Non-Surgical Managementof Urinary Incontinence and Pelvic Floor Dysfunction

Catherine A. Matthews, MDAssociate ProfessorUrogynecology and Reconstructive Pelvic SurgeryVirginia Commonwealth UniversityRichmond, Virginia

UI: Non-Surgical Management

Functional incontinence Lifestyle interventions Bladder retraining Physical therapies Devices Pharmacotherapy

Functional Incontinence

Patient Factors Environmental Disease/Medications

Debilitation Limited facilities Nocturnal diuresis

Immobility Access limitations Diuretics

Limited dexterity Unfamiliar setting Autonomic drugs

Dementia Fecal impaction

Aging Infection

Hormonal deficit ACE inhibitors

Functional Incontinence: Causes(AKA Transient or Reversible Incontinence)

Patient related Environmental related Disease related Medication related

“DIAPPERS” Pneumonic Delerium Infection Atrophy Pharmacologic Psychologic Endocrinologic Restricted mobility Stool impaction

Lifestyle Interventions

Weight loss Physical forces Smoking Dietary factors Constipation

Dietary Factors: Bladder Irritants

Alcohol - liquor, wine, beer Caffeine - coffee, tea, sodas, chocolate Very acid fruit or juices - orange, grapefruit Tomatoes - juice, spaghetti sauce, pizza, chili Spicy foods - Mexican, Thai, Indian, Cajun Sugar - sweeteners, honey Fluid intake – volume, timing

Screening Questions must include an intake/output diary

Caffeine Causes OAB

by releasing

intracellular Ca+ +

Ca+ +

Parasympathetic

Nerve

Sympathetic

Nerve

Pelvic Muscle Rehabilitation

Pelvic Floor Muscle Training(Kegel’s Exercises)

Kegel (1948) used pelvic floor muscle exercises with a perineometer for resistance and biofeedback

Rationale: strong and fast pelvic floor muscle contraction increases urethral pressure and prevents leakage during sudden increase in abdominal pressure

Recommend: 3 sets of 8-12 slow velocity maximum voluntary contractions, sustained for 6-8 seconds performed 3-4 times a week for at least 15-20 weeks

Effect depends upon type of exercise, frequency, intensity, and duration of training

Kegel’s Perineometer

Weighted Vaginal Cones

Pelvic PT and exercise adherenceBo and Nygaard. Obstet Gynecol, 2005

Less than ¼ of women continued exercises No difference in rate of subsequent SUI surgery

in women who had intensive pelvic PT versus not

Marked benefit of initial therapy not maintained 15 years later

Who will benefit from pelvic PT for SUI? Cammu et al. Am J Obstet Gynecol, 2004

Observational study of 447 women with SUI to determine predictors of treatment failure

Three independent predictors of failure:– >2 leakages per day (p<.001)– Use of psychotropic medication (p=.002)– Baseline positive stress test at first cough (p=.042)

Odds only 15% for successful treatment if all 3 present

Electrical Vaginal or Anal Stimulation

Bladder Retraining

Jeffcoate and Francis described in 1966 Educational and behavioral process used to re-

establish urinary control in adults AKA: bladder discipline, bladder drill, bladder

training, bladder re-education May be used with pelvic floor muscle training and/or

drug therapy

Behavioral Modification

Behavioral Behavioral ModificationModification

Education

Delayed voiding

Timed voiding

Reinforcement

Pelvic floor exercises

Bladder Retraining: Goals

Correcting faulty habit of frequent urination Improving ability to control urgency Prolonging voiding intervals Increasing bladder capacity Reducing incontinence episodes Building confidence in bladder control

Bladder Retraining

Pessary for Incontinence

UI: Pharmacotherapy

Stress urinary incontinence – Currently no FDA approved medication for SUI– Off-label drugs are being used– Possible role of seratonin (5-HT) and

norepinephrine (NE) reuptake inhibitors being studied

Urge incontinence (detrusor overactivity, overactive bladder; unstable bladder; detrusor instability)– Parasympatholytics

SUI: Off-Label Medications

Classification Examples Pharmacological Action

α-adrenergic agonists

Ephedrine

Midodrine

Pseudoephedrine

Increase urethral tone and closure pressure by direct stimulation of α-adrenergic receptors

Estrogen Estradiol Previously thought may increase thickness of urethral mucosa making better seal and reducing incidence of incontinence- CURRENT EVIDENCE DISPUTES

Tricyclic antidepressants

Imipramine

Amitriptyline

These agents have anticholinergic, direct smooth muscle relaxant, and norepinephrine-reuptake inhibition properties

SUI: Current Research into Pharmacotherapy

Blocking reuptake of serotonin (5-HT) and norepinephrine (NE) increases activation of α-1 adrenergic and 5-HT2 receptors, increasing pudendal nerve activity

Increased pudendal nerve activity strengthens urethral sphincter contraction

Urethral sphincter contraction helps prevent urine leakage when pressure is exerted on bladder

Duloxetine, a product of this research, was approved and marketed in Europe beginning in 2004

SYM

ON

Spinal Relay Neuron

Hypogastric N.

Pudendal N.

Pelvic N.

+ 1+ M2,3

Inhibition

Storage ReflexMicturition Reflex

Bladder

Rhabdosphincter

Periaquaductal

Gray

PAR

Pontine Micturition

Center

+5HT2Serotonergic

Effects

-5HT1

5HT Increases Urethral Tone,Decreases Detrusor Activity

Serotonin Central Effects

- ß3

+N+N

Spinal Reflex

rhabdosphincter

Serotonin & Norepinephrine: Effects at Onuf's Nucleus

Sacral Spinal Cord

Onuf’s nucleus

Lateral motor nucleus

Pudendal nerve

DC

LF

DH

VH +5HT2

Serotonin

+α1

Bladder

NE

*** *

Incontinence Improved With Duloxetine

*p<.05.Norton PA, et al. Neurourol Urodyn. 2001;20(4):532-534.

PlaceboDuloxetine 20 mgDuloxetine 40 mgDuloxetine 80 mg

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Urge Incontinence:Pharmacotherapy for Detrusor Overactivity

Drug Dosage Anticholinergic Effects

Dicyclomine 20 mg tid +++

Flavoxate 100-200 mg tid-qid +

Hyoscyamine 0.125 mg tid-qid ++

Imipramine 10-50 mg bid +++

Propantheline 15-30 mg tid-qid ++++

Oxybutynin 2.5-5.0 mg tid ++++

Oxybutynin ER 5-15 mg qd +

Tolterodine 1-2 mg bid +++

Tolterodine ER 2-4 mg qd +

Heading CE. Curr Opin CPNS Investig Drugs. 2000;3:321-325. Napier C et al. Proc ICS. 2002:445. Abstract.

*Animal models.

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10

20

30

40

50

60

Trospium Tolterodine Solifenacin Oxybutynin Darifenacin

Inh

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M3 selective

Primarily M3 selectiveNonselective

(M3/M2)

Detrol® LA (tolterodine tartrate extended release capsules)

Please see full prescribing information.

Receptor Selectivity

InterStim™ Sacral Neuromodulator

Results

70-90% of subjects are implanted 37-65% “cured” Mean reduction in UI episodes 8.8 to 2.3 Explantation rate 10.5%

– Infection– Failure to maintain response– Migrating leads– Pain

Revision rate 16.1%

Foster et al. Neurourol Urodyn 2006Latini et al. Urology 2006Amundsen et al. Urology 2005Hijaz etal. Urology 2006

Vaginal Pessaries

Pessaries for Prolapse

Uterine prolapse– 1st-2nd degree: Ring, Shaatz, Hodge– 2nd-3rd degree: Gellhorn, Donut, Cube, Inflatoball

Cystocele– Smith, Hodge, Ring, Gehrung, Shaatz, Gellhorn

Rectocele– Gehrung, Cube, Inflatoball

Pessaries for Prolapse

Patient indications– Diagnostic– Awaiting surgery– Refuses surgery– Surgically unfit

Amenable conditions– Uterine prolapse or malpositions– Vaginal prolapse– Stress incontinence

Select type and size as needed Use requires periodic removal,

cleansing, reinsertion Best tolerated by estrogenized

vagina

Pessary for Prolapse

Gellhorn Pessary

Pessary:Uterine Prolapse, Malposition, Cystocele

Vaginal Pessaries:Complications Associated with Use

Bladder dysfunction Bowel dysfunction Coital dysfunction

Infection Bleeding Ulceration Vaginal stretching Fistula

“Neglected” pessary

Selection of pessaries?

Successful fitting depends most on relationship between size of genital hiatus and vaginal length

Anterior and apical POP far more amenable than posterior wall

Ring with support (Stage I and II) and Gellhorn (Stage III and IV) most comfortable and commonly utilized

Non-surgical management of posterior compartment disorders

45 yo female with long-standing history of “constipation”, now with egg-sized vaginal bulge and constant pelvic pressure. Splints the vagina in order to evacuate.

Referred by internist for surgical correction of “rectocele”

Obstructed defecation: Anismus

“Pelvic floor dyssynergia” Abnormal defecatory colonic motor patterns,

impairment in rectoanal coordination and ineffective stool expulsion during defecation: An enigma

Prevalence: Estimated at 7% More common in women Frequently have to rely on enemas/ digital

evacuation

Treatment of paradox

Pelvic floor PT with biofeedback only effective method to re-train relaxation of puborectalis with valsalva.

Confirm reversal of disorder before considering surgical correction of secondary posterior compartment prolapse.

Pucciani et al. Int J Colorectal Dis, 1998Lewicky-Gaupp et al. Dis Colon Rectum, 2008