Stress urinary incontinence and pelvic organ prolapse: Nonsurgical management

Teaching pelvic floor muscle control

The goal of behavioral interventions for SUI is to teach patients how to improve urethral closure by contracting PFMs during physical activities that cause urine leakage, such as coughing, sneezing, or lifting. In patients who have a combination of SUI and UUI, quick PFM contractions are performed to lessen urgency sensations before voiding. The premise is that a deliberate PFM contraction will prevent urine loss, increasing intraurethral pressure by raising the urethra and pressing it toward the symphysis pubis, preventing urethral descent, limiting its downward movement during increases in abdominal pressure, and improving structural support of the pelvic organs ( ). PFMT may result in hypertrophy of the striated PFM, thus increasing the external mechanical pressure on the urethra. Intensive PFMT is also hypothesized to reinforce structural support of the bladder neck in women ( ; ). Using biofeedback or other teaching methods, patients are taught to identify the PFMs and to isolate, contract, and relax them selectively (without increasing intraabdominal pressure).

Many women fail PFM exercise by religiously exercising the wrong muscles. Helping women identify and isolate the correct muscles is an essential yet often overlooked step. The most common approach to PFMT is to give women a pamphlet or brief verbal instructions to “lift the pelvic floor” or to interrupt the urinary stream during voiding. This approach is generally ineffective, most likely because most women do not properly identify the PFMs or do not persist long enough to reap the benefits of behavioral treatment. It is more effective to begin treatment by ensuring that the patient understands which muscles to use. This understanding is often accomplished by palpating the vagina during pelvic examination and guiding her with verbal feedback to find the proper muscles. The levator ani can be palpated just proximal to the hymeneal ring ( Fig. 14.2 ), at the 4 and 8 o’clock positions, to determine strength and to determine whether palpation reproduces any discomfort or tenderness ( ).

Biofeedback is not a treatment in itself but a teaching technique that helps patients learn by giving them immediate feedback on their bladder or pelvic muscle activity. introduced a biofeedback device he called the perineometer, consisting of a pneumatic chamber that was placed in the vagina and a handheld pressure gauge that registered increased vaginal pressure generated by pelvic muscle contraction ( Fig. 14.3 ). This device provided immediate visual feedback to the woman learning to identify her PFMs and monitoring her practice.

Current biofeedback instruments are computerized. Pelvic muscle activity can be measured using vaginal or anal manometry (pressure measurement) or surface electrode electromyography (most common), with a probe or perianal surface skin electrodes. Signals are augmented through a computer, and muscle activity is displayed on a monitor where patients can receive immediate visual or auditory feedback. Patients learn better control through operant conditioning (learning by trial and error) by observing the results of their attempts to control bladder and PFM responses ( Fig. 14.4 ). Biofeedback-assisted behavioral training has been tested in several studies, producing mean reductions of incontinence ranging from 60% to 85% ( ). Patients can usually identify their PFMs in a single session; treatment may require less repetition of biofeedback than was originally thought.

The most common problem in identifying the PFMs is that women tend to contract other muscles, typically the rectus abdominis or gluteal muscles, instead of or in conjunction with PFM. Contracting abdominal muscles is counterproductive because it increases pressure on the bladder rather than the urethra. Women commonly will perform a straining Valsalva maneuver or fail to activate all layers of the pelvic musculature. Thus, it is important to notice these incorrect responses and to teach the patient to relax other muscle groups when contracting the PFMs. To avoid bearing down, the clinician should instruct the woman to not hold her breath or to count out loud during the muscle contraction. Coordinated training of transversus abdominis muscles has also been recommended by some clinicians, because it is believed that these muscles facilitate PFM contraction. However, in a systematic review of the literature, noted an absence of evidence for this type of training, and it remains controversial.

Daily exercise to improve strength and control

Once patients learn to properly contract and relax the pelvic muscles selectively, a program of daily exercise is prescribed. The purpose of the daily regimen is not only to increase muscle strength, but also to enhance the skill of using the muscles through practice. The optimal exercise regimen has yet to be determined; however, good results are generally achieved by performing 45 to 50 exercises per day. To avoid muscle fatigue, the exercises should be spaced across the day, usually in two to three sessions ( Box 14.1 ). Patients generally find it easiest to practice their exercises in the lying position at first. But they should be encouraged to practice in the sitting or standing positions as well, so they become comfortable using their muscles to avoid SUI, which primarily occurs in the standing position.

Box 14.1

Instructions for Daily Pelvic Muscle Exercises

Programs should be individualized ( ; ; ), but one approach is to recommend a series of “quick flicks” or 1- to 2-second contractions, followed by sustained contractions (endurance contractions) of 5 seconds, building to 10 seconds. The patient is encouraged to aim for a high level of concentrated effort with each PFM contraction, as greater contraction intensity is associated with improvement in PFM strength. Each muscle contraction is followed by a period of relaxation using a 1:1 or 1:2 ratio, allowing the muscles to recover between contractions.

Using PFMs to prevent stress incontinence: Stress strategies

Although exercise alone can improve urethral support and continence status, optimal results depend on patients learning to use their muscles actively to prevent urine loss during physical exertion. With practice and encouragement, patients can develop the habit of consciously contracting the PFMs to occlude the urethra before and during coughing, sneezing, or any other physical activities that have precipitated urine leakage. This skill has been referred to as the “stress strategy” ( ) and the “Knack maneuver” ( ; ). demonstrated immediate reduction in the volume of urine leakage with a cough when anticipatory PFM contraction was used. Some women will benefit simply from learning how to control their PFMs and use them to prevent incontinence episodes ( ). Others will need a more comprehensive program of PFM rehabilitation to increase strength and skill.

Using PFMs to prevent urgency incontinence: Urgency suppression strategies

Traditionally, PFMT and exercise were used almost exclusively for SUI. However, voluntary PFM contractions can also inhibit a detrusor contraction, and this skill is a part of a behavioral treatment involving an urgency suppression strategy for patients with urgency, frequency, and/or UUI. Patients are taught a new way to respond to the sensation of urgency: instead of rushing to the toilet, which increases intraabdominal pressure and exposes patients to visual cues that can trigger incontinence, patients are encouraged to pause, sit down if possible, relax the entire body, and contract the PFM repeatedly to diminish urgency, inhibit detrusor contraction, and prevent urine loss. When urgency subsides, they are to proceed to the toilet at a normal pace.

Behavioral training for UUI has been tested in several clinical series using pre-post designs and also in randomized trials. In controlled trials using intention-to-treat models, the mean reduction of incontinence episodes ranges from 60% to 80% ( ; ).

Pelvic floor muscle training and exercise for pelvic organ prolapse

PFMT has been used for the treatment of POP. By improving PFM strength, it is thought that training can lead to improved structural support for pelvic organs. In addition, active contraction of PFMs can be taught to brace against increases in intraabdominal pressure and thus protect the pelvic floor during coughing, sneezing, or any activity that increases pressure on the pelvic floor.

There is a small amount of literature on the effectiveness of PFMT for POP, including five randomized trials comparing training with no treatment ( ; ; ; ; ). The evidence indicates that training has a beneficial effect on PFM function, prolapse symptom burden, prolapse severity, and quality of life ( ).

Adherence and maintenance

PFMT and exercise require the active participation of a motivated patient ( ). It is often challenging to remember to use the PFMs strategically in daily life and to persist in a regular exercise regimen to maintain strength and skill. This reliance on patient behavior change represents the major limitation of this treatment approach. In addition, improvement with behavioral treatment is gradual, usually evident by the fourth week of training and continuing for up to 6 months. Herein lies the challenge for behavioral treatment: sustaining the patient’s motivation for long enough that she will experience noticeable change in her bladder control.

It is important in initiating behavioral treatment to communicate realistic expectations and make it clear to the patient that it may take weeks to months for symptom improvement, and that the improvement may be irregular, with “good” days and “bad” days. Success with symptom improvement will depend on consistent practice and use of her new skills. The patient who understands the usual course of treatment will be better prepared to persist until results are achieved. Clinicians can provide support by scheduling follow-up appointments to track and reinforce patient progress, make adjustments to the exercise regimen, and encourage persistence.

Measurement of adherence to PFM exercise and behavioral strategies is poor ( ; ). There is very little research on methods to identify barriers and improve adherence ( ; ; ; ). reported on adherence to PFM exercise and bladder control strategies as a secondary analysis of a multisite randomized controlled trial comparing three interventions for stress-predominant UI: intravaginal continence pessary, multicomponent behavioral therapy (including PFMT and bladder control strategies), and pessary and behavioral therapy combined ( ). The authors concluded that adherence to PFM exercises and bladder control strategies, when implemented by trained interventionists, can be high and sustained over time.

Electrical stimulation

Pelvic floor electrical stimulation has been used for the treatment of urinary incontinence since 1952 ( ). In this original study, electrical stimulation was added to PFM exercises to treat SUI in women who had failed treatment with exercise alone; seven of 17 women were cured. Fifteen years later, pelvic floor electrical stimulation was reported by using a vaginal probe, and thereafter this treatment was more widely used.

Pelvic floor electrical stimulation stimulates pudendal nerve afferents, activating pudendal and hypogastric nerve efferents, causing contraction of smooth and striated periurethral and pelvic muscles. This stimulation provides a form of passive exercise, with the goal of improving the urethral closure mechanism. In addition, electrical stimulation can be useful in teaching PFM contraction to women who cannot identify or contract these muscles voluntarily. Stimulation can be applied using surface electrodes, delivering transcutaneous electrical stimulation via suprapubic, sacral, or external anal skin surface electrodes or intravaginal or intrarectal sensors for 15 minutes at a time, one to three times per day. An alternative, noninvasive approach that may be easier and less embarrassing for women is to administer electrical stimulation via surface skin electrodes on a garment that holds the electrodes around the pelvic area to ensure satisfactory recruitment of the PFM ( ). The literature on pelvic floor electrical stimulation in women indicates that it is effective for improving SUI ( ) and urgency and mixed urinary incontinence compared to sham or no treatment ( ).

Weighted vaginal cones

Weighted vaginal cones provide a progressive muscular load during the performance of PFMT. A systematic review was performed of 23 small trials involving 1806 women, of whom 717 received cones ( ). The overall quality of the trials was not optimal. Use of cones was found to be better than no active treatment, but there was inconclusive evidence for a subjective cure between cones and PFMT. It has been recommended that, for motivated women with SUI, vaginal cones with supervised training sessions can be a first-line therapy ( ).