BEHAVIORAL INTERVENTION: PELVIC FLOOR MUSCLE TRAINING AND EXERCISE

Pelvic floor muscle training and exercise are the foundation of behavioral treatment for SUI. Kegel (1948), a gynecologist, first popularized it in the late 1940s. He asserted that women with stress incontinence lack awareness and coordination of the pelvic muscles; with training and improved strength, stress incontinence can be prevented (Kegel, 1948, 1956). Through the years, this intervention has evolved both as behavior therapy and physical therapy, combining principles from both fields into a widely accepted conservative treatment for stress incontinence.

Literature on outpatient behavioral treatment with pelvic muscle training and exercise has demonstrated that it is effective for reducing stress, urge, and mixed incontinence in most patients who cooperate with training. Behavioral treatments have been recognized for their efficacy by the 1988 Consensus Conference on Urinary Incontinence in Adults (1989) and by the Guideline for Urinary Incontinence in Adults developed by the Agency for Health Care Policy and Research (AHCPR) (Fantl et al., 1996). Although the majority of women are not cured with this approach, most can achieve significant improvement.

Teaching Daily Pelvic Floor Muscle Control

The goal of behavioral intervention for stress incontinence is to teach patients how to improve urethral closure by contracting pelvic floor muscles during physical activities that cause urine leakage, such as coughing, sneezing, or lifting. The premise is that deliberate muscle contraction will increase intraurethral pressure and prevent urine loss caused by the brief rise in bladder pressure. Using biofeedback or other teaching methods, patients are taught to identify the pelvic muscles and to contract and relax them selectively (without increasing intra-abdominal pressure).

Many women fail pelvic muscle exercise by religiously exercising the wrong muscles. It is an essential, yet often overlooked, step to help women identify and isolate the correct muscles. The most common approach to pelvic muscle training 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 the majority of women do not properly identify the pelvic muscles or persist long enough to reap the benefits of behavioral treatment.

A much more effective way to begin treatment is to ensure that the patient understands which muscles to use, which is often accomplished by palpating the vagina during pelvic examination and guiding her with verbal feedback to find the proper muscles. Pelvic muscle control can also be taught using biofeedback or electrical stimulation.

Biofeedback is a teaching technique that helps patients learn by giving them immediate feedback of their bladder or pelvic muscle activity. Kegel (1948) 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. This provided immediate visual feedback to the woman learning to identify her pelvic muscles and monitoring her practice.

Most biofeedback instruments are now computerized. Pelvic muscle activity can be measured using vaginal or anal manometry or electromyography (EMG), with a probe or perianal surface 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 (trial and error learning) by observing the results of their attempts to control bladder and pelvic muscle responses. 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 pelvic floor muscles in a single session; treatment requires less repetition of biofeedback than was previously thought.

The most common problem in identifying the pelvic floor muscles is that women tend to contract other muscles, typically the abdominal or gluteal muscles, instead of or in conjunction with pelvic muscles. Contracting abdominal muscles is counterproductive, because it increases pressure on the bladder rather than the urethra. Thus, it is important to notice this Valsalva response and to teach the patient to relax her abdominal muscles. Otherwise, her pelvic muscle exercises may be ineffective.

Once patients learn to properly contract and relax selectively the pelvic muscles, 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 using 45 to 50 exercises per day. To avoid muscle fatigue, the exercises should be spaced across the day, usually in two to three sessions per day (Fig. 14-2). Patients generally find it easiest to at first practice their exercises in the lying position. Encouraging them to practice sitting or standing as well is important, so that they become comfortable using their muscles to avoid accidents in any position.

Figure 14-2 Instructions for daily pelvic floor muscle exercise.

To improve muscle strength, contractions should be sustained for 2 to 10 seconds, depending on the patient’s initial ability. Programs can be individualized, so patients begin by holding contractions for a brief period (1 to 2 seconds) and gradually progress to 10 seconds. Each exercise consists of contracting the muscle for up to 10 seconds followed by a period of relaxation using a 1:1 or 1:2 ratio. This allows the muscles to recover between contractions.

Using Muscles to Prevent Stress Accidents: 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 pelvic muscles to occlude the urethra before and during coughing, sneezing, or other activities causing urine loss. This skill has been referred to as stress strategy, counterbracing, and “the knack.” Some women will benefit simply from learning how to control their pelvic muscles and use them to prevent accidents. Others will need a more comprehensive program of pelvic muscle rehabilitation to increase strength as well as skill.

Using Muscles to Prevent Urge Accidents: Urge Suppression Strategies

Traditionally, pelvic floor muscle training and exercise were used almost exclusively for stress incontinence. However, voluntary pelvic muscle contraction can also inhibit detrusor contraction. Therefore, pelvic muscle training is now frequently used as a component in the behavioral treatment of urge incontinence as well. In addition to using pelvic muscles to occlude the urethra, patients learn to use pelvic muscle contractions and other urge suppression strategies to inhibit bladder contraction. Further, patients are taught a new way to respond to the sensation of urgency: Instead of rushing to the toilet, which increases intra-abdominal 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 repeatedly contract pelvic muscles to diminish urgency, inhibit detrusor contraction, and prevent urine loss. When urgency subsides, patients are to proceed to the toilet at a normal pace.

Behavioral training for urge incontinence has been tested in several clinical series using prepost designs. Mean reductions of incontinence range from 76% to 86%. In controlled trials using intention-to-treat models by Burgio et al. (1998), 2002), mean reductions of incontinence episodes range from 60% to 80%.

Adherence and Maintenance

Pelvic muscle training and exercise require the active participation of a motivated patient. To remember to use muscles strategically in daily life is often challenging, as well as 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—to sustain the patient’s motivation long enough so that she will experience noticeable change in her bladder control.

In initiating behavioral treatment, it is important to make it clear to the patient that her improvement will be gradual and 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, to make adjustments to the exercise regimen, and to encourage persistence.

The long-term effectiveness of pelvic floor muscle exercise in treating incontinence symptoms is still unknown because most studies follow patients for 1 or 2 years only. One study by Glazener et al. (2005) showed that, after 6 years of a postpartum pelvic muscle exercise program, initial improvements in SUI did not persist, and incontinence was similar to the control group. Only half the women were still performing the exercises.

Electrical Stimulation

Pelvic floor electrical stimulation (PFES) has been used for the treatment of urinary incontinence since 1952 (Huffman et al., 1952). In this original study, PFES was added to pelvic muscle exercises to treat stress incontinence in women who had failed treatment with exercise alone. Seven of 17 women were cured. Fifteen years later, PFES was reported by Moore and Schofield (1967), using a vaginal probe, and has since become widely used.

PFES stimulates pudendal nerve afferents, activating pudendal and hypogastric nerve efferents, causing contraction of smooth and striated periurethral muscles and striated pelvic floor muscles. This provides a form of passive exercise, with the goal of improving the urethral closure mechanism. In addition, PFES can be useful in teaching pelvic muscle contraction to women who cannot identify or contract these muscles voluntarily. Stimulation is generally applied via vaginal or anal probe for 15 minutes at a time one to three times per day.

Research has demonstrated the efficacy of PFES compared to sham PFES (Sand et al., 1995; Yamanishi et al., 1997). Some evidence also shows that PFES yields similar results to pelvic muscle training (Hahn et al., 1991), although Bo et al. (1999) found pelvic muscle exercise to be superior. Several studies have combined PFES with various methods of pelvic muscle training and exercise and reported successful outcomes. One small study by Blowman et al. (1991) compared pelvic muscle exercise and exercise augmented with PFES in 14 patients and found that the addition of PFES improved outcomes as measured with bladder diaries and muscle strength. In another study by Sung et al. (2000), pelvic muscle exercises, augmented with both PFES and biofeedback, produced greater improvements compared with pelvic muscle exercises alone; however, the effect of PFES cannot be isolated from biofeedback. A third study by Goode et al. (2003) found that PFES did not significantly enhance the outcome of pelvic muscle training with biofeedback. Thus, although PFES shows promise in the treatment of stress incontinence, the role of electrical stimulation in combination with behavioral treatment with pelvic floor muscle training and exercise has not been clearly defined.

BEHAVIORAL INTERVENTION: BLADDER TRAINING

Bladder training is a behavioral intervention developed originally for urge incontinence. In its earliest form, known as bladder drill, it was an intensive intervention often conducted in an inpatient setting. Patients were placed on a strict voiding schedule for 7 to 10 days to lengthen the interval between voids and to establish a normal voiding interval. Cure rates in women ranged from 82% to 86% (Frewen et al., 1979, 1982). Bladder training is a modification that is conducted more gradually in the outpatient setting.

The premise of bladder training is that the habit of frequent urination can lead to reduced bladder capacity and detrusor overactivity, which, in turn, causes urge incontinence. The goal of the intervention is to break this cycle by encouraging patients to resist the sensation of urgency and postpone urination. Using consistent voiding schedules, the patient voids at predetermined intervals and, over time, gradually increases the voiding interval, which is believed to increase capacity and decrease overactivity, resulting in improved bladder control.

Cure rates ranging from 44% to 90% have been demonstrated using outpatient bladder training or a mixture of inpatient and outpatient intervention. The first randomized trial of bladder training was reported by Fantl et al. (1991) and demonstrated an average 57% reduction of incontinence in older women. Interestingly, the training not only reduced urge incontinence, but also stress incontinence. The presumed mechanism for improving stress incontinence is that regular voiding helps avoid situations in which the bladder is full, making the patient less vulnerable to urine loss during physical activities. It is also possible that training leads the patient to greater awareness of bladder function, and postponing urination increases the use of pelvic muscles.

BOWEL MANAGEMENT

Constipation and fecal impaction have been implicated as contributing factors in urinary incontinence. In severe cases, fecal impaction can obstruct normal voiding, contribute to overflow incontinence, or be an irritating factor in overactive bladder symptoms. Simple disimpaction can alleviate symptoms, especially common in nursing home patients. In outpatients who report that constipation aggravates urinary incontinence, it is often beneficial to implement a bowel management program, including instructions on normal fluid intake and dietary fiber (or supplements), to maintain normal stool consistency and regular bowel movements. When fiber is not enough, enemas can be used to stimulate a regular daily bowel movement.

WEIGHT LOSS AND INCONTINENCE

Obesity is one of the major chronic health problems in America today. It contributes to more than 300,000 deaths per year and is associated with increased risk for hypertension, heart disease, diabetes, cancer, arthritis, respiratory disease, and depression. Over 50% of American women are currently overweight (body mass index [BMI] = 25–30 kg/m²) or obese (BMI ≥ 30 kg/m²) (Mokdad et al., 2001).

Obesity is a strong risk factor for incontinence. Data from the Heart and Estrogen-Progestin Replacement Study (HERS: 2763 women with coronary artery disease) and the Study of Osteoporotic Fractures (SOF: 9500 women at risk for fractures) revealed that of those complaining of incontinence, 65% to 75% were overweight or obese (Brown et al., 1996, 1999). Each five-unit increase of BMI was associated with a 60% increase in the risk of daily incontinence. Furthermore, obesity had the largest attributable risk for daily incontinence compared with other risk factors. Because many obese women are at risk for morbidity secondary to other chronic diseases, in addition to incontinence, weight loss should have a tremendous impact on quality of life.

Weight loss has a positive effect on incontinence. Urinary symptoms can significantly improve in morbidly obese women with dramatic weight loss (45–50 kg) after bariatric surgery. Incontinence improves when women lose as little as 5% of their baseline weight, a reasonable goal for many overweight or obese women. In a small prospective cohort study with overweight and obese incontinent women enrolled in weight reduction programs, all patients with weight loss of 5% or greater had at least a 50% reduction in incontinence frequency. By comparison, only one in four women with less than 5% weight loss had a 50% or greater reduction in incontinence frequency. In a randomized trial, a very low-calorie liquid diet program was compared with no intervention in 42 overweight and obese women with incontinence (Subak et al., 2001). Women on the liquid diet lost an average of 1.4 kg over 3 months, and their frequency of incontinence episodes was reduced 60% compared with 4% in the controls.

Although promising, these studies were small and outcomes were obtained over a short period. Larger studies with longer follow-up are needed, with appropriate investigation to study the mechanism by which weight loss reduces incontinence, to determine whether improvements are sustained and to identify predictors of improvement in incontinence associated with weight loss.

ESTROGEN AND STRESS INCONTINENCE

Estrogen is discussed separately from other pharmacologic therapies for SUI because of the recent controversy over the effects of oral estrogen replacement therapy (ERT) on overall health and prevention of chronic disease. Despite this controversy, the benefits of oral and vaginal estrogen for urogenital health are undeniable. The prevalence of symptomatic urogenital atrophy in post-reproductive women may approach 50%. Since the lower urinary tract and vagina develop from the same embryologic origin, it is not surprising that estrogen receptors are present throughout the vagina, urethra, bladder trigone, pelvic connective tissue, and pelvic muscles. Decreased estrogen effect and resulting urogenital atrophy produce symptoms of vaginal dryness, pruritus, dyspareunia, vaginitis, recurrent urinary tract infections (UTIs), dysuria, urinary frequency, urinary urgency, nocturia, and incontinence. Painful urination or “urethral syndrome” secondary to decreased estrogen effect responds to local estrogen therapy, as do nocturia, irritative bladder symptoms, and recurrent UTI.

Outcomes regarding the effect of estrogen on SUI have been mixed. Estrogen exerts beneficial effects in the urethra by increasing the concentration of α-adrenergic receptors in the urethra and bladder, improving vascularity and perfusion of the periurethral tissue and increasing thickness of the urethral epithelium. These changes facilitate coaptation and increase urethral pressure. Most of the nonrandomized studies, few with control groups, showed significant benefit of oral estrogen alone or in combination with progestin, in the treatment of SUI. Improvements have been reported on both subjective and objective parameters, including improved abdominal pressure transmission to the proximal urethra, increased functional urethral length, and increased maximal urethral closure pressure. Some studies found only subjective benefit.

Large cohorts of women evaluated subjectively have had significant symptomatic improvement using vaginal estrogen. However, randomized controlled trials, with oral estrogen alone or combined with progestin, for the most part, showed no significant difference subjectively or objectively in SUI symptoms between groups. In one study by Grady et al. (2001), daily oral estrogen plus progestin was associated with worsening urinary incontinence. A recent questionnaire analysis of the Nurse’s Health Study participants by Grodstein et al. (2004) noted a significantly increased risk of developing urinary incontinence with use of postmenopausal hormone therapy. However, in randomized trials, ERT (oral and vaginal) combined with other therapies such as the α-adrenergic agonist, phenylpropanolamine (which is currently off the market due to increased risk of hemorrhagic stroke), pelvic muscle exercises, and surgery, have shown some benefit.

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