Committee 12 Adult Conservative Management Chairman J. HAY SMITH (New Zeland) Members B. BERGHMANS (The Nederlands), K. BURGIO (USA), C. DUMOULIN (Canada), S. HAGEN (U.K), K. MOORE (Canada), I. NYGAARD (USA) Consultant J. N'DOW (U.K) 1025 CONTENTS A. UI IN WOMEN III. ELECTRICAL STIMULATION (ESTIM) IV. MAGNETIC STIMULATION (MSTIM) I. LIFESTYLE INTERVENTIONS II. PELVIC FLOOR MUSCLE TRAINING V. SCHEDULED VOIDING REGIMENS (PFMT) VI. COMPLEMENTARY AND ALTERNATIVE MEDICINES III. WEIGHTED VAGINAL CONES (VC) VII. SUMMARY IV. ELECTRICAL STIMULATION (ESTIM) C. PELVIC ORGAN PROLAPSE V. MAGNETIC STIMULATION (MSTIM) I. LIFESTYLE INTERVENTIONS VI. SCHEDULED VOIDING REGIMENS II. PHYSICAL THERAPIES VII. COMPLEMENTARY AND ALTERNATIVE MEDICINES III. RINGS AND PESSARIES VIII. SUMMARY IV. COMPLEMENTARY AND ALTERNATIVE MEDICINES B. URINARY INCONTINENCE IN MEN V. SUMMARY I. LIFESTYLE INTERVENTIONS APPENDIX II. PELVIC FLOOR MUSCLE TRAINING REFERENCES (PFMT) 1026 Adult Conservative Management J. HAY SMITH, B. BERGHMANS, K. BURGIO, C. DUMOULIN, S. HAGEN, K. MOORE, J. N'DOW, I. NYGAARD report of Committee 20: Management using continence INTRODUCTION products) with regard to their ability to prevent and treat UI and POP effectively. Comment is also made on the Conservative treatment is any therapy that does not effect of conservative management on other lower involve pharmacological or surgical intervention. It urinary tract symptoms (in addition to UI) and also includes principally, lifestyle interventions, physical factors affecting outcome, in particular age. This therapies, scheduled voiding regimens, comple- information will assist in the counselling of mentary and alternative medicines (i.e. those not neurologically ‘normal’ adults regarding these treatment considered part of the traditional biomedical model), options (readers are directed to the chapters on anti-incontinence devices, supportive rings/pessaries children, the frail elderly and neuropathic patients for for pelvic organ prolapse (POP) and pads/catheters. discussion on the effect of conservative management In some countries a combination of the first three is in these specific groups). A systematic review of the called “behavioural therapy” (defined as an approach literature has been carried out, principally of that seeks to alter the individual’s actions or their randomised controlled trials (RCTs), resulting in some environment in order to improve bladder control). recommendations for practice based on the level of Conservative therapies are usually low cost, and evidence available (see preface) and suggestions for managed principally by the person with urinary future research. incontinence (UI) with instruction/supervision from a Notes to the reader: For ease, all studies are cited health professional. They differ from other forms of using the first author and year. Where summary incontinence and prolapse management, in that they statistics are presented, the raw data from which these have a low risk of adverse effects and do not prejudice are derived can be found in the trial reports and other subsequent treatments. Consequently systematic reviews cited in the chapter. Readers who conservative measures should be included in the are interested in the conservative management of counselling of patients who suffer from either UI or POP faecal incontinence are referred to the chapter on regarding their management options. As the faecal incontinence. prevalence of UI and POP is high, and with the current constraints on most healthcare economies, conser- vative treatment constitutes the principal form of management at the primary care level. It is also A. UI IN WOMEN indicated for those patients for whom other treatments, in particular surgery, are inappropriate, for example, those who are unwilling to undergo or who are not Female UI is a distressing condition with significant medically fit for surgery and women who plan future social implications. It is common – the median level pregnancies (as these may adversely affect surgery). of prevalence estimates gives a picture of increasing Other indications include patients awaiting surgery prevalence during young adult life (prevalence 20- or who wish to delay surgery and those whose 30%), a broad peak around middle age (prevalence symptoms are not serious enough for surgical 30-40%), and then a steady increase in the elderly intervention. (prevalence 30-50%) (see report of Committee 1: Epidemiology). Although the proportions of different To date, however, only a relatively small number of types of UI are difficult to estimate, approximately half intervention studies of adequate size have been carried of all incontinent women are classified as stress out to assess the effectiveness of conservative incontinent, a smaller proportion as mixed incontinent management of UI and POP. This chapter reviews and urge urinary incontinence is the smallest category. the main types of conservative management (excluding The various types most likely reflect different anti-incontinence devices and pads/catheters; see pathologies and aetiologies. 1027 Stress urinary incontinence (SUI) is thought to occur there are no RCTs for a particular lifestyle intervention, due to a lack of bladder neck support and/or poor other types of evidence are considered. urethral closure. As a result the urethral lumen is not closed effectively during activities that increase a) Weight loss intraabdominal pressure with consequent involuntary Two RCTs were found that specifically recruited leakage during effort, exertion, sneezing or coughing. incontinent women [1, 2]. Another RCT focused on the If during urodynamic assessment there is involuntary effect of intensive lifestyle intervention in overweight urine loss synchronous with a rise in intra-abdominal women with diabetes [3]; the bulk of this intervention pressure and in the absence of an involuntary detrusor was weight loss. Four prospective cohort studies [4- contraction this is described as urodynamic stress 7] evaluated the effect of weight loss. Other study incontinence. Urge urinary incontinence (UUI) can be designs were cross-sectional [8-14], retrospective due to a rise in intravesical pressure due to involuntary cohort [15], or case-control studies [16]. detrusor contraction, a condition known as detrusor overactivity (DO). This is further subclassified as 1. QUALITY OF DATA idiopathic (cause unknown) or neurogenic (where Sample sizes for the intervention studies were 12 [5], there is a known neurological cause for detrusor 138 [6], 10 [4], 48 [1], 338 [2], 1,957 [3] and 101 [7]. muscle overactivity). Some women experience Sample sizes for observational studies that assessed urgency with or without leakage, usually with urinary the association between obesity and UI ranged from frequency and nocturia. This constellation of symptoms 193 [15], 3536 [13], 27,936 [11] to 83,355 [14]. The is called the overactive bladder (OAB) syndrome. case control study had a sample size of 108 cases and Mixed urinary incontinence (MUI) is used when the 108 controls [16]. person has evidence of both SUI and UUI. This chapter addresses the effect of conservative management in Participant blinding was not possible in any of the women and men with stress, urge (idiopathic), and three RCTs. Of 48 randomized in one trial, 40 remained mixed urinary incontinence, and OAB syndrome. in the study at the time of assessment [1]. Another trial [2] is in abstract form and full details have not been Where able, the authors of the chapter have published. In the large RCT with diabetes as the differentiated the effects of interventions by diagnosis primary focus, 2191 women were enrolled and 234 (such as SUI, UUI, OAB, and MUI). This diagnostic were excluded because data about UI were not distinction was not made or not reported in some of available; the number that dropped out before the the studies reviewed; where it was not possible to endpoint is not detailed for this subpopulation of distinguish effect by diagnosis the more generic term women. urinary incontinence (UI) is used in summaries and recommendations. The outcome measure in most studies was subjective, determined by either validated or non-validated I. LIFESTYLE INTERVENTIONS questionnaires. Studies by Bump (1992) and Subak (2002, 2005, 2007) also used objective measures including urodynamics, bladder diary and a Various lifestyle factors may play a role in either the standardised fluid loss quantification test. pathogenesis or, later, the resolution of UI. While published literature about lifestyle factors and UI is Follow-up periods for the interventional studies were sparse, alterations in lifestyle are frequently recom- one year after gastroplasty surgery [5] and mended by healthcare professionals and lay people laparoscopic Roux-en-Y gastric bypass [7], six months alike. However, to date, most studies about lifestyle after completion of weight reduction, either by means report associations only and do not assess the actual of low calorie liquid or reduced calorie solid diet [4], effect on UI of applying or avoiding the behaviour in three months after completion of a very low calorie question. Currently, only a relatively small number of liquid diet and exercise [1], six months after completing RCTs have been carried out to assess the effect of a an intensive group weight intervention programme specific lifestyle change on UI. This section will that included lifestyle and behaviour changes [2], examine the evidence for the association and use of mean 2.9 years after beginning