Urinary incontinence and the role of physical therapy
Amandeep Mahal, MD, FACOG Female Pelvic Medicine and Reconstructive Surgery About me & disclosures
Born in California I have no financial
Trained in Nebraska disclosures and Iowa I have a lot of
Completed medical school debt subspecialty training at Stanford. Rules of the lecture Objectives -
1. Identify patients who would benefit from physical therapy for urinary incontinence (almost everyone)
2. Utilize office evaluation to discriminate between stress and urge incontinence (H and P)
3. Understand key clinical concepts regarding the pathophysiology of female incontinence Why is it important to screen for urinary incontinence?
Common
10% of all women*
75% of older women
Under-reported and under-treated
Large impact on quality of life
Herald of serious underlying disease Basic Definitions
1)Stress Incontinence
Loss of urine w/ valsalva 2)Urgency Incontinence
Uninhibited detrusor contractions 3)Mixed Incontinence
1 and 2 in varying proportions 4) Functional Incontinence 5)Overflow Incontinence
Flaccid detrusor or obstruction Why PFMT works… ACOG definitions
These are not all ICD 10 codes
These are less useful clinically The patient evaluation
History taking Differential Diagnosis of Urinary Incontinence in Women Genito-urinary Etiology
Storage Disorders
Detrusor over activity (idiopathic) Detrusor hyperreflexia (neurogenic) Stress incontinence Mixed incontinence Overflow incontinence (retention)
Fistula Vesical Ureteral Urethral
Congenital Ectopic ureter Non Genito-Urinary reasons for Urinary Incontinence
Urinary infection Delirium/depression Restricted mobility Drugs Urinary retention
Postoperative
Severe constipation/fecal impaction
Spinal cord compression Polyuria Questions to Ask
Stress incontinence? Overflow incontinence?
cough Voiding difficulties?
sneeze Need to strain?
laugh Empty completely?
exercise Urgency incontinence? Episodes per day?
urgency? Pads?
frequency? total per day?
daytime? type?
nocturia? How wet? Questions to Ask .Dysuria or pain? .UTI’s? .Blood? .Urinary stones?
.Fecal incontinence? . Gas, liquid, or solid stool? Questions to Ask
Prior treatment? PSH:
Surgical or medical Hysterectomy
PMH: Vaginal repair
Diabetes Urethropexy
COPD Pelvic radiation
Glaucoma
Stroke
Multiple Sclerosis
Parkinson’s Questions to Ask
Frequency: Current Diuretics medications:
Retention: Urgency & Frequency Alpha-agonists Fluids Anti-cholinergics Caffeine Beta-agonists Alcohol CA channel blockers
SUI: Tobacco
Alpha-blockers Pearls
Get the numbers (quantify)
Fluid in daily
# incontinence episodes
Insensible loss STINKS
When advanced ADLs change, patients will change The patient evaluation
Physical examination
PVR (ultrasound or cath)
UA
Neuro examination 36 yo G3 P3
CC- urine loss with cough
HPI- denies dysuria, urgency, frequency
wears pad daily/ changes x 4
PMH, PSH – none, no neuro illness
Past Ob Hx – NSVD x 3 no comp
Meds - none Physical Exam
Postvoid residual <50-100 ml Pelvic exam
Prolapse (POP-Q)
Urethral hypermobility >30° Neurologic screen
Kegel squeeze
Sacral reflexes
Lower extremity: motor, sensory, reflexes Stress Incontinence - PE
Urine loss with acute valsalva or cough
Poor levator tone
Urethral Hypermobility
Pertinent negative PE findings: Neuro exam intact Options – Stress incontinence
Do nothing!
Change medical therapies
Conservative therapies
Fluid restriction
Pessary
Kegel exercise program, PT, weight loss
Bulking agents
Mid-urethral sling/burch History
65 yo WF G2 P2 complains of:
frequency: voids q 30-60 minutes
nocturia: voids 3-4 times a night
urgency, occ. urge incontinence
denies SUI, hematuria, dysuria, or UTI’s
no PMH, PSH, meds
smokes 1 pack / day x 30 years
drinks 3-4 cups coffee / day History
65 yo WF G2 P2 complains of:
frequency: voids q 30-60 minutes
nocturia: voids 3-4 times a night
urgency, occ. urge incontinence
denies SUI, hematuria, dysuria, or UTI’s
no PMH, PSH, meds
smokes 1 pack / day x 30 years
drinks 3-4 cups coffee / day
Differential?? Differential Diagnosis
Detrusor overactivity (idiopathic)
Detrusor hyperreflexia (neurogenic)
Overflow incontinence (retention)
UTI
Genital atrophy
Excessive fluid intake
Cancer
Bladder stone 65 yo G2 P2
Exam no prolapse, normal neuro atrophic vagina weak Kegel squeeze (2/5) non-mobile urethra: 10 --> 20 degrees PVR - 30 cc, voided 200 cc Cough --> no leak
What is one lab test that must be done? Urinalysis/Urine C&S Options – Urge incontinece
Estrogen cream
Behavioral changes
PT, fluid reduction, timed voiding
Medications
Ach medications, mirabegron
Advanced OAB treatments
Neuromodulation device, botox therapy Where is physical therapy appropriate?
As first line therapy with behavioral changes
Patients who decline interventional options The picture can't be displayed.
What is Stress Urinary Incontinence (SUI)?
The involuntary loss of urine during physical activities such as coughing, sneezing, laughing and lifting.
There are two types of conditions that result in SUI:
The picture can't be displayed.
Intrinsic Sphincter Hypermobility Deficiency (ISD)
28 Types of Physical therapy
Pelvic floor muscle training (PFMT)
Discussion of symptoms and triggers
Endurance training
Mechanical device use Types of Physical therapy
Two Goals
Identify Incontinence triggers
Avoid incontinence by pelvic floor contraction
Timed voiding
Caffeine alcohol avoidance
Freeze and squeeze technique Types of Physical therapy
Pelvic floor muscle training (PFMT)
Biofeedback
Discussion of symptoms and triggers
Endurance training
Mechanical device use PFMT
Over 30 clinical trials reviewed. Therapy is cost effective and can improve both stress and urge incontinence symptoms
Cochrane review 2018 (Dumoulin et al) Can I work from home?
Pelvic floor muscle training in groups versus individual or home treatment of women with urinary incontinence: systematic review and meta-analysis. 1 2 3 1 3 Paiva LL , Ferla L , Darski C , Catarino BM , Ramos JG .
CERTAINLY! PFMT PFMT
Over 30 clinical trials reviewed. Therapy is cost effective and can improve both stress and urge incontinence symptoms
Cochrane review 2018 (Dumoulin et al) PFMT
Over 30 clinical trials reviewed. Therapy is cost effective and can improve both stress and urge incontinence symptoms
Cochrane review 2018 (Dumoulin et al) Burgio et al. JAMA 1998
Three arm prospective study comparing placebo vs Ach medication vs. pelvic floor training
Reduction in incontinence epidsodes: 80% PF training 69% Ach medication group 39% placebo group Behavioral Modification
Bladder drills
adult toilet training
break the cycle of frequency/ urgency
re-establish cortical control over bladder
Gradually increase time between voids
start at smallest interval tolerated: q 1 hr
each week increase by 15 min intervals
void q 1.25 hour regardless, try to hold it
80% success rate Nonsurgical treatment for Urinary Incontinence in Elderly Women
“Although there is clearly a benefit to PFMT, the effectiveness of the training and compliance with regimens is paramount to success”
Parker, Griebling. Clin Geriatr Med. 2015 Biofeedback Biofeedback
May improve and augment PFMT, though further research is needed to determine the causative agent.
2011 Cochrane review (Herderschee et al) MINIMAL DATA Which patient should I send to PT?
Complaints of incontinence following H and P with:
Normal PVR
Normal UA Which patients need to see a Urogynecolgist?
Feeling of incomplete emptying
Failed behavioral management
Patients with h/o prior prolapse or incontinence surgery
MS, parkinsons patients
Anyone! Good resources
https://familydoctor.org/condition/urina ry-incontinence/
Voicesforpfd.org
Urinary incontinence in women. – Anger and wood. BMJ 2014 (in depth review)
Clinical Management of Urinary Incontinence in Women. Hersh and Salzman AAFP 2013. Surgical Options What are Some Common Surgical Treatment Options?
Bulking Agents: Injectable agents increase the bulk around the urethra, helping to close the sphincter and control urinary loss.
47 Surgical Options
Burch Retropubic Urethropexy
Traditional Gold Standard for SUI
Laparotomy vs Laparoscopy
Retropubic Sling a.k.a Tension Free Vaginal Tape
Trans-obturator Sling
Strictly Vaginal procedures Burch Urethropexy Mid-urethral Sling
Retropubic Sling Trans-obturator Sling Conservative Therapy
Estrogen vaginal cream
1-2 gm 2-3x weekly Decrease caffeine Kegel exercises: 10-20 reps, 4 times/day
Not only to improve tone, but vascularity Anti-cholinergic medication Pills/ patches/ gels Behavioral modification Anti-Cholinergic Drugs (Muscarinic Antagonists)
Detrol (tolteridine) Contraindication:
Ditropan (oxybutynin) glaucoma
Enablex (darifenacin) (narrow angle)
Vesicare (solifenacin) Side Effects:
Sanctura (tropsium dry mouth chloride) constipation
drowsiness
Mirabegron* increased pulse
NOT Anticholinergic confusion Urge incontinence: advanced treatments
Botox injections
Interstim and other sacral neuromodulators (SNS, SNM)
Percutaneous Tibial nerve stimulation (PTNS) Urge: advanced therapies Botox
Well tolerated
2/3 reduction in leaking and frequency
7% risk of retention Urge: advanced therapies Intersim
Well tolerated
2/3 will have a 50% reduction in leaking and frequency
no risk of retention Urge: advanced therapies Intersim
Well tolerated
Requires trial phase prior to implantation Urge: advanced therapies PTNS Mixed Incontinence
Urodynamic testing
Bladder pressures
Volume at first urge
Uninhibited contractions
Treat whichever (SUI or OAB) bothers most WHAT TIME IS IT?
Lets talk about fun new stuff…
What to do with retention of urine?
Check Cr, drain bladder (CIC?)
Common questions? Questions
What tests do I need before treating urgency/frequency?
Help! My patient has retention of urine!
Help! My patient has blood in the urine!
My patient has recurrent UTIs! Is it from incontinence?
Can I use a pessary for incontinence? Emerging therapies: URGE
Axonics
Botox alternatives nd 2 medical therapy alternative Emerging therapies: overflow
Bladder atony treatment with device Neuroanatomy & Physiology
Sympathetic Innervation: T10-L2
Inhibits detrusor contraction
Stimulates urethral smooth muscle
Parasympathetic Innervation: S2-4
Stimulates detrusor contraction
Somatic motor neurons: S2-4
Voluntary sphincter contraction Pharmacology
What type of receptors at urethra?
alpha-receptors: contractile
alpha agonists treat SUI What type of receptors at bladder?
cholinergic: contractile
anti-cholinergics treat detrusor overactivity
excess anticholingergic effect-> retention
beta-receptors: inhibitory Multiple sclerosis (MS)
Most common urinary complaints:
URGENCY
URGE INCONTINENCE
usually the result of uninhibited detrusor contractions
due to a suprasacral lesion Urinary incontinence- MS
Progressive involvement of sacral cord
Bladder hypoactivity: decreased urinary flow, interrupted micturition, incomplete bladder emptying, residual -> UTI
Atonic dilated bladder: empties by overflow due to loss of perception of bladder fullness, associated with urethral, anal, and genital hypoesthesia, and sensory deficits in the sacral dermatomes Pessaries Various types of pessaries:
(A) Ring, (B) Shaatz, (C) Gellhorn, (D) Gellhorn, (E) Ring with support, (F) Gellhorn, (G) Risser, (H) Smith, (I) Tandem cube, (J) Cube, (K) Hodge with knob, (L) Hodge, (M) Gehrung, (N) Incontinence dish with support, (O) Donut, (P) Incontinence ring, (Q) Incontinence dish, (R) Hodge with support, (S) Inflatoball (latex). Pessaries
Ring or Donut Pessaries –
like a diaphragm but more rigid/larger
Apply significant pressure to vaginal walls
May cause vaginal erosions
Rarely, infection can become systemic
Must be removed regularly & examined
Others: Cube, Gelhorn, etc (see text) Should I just have a Csec?
Depends on who you ask?
Some degree of pelvic organ prolapse is found in all parous women.
Studies show grade I does not progress. Some Grade II will regress
Surgical repair is estimated to occur in only 10% of Vag Del pts -ACOG Clinical Review