Conservative management for female urinary incontinence and pelvic organ prolapse review 2013 : summary of the 5th International Consultation on Incontinence

Aims The objective of the 5th International Consultation on Incontinence (ICI) chapter on Adult Conservative Management was to review and summarize the new evidence on conservative management of urinary incontinence (UI) and pelvic organ prolapse (POP) in order to compile a current reference source for clinicians, health researchers, and service planners. In this paper, we present the review highlights and new evidence on female conservative management. Methods Revision and updates of the 4th ICI Report using systematic review covering years 2008–2012. Results Each section begins with a brief definition and description of the intervention followed by a summary, where possible, of both the state and level of evidence for prevention and treatment, and ends with a “grade of recommendation.” The paper concludes with areas identified as requiring further research. Conclusions For UI, there are no prevention trials on lifestyle interventions. There are, however, few new intervention trials of lifestyle interventions involving weight loss and fluid intake with improved levels of evidence and grade of recommendation. Outside of pre- and post-natal pelvic floor muscle training (PFMT) trials for the prevention of female UI, there is a dearth of PFMT prevention trials for women with UI. PFMT remains the first-line treatment for female UI with high levels of evidence and grades of recommendation. Bladder training levels of evidence and grades of recommendation are maintained. For POP, new evidence supports the effectiveness of physiotherapy in the treatment of POP and there are now improved levels of evidence and grades of recommendation.

Physical therapy for urinary incontinence in postmenopausal women with osteoporosis or low bone density : a randomized controlled trial

Objective: To assess the effectiveness of 12 weekly physical therapy sessions for urinary incontinence (UI) compared with a control intervention, for reducing the number of UI episodes measured with the 7-day bladder diary, at 3 months and 1 year postrandomization. Methods: A single parallel-group randomized controlled trial was conducted at one outpatient public health center, in postmenopausal women aged 55 years and over with osteoporosis or low bone density and UI. Women were randomized to physical therapy (PT) for UI or osteoporosis education. The primary outcome measure was number of leakage episodes on the 7-day bladder diary, assessed at baseline, after treatment and at 1 year. The secondary outcome measures included the pad test and disease-specific quality of life and self-efficacy questionnaires assessed at the same timepoints. Results: Forty-eight women participated (24 per group). Two participants dropped out of each group and one participant was deceased before 3-month follow-up. Intention-to-treat analysis was undertaken. At 3 months and 1 year, there was a statistically significant difference in the number of leakage episodes on the 7-day bladder diary (3 mo: P = 0.04; 1 y: P = 0.01) in favor of the PT group. The effect size was 0.34 at 1 year. There were no harms reported. Conclusions: After a 12-week course of PT once per week for UI, PT group participants had a 75% reduction in weekly median number of leakage episodes, whereas the control group's condition had no improvement. At 1 year, the PT group participants maintained this improvement, whereas the control group's incontinence worsened.

Exactitude du rappel de la qualité de vie préopératoire chez les femmes opérées pour une incotinence urinaire à l'effort

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Application of a new method in the study of pelvic floor muscle passive properties in continent women

The aim of this study was to present a new methodology for evaluating the pelvic floor muscle (PFM) passive properties. The properties were assessed in 13 continent women using an intra-vaginal dynamometric speculum and EMG (to ensure the subjects were relaxed) in four different conditions: (1) forces recorded at minimal aperture (initial passive resistance); (2) passive resistance at maximal aperture; (3) forces and passive elastic stiffness (PES) evaluated during five lengthening and shortening cycles; and (4) percentage loss of resistance after 1 min of sustained stretch. The PFMs and surrounding tissues were stretched, at constant speed, by increasing the vaginal antero-posterior diameter; different apertures were considered. Hysteresis was also calculated. The procedure was deemed acceptable by all participants. The median passive forces recorded ranged from 0.54 N (interquartile range 1.52) for minimal aperture to 8.45 N (interquartile range 7.10) for maximal aperture while the corresponding median PES values were 0.17 N/mm (interquartile range 0.28) and 0.67 N/mm (interquartile range 0.60). Median hysteresis was 17.24 N∗mm (interquartile range 35.60) and the median percentage of force losses was 11.17% (interquartile range 13.33). This original approach to evaluating the PFM passive properties is very promising for providing better insight into the patho-physiology of stress urinary incontinence and pinpointing conservative treatment mechanisms.

Comparison between transperineal ultrasound and digital dectection of levator ani trauma : can we improve the odds?

Aims To investigate the predictive ability of four digital assessment parameters to detect levator ani (LA) muscle defects (avulsion injury) and compare these to transperineal tomographic ultrasound images. Methods This was an observational study imbedded in a larger quasi-experimental cohort study for women with urinary incontinence. Seventy-two women, ≥60 years who had attended or were going to attend physiotherapy for treatment of urinary incontinence, were included in the study. Inclusion criteria from the parent study were symptoms of stress, urge or both types of urinary incontinence. The predictive ability of the following digital parameters: direct palpation of a discontinuity of the LA muscle from insertion on the pubic ramus; palpation of the distance between the muscle insertion sites; palpation of LA strength; palpation of LA tone, were analyzed against findings from tomographic transperineal ultrasound images. Correlation between methods was measured using Cohen's kappa for each of the individual parameters. Results Seventeen women (24%) presented with a complete or partial avulsion of the puborectalis muscle as diagnosed with tomographic ultrasound imaging. Nine women (13%) had complete avulsions, one of which was bilateral. The predictive ability of the digital assessment parameters varied from poor (k = 0.187, 95% CI [0.02–0.36]) to moderate (k = 0.569, 95% CI [0.31–0.83]). The new parameter of ‘width between insertion sites’ performed best. Conclusions Adding the parameter of “width between insertion sites” appears to enhance our ability to detect avulsion of the levator ani (LA) muscle by digital examination however it does not distinguish between unilateral or bilateral avulsion.

Pelvic floor muscles training to reduce symptoms and signs of vulvovaginal atrophy : a case study

Objective: Vulvovaginal atrophy (VVA), caused by decreased levels of estrogen, is a common problem in aging women. Main symptoms of VVA are vaginal dryness and dyspareunia. First-line treatment consists of the application of local estrogen therapy (ET) or vaginal moisturizer. In some cases however, symptoms and signs persist despite those interventions. This case study describes a 77-year-old woman with severe VVA symptoms despite use of local ET and the addition of pelvic floor muscle (PFM) training to her treatment. Methods: A patient with stress urinary incontinence and VVA was referred to a randomized clinical trial on PFM training. On pretreatment evaluation while on local ET, she showed VVA symptoms on the ICIQ Vaginal Symptoms questionnaire and the ICIQ-Female Sexual Matters associated with lower urinary tract Symptoms questionnaire, and also showed VVA signs during the physical and dynamometric evaluation of the PFM. She was treated with a 12-week PFM training program. Results: The patient reported a reduction in vaginal dryness and dyspareunia symptoms, as well as a better quality of sexual life after 12 weeks of PFM training. On posttreatment physical evaluation, the PFMs' tone and elasticity were improved, although some other VVA signs remained unchanged. Conclusions: Pelvic floor muscle training may improve some VVA symptoms and signs in women taking local ET. Further study is needed to investigate and confirm the present case findings and to explore mechanisms of action of this intervention for VVA.