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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 deficiency Defects in extrinsic continence mechanism
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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 deficiency • Defects in extrinsic continence mechanism Defects of attachments to archus tendineus fascia pelvis Defects of attachments to levator ani Damage or degenerative change of endopelvic fascia Pelvic floor muscle relaxation Damage of anococcygeal ligaments • Urethrovesical facilitative reflex (detrusor overactivity ?)
Factors Influencing Continence • Bladder neck • Urethral smooth muscle • External urethral sphincter • Pelvic floor musculatures • Connective tissue and collagen • Intact neurological innervation
Conservative management of Stress incontinence • Weight reduction • Stop smoking • Reduced caffeine intake • Decrease fluid intake • Resolving chronic straining and constipation • Prevent 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 1948 • Effective PFM contractions increase urethral resistance, increase activated motor units, frequency of excitation, and muscle volume • Repeat PFMT may reflexly inhibit detrusor contractions • Successful PFMT depends on ability to perform a correct 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 discouraged • Use of voluntary PFMC prior to anticipated increased intra-abdominal pressure • Near maximal contractions are the most significant factor in increasing strength • Prevent muscle fatigue with vigorous exercise • Assessed by a specialist for correct PFMC
Effects of PFMT in Incontinence • A meta-analysis of 10 studies concluded improvement ranges from 61 to 85% • Cure ranges from3 to 38% • Severity of urine loss decreases by 61 to 82% in women who leaks after PFMT • In 23 women with repeat training for 5 years, 14 were satisfied with current condition, 15 were continent, a high durability was noted
Combination of PFMT with other Physical therapies • For a woman with stress, urge, and mixed incontinence, PFMT is better than no treatment • Combined PFMT with electrical stimulation • PFMT with biofeedback • PFMT with intravaginal resistance devises • No consistent data proves that combination therapies are better than PFMT alone, but can be used as an initial training 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 1993) • Increased in MUCP and FPL (Benevenuti 1987) • No changes in MUCP or FPL (Ferguson 1990, Meyer 1992, Burns 1993) • No changes in all urodynamic parameters (McClish 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 pressure – Functional profile length • Stress UPP – Pressure transmission ratio • PFMT UPP – Maximal pelvic floor muscle contractions • Concomitant recording Pves and Pabd
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
Correct Pelvic Floor Muscle Contractions No Abdominal muscle contractions
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 cystometric capacity • No change in MUCP, PTR, and FPL • Significant increase in pelvic floor contraction pressure in PFC - UPP • Successfully treated patients had more changes • ALPP changed little in patients with persistent UI
The Urodynamic Parameters after Pelvic Floor Muscle Training (I)
The Urodynamic Parameters after Pelvic Floor Muscle Training (II)
The Urodynamic Parameters after Pelvic Floor Muscle Training (III)
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)