Stress Urinary Incontinence in Active Elderly Women

Effects of voluntary pre-contraction of the pelvic floor muscles (the Knack) on female stress urinary incontinence-a study protocol for a RCT

Background

Stress urinary incontinence (SUI) is a subtype of urinary incontinence that occurs more commonly amongst women. The pelvic floor muscle training (PFMT) is considered the gold standard for treating SUI. Another technique called the Knack postulated that pre-contraction of the pelvic floor muscles (PFM) during activities of increasing intra-abdominal pressure prevents urinary loss. Currently, there are no studies supporting the Knack for the treatment of SUI. Thus, the aim of this study is to test the hypothesis that voluntary pre-contraction of PFM can treat SUI. For this purpose, the following parameters will be analysed and compared amongst (1) the Knack, (2) PFMT and (3) the Knack + PFMT groups: urine leakage as assessed by the pad test, urinary symptoms, muscle function, quality of life, subjective cure, adherence to exercises in the outpatient setting and at home and perceived self-efficacy of PFM exercises.

Methods

A single-centre, double-blind (investigator and outcome assessor) randomised controlled trial with a 3-month follow-up of supervised treatment and an additional 3 months of follow-up (unsupervised) for a total of 6 months of follow-up. Two hundred ten women with mild to moderate SUI will be included, aged between 18 and 70 years. To compare the primary and secondary outcome measures within and between the groups studied (before and after intervention), the ANOVA statistical test will be used. Primary and secondary outcome measures will be presented as mean, standard deviation, 95% confidence interval and median and minimum and maximum values.

Discussion/significance

This study closes a gap, as voluntary PFM pre-contraction (the Knack) has not yet been included in the physiotherapeutic treatment of SUI, and if shown successful could be implemented in clinical practice.

Trial registration

ClinicalTrials.gov NCT03722719. Registered on October 29, 2018. Study protocol version 1.

Was this trial prospectively registered? Yes

Funded by: The present study did not receive funding.

Anticipated completion date: The anticipated trial commencement and completion dates are October 2018 and October 2021, respectively.

Provenance: Not invited. Peer reviewed.

Human research ethics approval committee: Research Ethical Board of the Universidade Federal de São Paulo (UNIFESP), Brazil.

Human research ethics approval number: 2.517.312.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05440-0.

Effect of vibrational therapy on muscle tissue

In an adult human, on average, muscles constitute about 40% of their body mass. They are the basic structural and functional elements of the musculoskeletal system based mainly on shrinkage of their fibres. This state, among others, ensures and induces motor reactions defined in a given situation, affects balance and muscle balance, the efficiency of neuromuscular connections, and also decides the efficiency of the motor system. The aim of the work was to review literature regarding the impact of treatments using vibrational stimulus on human muscle tissue. Particular attention was paid to the observed improvement of its motor properties after the completion of t vibrational therapy application. An attempt was also made to present the widest possible use of vibrational procedures in various disease states related to the functionality of muscle tissue, which is why in the present overview, the included research was differentiated in terms of target groups and investigated muscles. The analysis included domestic and foreign literature, in which the positive effect of vibrational treatments on the motor properties of adults was discussed. Studies were selected, the authors of which described the most important parameters of the vibrational stimulus used, such as: frequency, amplitude and duration of exposure. Research work from the last 15 years has been analysed (not including the historical part). However, as many as 70% of the studies referred to have been published in the last 5 years. Data from the following databases was analysed: Medline, Embase, Cochrane CENTRAL trials register, ScienceDirect, PubMed, IEEE Xplore, Wiley Online Library. Key words used: muscles, force, vibration, WBV. Numerous reports indicate the positive effect of vibrational therapy on human muscle tissue. These treatments, among others, prevent muscle atrophy, and in this way, improve or reproduce the lost motor skills of the investigated people. Treatments with the use of vibrations can be performed by the patients themselves without special supervision, the devices that trigger them are easy to use and do not require significant physical effort, which is an undoubted advantage for the elderly and ill patients as well as athletes during the restitution period. It seems wise that any future research regarding the possibility of use of using vibrations in various disease states, including covering the broadly understood pathology of the musculoskeletal system, should focus on the development of optimal parameters and conditions for the use of vibration treatments, associating them with selected disease entities, developing indications and contraindications for their use, as well as determine hypotheses of the effectiveness of undertaken activities and their scientific verification. This article is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. null

Comparison of Three Kinds of Mid-Urethral Slings for Surgical Treatment of Female Stress Urinary Incontinence

Aims

A study was conducted to compare the efficacy and complications of tension-free vaginal tape (TVT), transobturator vaginal tape inside-out TVT-0 and transobturator vaginal tape out-inside (TOT) procedures for the surgical treatment of female stress urinary incontinence SUI.

Methods

This study is a prospective randomized trial involving 187 women with primary SUI; 77 received TVT, 65 received TVT-O, and 45 patients were treated with TVT-0 between June 2002 and December 2009. Before the operation, a complete medical history was taken and a gynecologic examination was performed, including subjective symptoms, history and urodynamic studies. Postoperative data included mean operation time, days of hospitalization, postoperative complications and efficacy evaluation. Therapeutic effect was assessed by presence or absence of incontinence when abdominal pressure increased.

Results

The history, physical examination and urodynamic studies among the three groups have no significant difference (P>0.05). The total cure rate was 91.4%. The cure rate in TVT, TVT-O and TOT groups were 90.9%, 92.3% and 91.1%, respectively. There was no significant difference (P>0.05). Mean operative time showed no significant difference between TVT-O and TOT groups, but both were significantly shorter than TVT group (26.90±16.80, 20.00±13.50 vs 48.20±21.90). The mean postoperative hospital stay showed no significant difference between TVT and TVT-O groups, but both groups were significantly longer than TOT group. Mean postoperative hospital stay of TVT, TVT-O and TOT were 5.00±2.40 days, 4.00±2.20 days and 2.30±0.80 days, respectively. The complication rate in TVT, TVT-O and TOT groups was 15.60%, 9.20% and 8.90%, respectively. In TVT group, 4 patients experienced bladder perforation, postoperative dysuria or retention occurred in 7 cases and was cured by urethral dilation, hematomas of retropubic space in 1 patient. No bladder injury occurred in TVT-O and TOT group, 3 patients had postoperative dysuria or retention and 3 patients had transient dysfunction of both lower limbs postoperatively in TVT-O group, 2 patients had postoperative dysuria or retention and 2 patients had transient dysfunction of both lower limbs postoperatively in TOT group.

Summary

The three tension-free urethral suspension techniques have similar efficacy, all of them are safe and effective procedures for the treatment of female SUI. Compared with TVT, TVT-O and TOT are simpler, less invasive and have fewer complications.

Minimally invasive treatment of female stress urinary incontinence with the adjustable single-incision sling system (AJUST ™) in an elderly and overweight population

Introduction

The prevalence of urinary incontinence is increasing. Two major risk factors are overweight and age. We present objective and subjective cure rates of elderly and overweight patients treated with an adjustable single-incision sling system (AJUST™, C.R. BARD, Inc.).

Materials and Methods

Between 04/2009 and 02/2012 we treated 100 female patients with the single incision sling. Patients were retrospectively evaluated by Stamey degree of incontinence, cough test, pad use, and overall satisfaction. The primary outcomes of the study were objective and subjective cure rates, secondary outcomes were the safety profile of the sling and complications.

Results

The overall success rate in this population was 84.6% with a mean follow-up of 9.3 months. The average usage of pads per day decreased from 4.9 to 1.6 and was significantly lower in patients with a BMI <30 (p=0.004). Postoperative residual SUI was also lower in patients with a BMI <30 (p=0.006). Postoperative satisfaction was better in patients with a lower BMI, but this difference did not reach a level of significance (p=0.055). There were no complications such as bleeding, bladder injury, or tape infection.

Conclusions

In elderly and obese patients a considerable success rate is achievable with this quick and minimal invasive procedure. However, the success rate shows a clear trend in favor of a lower body-mass-index. The cut-off point has been identified at a BMI of 30. The AJUST™ system can be regarded as safe and beneficial for elderly and obese patients.

Do women have realistic expectations of treatment for stress urinary incontinence?

AIMS

Our objective was to determine what women find acceptable regarding treatment and outcomes for treatment of stress urinary incontinence (SUI), and correlate this to age, distress and quality of life (QOL).

MATERIALS AND METHODS

This prospective cross-sectional IRB-approved study evaluated women with primary SUI. One hundred sequential women (mean age, 53.8 years) answered questionnaires on initial interview, including the Urogential Distress Inventory (UDI-6), the American Urologic Association QOL questionnaire, as well as other validated questions regarding treatment options and possible outcomes. Statistical analysis was performed using Chi Squared, Fisher Exact, and t tests as well as the Wilcoxon Rank Score.

RESULTS

Of the 100 women who submitted questionnaires, 22% overall expected a complete cure, 57% a good improvement, 12% to be able to cope better, and 9% expected any improvement at all. We found this to be a realistic expectation of possible outcomes of treatment, with 79% expecting a good improvement or cure for their SUI. The women were also asked what type of treatment they found acceptable for their SUI: 22% found a major surgery acceptable, 39% found a minor surgery acceptable, 32% found a clinical procedure acceptable, and 7% found medication acceptable. The majority of women (71%) found a minor surgery, like a transobturator tape, or a clinical procedure, like collagen injection, most desirable. These results were then analyzed for correlation to age, degree of distress (measured by UDI-6), and QOL (measured by AUA QOL score).

CONCLUSIONS

Overall women have realistic expectations of treatment for SUI. They are willing to accept varied results depending on their distress regarding incontinence. Choices regarding treatments are influenced by age, severity and quality of life. It may be beneficial to include the UDI-6, age and QOL score as a part of the work up and planning for treatment of SUI to better meet patient's expectations.

Duloxetine treatment of stress urinary incontinence in women: effects of demographics, obesity, chronic lung disease, hypoestrogenism, diabetes mellitus, and depression on efficacy

OBJECTIVE

To identify poor responders, we evaluated the impact of demographic characteristics and comorbidities on efficacy using an integrated database including data from four large randomized controlled trials. Duloxetine has been shown to be effective in women with stress urinary incontinence (SUI).

STUDY DESIGN

A total of 1913 women 22-83 years of age with predominant SUI (diagnosed using a validated clinical algorithm) were randomly assigned to receive placebo (n = 955) or duloxetine (n = 958) for 12 weeks. Efficacy outcome variables included a weekly incontinence episodes frequency (IEF) from patient-completed diaries, the Incontinence Quality-of-Life (I-QOL) questionnaire score, and a Patient Global Impression of Improvement rating. Subgroups selected a priori included: ethnicity, age, body mass index (BMI), chronic lung disease, hypoestrogenism, diabetes mellitus, and depression. For safety comparisons, adverse events were compared across age and ethnicity subgroups.

RESULTS

Reduction in IEF was minimal and not significantly different between duloxetine and placebo in women with chronic lung disease. The decrease in IEF for women > or =65 years of age was slightly diminished for duloxetine and placebo groups, but the treatment differences were maintained. There was a significantly different I-QOL improvement by BMI subgroup, with greater increases in scores associated with a higher BMI (>28 kg/m2). There were no other notable subgroup impacts on efficacy.

CONCLUSIONS

With the possible exception of chronic lung disease, no characteristic was identified that predicted a lack of treatment response with duloxetine in the treatment of women with SUI. Elderly patients may experience lower response rates to duloxetine presumably due to age related changes in the lower urinary tract.

Role of noradrenergic pathways in sneeze-induced urethral continence reflex in rats

To clarify the role of noradrenergic pathways in preventing stress urinary incontinence (SUI) during sneezing, we investigated the effect of the norepinephrine reuptake inhibitor nisoxetine and α-adrenoceptor antagonists phentolamine (nonspecific blocker) and prazosin (α1-receptor-selective blocker) on the neurally evoked urethral continence reflex induced by sneezing in rats. The amplitude of urethral pressure responses during sneezing (A-URS), urethral baseline pressure (UBP) at the midurethra, and sneeze-induced leak point pressure (S-LPP) were measured in normal female adult rats and rats with SUI induced by vaginal distention (VD). In normal rats, intrathecal (it) phentolamine (0.02 nmol) and prazosin (0.02 nmol) decreased A-URS by 11.9 and 15.7%, respectively, without affecting UBP. In both normal and VD rats, intravenous (iv) application of nisoxetine (1 mg/kg) increased A-URS by 17.2 and 18.3% and UBP by 23.7 and 32.7%, respectively. Phentolamine or prazosin (both it) eliminated nisoxetine-induced increases in A-URS, but not the increases in UBP, which were, however, suppressed by iv phentolamine (5 mg/kg) or prazosin (1 mg/kg). Sneezing induced fluid leakage from the urethral orifice in VD rats, but not in normal rats. In VD rats, S-LPP was increased by 30.2% by iv nisoxetine. Application of phentolamine and prazosin (both it) decreased S-LPP by 15.7 and 20.6%, respectively, and nisoxetine induced increases in S-LPP to 13.2 and 12.3%, respectively. These results indicate that activation of the noradrenergic system by a norepinephrine reuptake inhibitor can prevent SUI via α1-adrenoceptors by enhancing the sneeze-induced active urethral closure mechanism at the spinal level and augmenting UBP at the periphery.

Psychological morbidity and female urinary incontinence

Female urinary incontinence is a common yet distressing condition. It affects women of all ages, but is especially common in the elderly. Its prevalence ranges from 15 to 55%, depending on age and population studied. Despite the ubiquity of female urinary incontinence, many incontinent women do not voice their suffering, and urinary incontinence has therefore been dubbed 'the silent epidemic'. The physical impact and social isolation associated with urinary incontinence lead to impairment of quality of life and psychological well-being. It is the aim of this review to discuss the epidemiology and psychological impact of urinary incontinence. The recognition and management of incontinence-related psychological morbidity are also explored.

Incontinence surgery in the older woman

PURPOSE OF REVIEW

To review recently published studies on stress urinary incontinence surgery outcomes in older women.

RECENT FINDINGS

Five prospective and two retrospective studies were identified that reported tension-free vaginal tape (n = 6), colposuspension (n = 1) and cadaveric fascia transvaginal sling (n = 1) procedure results. In each study, 21-175 older women were included, with mean ages ranging from 71 to 83 years; most studies included younger comparison groups. Mean follow-ups ranged from 3 to 30 months. Subjective stress urinary incontinence 'cure/improvement' rates after surgery were significantly lower in older women when compared with younger women in only one study, although similar trends were seen in two additional studies. Intraoperative complications occurred at similar rates in older and younger women. Postoperative complications (urinary tract infection, urgency, voiding dysfunction, and mesh erosion) were more common in older women in only a few studies.

SUMMARY

Recent studies demonstrate that surgery for stress urinary incontinence in older women improves symptoms, although in some reports, not to the extent seen in younger women. It is unclear if some postoperative complications are more common in older women undergoing incontinence surgery. Results from randomized trials focusing on stress urinary incontinence surgery in older women are needed.

Stress Urinary Incontinence in Women: Review and Update on Neurological Control

BACKGROUND

Female stress urinary incontinence (SUI) is a common disease that involves leakage of urine during coughing, sneezing, or other increases in intraabdominal pressure. Treatments for SUI include pelvic floor muscle training, electrical stimulation, surgery, and off-label alpha-adrenergic agonists that stimulate contraction of the urethral smooth muscle. None of these treatments is universally or completely effective, and because drug therapy with the alpha- adrenergic agonists phenylpropanolamine and ephedrine can cause serious pressor adverse effects, the former has been banned in the United States, and the latter is under scrutiny. The central nervous system (CNS) affects reflexes that control urine storage and micturition, and norepinephrine and serotonin play a key role in maintaining storage capability by means of contraction of the external striated muscle of the urethral sphincter. Duloxetine hydrochloride, which inhibits reuptake of both of these neurotransmitters, has been shown to promote striated urethral sphincter contraction in animal models and to reduce the incidence of involuntary urine release in women with SUI without interfering with micturition.

CONCLUSION

Neuromodulation of noradrenergic and serotonergic neurotransmitters with such drugs as duloxetine provides an additional treatment option for women with SUI.