 . 3. Brubaker L, Bump R, Fynes M, et al. Surgery for 8. Kahn M. Posterior compartment: rectocele recon- pelvic organ prolapse. In: Abrams P, Cardozo L, struction. In: Stanton SL, Zimmern P, editors . Female pelvic reconstructive surgery. London: Springer-Verlag; 2002:219-226.
5.3 The Anal Sphincter Klaus E. Matzel, Manuel Besendorfer, and Stefanie Kuschel Key Messages fecal loss). Only if these conservative therapies fail to improve symptoms should surgical inter- We review the treatment of fecal incontinence, vention be considered. starting with biofeedback to teach awareness and recruitment of residual function. Should that fail, Sacral Nerve Stimulation sacral nerve stimulation (SNS) is suggested. After a percutaneous test stimulation, a neurostimula- Sacral nerve stimulation is based on the concept tory device is implanted. The indications for this of recruiting residual function of the continent are a defect in the internal or external anal organ by stimulation of its peripheral nerve sphincter or neurogenic incontinence. Recon- supply.' Various physiological functions con- structive techniques involve surgical repair of the tributing to continence are activated by low- anal sphincter by several techniques, with frequency electrostimulation of 1 or more sacral approximately 66% of patients showing improve- spinal nerves by a fully implantable neurostimu- ment. Should this fail, sphincter replacement lation device that looks like a pacemaker. ' A per- using either autologous tissues (e.g, gracilis cutaneous test stimulation is usually done before transposition), the artificial bowel sphincter surgery. The results of the test stimulation have (developed by American Medical Systems), or a highly predictive value. Implantation of the stomal diversion can be considered. Outcome final permanent neurostimulation device will measurements for all of these techniques is dis- only take place when a >50% reduction in incon- appointingly rare . tinent episodes or in days with incontinence is achieved.' Introduction With the help of test stimulation, the spectrum Biofeedback is the first choice for functional of indications for SNS has been continuously rehabilitation. Based on the principle of operant expanded to patients suffering from fecal incon- conditioning, visual or acoustic signals are used tinence, which is attributable to a wide variety of to teach the patient awareness and use of specific causes: weakness of the external anal sph incter, physiologic functions and, thus, to recruit resid- with concomitant urinary incontinence or a ual function. Success ranges widely, from 38% defect and/or deficit of the smooth-muscle inter- to 100%.1 Retrograde irrigation is intended to nal anal sphincter; status postrectal resection; improve rectal reservoir function (by distension limited structural defects of the external anal and improved perception through a defined stim- sphincter combined with limited defects of ulus) and to establish a rhythm for sufficient the internal anal sphincter; and neurogenic bowel emptying (to ensure time intervals free of incontinence. 289
290 K.E.Matzel et al. The short-and long-term effects of SNS have such as biofeedback, irrigation, and sacral nerve been demonstrated in multiple single and multi- stimulation. center trials. With chronic SNS the frequency of involuntary loss of bowel content is reduced, both Sphincter Replacement the ability to postpone defecation and quality of life is improved,\" and a substantial percentage of Sphincter replacement procedures are indicated patients gain full continence. Complications are if functional rehabilitation is not successful, if rare. In only less than 5% of patients has device incontinence is the result of a substantial muscu- removal become necessary, mostly because of lar defect that is not suitable for sphincter repair, pain or infection. After removal because of infec- or if a neurological defect is present. Two tech- tion, reimplantation can be performed success- niques have gained broad acceptance: dynamic fully at a later date. graciloplasty (DGP)6 and the artificial bowel sphincter (ABS).7The indications for both proce- The physiological mode of action of SNS is not dures are similar; end-stage incontinence in yet clearly understood. Its effect is complex and patients with a substantial muscular and/or multifactorial, involving somatomotor, somato- neural defect of the anal sphincter complex. Both sory, and autonomic functions of the anorectal procedures represent an alternative to the cre- continence organ . ation of a stoma. Reconstructive Techniques Dynamic Graciloplasty Morphological reconstruction is indicated if a Dynamic graciloplasty is a modification of the defined, functionally relevant, sphincteric defect transposition of the gracilis muscle around the is diagnosed. Sphincter repair aims to reestablish anus to function as a neosphincter, which was function by reconstructing the morphological first described in the early 1950s.8 The aim of this defect: a muscular gap is closed by adaptation of transposition is to encircle the anal canal com- the dehiscent muscle. Several techniques, such pletely with muscle tissue. Thus, the configura- as direct overlapping sphincter repair, postanal tion of the muscle sling - alpha, gamma, or repair, and total pelvic floor repair, have been epsilon configuration - is determined by the advocated in the past, and sphincter repair is now length of the muscle and its tendon. This passive generally accepted as first-line treatment for muscle wrap is rendered dynamic by the implan- incontinence caused by sphincteric defects. The tation of a neurostimulation device that is placed results of sphincter repair are not reported uni- subcutaneously. Therefore, the innervation of formly and, thus, it is difficult to evaluate series the gracilis muscle must be intact. To adapt the and to compare the outcome of this technique muscle to prolonged contraction, the periods of with that of other procedures. Moreover, pro- stimulation are increased in stepwise fashion. spective outcome recording is rare; most reported The stimulator may be deactivated by an external results are based on patients' recall and are magnet. Thus, bowel emptying becomes a volun- limited to functional issues without addressing taryact. quality of life. Approximately two thirds of patients report a significant improvement in con- Artificial Bowel Sphincter tinence. However, the long-term therapeutic effect of sphincter repair has recently been ques- The ABS (Acticon neosphincter; American tioned, as several studies have reported a deterio- Medical Systems) consists of three components: ration in function over time. an inflatable Silastic cuff placed around the anus via perianal tunnels; a liquid-filled, pressure- If sphincter repair - despite reestablishment of regulating balloon positioned in the preperito- morphological integrity - fails to achieve success, neal fat; and a manual pump connecting these or if function deteriorates over time, patients components, which is placed in either the labia can be considered for functional rehabilitation,
5.3. The Anal Sphincter 291 majora or the scrotum. The anal canal is closed removal is unavoidable. The functional compli- as the cuff fills with liquid. At the time for defeca- cation most clinically relevant is outlet obstruc- tion the device is deactivated via the manual tion. This may be caused by a preexisting pump; the cuff empties and the anus opens to obstruction that is not identifiable because of pass stool. The cuff is refilled and the anus is incontinence or by \"hypercontinence\" subse - closed after a few minutes. quent to neosphincter creation. In most cases , this functional problem can be treated with As with dynamic graciloplasty, opening of the regular enemas. ABS becomes a voluntary act and closure of the anal canal is maintained without conscious Stoma Creation effort, mimicking the initiation of defecation in the healthy. Compared with DGP,there is a higher The creation of a diverting stoma should be con- risk of infection with this implanted artificial sidered an alternative to surgery for end-stage material, especially if the Silastic cuff of the ABS incontinence, although it doesn't address incon- cannot provide sufficient coverage . tinence, per se, if comorbidity or intellectual or physical inability precludes the above-described Short- and long-term effects on function and sphincter replacements. Stoma creation carries quality of life have been published in several its own risks, however, and patient counseling studies, both single- and multicenter,\" Again, and performance of the procedure and postop- outcome measurement is inconsistent and data erative management should be handled with must be interpreted cautiously. great care. Both sphincter replacement procedures are Summary associated with substantial morbidity in virtu- ally all reports. In larger multicenter trials, the The surgical options for fecal incontinence have need for operative revision reached 42% for the increased during recent years, and a new treat- DGplO and 46% for the ABSll; treatment had to be ment algorithm has evolved (Fig. 5.3.1). Symp- discontinued in 8% and 30%, respectively. The toms and quality oflife can be improved if patient most severe complications were infections. Their occurrence is not surprising when one bears in mind that the operation is performed in a natu- rally contaminated area. In most cases, device diagnostics / neural deficit musculardeficit isolated functional deficit EAS, lAS substantial defect - without morphological defect muscular, EAS,IAS - with limited morphological defect neural neurogenic incontinence EAS defect j jd;8.0ost;, SNS (PNE) j FIGURE 5.3.1. Surgery for Sphincter Repa!i h • .- -S-N-S- ---- -/- ... Sphincter- Stoma fecal incontinence treatment t erapeunc replacement alogrithm. EAS: external anal /\"\\,. DGP, ASS sphincter, lAS: internal anal / sphincter. Success Failure /\"\\,. /\"\\,. Success Failure Success Failure
292 K.E. Matzel etal, selection is appropriate. Although these proce- tinence: Report of a prospective multicenter trial. dures carry some morbidity, they may offer an Dis Colon Rectum . 2000;43:743-751. alternative to the creation of a diverting stoma. 7. Lehur PA, Roig J, Duinslaeger M. Artificial anal sphincter: Prospective clinical and manometric References evaluation. Dis Colon Rectum. 2000;43:1213- 1216. 1. Madoff RD, Parker SC, Varma MV, et al. Fecal 8. Pickrell KL, Broadbent TR, Masters FW, et al. incontinence in adults. Lancet. 2004;364:621-32. Construction of a rectal sphincter and restoration of anal continence by transplanting the gracilis 2. Matzel KE, Schmidt RA, Tanagho EA. Neuroanat- muscle; a report of four cases in children. Ann omy of the striated muscular anal continence Surg. 1952;135:853-862. mechanism: Implications for the use of neuro- 9. Chapmann AE, Geerdes B, Hewett P, et al System- stimulation. Dis Colon Rectum. 1990;33:666-673. atic review of dynamic graciloplasty in the treat- ment of faecal incontinence. Br J Surg. 2002;89: 3. Matzel KE, Stadelmaier U, Hohenfellner M, et al. 138-153. Electrical stimulation for the treatment of faecal 10. Matzel KE, Madoff R, LaFontaine LJ, et al and incontinence. Lancet. 1995;346:1124-1127. the Dynamic Graciloplasty Therapy Study Group. Complications of dynamic graciloplasty: Inci- 4. Matzel KE, Stade1maier U, Hohenberger W. Inno- dence, management and impact on outcome. Dis vations in fecal incontinence: Sacral nerve stimu- Colon Rectum. 2001;44:1427-1435. lation. Dis Colon Rectum. 2004;47;1720-1728. 11. Wong WD, Congliosi SM, Spencer MP. The safety and efficacy of the artificial bowel sphincter for 5. Matzel KE, Kamm MA, Stosser M, et al. MDT 301 fecal incontinence: results from a multicenter study group. Sacral nerve stimulation for fecal cohort study. Dis Colon Rectum. 2002;45:1139- incontinence: a multicenter study. Lancet. 2004; 1153. 363:1270-1276. 6. Baeten C, Bailey RA, Bakka A, et al. Safety and efficacy of dynamic graciloplasty for fecal incon-
Index A Anal probes, for electrical Antepartum pelvic floor muscle Abdominal/pelvic floor EMG, stimulation, 192 training, to prevent postpartum urinary uroflow with, 114 Anal/rectal sensation, 129 incontinence, 230-231 Abdominal ultrasound, 137-138 balloon distension and , 129 Advanced uterovaginal prolapse, Antepartum/postpartum urinary Anal sphincter, 289-292 incontinence prevention, rectal prolapse and , 79 anatomy of, 76 PFMT and, during Afferent pathways, of PFMs, 27-28 complex, anatomy of, 18-19 pregnancy, 231-232 Aging, muscle function and , continuously firing tonic motor unit from , frequency Anterior rectocele, defecating 49-58 histogram of, 24 proctogram of, 131 AI. See Anal incontinence dynamic graciloplasty for, 290 Alcock's canal, 12, 27 introduction to, 289 Anterior vaginal wall prolapse, Alpha-agonists, for SUI, 225 key messages of, 289 surgery for, 286 Alternative methods, of pelvic laceration, anal incontinence and, 41-42 Anterior wall support, urethra floor muscle awareness/ mechanism of, 76 and, 14-16 training, 208-211 reconstructive techniques, Anal canal, high-pressure zone of, 290 Antidepressants, for OAB,251 124 replacement of, 290 Antidiuretic agents, for OAB, Anal fissure, management sacral nerve stimulation and, pathway for, 244 289-290 251 Anal incontinence (AI), 75-82, Antimuscarinic drugs, for OAB, 259-265 Anal tear, management pathway anal sphincter laceration and , for, 245 250-251 41-42 Arcus tendineus, pelvic anatomy of, 75-76 Anismus,79 biofeedback for, 263-264 functional causes of, 79 attachment of, 15 cases of, 264-265 Arcus tendineus levator ani exercises for, 263 Anorectal constipation, 78-79 introduction to, 75, 259 functional causes, 79 (ATLA),11 key message of, 75, 259 organic causes , 78-79 Arcus tendineus of fasciae pelvis neurogenic mechanism of, 81 Anorectal function, neural control (ATFP),l1 obstetric/maternal risk factors of, 30-31 Artificial bowel sphincter, for, 42 pathophysiology of, 77 Anorectal manometry, 124-126 290-291 patient education and, 259 normal recordings and, 125-126 Artificial urinary sphincter, for physiology of, 75-76 perfusion systems and, 125 Anal motility, electrical resting anal pressure and, SUI, 282-283 stimulation and, 264 125-126 ATFP. See Arcus tendineus of Anal pressures, normal mean, 125 Anorectal physiology, 124-132 fasciae pelvis introduction to, 124 ATLA. See Arcus tendineus key message of, 124 levator ani Anorectum, midcoronal section of, 18 B Balloon training, bowel routine and , 261-262 Behavioral/drug therapy combination, for OAB, 251 293
294 Index Behavioral treatment guidelines for, 247 Constipation for GAB, 246 for GAB, 246-248 anorectal, 78-79 with PFM rehabilitation, 248 Bonney's analogy, of vaginal biofeedback for, 263-264 for PFMT, 215-219 causes of, 77 introduction to, 215 prolapse, 9 colonic, 77 key messages of, 215 Bowel fecal incontinence and, 79-80 pathogenesis of, 80 Biofeedback management, urinary pathophysiology of, 77 for AI, 263-264 incontinence and, 219 for constipation, 263-264 Continence definition of, 184-185 GAPF and, 84 mechanism for detrusor overactivity retraining, 263 deterioration of, 4 control, 188 routine, 259-260 levator ani muscle and, 12-13 with dynamic ultrasound, 188 mechanism of, 77 electromyographic, 187 balloon training and, 261-262 neural control of, 30 with inflated indwelling diet and, 260 with normal voiding, example catheter, 186 fluids and, 260 of, 114-116 kinesthetic, 186-187 physical activity and, 260 physiology of, 76-77 manometric visual, 187-188 posture and, 261 pregnancy and, 4 motor learning and, 184 sphincter, artificial, 290-291 promotion, with routine health PFM rehabilitation and, Bulking agents, for SUI, 281 care, 240-241 185-189 with sonography, 188 C Continuity of care, 44 SUI and, during sports/fitness Cantienica training, of pelvic Contraceptive diaphragm, for SUI, activities, 268-269 tactile/verbal, 185-186 floor, 210-211 205 with vaginal cones, 187 Cellular mechanisms, of muscle Coronal scan, 137-138 with vaginal EMG-electrode, 188 repair/rehabilitation, 53-54 with perineum ultrasound with vaginal probe, 187 Central motor conduction time probe placement, 138 visual, 186 (CMCT),28 Coughing, sonographic evaluation Biomechanical stimulation, of Cesarean section, 44 of,138-140 pelvic floor, 211 Childbirth Cough stress profile, 115 Birth position, uprightllateral, pelvic floor function and, 39-44 of continent woman, 115 44 perineal ultrasound findings of stress-incontinent woman, 117 Bladder on,40 anatomy of, 5 urinary incontinence after, 41 CSM. See Circular smooth muscle function of, 5 urodynamic findings on, 40 Cystocele innervation of, 5-6 Circular smooth muscle (CSM), 7 neck of, 5 Circumvaginal musculature illustration of, 14 GAPF and, 83-84 left displacement, 15 rating scale, 98 Cystometrogram (CMG), 110 Bladder base, MRI of, 147 Clam exercise, for pelvic floor, 209 Bladder diary, 215-217 CMCT. See Central motor D Darifenacin, for GAB, 250-251 leakage frequency on, 166 conduction time Defecating proctogram, 130-131 sample, 216 CMG. See Cystometrogram Bladder function, phases of, 62 CNE. See Concentric needle of anterior rectocele, 131 Bladder neck, MRI of, T2 weighted of descending perineum, 131 electrode findings at, 131-132 transverse sections, 148 Coccygeus muscle, 10 Defecation Bladder neck mobility, Coccyx, pelvic floor muscles and, mechanism of, 77 GAPF and, 86 urethrovesical angle and, 10 physiology of, 76-77 measurement of, 139 Colonic constipation sonographic evaluation of, 140 Bladder neck/perineum Defecation scintigraphy, 130 during pregnancy, 40 inorganic causes of, 77 Defecography, 130-131 after vaginal delivery, 40 organic causes of, 77 Delayed voiding, 218 Bladder training, 218 Colonic function, measurement Denervation disorder, of skeletal of,129-130 muscle, 54 Colonic manometry, 130 Colonic transit studies, 129-130 Colposuspension, for SUI, 282 Concentric needle electrode (CNE),157
Index 295 Descending perineum, defecating RCTs of, 197-198 medication for, 263 proctogram of, 131 treatment protocols for, 197-198 studies on, 199 Electromyography (EMG), 128 surgical treatment algorithm Descending perineum syndrome, biofeedback, 187 10,73 from pelvic floor, 157 for, 291 striated muscle activity and, Feldenkrais approach, to pelvic Desmopressin, for DAB, 251 Detrusor overactivity control, 155-157 floor, 209-210 Electrophysiology, 155-161 Fembrace, for POP, 276 biofeedback for, 188 FI. See Fecal incontinence Detrusor overactivity , pure, introduction to, 155 Filling cystometry key message of, 155 urodynamic findings and, EMG. See Electromyography normal example of, 116 118-122 Endoanal ultrasound, 132, 138 in DAB female patient, 118 Devices for, for PFM abnormal, 132 pressure-flow studies and, rehabilitation, 201-206 normal,132 Diet, bowel routine and , 260 Endopelvic fascia 111-112 Digital self-assessment, pelvic of pelvic floor, 13-14 Fistulas, pessaries with, 275 re-education regimen and, of urethra, 6 Fluids 97 Evacuation Digital self examination, 91 difficulties, 259-265 bowel routine and, 260 Drydock boat concept, of POP, 73 normal,131 management of, 218 Dynamic graciloplasty, for anal techniques, 261 Frequency volume chart, leakage sphincter, 290 Dysfunctional voiding, 122-123 success rates for, 262 frequency on, 166 Dyspareunia, 253-254 training, 260-262 point-form treatment of, 256 Evidence-based exercise G General muscle training E parameters, for functional Electrical neurostimulation capacity improvement, of overload and, 178 striated pelvic floor principles of, 178 evidence for use of, 193-194 muscles, 238 reversibility and , 178 for fecal incontinence, 194 Evoked potentials, of pelvic floor, specificity and, 178 for mixed incontinence, 160-161 Genital muscles, external, Exercise. See also Pelvic floor 193-194 exercises perineal membrane and, for OAPF, 194 active muscle use and, 224 16-17 for stress urinary incontinence, adherence/maintenance, Genital prolapse 217-218 classification of, 286 193 initial program for, pelvic floor surgery for, 285-288 for urge incontinence, 193-194 muscle training, 223-224 introduction to, 285 Electrical stimulation, 190-194 for PFMs, 100-101, 184 key messages of, 285 action mechanisms of, 190-191 PFMT and , 179, 180,216-217 role of mesh in, 286 anal motility and , 264 progression of, 224 Groutz Score, 165 anal probes for, 192 protocol adherence, for PFMT, application of, for pelvic 181-182 H External palpation activations, of High-pressure zone, of anal canal, dysfunction, 191 pelvic floor, 210 introduction to, 190 Extracorporeal magnetic 124 key messages of, 190 stimulation, 196-199 Hirschsprung's disease , methods of peripheral, 191-192 introduction to, 196 in practice, 192-193 key messages of, 196 functional causes of, vaginal probes for, 192 79 Electromagnetic induction F Hook wire electrodes, 157-158 Fecal incontinence (FI), 259 EMG recording with, 158 therapy Hormone therapy, for SUI, indications for, 197 constipation and, 79-80 225-226 Neotonus chair for, 197 electrical neurostimulation for, Hymenal ring, 17 neuromuscular tissue response Hypotone urethra, 116 194 Hysterectomy to, 196-197 perineal descent/enterocele pelvic floor rehabilitation and, after, 153 vaginal support levels after, 199 13 principles of, 196
Search
Read the Text Version
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- 107
- 108
- 109
- 110
- 111
- 112
- 113
- 114
- 115
- 116
- 117
- 118
- 119
- 120
- 121
- 122
- 123
- 124
- 125
- 126
- 127
- 128
- 129
- 130
- 131
- 132
- 133
- 134
- 135
- 136
- 137
- 138
- 139
- 140
- 141
- 142
- 143
- 144
- 145
- 146
- 147
- 148
- 149
- 150
- 151
- 152
- 153
- 154
- 155
- 156
- 157
- 158
- 159
- 160
- 161
- 162
- 163
- 164
- 165
- 166
- 167
- 168
- 169
- 170
- 171
- 172
- 173
- 174
- 175
- 176
- 177
- 178
- 179
- 180
- 181
- 182
- 183
- 184
- 185
- 186
- 187
- 188
- 189
- 190
- 191
- 192
- 193
- 194
- 195
- 196
- 197
- 198
- 199
- 200
- 201
- 202
- 203
- 204
- 205
- 206
- 207
- 208
- 209
- 210
- 211
- 212
- 213
- 214
- 215
- 216
- 217
- 218
- 219
- 220
- 221
- 222
- 223
- 224
- 225
- 226
- 227
- 228
- 229
- 230
- 231
- 232
- 233
- 234
- 235
- 236
- 237
- 238
- 239
- 240
- 241
- 242
- 243
- 244
- 245
- 246
- 247
- 248
- 249
- 250
- 251
- 252
- 253
- 254
- 255
- 256
- 257
- 258
- 259
- 260
- 261
- 262
- 263
- 264
- 265
- 266
- 267
- 268
- 269
- 270
- 271
- 272
- 273
- 274
- 275
- 276
- 277
- 278
- 279
- 280
- 281
- 282
- 283
- 284
- 285
- 286
- 287
- 288
- 289
- 290
- 291
- 292
- 293
- 294
- 295
- 296
- 297
- 298
- 299
- 300
- 301
- 302
- 303
- 304
- 305
- 306
- 307
