排尿障礙治療中心版權所有 Conservative Treatment of Stress Urinary Incontinence Hann-Chorng Kuo. M.D. Department of Urology Buddhist Tzu Chi General Hospital, Hualien,

排尿障礙治療中心版權所有

Conservative Treatment of Stress Urinary Incontinence

Hann-Chorng Kuo. M.D.Department of Urology

Buddhist Tzu Chi General Hospital, Hualien, Taiwan


Pathophysiology of Stress urinary incontinence Intrinsic sphincteric deficiencyIntrinsic sphincteric deficiency Defects in extrinsic continence mechanismDefects in extrinsic continence mechanism

Defects of attachments to archus tendineus fascia pelvisDefects of attachments to archus tendineus fascia pelvis

Defects of attachments to levator aniDefects of attachments to levator ani

Damage or degenerative change of endopelvic fasciaDamage or degenerative change of endopelvic fascia

Pelvic floor muscle relaxationPelvic floor muscle relaxation

Damage of anococcygeal ligamentsDamage of anococcygeal ligaments Urethrovesical facilitative reflex (detrusor overactivity ?)Urethrovesical facilitative reflex (detrusor overactivity ?)


Damage of continence mechanism


Hypermobility of Bladder Neck


Factors Influencing Continence

Bladder neckBladder neck Urethral smooth muscleUrethral smooth muscle External urethral sphincterExternal urethral sphincter Pelvic floor musculaturesPelvic floor musculatures Connective tissue and collagenConnective tissue and collagen Intact neurological innervationIntact neurological innervation


Conservative management of Stress incontinence Weight reductionWeight reduction Stop smokingStop smoking Reduced caffeine intakeReduced caffeine intake Decrease fluid intakeDecrease fluid intake Resolving chronic straining and constipationResolving chronic straining and constipation Prevent heavy exertion or exercisePrevent heavy exertion or exercise


Physical Therapies for Stress Incontinence

Bladder retraining

Pelvic floor muscle exercises

Vaginal cones

Biofeedback

Functional electrical stimulation


Pelvic floor muscle training (PFMT)

Kegel 1948Kegel 1948 Effective PFM contractions increase urethral resistEffective PFM contractions increase urethral resist

ance, increase activated motor units, frequency of eance, increase activated motor units, frequency of excitation, and muscle volumexcitation, and muscle volume

Repeat PFMT may reflexly inhibit detrusor contracRepeat PFMT may reflexly inhibit detrusor contractionstions

Successful PFMT depends on ability to perform a cSuccessful PFMT depends on ability to perform a correct contraction, 50% women failed to do PFMTorrect contraction, 50% women failed to do PFMT


ICS recommendedIdeal PFMT Program

Three sets of 8 to 12 slow velocity

maximal contractions

Sustained for 6 to 8 seconds each

Performed 3 to 4 times a week

Continued for at least 15 to 20 weeks


Correct PMF contraction

Co-contraction of related muscles should be Co-contraction of related muscles should be discourageddiscouraged

Use of voluntary PFMC prior to anticipated Use of voluntary PFMC prior to anticipated increased intra-abdominal pressureincreased intra-abdominal pressure

Near maximal contractions are the most Near maximal contractions are the most significant factor in increasing strengthsignificant factor in increasing strength

Prevent muscle fatigue with vigorous exercisePrevent muscle fatigue with vigorous exercise Assessed by a specialist for correct PFMCAssessed by a specialist for correct PFMC


Effects of PFMT in Incontinence

A meta-analysis of 10 studies concluded A meta-analysis of 10 studies concluded improvement ranges from 61 to 85%improvement ranges from 61 to 85%

Cure ranges from3 to 38%Cure ranges from3 to 38% Severity of urine loss decreases by 61 to 82% in Severity of urine loss decreases by 61 to 82% in

women who leaks after PFMTwomen who leaks after PFMT In 23 women with repeat training for 5 years, 14 In 23 women with repeat training for 5 years, 14

were satisfied with current condition, 15 were were satisfied with current condition, 15 were continent, a high durability was notedcontinent, a high durability was noted


Combination of PFMT with other Physical therapies For a woman with stress, urge, and mixed incontinence, For a woman with stress, urge, and mixed incontinence,

PFMT is better than no treatmentPFMT is better than no treatment Combined PFMT with electrical stimulationCombined PFMT with electrical stimulation PFMT with biofeedbackPFMT with biofeedback PFMT with intravaginal resistance devisesPFMT with intravaginal resistance devises No consistent data proves that combination therapies are No consistent data proves that combination therapies are

better than PFMT alone, but can be used as an initial traibetter than PFMT alone, but can be used as an initial training for women who cannot perform VPFCning for women who cannot perform VPFC





Effects of Conservative Treatment

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


Predictive Factors for a Successful Physiotherapy

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


Postulated Physiological Changes after PFMT

Press urethra against pubis symphysis Increase activated motor units and muscle

volume Build a structural support for urethra Reflexic inhibition of detrusor contractions


Reported Urodynamic Findings in PFMT Increased in MUCP (Wilson 1987, Bo 1990, Elia 199

3) Increased in MUCP and FPL (Benevenuti 1987) No changes in MUCP or FPL (Ferguson 1990, Meye

r 1992, Burns 1993) No changes in all urodynamic parameters (McClis

h 1991, Elser 1999)


Videourodynamics in Evaluation of PFMT Determine abdominal leak point pressure

Measure bladder base descent during

straining

Measure bladder base elevation during PME

Educate patient to perform an effective PME




Dynamic Urethral Pressure Profilometry Resting UPP – Maximal urethral closure press

ure – Functional profile length

Stress UPP – Pressure transmission ratio PFMT UPP – Maximal pelvic floor muscle

contractions Concomitant recording Pves and Pabd






陰道壓力儀



Materials and Methods

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

failed treatment groups


PFMT Program

A 12- week structured treatment course

Performed by a trained nurse specialist

Involve a gradual home exercise and 6 office biofeedback sessions

15 sustained 10-second contractions, 3 timed daily

Results assessed by subjective satisfaction and improvement rate


Abdominal Muscle EMG Recording


Correct Pelvic Floor Muscle Contractions No Abdominal muscle contractions


PFM Contractions with Abdominal muscle contractions


PFMT 2 weeks, Weak Contractions


PFMT 6 weeks Strengthening


Strengthened PFM after 3 M training


Results of PFMT

Cure or improvement in 22 patients

(55%)

Treatment failure in 18 patients (45%)

Mean age 45 ± 12 and 47 ± 15 years

(p>0.05) of successful and failed

treatment group


Urodynamic Changes after PFMT Increase in first sensation, full sensation and cyst

ometric capacity No change in MUCP, PTR, and FPL Significant increase in pelvic floor contraction pre

ssure in PFC - UPP Successfully treated patients had more changes ALPP changed little in patients with persistent UI

排尿障礙治療中心版權所有The Urodynamic Parameters after Pelvic Floor Muscle Training (I)

Pre-treatment

Post-treatment

Statistics (p value)

Qmax (mL/s) Total 22.6 ± 13.0 20.9 ± 10.2 0.390

Successful26.0 ± 10.7

7 23.4 ± 10.7 0.236

Failure 18.3 ± 14.9 17.8 ± 9.2 0.881Voided volume

Total340.5 ± 123.

4 386.1 ± 152.9 0.240

Successful395.4 ± 69.

8 414.1 ± 176.3 0.780

Failure273.3 ± 144.

5 351.9 ± 119.4 0.021

FSF (mL) Total101.0 ± 26.

8 128.2 ± 41.6 0.025

Successful 96.1 ± 21.1 136.4 ± 45.8 0.027

Failure107.0 ± 32.

7 118.1 ± 35.7 0.484

FS (mL) Total189.0 ± 47.

5 229.5 ± 46.9 0.006

Successful190.4 ± 51.

4 245.0 ± 47.4 0.015

Failure187.3 ± 45.

2 210.4 ± 40.9 0.218

排尿障礙治療中心版權所有The Urodynamic Parameters after Pelvic Floor Muscle Training (II)

Pre-treatmentPost-

treatmentStatistics (p

value)

Cystometric Capacity (mL)

Total 288.2 ± 83.8 338.0 ± 96.1 0.050Successful 303.0 ± 82.9 377.8 ± 100.6 0.086Failure 270.1 ± 86.0 289.3 ± 66.8 0.376

Compliance (mL / cmH2O)

Total 63.8 ± 69.7 138.3 ±170.3 0.069Successful 58.7 ± 53.0 190.4 ± 208.0 0.045Failure 70.0 ± 89.1 74.7 ± 80.4 0.914

Pdet (cmH2O) Total 22.5 ± 9.0 21.9 ± 10.3 0.777Successful 21.5 ± 8.9 18.3 ± 8.3 0.328Failure 23.8 ± 9.5 26.2 ± 11.3 0.465

LPP(cmH2O) Total 111.7 ± 43.9 113.9 ± 20.7 0,816Successful 122.3 ± 44.9 109.3 ± 23.3 0.518Failure 99.6 ± 42.8 119.3 ± 17.4 0.233

排尿障礙治療中心版權所有The Urodynamic Parameters after Pelvic Floor Muscle Training (III)

Pre-treatmentPost-


value)

MUCP (cmH2O)


FPL (mm) Total 34.5 ± 4.59 36.6 ± 4.9 0.300Successful 34.4 ± 4.9 36.3 ± 5.1 0.089Failure 34.8 ± 4.4 36.9 ± 5.0 0.198

PTR (%) Total 47.9 ± 15.1 50.8 ± 10.2 0.486Successful 51.6 ± 17.4 50.2 ± 9.9 0.847Failure 43.4 ± 11.1 51.7 ± 11.1 0.049

PFC (cmH2O) Total 15.7 ± 13.4 23.0 ± 22.2 0.043Successful 20.5 ± 12.5 36.0 ± 21.2 0.009Failure 9.9 ± 12.7 7.1 ± 9.6 0.051




Bladder Base Changes after PFMT Less bladder neck descent after PFMT

Increased bladder neck elevation after PFMT

Both successfully and failure treated patients

had significant reduction of BN descent after

PFMT

BN descent and increase of BN elevation after

PFMT


The Urodynamic Parameter after Pelvic Floor Muscle Training (Ⅳ)

Pre-treatmentPost-


value)

Resting BN position (cm)

Total 1.40 ± 0.74 1.65 ± 1.13 0.304Successful 1.14 ± 0.95 1.54 ± 1.21 0.213

Failure 1.72 ± 1.20 1.77 ± 1.06 0.886

Straining BN position (cm)


BN descent (cm)


BN elevated PFMT (cm)







Prediction for a Successful PFMT Young age, fewer pad changes, less

urethral incompetence, higher MUCP

A greater voluntary BN elevation on PME

A greater PFM contractility

Pretreatment BN position and BN descent

does not affect outcome of PFMT




Results of PFMT for SUI

PFM can be strengthened by a 12-week PFMT program

Effective PFMT increases Pura during voluntary contractions

Strengthened PFM do not change BN resting position

Strengthened PFM reduce BN descent on straining

55% of SUI patients have benefit from PFMT

排尿障礙治療中心版權所有Pelvic floor muscle training for Stress urinary incontinence An improved hammock effect after PFMT

can be achieved No effect of PFMT on intrinsic continence

mechanism Patients with ISD might not benefit from

PFMT Patients with low cortical control of PFM

have unfavorable results Good patient intention and compliance are

the utmost important


Electrical Stimulation for SUI

Transvaginal ES has been used for genuine SUI, uTransvaginal ES has been used for genuine SUI, urge and mixed urinary incontinencerge and mixed urinary incontinence

Reported efficacy ranges 35 to70%Reported efficacy ranges 35 to70% A placebo-controlled study revealed after 15-weeA placebo-controlled study revealed after 15-wee

k treatment course, pad usage diminished by >50k treatment course, pad usage diminished by >50% in 62% women compared to 19% in sham devi% in 62% women compared to 19% in sham device, incontinence episode reduced >50% in 48% wce, incontinence episode reduced >50% in 48% women compared to 13% in sham deviceomen compared to 13% in sham device


Transvaginal electrical simulator

排尿障礙治療中心版權所有Transvaginal electrical stimulation for Urge incontinence Leach reported 6% after long period of stimulationLeach reported 6% after long period of stimulation McGuire observed improvement in 93% women with urgMcGuire observed improvement in 93% women with urg

e incontinencee incontinence Plevnik found 52% improved (30% cured) in pure urge iPlevnik found 52% improved (30% cured) in pure urge i

ncontinencencontinence Brubaker used 20 Hz frequency current and cured 49% wBrubaker used 20 Hz frequency current and cured 49% w

ith urodynamic DIith urodynamic DI Smith found ES reduced urine loss by 50% in 20womenSmith found ES reduced urine loss by 50% in 20women Sand reported 38% success rate in 20 women with DISand reported 38% success rate in 20 women with DI


Transvaginal electrical stimulation

Low frequency (20 Hz) was appliedLow frequency (20 Hz) was applied Contrasting data of effects on genuine SUIContrasting data of effects on genuine SUI Transvaginal ES is effective in urge UITransvaginal ES is effective in urge UI First line treatment for women with pure urge incFirst line treatment for women with pure urge inc

ontinenceontinence For the women with mixed type UI who does not For the women with mixed type UI who does not

wish to undergo PME or surgery wish to undergo PME or surgery


Other Non-surgical Therapiesfor Incontinence Vaginal cones are a method of biofeedbackVaginal cones are a method of biofeedback 70% (19/27) with mild SUI had complete or >5070% (19/27) with mild SUI had complete or >50

% improvement after vaginal cone therapy, 7/50 % improvement after vaginal cone therapy, 7/50 with severe SUI had similar success ratewith severe SUI had similar success rate

Electrostimulation of pudendal nerve Electrostimulation of pudendal nerve (prolonged (prolonged pudendal nerve conduction velocity in 97% SUI)pudendal nerve conduction velocity in 97% SUI) i is effective in 62% with SUI and 20% were drys effective in 62% with SUI and 20% were dry

Electromagnetic stimulationElectromagnetic stimulation


Multiple purposesElectrostimulator and Biofeedback


Patient visualization & biofeedback


Cystometry biofeedback for urge incontinence For women who failed electrical stimulation, werFor women who failed electrical stimulation, wer

e intolerant to anticholinergics, e intolerant to anticholinergics, Urodynamic detrusor overactivity was provenUrodynamic detrusor overactivity was proven Performed several voluntary PFMC at episodes of Performed several voluntary PFMC at episodes of

DI while watching CMG tracing and EMG activitDI while watching CMG tracing and EMG activityy

Try to inhibit urge incontinence as longer duratioTry to inhibit urge incontinence as longer duration as possible at homen as possible at home


Detrusor overactivity and CMG biofeedback


Biofeedback to inhibit detrusor instability

Documents

排尿障礙治療中心 版權所有 Conservative Treatment of Stress Urinary Incontinence Hann-Chorng Kuo. M.D. Department of Urology Buddhist Tzu Chi General Hospital, Hualien,

排尿障礙治療中心版權所有 Conservative Treatment of Stress Urinary Incontinence Hann-Chorng Kuo. M.D. Department of Urology Buddhist Tzu Chi General Hospital, Hualien,