Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

Effect of conservative treatment of pelvic floor dysfunctions in women: An umbrella review

OBJECTIVE

Due to their high worldwide prevalence, pelvic floor dysfunctions (PFD's) are a public health problem. There is high heterogeneity in the types and effectiveness of conservative treatment. The objective was to analyze the scientific evidence on conservative treatment of PFDs in women.

METHODS

Umbrella review, covering MEDLINE (1950-2019), Scopus (1960-2019), Web of Science (1980-2019), and Cochrane Library (2000-2019). Inclusion criterion: review on conservative treatments about pelvic floor disorders in the adult women, in Spanish or English; exclusion criterion: studies about other urological, gynecological, and coloproctological pathologies, among others.

RESULTS

Thirty-two reviews (2000-2019) and 12 meta-analyses were included. 53.1% showed an improvement on urinary incontinence. Pelvic floor muscle training worked on 70.6% of them, followed by electrical stimulation and estrogen (11.7%), and weight loss (5.9%). 6.3% of reviews and meta-analyses fulfilled all items in PRISMA, and 93.7% of them fulfilled more than 60% of the checklist. 60% de los ítems.

CONCLUSIONS

PFMT and weight loss are the most effective treatments for UI, but there is no evidence for other PFDs. The methodological quality of conservative treatments must be improved for a more effective treatment of PFDs in women. Pelvic floor muscle training and weight loss are the most effective treatments for urinary incontinence. Only the 6.3% of the review fulfilled all PRISMA ítems.

Pelvic floor muscle exercise and training for coping with urinary incontinence

The pelvic floor consists of levator ani muscles including puborectalis, pubococcygeus and iliococcygeus muscles, and coccygeus muscles. Pelvic floor muscle exercise (PFME) is defined as exercise to improve pelvic floor muscle strength, power, endurance, relaxation, or a combination of these parameters. PFME strengthens the pelvic floor muscles to provide urethral support to prevent urine leakage and suppress urgency. This exercise has been recommended for urinary incontinence since first described by Kegel. When treating urinary incontinence, particularly stress urinary incontinence, PFME has been recommended as first-line treatment. This article provides clinical application of PFME as a behavioral therapy for urinary incontinence. Clinicians and physical therapist should understand pelvic floor muscle anatomy, evaluation, regimen, and instruct patients how to train the muscles properly.

Current pharmacotherapy of overactive bladder

Overactive bladder is a symptom complex consisting of bothersome storage urinary symptoms that is highly prevalent among both sexes and has a significant impact on quality of life. Various antimuscarinic agents and the beta-3 agonists mirabegron and vibegron are currently available for the treatment of OAB. Each drug has specific pharmacologic properties, dosing schedule and tolerability profile, making it essential to individualize the medical treatment for the patient's characteristics and expectations. In this manuscript, we review the most important factors involved in the contemporary pharmacological treatment of OAB.

Effects of inner muscle resistance exercise on stress urinary incontinence: a randomized clinical controlled trial

[Purpose] This study investigated the effects of co-contraction resistance exercises of the transverse abdominal and pelvic floor muscles in middle-aged females with stress urinary incontinence. [Participants and Methods] We included 32 females with stress urinary incontinence and divided them into two groups: the inner muscle training group and the pelvic floor muscle group. The thickness of the transverse abdominal muscle was measured during four tasks: (1) rest, (2) maximum contraction of the transverse abdominal muscle, (3) maximum contraction of the pelvic floor muscle, and (4) maximum co-contraction of the transverse abdominal and pelvic floor muscles. In the latter three tasks, measurements were obtained while the participants performed resistance movements using a Thera-band^®. A home program was conducted in both groups, and the intervention lasted for 8 weeks. [Results] The cure rates for SUI were 87.5% and 68.8% in the inner muscle training and pelvic floor muscle groups, respectively. After the intervention, the thickness of the transverse abdominal muscle significantly increased in the inner muscle training groups performing maximum co-contraction of the transverse abdominal and pelvic floor muscles and maximum contraction of the transverse abdominal muscle. [Conclusion] Inner muscle training exercises are more effective than pelvic floor muscle exercises in improving inner muscle function and urinary incontinence in middle-aged females.

Efficacy of Yun-Type Optimized Pelvic Floor Training Therapy for Middle-Aged Women With Severe Overactive Bladder: A Randomized Clinical Trial

Background: This study aimed to evaluate the clinical efficacy of Yun-type optimized pelvic floor training therapy for middle-aged women with severe overactive bladder (OAB). Methods: This randomized, observer-blinded, parallel-group controlled clinical trial included 108 middle-age women with severe OAB and assigned them to the intervention group (treated with combination of Yun-type optimized pelvic floor training with solifenacin for 12 weeks) and control group (treated with solifenacin for 6 weeks and, after 2 weeks of elution, received the combination of Yun-type optimized pelvic floor training and solifenacin for 6 weeks). The outcomes associated with OAB, pelvic floor muscle (PFM) function, and sexual function were compared after 6 and 12/14 weeks of treatment. Results: The primary variables were OAB-associated outcomes, including overactive bladder symptom score (OABSS), urgent urination, urine, nocturia, urge urinary incontinence, patient's perception of bladder condition, urogenital distress inventory-6, incontinence impact questionnaire-7, voiding volume, average flow rate, and maximum flow rate. The secondary variables were indicators related to PFM function and sexual function. These indicators were significantly improved in both groups after interventions. Notably, the improvements in most of these indicators were superior in the intervention group than in the control group after 6 weeks and 12/14 weeks of treatment. Conclusions: The use of Yun-type optimized pelvic floor training adds to the benefits of solifenacin regarding severe OAB-associated outcomes, PMF function, and sexual function in middle-aged women with severe OAB. Combining Yun-type optimized pelvic floor training with traditional drug therapies may improve clinical outcomes in patients with severe OAB. Trial Registration: ChiCTR-INR-17012189.

Survey on surgery for stress urinary incontinence in an era mid-urethral slings are being questioned

INTRODUCTION

Concerns about vaginal mesh have reduced the use of mid-urethral slings (MUS) in some countries. In view of their potential withdrawal in Belgium and The Netherlands, we polled urogynaecologists on their practice for treating stress urinary incontinence (SUI) and what their experience is with alternative procedures, and we asked them how their patients perceive the risk and success rates.

METHODS

A survey among members of the pelvic floor special interest group of the Flemish Society for Obstetrics and Gynaecology, Belgian Association of Urology and Dutch Society of Obstetrics and Gynaecology.

RESULTS

Their primary procedure of choice is the MUS (99%). Sixty-five per cent performs at least 25 MUS yearly; they report high success (90%; IQR [85-92]) and low adverse outcome rates. Physicians anticipate complications as reported in the literature: 5% (IQR [410]) overactive bladder, 5% (IQR [2-10]) voiding problems, 2% (IQR [15]) exposures, 2% (IQR [1-5]) dyspareunia and 1% (IQR [1-3]) chronic pain. Eighty-five per cent of physicians report their patients express fears about having a MUS though usually they cannot precisely tell why. Reportedly they tell their physicians of concerns about pain (54%), exposure (45%), dyspareunia (25%), voiding problems (15%) or overactive bladder (8%). Only half of respondents had ever performed a colposuspension. The majority of these were older and performed colposuspension via laparotomy. Only six (4%) had performed > 20 colposuspensions yearly.

CONCLUSION

Dutch and Belgian urogynaecologists estimate success and adverse effect rates of MUS in line with the literature. Their patients most cited worries were fear of chronic pain and exposure. Only half of respondents had ever performed a colposuspension. They were older and performed the procedure via laparotomy.

The impact of vaginal cone therapy on stress urinary incontinence compared with transobturator tape

Objective:

To emphasize the efficiency of vaginal cone (VC) therapy in stress urinary incontinence (SUI) through a comparison with transobturator tape (TOT).

Materials and Methods:

A prospective randomized controlled study was conducted at the Etlik Zübeyde Hanım Maternity and Women Hospital during a one year study period. Forty women were allocated into two equal groups; those treated with VCs for a 3 month period, and women who underwent TOT procedures. These women were followed up at 6 weeks and 6 months after the treatments. Subjective cure was assessed using Wagner’s Quality of Life Questionnaire. Objective cure was evaluated through a cough stress and pad test results.

Results:

Maternal demographic features were comparable among groups. We observed improvement in pad weight test among groups when compared with the pretreatment state (p=0.015, p=0.005). Although the subjective cure rate was similar in both groups at the 6^th week and 6^th month follow up (65% vs. 75%; 75% vs. 80%) (p>0.05), the objective cure rate was significantly higher in the TOT group than in the VC group, as expected (10% vs. 80%; 30% vs. 75%) (p<0.05).

Conclusion:

The main treatment of SUI is surgery; however, VC could be offered as an alternative treatment for women who refuse surgery, those at high risk for surgery or it could be used temporarily before surgery.

Skillful Cycling Training Induces Cortical Plasticity in the Lower Extremity Motor Cortex Area in Healthy Persons

Cycling exercise is commonly used in rehabilitation to improve lower extremity (LE) motor function and gait performance after stroke. Motor learning is important for regaining motor skills, suggesting that training of motor skills influences cortical plasticity. However, the effects of motor skill learning in dynamic alternating movements of both legs on cortical plasticity remain unclear. Here, we examined the effects of skillful cycling training on cortical plasticity of the LE motor area in healthy adults. Eleven healthy volunteers participated in the following three sessions on different days: skillful cycling training, constant-speed cycling training, and rest condition. Skillful cycling training required the navigation of a marker up and down curves by controlling the rotation speed of the pedals. Participants were instructed to fit the marker to the target curves as accurately as possible. Amplitudes of motor evoked potentials (MEPs) and short-interval intracortical inhibition (SICI) evoked using transcranial magnetic stimulation (TMS) were assessed at baseline, after every 10 min of the task (a total of 30 min), and 30 min after the third and final trial. A decrease in tracking errors was representative of the formation of motor learning following skillful cycling training. Compared to baseline, SICI was significantly decreased after skillful cycling training in the tibialis anterior (TA) muscle. The task-induced alterations of SICI were more prominent and lasted longer with skillful cycling training than with the other conditions. The changes in SICI were negatively correlated with a change in tracking error ratio at 20 min the task. MEP amplitudes were not significantly altered with any condition. In conclusion, skillful cycling training induced long-lasting plastic changes of intracortical inhibition, which corresponded to the learning process in the LE motor cortex. These findings suggest that skillful cycling training would be an effective LE rehabilitation method after stroke.

Is Pelvic Floor Dysfunction Associated With Development of Transient Low Back Pain During Prolonged Standing? A Protocol

Background

Prolonged standing has been associated with an increased prevalence of low back pain (LBP) and is recognized as a potential workplace hazard for employees such as retail staff, assembly line workers, and healthcare personnel. Low back pain is more prevalent in women than in men, and disability due to LBP is worse in women with severe urinary incontinence. However, it is unclear whether pelvic floor dysfunction observed in stress urinary incontinence is a risk factor for LBP. The main purpose of this study is to determine whether co-activation patterns between the pelvic floor and abdominal muscles during a 2-hour prolonged standing task predict transient LBP in women with and without stress urinary incontinence.

Methods

In this is prospective cohort study, 60 female volunteers will stand in a confined area for 2 hours (120 minutes) while performing tasks such as, 'computer work' and 'small object assembly'. The primary outcome measure is transient LBP, which will be monitored every 10 minutes using a numeric pain rating scale. Surface electromyography (EMG) will be collected from the gluteus medius and internal oblique/transverse abdominis muscles, and an intravaginal electrode will be used to monitor pelvic floor muscle activity. The EMG signals will be divided into 12 10-minute blocks to assess changes in co-activation over time. Cross-correlation analyses will be used to quantify co-activation between the muscle pairs (e.g. pelvic floor and internal oblique/transverse abdominis), and the coefficient of co-activation will be expressed as a percentage for each block. A mixed-model regression analysis will be used to determine whether co-activation patterns can predict transient LBP during the prolonged standing task.

Discussion

The primary objective of this research is to improve current understanding regarding the role of pelvic floor muscles in the onset of LBP and the potential association between stress urinary incontinence and LBP. These findings have the potential to inform prevention and rehabilitation programmes for women with stress urinary incontinence and LBP.

Trial registration

ACTRN12618000446268 [Protocol Version 2].

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a cochrane systematic review abridged republication

BACKGROUND

Pelvic floor muscle training is the most commonly used physical therapy treatment for women with urinary incontinence.

OBJECTIVES

To assess the effects of Pelvic floor muscle training for women with urinary incontinence in comparison to a control treatment and to summarize relevant economic findings.

METHODS

Cochrane Incontinence Group Specialized Register (February 12, 2018).

SELECTION CRITERIA

Randomized or quasi-randomized trials in women with stress, urgency or mixed urinary incontinence (symptoms, signs, or urodynamic).

DATA COLLECTION AND ANALYSIS

Trials were independently assessed by at least two reviewers authors and subgrouped by urinary incontinence type. Quality of evidence was assessed by adopting the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

The review included thirty-one trials involving 1817 women from 14 countries. Overall, trials were small to moderate size, and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration. Based on data available, we can be confident that Pelvic floor muscle training can cure or improve symptoms of stress and all other types of urinary incontinence. It may reduce the number of leakage episodes and the quantity of leakage, while improving reported symptoms and quality of life. Women were more satisfied with Pelvic floor muscle training, while those in control groups were more likely to seek further treatment. Long-term effectiveness and cost-effectiveness of Pelvic floor muscle training needs to be further researched.

CONCLUSIONS

The addition of ten new trials did not change the essential findings of the earlier review, suggesting that Pelvic floor muscle training could be included in first-line conservative management of women with urinary incontinence.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training (PFMT) is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed urinary incontinence (MUI) and, less commonly, urgency urinary incontinence (UUI).This is an update of a Cochrane Review first published in 2001 and last updated in 2014.

OBJECTIVES

To assess the effects of PFMT for women with urinary incontinence (UI) in comparison to no treatment, placebo or sham treatments, or other inactive control treatments; and summarise the findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (searched 12 February 2018), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with SUI, UUI or MUI (based on symptoms, signs or urodynamics). One arm of the trial included PFMT. Another arm was a no treatment, placebo, sham or other inactive control treatment arm.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for eligibility and risk of bias. We extracted and cross-checked data. A third review author resolved disagreements. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We subgrouped trials by diagnosis of UI. We undertook formal meta-analysis when appropriate.

MAIN RESULTS

The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. Overall, trials were of small-to-moderate size, with follow-ups generally less than 12 months and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration, study populations and outcome measures. There was only one study of women with MUI and only one study with UUI alone, with no data on cure, cure or improvement, or number of episodes of UI for these subgroups.Symptomatic cure of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were eight times more likely to report cure (56% versus 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68 to 19.07; 4 trials, 165 women; high-quality evidence). For women with any type of UI, PFMT groups were five times more likely to report cure (35% versus 6%; RR 5.34, 95% CI 2.78 to 10.26; 3 trials, 290 women; moderate-quality evidence).Symptomatic cure or improvement of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were six times more likely to report cure or improvement (74% versus 11%; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women; moderate-quality evidence). For women with any type of UI, PFMT groups were two times more likely to report cure or improvement than women in the control groups (67% versus 29%; RR 2.39, 95% CI 1.64 to 3.47; 2 trials, 166 women; moderate-quality evidence).UI-specific symptoms and quality of life (QoL) at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT group were more likely to report significant improvement in UI symptoms (7 trials, 376 women; moderate-quality evidence), and to report significant improvement in UI QoL (6 trials, 348 women; low-quality evidence). For any type of UI, women in the PFMT group were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate-quality evidence) and to report significant improvement in UI QoL (4 trials, 258 women; moderate-quality evidence). Finally, for women with mixed UI treated with PFMT, there was one small trial (12 women) reporting better QoL.Leakage episodes in 24 hours at the end of treatment: PFMT reduced leakage episodes by one in women with SUI (mean difference (MD) 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women; moderate-quality evidence) and in women with all types of UI (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women; moderate-quality evidence).Leakage on short clinic-based pad tests at the end of treatment: women with SUI in the PFMT groups lost significantly less urine in short (up to one hour) pad tests. The comparison showed considerable heterogeneity but the findings still favoured PFMT when using a random-effects model (MD 9.71 g lower, 95% CI 18.92 lower to 0.50 lower; 4 trials, 185 women; moderate-quality evidence). For women with all types of UI, PFMT groups also reported less urine loss on short pad tests than controls (MD 3.72 g lower, 95% CI 5.46 lower to 1.98 lower; 2 trials, 146 women; moderate-quality evidence).Women in the PFMT group were also more satisfied with treatment and their sexual outcomes were better. Adverse events were rare and, in the two trials that did report any, they were minor. The findings of the review were largely supported by the 'Summary of findings' tables, but most of the evidence was downgraded to moderate on methodological grounds. The exception was 'participant-perceived cure' in women with SUI, which was rated as high quality.

AUTHORS' CONCLUSIONS

Based on the data available, we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-specific symptom questionnaires. The authors of the one economic evaluation identified for the Brief Economic Commentary reported that the cost-effectiveness of PFMT looks promising. The findings of the review suggest that PFMT could be included in first-line conservative management programmes for women with UI. The long-term effectiveness and cost-effectiveness of PFMT needs to be further researched.

Patients' perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to identify all treatment decision factors that determined the preference for peri-urethral bulk injection therapy (PBI) or mid-urethral sling (MUS) surgery in patients with primary stress urinary incontinence (SUI). Second, we explored what patients expect from treatment for SUI and whether patients would consider PBI as a primary treatment option.

METHODS

In a qualitative design, 20 semi-structured, face-to-face interviews were conducted in women with primary SUI. Exclusion criteria were: previous PBI or MUS surgery; predominating urgency. Interviews were guided by three open-ended questions and a topic list. PBI treatment and MUS surgery were described in detail, and the efficacy was stated as 70% and 90%, respectively. Data saturation was reached when no new treatment decision factors were identified in three consecutive interviews. Interviews were audiotaped and fully transcribed. Thematic analysis by a coding process was done independently by two researchers.

RESULTS

Sixteen procedural, personal, professional, social and external treatment decision factors were identified. Regarding expectations about treatment for SUI, women believed 'becoming dry' was wishful thinking. The majority of patients accepted a small degree of persistent urinary incontinence after treatment. Regardless of their treatment preference, patients indicated that women should be informed about PBI as a primary treatment option.

CONCLUSION

Patients with primary SUI are open to PBI as an alternative treatment option even with lower cure rates compared with MUS surgery performed under general or spinal anesthesia. Patients indicated that women with primary SUI seeking treatment should be informed about PBI as a treatment option.

Effects of vaginal tampon training added to pelvic floor muscle training in women with stress urinary incontinence: randomized controlled trial

INTRODUCTION AND HYPOTHESIS

We evaluated whether vaginal tampon training (VTT) combined with pelvic floor muscle training (PFMT) results in better outcomes than PFMT alone for treating stress urinary incontinence (SUI).

METHODS

This was a randomized, controlled study. Patients were allocated to either the combined program, consisting of PFMT and VTT over 12 weeks [PFMT and VTT group (n = 24)] or to PFMT alone [PFMT group (n = 24)]. The primary outcome measure was self-reported improvement, while secondary outcome measures were severity of incontinence, quality of life (QoL), urinary parameters, and pelvic floor muscle strength (PFMS) and endurance (PFME). Values were analyzed with Friedman, Mann-Whitney U, Wilcoxon, and chi-square tests.

RESULTS

Between-group analysis showed no statistically significant differences in self-reported improvement, severity of incontinence, symptom distress score, PFMS, PFME, urinary parameters, and all domains of QoL scores, except social limitations, at weeks 4, 8, and 12 (p > 0.05). However, the increase in PFMS and PFME between baseline and week 12 and earlier improvement was significantly greater in the PFMT and VTT than in the PFMT group (both p < 0.05) CONCLUSION: Short-term results demonstrated that PFMT with and without VT exercises had similar effectiveness on the symptoms of SUI and QoL.

Anterior vaginal repair for urinary incontinence in women

BACKGROUND

Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence (SUI) in women. About a third of adult women experience urinary incontinence. SUI imposes significant health and economic burden to the society and the women affected.

OBJECTIVES

To determine the effects of anterior vaginal repair (anterior colporrhaphy) on urinary incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 September 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. Three trial investigators were contacted for additional information.

MAIN RESULTS

Ten trials were identified which included 385 women having an anterior vaginal repair and 627 who received comparison interventions.A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with bladder neck needle suspension appeared similar (risk ratio (RR) for failure after one year 1.16, 95% confidence interval (CI) 0.86 to 1.56), but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic colposuspensions, or compared alternative vaginal operations.Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the medium term (failure rate within one to five years after anterior repair 97/259 (38%) versus 57/327 (17%); RR 2.29, 95% confidence Interval (CI) 1.70 to 3.08) and in the long term (after five years, (49/128 (38%) versus 31/145 (21%); RR 2.02, 95% CI 1.36 to 3.01). There was evidence from three of these trials that this was reflected in a need for more repeat operations for incontinence (25/107 (23%) versus 4/164 (2%); RR 8.87, 95% CI 3.28 to 23.94). These findings held, irrespective of the co-existence of prolapse (pelvic relaxation). Although fewer women had a prolapse after anterior repair (RR 0.24, 95% CI 0.12 to 0.47), later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation.In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension.

AUTHORS' CONCLUSIONS

There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in eight trials, even in women who had prolapse in addition to stress incontinence (six trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about postoperative complications and morbidity.A Brief Economic Commentary (BEC) identified one study suggesting that vaginoplasty may be more cost-effective compared with tension-free vaginal tape (TVT-O).

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Stress urinary incontinence (SUI) imposes significant health and economic burden on society and the women affected. Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with SUI, with the presumed advantages of avoiding major incisions, shorter hospital stays and quicker return to normal activities.

OBJECTIVES

To determine the effects of laparoscopic colposuspension for urinary incontinence in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Trials Register (searched 2 July 2009), and sought additional trials from other sources and by contacting study authors for unpublished data and trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery as the intervention in at least one arm of the studies.

DATA COLLECTION AND ANALYSIS

The review authors evaluated trials for methodological quality and their appropriateness for inclusion in the review. Two review authors extracted data and another cross checked them. Where appropriate, we calculated a summary statistic.

MAIN RESULTS

We identified 22 eligible trials. Ten involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures, in the short- and medium-term follow-up, there was some evidence of poorer results of laparoscopic colposuspension on objective outcomes. The results showed trends towards fewer perioperative complications, less postoperative pain and shorter hospital stay for laparoscopic compared with open colposuspension, however, laparoscopic colposuspension was more costly.Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. There were no significant differences in the reported short- and long-term subjective cure rates of the two procedures but objective cure rates at 18 months favoured slings. We observed no significant differences for postoperative voiding dysfunction and perioperative complications. Laparoscopic colposuspension had a significantly longer operation time and hospital stay. We found significantly higher subjective and objective one-year cure rates for women randomised to two paravaginal sutures compared with one suture in a single trial. Three studies compared sutures with mesh and staples for laparoscopic colposuspension and showed a trend towards favouring the use of sutures.

AUTHORS' CONCLUSIONS

Currently available evidence suggests that laparoscopic colposuspension may be as good as open colposuspension at two years post surgery. However, the newer vaginal sling procedures appear to offer even greater benefits, better objective outcomes in the short term and similar subjective outcomes in the longer term. If laparoscopic colposuspension is performed, the use of two paravaginal sutures appears to be the most effective method. The place of laparoscopic colposuspension in clinical practice should become clearer when there are more data available describing long-term results. A brief economic commentary (BEC) identified three studies suggesting that tension-free vaginal tape (TVT) may be more cost-effective compared with laparoscopic colposuspension but laparoscopic colposuspension may be slightly more cost-effective when compared with open colposuspension after 24 months follow-up.

The attitudes of Urologists and Gynecologists about overactive bladder and treatment of it in Turkey: A questionnaire survey

OBJECTIVE

We aimed to review the approaches of urologist and gynecologist in the management of overactive bladder (OAB).

MATERIAL AND METHODS

A questionnaire consisting of 12 items were answered by 375 urologist and 46 gynecologist. The differences between frequency of encountering OAB, their viewpoints concerning conservative treatment, and their experience related to anticholinergic drug use and the management of refractory OAB were compared.

RESULTS

The majority of the urologists, and gynecologists responded to the question "How often do you encounter OAB patients in your daily practice?" as 'in 10-25, and 50% of our patients', respectively (<0.001). The most common complaint consulted to urologists, and gynecologists were urge incontinence (51.1% vs. 64.8). The frequency of using questionnaire and voiding diary was similar in both specialties (23.9% vs. 25.1%, p=0.892). It was observed that 38.6% of the urologists, and 50% of the gynecologists had recommended conservative treatment as a first-line treatment of overactive bladder (p=0.049). The low sociocultural level was the most important obstacle confronting application of conservative treatment methods (54.3% vs. 37%, p=0.012). The survey participants indicated that the most important factor which affected their decision to select an anticholinergic agent as the first-line treatment of overactive bladder was higher effectiveness of these drugs (urologists; 55.7%, and gynecologists 64%, p=0.371). The patients who started to receive anticholinergic drugs most frequently complained both to their urologists, and/or gynecologists about dry mouth (76.3 vs. 74.5%). Based on the responses of the urologists, and gynecologists, the most frequent reason of anticholinergic drug withdrawal was patients' inability to tolerate side effects of these drugs (48% vs. 47.8%, p=0.697). The participants indicated that in case of unsatisfactory response to one anticholinergic agent, swithching rate to another anticholinergic drug was 56.9% among urologists vs. 59.6%, among gynecologists. In addition, 36.9% of urologists and 38.5% of gynecologists recommended another pharmaceutical form of the drug with a higher dose to their patients (p=0.279). Similar number of physicians indicated that the prescribed anticholinergic drug should be continued for at least 3 months and in case of unresponsiveness patient could be considered refractory. Majority of urologists (68.8%), and gynecologists (56.5%) chose to perform urodynamic tests in patients who are unresponsive to anticholinergic treatment, (p=0.093).

CONCLUSION

The attitudes of urologist and gynecologist for diagnosis and treatment of OAB are mostly correlating with current guideline practices with few exceptions. Urologists tend to use bladder diaries or questionnaires less frequently whereas, gynecologists refer to urodynamic studies in patients with refractory OAB less than the urologists do. However, irrespective of the clinical speciality, conservative treatment modalities are rarely administered.

Measurement the thickness of the transverse abdominal muscle in different tasks

[Purpose] This study examined the measurement of the thickness of the transverse abdominal muscle in different tasks. [Subjects and Methods] The subjects were eleven healthy adult females. Thicknesses of transverse abdominal muscle were measured in seven tasks in the supine position. The tasks were: 1) Resting state, 2) Maximal contraction of transverse abdominal muscle, 3) Maximal contraction of levator ani muscle, 4) Maximal simultaneous contraction of both transverse abdominal muscle and levator ani muscle, 5) Maximal simultaneous contraction of both transverse abdominal muscle and levator ani muscle with front side resistance added to both knee, 6) Maximal simultaneous contraction of both transverse abdominal muscle and levator ani muscle with diagonal resistance added to both knees, and 7) Maximal simultaneous contraction of both transverse abdominal muscle and levator ani muscle with lateral resistance added to both knees. [Results] The thicknesses of transverse abdominal muscle during maximal simultaneous contraction and maximal simultaneous contraction with resistance were greater than during the resting state. [Conclusion] The muscle output during simultaneous contraction and resistance movement were larger than that of each individual muscle.

Evaluation and management of overactive bladder: strategies for optimizing care

Overactive bladder (OAB) is a common condition affecting millions of men and women worldwide. It is an embarrassing condition with far-reaching consequences. Although many treatment options exist, no single treatment has been proven to be most effective. Often a combination of therapy is required to successfully manage OAB symptoms. In this review, we provide an overview of OAB, including risk factors for development of OAB; keys to diagnosis; therapeutic options including conservative and medical management, as well as treatments for refractory OAB; when to consider referral to a specialist; and resources for clinicians and patients. The aim of this review is to inform clinicians regarding OAB management in order to improve patient counseling and care.

The investigation and treatment of female pelvic floor dysfunction

BACKGROUND

25% of all women report involuntary loss of urine, and 7% may require treatment.

METHODS

This review is based on a selection of pertinent literature, including guidelines and Cochrane reviews.

RESULTS

The assessment of pelvic floor dysfunction in women begins with a basic evaluation that is followed by special diagnostic tests if indicated. The physician taking the clinical history should inquire about the patient's behavior, personality, social and other stressors, and eating and drinking habits, as well as any mental disorders that may be present, including anxiety disorders, depression, somatization disorders, and disorders of adaptation. Conservative treatment consists mainly of lifestyle changes, physiotherapy, and medication. Stress incontinence is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1% vs. 6% without such treatment (relative risk 8.38, 95% confidence interval 3.67-19.07). If incontinence persists, surgery may be indicated ( implantation of suburethral tension-free slings, or colposuspension). Feedback and biofeedback training can be used to treat an overactive bladder. If these techniques and drug therapy are unsuccessful, botulinum toxin injections can be considered.

CONCLUSION

Well-validated treatments for pelvic floor dysfunction are available. Psychosomatic factors must be taken into account and can have a major effect on treatment outcomes.

Mental health of Chinese primary care patients with lower urinary tract symptoms

The aim of this study was to evaluate the mental health of Chinese primary care patients with lower urinary tract symptoms (LUTS). This was a cross-sectional observational study. Five hundred and nineteen subjects with LUTS completed a structured questionnaire containing the Depression, Anxiety, and Stress Scale-Short Form, the International Prostate Symptom Score, the adapted International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and questions about socio-demographics. Overall, 17.7% of subjects reported depressive symptoms, 24.3% anxiety symptoms and 9.6% stress symptoms. In males, demographic factors associated with poorer mental health included being not married; clinical factors included higher LUTS severity, weak stream, straining and mixed urinary incontinence. In females, demographic factors associated with poorer mental health included being younger, not married and lower household income; clinical factors included higher LUTS severity, incomplete bladder emptying, urgency and weak stream. Chinese primary care patients with LUTS appear to be an at-risk group for poorer mental health with increased prevalence of anxiety and depressive symptoms and may require routine screening to identify those who may require more tailored interventions to address both their urinary symptoms and psychological distress.

Short-term effect of adding pelvic floor muscle training to bladder training for female urinary incontinence: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess whether bladder training (BT) combined with high-intensity pelvic floor muscle training (BT + PFMT) results in better outcomes in the short term than BT alone on female urinary incontinence (UI).

METHODS

We randomly assigned 108 women with diagnoses of stress UI (SUI, n = 50), urgency UI (UUI, n = 16), or mixed UI (MUI, n = 42) to 6 weeks of BT + PFMT or BT alone (control group). The primary outcome measure was self-reported improvement. Secondary outcome measures were UI severity, symptom distress, quality of life (QOL), mean number of UI episodes and micturitions per day, and pelvic floor muscle strength and endurance (PFME).

RESULTS

Overall and in the SUI and MUI subgroups, significantly more patients in the BT + PFMT group reported cured and improved symptoms. Overall and in SUI patients, the BT + PFMT group also improved to significantly greater degree in UI severity, symptom distress, QOL, daily UI episodes, and PFME. The only parameter showing more improvement in patients with UUI was QOL, and UI severity in patients with MUI (p < 0.05). There were no other significant differences between the two study groups in overall and subgroup analysis (p > 0.05).

CONCLUSIONS

High-intensity PFMT combined with BT is more effective than BT alone in the short term for treating UI or SUI. It appears that the combination therapy may also lead to greater benefits for patients with UUI and MUI. Based on the results of this study, further studies with larger sample sizes (for UUI) and long-term follow-ups are warranted.

The effect of pelvic muscle exercises on urinary incontinency and self-esteem of elderly females with stress urinary incontinency, 2013

Introduction:

Millions of women are afflicted with stress urinary incontinence. Urinary incontinence is mentioned as one of the geriatric syndromes, together with pressure ulcers, functional decline, falls, and low self-esteem. The aim of the present study was to determine the effect of pelvic muscle exercises on urinary incontinency and self- esteem of elderly females with stress urinary incontinency in Shiraz, Iran, 2013.

Material and Method:

In this interventional study, 50 old females aged 60-74 years were chosen among the members of Jahandidegan center, and they were asked to sign the informed consent form and complete the demographic questionnaire. Then, Quid questionnaire was used for choosing the type of incontinence in the elderly females. Next, the participants completed the ICIQ and self-esteem questionnaires. Then, they were randomly assigned to case and control groups. Each participant took part in 8 training classes. Finally, the subjects filled the ICIQ and self-esteem questionnaires before and 2 months after the intervention.

Result:

The results is shown that after the intervention, ICIQ score has a significant difference between the two groups (P=0.001). Also, after the treatment, self-esteem average scores of studied unit indicated a significant statistical difference in experimental group. In other words, the training sessions improved the score of self-esteem in the experimental group (P<0.001) versus control group (P=0.08).

Conclusion:

Pelvic muscle exercises were an empowerment mechanism for incontinent women in improving their quality of life and self-esteem, so recommended that such these exercising programs be used in elderly health care centers as a factor to improve health promotion of elderlies ’that are suffering from urinary incontinence.

Physiotherapy for women with stress urinary incontinence: a review article

[Purpose] This review article is designed to expose physiotherapists to a physiotherapy assessment of stress urinary incontinence (SUI) and the treatment and possibly preventive roles that they might play for women with SUI. Specifically, the goal of this article is to provide an understanding of pelvic floor muscle function and the implications that this function has for physiotherapy treatment by reviewing articles published in this area. [Methods] A range of databases was searched to identify articles that address physiotherapy for SUI, including the Cochrane Library, Medline, and CINAHL. [Results] According to the articles identified in our databases research, greater improvements in SUI occur when women receive a supervised exercise program of at least three months. The effectiveness of physiotherapy treatment is increased if the exercise program is based on some principles, such as intensity, duration, resembling functional task, and the position in which the exercise for pelvic floor muscles is performed. Biofeedback and electrical stimulation may also be clinically useful and acceptable modalities for some women with SUI. [Conclusion] We concluded that the plan for physiotherapy care should be individualized for each patient and include standard physiotherapy interventions.

Effects of Co-contraction of Both Transverse Abdominal Muscle and Pelvic Floor Muscle Exercises for Stress Urinary Incontinence: A Randomized Controlled Trial

[Purpose] The purpose of this study was to devise a new urinary incontinence exercise using co-contraction of both the transverse abdominal muscle (TA) and pelvic floor muscle (PFM) and examine the intervention effect in middle-aged women with stress urinary incontinence (SUI). [Subjects] The subjects were fifteen women with SUI who were divided into two groups: the TA and PFM co-contraction exercise group (n=9) and the control group (n=6). [Methods] Participants in the exercise group performed TA and PFM co-contraction exercise. The thickness of the TA was measured before and after 8 weeks of exercise using ultrasound. The thickness of the TA was measured under 4 conditions: (1) at rest, (2) maximal contraction of the TA, (3) maximal contraction of the PFM, and (4) maximal co-contraction of both the TA and PFM. [Results] There were no significant differences among the results of the control group. In the exercise group, the cure rate of SUI was 88.9% after the intervention. There were significant differences in the thickness of the TA during maximal co-contraction of both the TA and PFM after the intervention. [Conclusion] The TA and PFM co-contraction exercise intervention increases the thickness of the TA and may be recommended to improve SUI in middle-aged women.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed and, less commonly, urgency urinary incontinence.

OBJECTIVES

To determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL) (1999 onwards), MEDLINE (1966 onwards) and MEDLINE In-Process (2001 onwards), and handsearched journals and conference proceedings (searched 15 April 2013) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in women with stress, urgency or mixed urinary incontinence (based on symptoms, signs, or urodynamics). One arm of the trial included pelvic floor muscle training (PFMT). Another arm was a no treatment, placebo, sham, or other inactive control treatment arm.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed by two review authors for eligibility and methodological quality. Data were extracted then cross-checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. Trials were subgrouped by diagnosis of urinary incontinence. Formal meta-analysis was undertaken when appropriate.

MAIN RESULTS

Twenty-one trials involving 1281 women (665 PFMT, 616 controls) met the inclusion criteria; 18 trials (1051 women) contributed data to the forest plots. The trials were generally small to moderate sized, and many were at moderate risk of bias, based on the trial reports. There was considerable variation in the interventions used, study populations, and outcome measures. There were no studies of women with mixed or urgency urinary incontinence alone.Women with SUI who were in the PFMT groups were 8 times more likely than the controls to report that they were cured (46/82 (56.1%) versus 5/83 (6.0%), RR 8.38, 95% CI 3.68 to 19.07) and 17 times more likely to report cure or improvement (32/58 (55%) versus 2/63 (3.2%), RR 17.33, 95% CI 4.31 to 69.64). In trials in women with any type of urinary incontinence, PFMT groups were also more likely to report cure, or more cure and improvement than the women in the control groups, although the effect size was reduced. Women with either SUI or any type of urinary incontinence were also more satisfied with the active treatment, while women in the control groups were more likely to seek further treatment. Women treated with PFMT leaked urine less often, lost smaller amounts on the short office-based pad test, and emptied their bladders less often during the day. Their sexual outcomes were also better. Two trials (one small and one moderate size) reported some evidence of the benefit persisting for up to a year after treatment. Of the few adverse effects reported, none were serious.The findings of the review were largely supported by the summary of findings tables, but most of the evidence was down-graded to moderate on methodological grounds. The exception was 'Participant perceived cure' in women with SUI, which was rated as high quality.

AUTHORS' CONCLUSIONS

The review provides support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress and any type of urinary incontinence. Long-term effectiveness of PFMT needs to be further researched.

Behavioral Intervention Program versus Vaginal Cones on Stress Urinary Incontinence and Related Quality of Life: A Randomized Clinical Trial

OBJECTIVE

To compare the efficacy of behavioral intervention program and vaginal cones on stress urinary incontinence.

METHODS

In this randomized clinical trial, 60 women aged 25-65 years with stress urinary incontinence were randomly divided into two groups, those who participated in a behavioral intervention program (n=30) and those who used vaginal cones (n=30). The women in the behavioral intervention group were instructed on pelvic floor exercise and bladder control strategies. In the other group, pelvic floor exercises were performed using the vaginal cones. All participants were treated for 12 weeks and followed-up every 2 weeks. The subjective changes in severity of stress urinary incontinence were measured using a detection stress urinary incontinence severity questionnaire, leakage index, and a 3-day urinary diary. The objective changes were measured by pad test. For better evaluation of the effects, two questionnaires were used: Incontinence Quality of Life and King's Health Questionnaire.

RESULTS

Among the 51 women who completed the study, 25 subjects were in the vaginal cones group and 26 participated in the behavioral intervention program. The changes in leakage rate on pad test and leakage index in the behavioral intervention program group were significantly higher than in the vaginal cones group (p=0.001 and p=0.008, respectively), but the severity of stress urinary incontinence was not significantly different between the two groups (p=0.2). The changes in strength of the pelvic floor, Incontinence Quality of Life, and King's Health Questionnaire scores showed no significant differences between the two groups after 12 weeks of intervention.

CONCLUSION

Vaginal cones and behavioral intervention programs are both effective methods of treatment for mild to moderate stress urinary incontinence, but the behavioral intervention program is superior to vaginal cones in terms of cost-effectiveness and side effects.

The evaluation of bioelectrical activity of pelvic floor muscles depending on probe location: a pilot study

Objectives. The main objective was to determine how the depth of probe placement affects functional and resting bioelectrical activity of the PFM and whether the recorded signal might be dependent on the direction in which the probe is rotated. Participants. The study comprised of healthy, nulliparous women between the ages of 21 and 25. Outcome Measures. Bioelectric activity of the PFM was recorded from four locations of the vagina by surface EMG and vaginal probe. Results. There were no statistically significant differences between the results during functional sEMG activity. During resting sEMG activity, the highest bioelectrical activity of the PFM was observed in the L1 and the lowest in the L4 and a statistically significant difference between the highest and the lowest results of resting sEMG activity was observed (P = 0.0043). Conclusion. Different electrodes placement during functional contraction of PFM does not affect the obtained results in sEMG evaluation. In order to diagnose the highest resting activity of PFM the recording plates should be placed toward the anterior vaginal wall and distally from the introitus. However, all of the PFM have similar bioelectrical activity and it seems that these muscles could be treated as a single muscle.

Pelvic floor muscle training in women with stress urinary incontinence causes hypertrophy of the urethral sphincters and reduces bladder neck mobility during coughing

AIMS

The purpose of this study was to determine the effect of a 12-week pelvic floor muscle (PFM) training program on urethral morphology and mobility in women with stress urinary incontinence (SUI).

METHODS

Forty women with SUI were randomly assigned to one of two groups: the treatment group received 12 weekly physiotherapy sessions during which they learned how to properly contract their pelvic floor muscles (PFMs) and a home exercise program was prescribed, reviewed, and progressed; the control group received no treatment. Before and after the 12-week study period, ultrasound imaging was used to evaluate bladder neck position and mobility during coughing and Valsalva maneuver in supine and in standing, as well as urethral morphology. Secondary outcome measures included a 3-day bladder diary, 30-min pad test, the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Inventory (UDI-6).

RESULTS

The women in the treatment group demonstrated reduced bladder neck mobility during coughing and increased cross-sectional area of their urethra after as compared to before the training. These changes were not evident in the control group. No differences in the resting position of the bladder neck or in bladder neck excursion during Valsalva maneuver were noted in either group. Concomitantly the women in the treatment group demonstrated significant improvements in the 3-day bladder diary and IIQ-7 after the PFM training and improved significantly more than the control group.

CONCLUSION

Physiotherapist-supervised PFM training reduces bladder neck motion during coughing, and results in hypertrophy of the urethral sphincter in women who present with SUI.

Weighted vaginal cones for urinary incontinence

BACKGROUND

For a long time pelvic floor muscle training (PFMT) has been the most common form of conservative (non-surgical) treatment for stress urinary incontinence (SUI). Weighted vaginal cones can be used to help women to train their pelvic floor muscles. Cones are inserted into the vagina and the pelvic floor is contracted to prevent them from slipping out.

OBJECTIVES

The objective of this review is to determine the effectiveness of vaginal cones in the management of female urinary stress incontinence (SUI).We wished to test the following comparisons in the management of stress incontinence: 1. vaginal cones versus no treatment; 2. vaginal cones versus other conservative therapies, such as PFMT and electrostimulation; 3. combining vaginal cones and another conservative therapy versus another conservative therapy alone or cones alone; 4. vaginal cones versus non-conservative methods, for example surgery or injectables.Secondary issues which were considered included whether:1. it takes less time to teach women to use cones than it does to teach the pelvic floor exercise; 2. self-taught use is effective;3. the change in weight of the heaviest cone that can be retained is related to the level of improvement;4. subgroups of women for whom cone use may be particularly effective can be identified.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 19 September 2012), MEDLINE (January 1966 to March 2013), EMBASE (January 1988 to March 2013) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing weighted vaginal cones with alternative treatments or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion and trial quality. Data were extracted by one reviewer and cross-checked by the other. Study authors were contacted for extra information.

MAIN RESULTS

We included 23 trials involving 1806 women, of whom 717 received cones. All of the trials were small, and in many the quality was hard to judge. Outcome measures differed between trials, making the results difficult to combine. Some trials reported high drop-out rates with both cone and comparison treatments. Seven trials were published only as abstracts.Cones were better than no active treatment (rate ratio (RR) for failure to cure incontinence 0.84, 95% confidence interval (CI) 0.76 to 0.94). There was little evidence of difference for a subjective cure between cones and PFMT (RR 1.01, 95% CI 0.91 to 1.13), or between cones and electrostimulation (RR 1.26, 95% CI 0.85 to 1.87), but the confidence intervals were wide. There was not enough evidence to show that cones plus PFMT was different to either cones alone or PFMT alone. Only seven trials used a quality of life measures and no study looked at economic outcomes.Seven of the trials recruited women with symptoms of incontinence, while the others required women with urodynamic stress incontinence, apart from one where the inclusion criteria were uncertain.

AUTHORS' CONCLUSIONS

This review provides some evidence that weighted vaginal cones are better than no active treatment in women with SUI and may be of similar effectiveness to PFMT and electrostimulation. This conclusion must remain tentative until larger, high-quality trials, that use comparable and relevant outcomes, are completed. Cones could be offered as one treatment option, if women find them acceptable.

Short-term outcomes after rehabilitation treatment in patients selected by a novel rehabilitation score system (Brusciano score) with or without previous stapled transanal rectal resection (STARR) for rectal outlet obstruction

PURPOSE

The purpose of this study was to examine short-term outcomes of rehabilitation treatment in patients with or without previous stapled transanal resection (STARR) for rectal outlet obstruction by using a novel rehabilitation score system (Brusciano score).

METHODS

This is a retrospective cohort study conducted at a single tertiary referral institution including all patients with chronic functional constipation admitted to the outpatient unit from 2004 to 2009.

RESULTS

Among 330 consecutive patients, 247 (74.8 %) (204 females and 43 males) showing a significantly higher rehabilitation score (mean of 15.7 ± 1.8; range, 7-25) than healthy controls (mean, 3.2 ± 1.2; range 2-6) (p < .0001) were selected for rehabilitation. Of the 247 patients evaluated, group A (no previous surgery) consisted of 170 patients (53 males; mean age, 44.8 ± 12.9 years; range, 19-80) of which 38 presented mixed constipation, whereas group B (previous surgery) consisted of 77 patients (18 males; mean age, 47.0 ± 11.2 years; range, 22-81). The Brusciano score, Agachan-Wexner score and quality of life improved in both groups of patients after treatment. Better improvements of Brusciano and Agachan-Wexner scores were observed in patients with previous STARR (group B).

CONCLUSIONS

The rehabilitation score system employed in this study seems to be a useful tool in selecting and assessing the outcome of patients who might benefit from rehabilitation treatment. Constipation and quality of life were significantly improved by the rehabilitation treatment. Further studies are needed to clarify either the impact of rehabilitation treatment on long-term outcome of patients treated for rectal outlet obstruction or its role in those who develop problems over time.

Disability among elderly rural villagers: report of a survey from Gonoshasthaya Kendra, Bangladesh

BACKGROUND

The study was set up to identify the extent and nature of difficulty with activities of daily living (disabilities) among elderly village residents of Bangladesh, to describe help currently given and to identify possible interventions. It was carried out at Gonoshasthaya Kendra (GK), a community development organization responsible for the health care of 600 villages with a population of some 1.5 million.

METHODS

A survey card was designed and piloted using 12 questions on disability, elaborated from the Washington Group Disability questions, together with a checklist of health problems. A survey was carried out in 2010 in 535 villages under the care of GK since 2005, with village paramedics interviewing residents believed to be age 60 years or older. Respondents were matched where possible to data from the 2005 GK household census, giving data on education, occupation, socioeconomic group and smoking habit.

RESULTS

Survey cards were completed for 43417 residents of which 17346 were matched to residents recorded in the GK census as born ≤ 1945. The proportion reporting 'much difficulty' on one or more functional capacities increased steadily with age, reaching 55% (1796/3620) among those ≥ 85 years. Difficulties most frequently reported were lifting and carrying, vision and going outside the home. At all ages women were more likely to report 'much difficulty' than men (OR = 1.43 (1.35 to 1.48)), with widows and the illiterate at greater risk. Health problems, particularly hemiplegia, resting tremor, urinary incontinence and depression were strongly related to the 12 disabilities assessed. Help came almost entirely from family members; of 11211 villagers with 'much difficult' on at least one functional capacity, only 15 reported getting help outside the family.

CONCLUSIONS

Disabled elderly residents were dependent on the family for help but, with family cohesiveness under threat from migration to the city, there is a pressing need for the development and critical evaluation of community-based interventions designed specifically for the elderly in poor rural societies. New approaches to training and practice will be needed to integrate such disability management into primary care.

Urinary symptoms in breast cancer: a systematic review

A large body of research has documented the prevalence and severity of menopausal symptoms, especially vasomotor symptoms, in breast cancer survivors and their impact on quality of life. However, urinary symptoms as part of the constellation of menopausal symptoms have received relatively little attention. Thus, less is known about the prevalence and severity of urinary symptoms in breast cancer survivors. The authors of this report conducted a systematic review of studies published between 1990 and 2010 to describe the prevalence and severity of urinary symptoms in breast cancer survivors. In total, 16 eligible studies that involved >2500 women were identified. The studies varied with respect to purpose, design, and nature of the samples included; the majority used the same definition and assessment approach for urinary symptoms. Prevalence rates for symptoms ranged from 12% of women reporting burning or pain on micturition to 58% reporting difficulty with bladder control. Although, in many studies, the largest percentage of women rated symptoms as mild, 23% reported severe symptoms. Symptoms appeared to adversely affect women's quality of life. The authors concluded that there is a need for additional research assessing the natural history of urinary symptoms using consensus definitions and validated measures in diverse populations. Nevertheless, this review suggested that clinicians should screen for urinary symptoms in breast cancer survivors and should offer treatment recommendations or make referrals as appropriate.

Pelvic floor muscle training for urgency urinary incontinence in women: a systematic review

The objective of this study is to evaluate the effectiveness of existing physiotherapy modalities for the treatment of urge urinary incontinence (UUI). A systematic review was performed for primary studies of physiotherapy techniques for UUI published in English between 1996 and August 2010 in major electronic databases. Only randomized clinical trials that reported outcomes separately for women with UUI were included. Outcomes assessed were reduction in UUI, urinary frequency, and nocturia. Data from 13 full-text trials including the modalities of pelvic floor muscles exercises with or without biofeedback, vaginal electrical stimulation, magnetic stimulation, and vaginal cones were analyzed. The methodologic quality of these trials was fair. Significant improvement in UUI was reported for all physiotherapy techniques except vaginal cone therapy. There are insufficient data to determine if pelvic physiotherapy improves urinary frequency or nocturia. Evidence suggests that physiotherapy techniques may be beneficial for the treatment of UUI.

Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress urinary incontinence. It is also sometimes recommended for mixed and, less commonly, urge urinary incontinence. The supervision and content of pelvic floor muscle training programmes are highly variable, and some programmes use additional strategies in an effort to increase adherence or training effects.

OBJECTIVES

To compare the effects of different approaches to pelvic floor muscle training for women with urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings (searched 17 May 2011), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised trials or quasi-randomised trials in women with stress, urge or mixed urinary incontinence (based on symptoms, signs or urodynamics). One arm of the study included pelvic floor muscle training. Another arm was an alternative approach to pelvic floor muscle training, such as a different way of teaching, supervising or performing pelvic floor muscle training.

DATA COLLECTION AND ANALYSIS

We independently assessed trials for eligibility and methodological quality. We extracted then cross-checked data. We resolved disagreements by discussion. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.2.2). We subgrouped trials by intervention.

MAIN RESULTS

We screened 574 records for eligibility and included 21 trials in the review. The 21 trials randomised 1490 women and addressed 11 comparisons. These were: differences in training supervision (amount, individual versus group), in approach (one versus another, the effect of an additional component) and the exercise training (type of contraction, frequency of training). In women with stress urinary incontinence, 10% of those who received weekly or twice-weekly group supervision in addition to individual appointments with the therapist did not report improvement post-treatment compared to 43% of the group who had individual appointments only (risk ratio (RR) for no improvement 0.29, 95% confidence interval (CI) 0.15 to 0.55, four trials). Looking at this another way, 90% of those who had combined group and individual supervision reported improvement versus 57% of women receiving individual supervision only. While women receiving the combination of frequent group supervision and individual supervision of pelvic floor muscle training were more likely to report improvement, the confidence interval was wide, and more than half of the 'control' group (the women who did not get the additional weekly or twice-weekly group supervision) reported improvement. This finding, of subjective improvement in both active treatment groups, with more improvement reported by those receiving more health professional contact, was consistent throughout the review.We feel there are several reasons why caution is needed when interpreting the results of the review: there were few data in any comparison; a number of trials were confounded by comparing two arms with multiple differences in the approaches to pelvic floor muscle training; there was a likelihood of a relationship between attention and reporting of more improvement in women who were not blind to treatment allocation; some trials chose interventions that were unlikely to have a muscle training effect; and some trials did not adequately describe their intervention.

AUTHORS' CONCLUSIONS

This review found that the existing evidence was insufficient to make any strong recommendations about the best approach to pelvic floor muscle training. We suggest that women are offered reasonably frequent appointments during the training period, because the few data consistently showed that women receiving regular (e.g. weekly) supervision were more likely to report improvement than women doing pelvic floor muscle training with little or no supervision.

Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction

OBJECTIVES

The objectives of the present review was to present and discuss evidence for pelvic floor muscle (PFM) training on female stress urinary incontinence (SUI), pelvic organ prolapse (POP) and sexual dysfunction.

METHODS

This manuscript is based on conclusions and data presented in systematic reviews on PFM training for SUI, POP and sexual dysfunction. Cochrane reviews, the 4th International Consultation on Incontinence, the NICE guidelines and the Health Technology Assessment were used as data sources. In addition, a new search on Pubmed was done from 2008 to 2011. Only data from randomized controlled trials (RCTs) published in English language is presented and discussed.

RESULTS

There is Level 1, Grade A evidence that PFM training is effective in treatment of SUI. Short-term cure rates assessed as <2 g of leakage on pad testing vary between 35 and 80%. To date there are 5 RCTs showing significant effect of PFM training on either POP stage, symptoms or PFM morphology. Supervised and more intensive training is more effective than unsupervised training. There are no adverse effects. There is a lack of RCTs addressing the effect of PFM training on sexual dysfunction.

CONCLUSIONS

PFM training should be first line treatment for SUI and POP, but the training needs proper instruction and close follow-up to be effective. More high quality RCTs are warranted on PFM training to treat sexual dysfunction.

A healthy bladder: a consensus statement

A panel of experts in urology, urogynecology, nursing, and behavioral therapy convened in 2010 to discuss the importance of a healthy bladder on overall health. They determined that a consensus statement was necessary to raise awareness among the general public, healthcare providers, payors, and policymakers, with the goals of minimizing the impact of poor bladder health and stimulating primary prevention of bladder conditions. In this statement, 'healthy' bladder function is described, as well as internal and external factors that influence bladder health. It is suggested that primary prevention strategies should be aimed at providing education regarding normal lower urinary tract structures and functioning to the public, including patients and healthcare providers. This education may promote the achievement of optimal bladder health by increasing healthy bladder habits and behaviors, awareness of risk factors, healthcare seeking, and clinician engagement and reducing stigma and other barriers to treatment. Promoting optimal bladder health may reduce the personal, societal and economic impact of bladder conditions, including anxiety and depression and costs associated with conditions or diseases and their treatment. While adopting healthy bladder habits and behaviors and behaviors may improve or maintain bladder health, it is important to recognize that certain symptoms may indicate the presence of conditions that require medical attention; many bladder conditions are treatable with a range of options for most bladder conditions. Lastly, the authors propose clinical directives based on persuasive and convergent research to improve and maintain bladder health. The authors hope that this statement will lead to promotion and achievement of optimal bladder health, which may improve overall health and help minimize the effects of bladder conditions on the public, healthcare professionals, educators, employers, and payors. The advisors are in consensus regarding the recommendations for improving and maintaining bladder health presented herein.

Does better quality of care for falls and urinary incontinence result in better participant-reported outcomes?

OBJECTIVES

To determine whether delivery of better quality of care for urinary incontinence (UI) and falls is associated with better participant-reported outcomes.

DESIGN

Retrospective cohort study.

SETTING

Assessing Care of Vulnerable Elders Study 2 (ACOVE-2).

PARTICIPANTS

Older (≥ 75) ambulatory care participants in ACOVE-2 who screened positive for UI (n = 133) or falls or fear of falling (n=328).

MEASUREMENTS

Composite quality scores (percentage of quality indicators (QIs) passed per participant) and change in Incontinence Quality of Life (IQOL, range 0-100) or Falls Efficacy Scale (FES, range 10-40) scores were measured before and after care was delivered (mean 10 months). Because the treatment-related falls QIs were measured only on patients who received a physical examination, an alternative Common Pathway QI (CPQI) score was developed that assigned a failing score for falls treatment to unexamined participants.

RESULTS

Each 10% increment in receipt of recommended care for UI was associated with a 1.4-point improvement in IQOL score (P = .01). The original falls composite quality-of-care score was unrelated to FES, but the new CPQI scoring method for falls quality of care was related to FES outcomes (+0.4 points per 10% increment in falls quality, P = .01).

CONCLUSION

Better quality of care for falls and UI was associated with measurable improvement in participant-reported outcomes in less than 1 year. The connection between process and outcome required consideration of the interdependence between diagnosis and treatment in the falls QIs. The link between process and outcome demonstrated for UI and falls underscores the importance of improving care in these areas.

Refractory overactive bladder: Beyond oral anticholinergic therapy

Objectives:

In this review, we discuss the treatment of refractory overactive bladder (OAB) that has not adequately responded to medication therapy and we propose an appropriate care pathway to the treatment of OAB. We also attempt to address the cost of OAB treatments.

Materials and Methods:

A selective expert review of the current literature on the subject of refractory OAB using MEDLINE was performed and the data is summarized. We also review our experience in treating refractory OAB. The role and outcomes of various treatment options for refractory OAB are discussed and combined therapy with oral anticholinergics is explored. Emerging remedies including intravesical botulinum toxin injection and pudendal neuromodulation are also reviewed, along with conventional surgical options.

Results:

In general behavioral therapy, pelvic floor electrical stimulation, magnetic therapy and posterior tibial nerve stimulation (PTNS), have shown symptom decreases in 50-80% of patients with OAB. Depending on the study, combination therapy with oral anticholinergics seems to improve efficacy of behavioral therapy and PTNS in approximately 10-30%. In multicenter, long-term randomized controlled trials, sacral neuromodulation has been shown to improve symptoms of OAB and OAB incontinence in up to 80% of the patients treated. Studies involving emerging therapies such as pudendal serve stimulation suggest that there may be a 15-20% increase in efficacy over sacral neuromodulation, but long-term studies are not yet available. Another emerging therapy, botulinum toxin, is also showing similar success in reducing OAB symptoms in 80-90% of patients. Surgical approaches, such as bladder augmentation, are a last resort in the treatment of OAB and are rarely used at this point unless upper tract damage is a concern and all other treatment options have been exhausted.

Conclusion:

The vast majority of OAB patients can be managed successfully by behavioral options with or without anticholinergic medications. When those fail, neuromodulation or intravesical botulinum toxin therapies are successful alternatives for most of the remaining group. We encourage practitioners responsible for the care of OAB patients to gain experience with these options. More research is needed to assess the cost-effectiveness of various OAB treatments

Nonsurgical outpatient therapies for the management of female stress urinary incontinence: long-term effectiveness and durability

Objective. To evaluate long-term effectiveness and safety of conservative and minimally invasive outpatient treatments for female stress urinary incontinence (SUI) through a review of the literature. Methods. PubMed was searched for reports on prospective clinical trials with at least 12-month follow-up of minimally invasive treatments, pelvic floor rehabilitation, or pharmacotherapy in women with SUI. Each report was examined for long-term rates of effectiveness and safety. Results. Thirty-two clinical trial reports were included. Prospective long-term studies of pelvic floor rehabilitation were limited but indicated significant improvements with treatment adherence for at least 12 months. Poor initial tolerability with duloxetine resulted in substantial discontinuation. Most patients receiving transurethral radiofrequency collagen denaturation or urethral bulking agents reported significant long-term improvements, generally good tolerability, and safety. Conclusions. Conservative therapy is an appropriate initial approach for female SUI, but if therapy fails, radiofrequency collagen denaturation or bulking agents may be an attractive intermediate management step or alternative to surgery.

Study protocol: ICONS: identifying continence options after stroke: a randomised trial

BACKGROUND

Urinary incontinence following acute stroke is common, affecting between 40%-60% of people in hospital after a stroke. Despite the availability of clinical guidelines for urinary incontinence and urinary incontinence after stroke, national audit data suggest incontinence is often poorly managed. Conservative interventions (e.g. bladder training, pelvic floor muscle training and prompted voiding) have been shown to have some effect with participants in Cochrane systematic reviews, but have not had their effectiveness demonstrated with stroke patients.

METHODS/DESIGN

A cluster randomised controlled pilot trial designed to assess the feasibility of a full-scale cluster randomised trial and to provide preliminary evidence of the effectiveness and cost-effectiveness of a systematic voiding programme for the management of continence after stroke. Stroke services will be randomised to receive the systematic voiding programme, the systematic voiding programme plus supported implementation, or usual care. The trial aims to recruit at least 780 participants in 12 stroke services (4 per arm). The primary outcome is presence/absence of incontinence at six weeks post-stroke. Secondary outcomes include frequency and severity of incontinence, quality of life and cost-utility. Outcomes will be measured at six weeks, three months and (for participants recruited in the first three months) twelve months after stroke. Process data will include rates of recruitment and retention and fidelity of intervention delivery. An integrated qualitative evaluation will be conducted in order to describe implementation and assist in explaining the potential mediators and modifiers of the process.

TRIAL REGISTRATION

ISRCTN: ISRCTN08609907

Pelvic floor muscle training for treatment of pelvic organ prolapse: an assessor-blinded randomized controlled trial

INTRODUCTION AND HYPOTHESIS

This pilot study aimed to investigate the effectiveness of pelvic floor muscle training (PFMT) for the treatment of pelvic organ prolapse.

METHODS

Thirty-seven women with stage II prolapse were randomized to either the intervention group (n = 21) or the control group (n = 16). The evaluation included assessments of pelvic floor muscle function and surface electromyography at baseline and post 14 weeks of treatment. The severity of prolapse was quantified by the POP-Q method and symptoms by P-QoL questionnaire.

RESULTS

The intervention group showed significantly greater anatomic improvements in the anterior and posterior vaginal wall prolapses than did the control group (P < 0.001 and 0.025, respectively) and a decrease of symptoms. In addition, the intervention group had greater improvements in muscle strength (P < 0.001), endurance (P < 0.001), and electromyography parameters (P = 0.008) compared to the control group.

CONCLUSIONS

PFMT is effective in the treatment of pelvic organ prolapse.