Defeating Urinary Incontinence with Exercise Training: Results of a Pilot Study in Frail Older Women

A review of the role for pelvic floor physiotherapy in postmenopausal women with urinary incontinence

Urinary incontinence is a prevalent condition affecting women. Pelvic floor physiotherapy is a specialized field of physiotherapy dedicated to assessing and treating pelvic floor muscles. This therapy has demonstrated benefits in addressing stress urinary incontinence in premenopausal women, with numerous studies supporting its efficacy in this population. However, pelvic floor physiotherapy in the treatment of postmenopausal women is less well-established, and furthermore, the types of urinary incontinence in postmenopausal women are much broader. We provide a comprehensive review of recent literature investigating the effectiveness of pelvic floor physiotherapy therapy for various conditions in postmenopausal women, including urinary incontinence, urgency urinary incontinence, pelvic organ prolapse, genitourinary syndrome of menopause, sexual dysfunction, and urinary incontinence in the context of obesity, frailty, mobility, and dementia. After evaluating the current literature, it is evident that there is insufficient data to definitively endorse or dismiss the utilization of Pelvic floor physiotherapy for treating urinary incontinence in postmenopausal women. Nevertheless, considering the low associated risks of pelvic floor physiotherapy, we advocate for the initiation of comprehensive, large-scale randomized studies aimed at evaluating its effectiveness in addressing urinary incontinence in postmenopausal women with special attention to vulnerable subgroups, including individuals who are obese, frail or experiencing cognitive impairment.

Effectiveness of non-pharmacological interventions delivered at home for urinary and faecal incontinence with homebound older people: systematic review of randomised controlled trials

INTRODUCTION

Incontinence is a common, distressing condition, most prevalent in older people. There is an unmet need for effective interventions to support continence. This review focuses on non-pharmacological interventions to reduce incontinence among homebound older people. Aim: to identify interventions with potential to be delivered by care workers, nurses or family members in a person's home.

METHODS

Multiple databases were searched until 15 September 2023 for randomised controlled trials reporting home-based interventions for incontinence for older people (≥65 years) living at home. Two reviewers independently screened titles, abstracts and papers against inclusion criteria, then assessed for the Risk of Bias (RoB2). A third reviewer resolved the discrepancies. Primary data were extracted and synthesised.

RESULTS

A full-text review of 81 papers identified seven eligible papers (1996-2022, all USA), including n = 636 participants (561 women and 75 men). Two studies focusing on multicomponent behavioural interventions showed benefit, as did one study of transcutaneous tibial nerve stimulation self-administered through electrode-embedded socks. Three, which included cognitively impaired people, reported improvement with toileting assistance programmes, but the effects were not all significant. Results were inconclusive from a study examining the effects of fluid intake adjustments. Interventions were delivered by nurses, three in collaboration with family caregivers. No faecal incontinence interventions met the criteria.

CONCLUSION

There is scant evidence for continence supporting interventions delivered in older people's own homes. With an ageing population often reliant on family or social care workers well-placed to support continence promotion and policy drives for services to support older people remaining at home, this evidence gap needs addressing.

Reducing Falls in Older Women with Urinary Incontinence

Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

Similarities and Differences of Interventions to Promote Physical and Psychological Health Between Prefrail and Frail Older Women: A Systematic Review

The current review aimed to explore similarities and differences in the properties of interventions that promote physical and psychological health between prefrail and frail older women. Ten databases were searched for studies published from database inception to May 2023. Two Cochrane tools were used to assess the risk of bias in experimental and quasi-experimental studies. Twenty-three studies were selected, including 11 studies on prefrailty and 12 studies on frailty. Exercise interventions were predominant, but the contents and standards of exercise intensity were inconsistent between prefrail and frail women. For the main outcomes of the interventions, balance ability and biochemical factors were measured more frequently for frail older women than prefrail older women. Psychological health was less measured for prefrail and frail older women compared to physical health. Future research needs to consider balance training, as well as the evaluation of biochemical factors and psychological health among prefrail or frail older women. [Journal of Gerontological Nursing, 49(10), 20-28.].

Effect of Pelvic Floor Workout on Pelvic Floor Muscle Function Recovery of Postpartum Women: Protocol for a Randomized Controlled Trial

BACKGROUND

There is a risk of pelvic floor dysfunction (PFD) from baby delivery. Many clinical guidelines recommend pelvic floor muscle training (PFMT) as the conservative treatment for PFD because pelvic floor muscles (PFMs) play a crucial role in development of PFD. However, there is disagreement about the method and intensity of PFM training and the relevant measurements. To pilot the study in PFM training, we designed a Pelvic Floor Workout (PEFLOW) for women to train their pelvic through entire body exercises, and we planned a trial to evaluate its effectiveness through comparing the outcomes from a group of postpartum women who perform PELFLOW at home under professional guidance online with the control group.

METHODS/DESIGN

The randomized controlled trial was projected to be conducted from November 2021 to March 2023. A total of 260 postpartum women would be recruited from the obstetrics departments of the study hospital and women would be eligible for participation randomized into experimental or control groups (EG/CG) if their PFM strength are scaled by less than Modified Oxford grading Scale (MOS) to be less than grade 3. Women in EG would perform a 12-week PEFLOW online under the supervision and guidance of a physiotherapist, while women in CG would have no interventions. Assessments would be conducted at enrollment, post intervention (for EG) or 18th to 24th week postpartum (for CG), and 1 year postpartum. Assessment would be performed in terms of pelvic floor symptoms, including MOS, cough stress test, urinary leakage symptoms, pelvic organ prolapse quantitation (POP-Q), and vaginal relaxation, clinic examinations including Pelvic floor electrophysiological test, Pelvic floor ultrasound and Spine X-ray, overall body test including trunk endurance test, handgrip test, body composition test, and questionnaires including International Physical Activity Questionnaire Score-Short Form(IPAQ-SF), Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the 6-item Female Sexual Function Index (FSFI-6), and the Pittsburgh Sleep Quality Index (PSQI). Primary analysis will be performed to test our main hypothesis that PEFLOW is effective with respect to strengthen PFM strength.

DISCUSSION

This trial will demonstrate that pelvic floor-care is accessible to most women and clinical practice on PFD may change relevantly should this study find that Online PEFLOW approach is effective to improve PFMs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05218239.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Exercise as Medicine for Older Women

Exercise is associated with protective effects, yet most adult women in this country do not meet the physical activity recommendations set forth in the Physical Activity Guidelines for Americans. This article discusses how exercise affects disease and prevents functional decline. It also clarifies why exercise is not a generic cure-all but is instead a tool physicians can use with precision to affect a myriad of health issues. Specifics will be provided regarding physical fitness assessments and comprehensive treatments and how physicians can be more involved in using physical fitness to keep their older female patients healthy.

Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition)

The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.

The effect of exercise on quality of life and activities of daily life in frail older adults: A systematic review of randomised control trials

While the positive effects of exercise on frailty are well documented, the effect of exercise on quality of life (QoL) and activities of daily living (ADL) in frail older adults remains less certain. Therefore, this paper aimed to systematically review the literature investigating the effect of exercise on QoL and ADL in this group. Embase, MEDLINE, CENTRAL, PEDro and Web of Science Core Collections were searched systematically using relevant MeSH terms. The inclusion criteria were: controlled trial design, published in English, population included frail older adults, frailty measured quantitatively, interventions that included exercise, and QoL or ADL measurements (PROSPERO: CRD42018106173). After screening, 15 studies were eligible for inclusion in the qualitative synthesis (total n: 2467; mean age range: 70-85 years). There was a positive effect on QoL or ADL measures in 10 out of the 15 studies. QoL and ADLs only improved in studies that also reported improved physical outcomes. These results reflect the multi-factoral nature of frailty and how physical capability and QoL are interlinked. Heterogeneity precluded formal meta-analysis. Future trials in frail older adults should focus on interventions that include exercise, measure physical outcomes and use consistent study design to enable meta-analysis to be conducted.

Predictive Factors of Mortality in Older Adult Residents of Long-Term Care Facilities

BACKGROUND

Various factors affect the mortality of older adult residents of long-term care facilities. To provide adequate nursing care for older adults, it is necessary to understand the factors that affect their risk of mortality.

PURPOSE

This study was designed to (a) evaluate the 24-month survival rate and (b) identify the underlying cause of death in various dimensions, including cognitive, psychological, and physical function; nutritional status; and chronic disease.

METHODS

A longitudinal study was carried out between 2011 and 2013 at seven long-term care facilities. The participants comprised 276 residents who were all older than 65 years old. Baseline measurements included cognitive function (Mini-Mental State Examination for Dementia Screening), psychological function (Cornell Scale for Depression in Dementia), physical function (Barthel Index), nutritional status (Mini Nutritional Assessment, mid-arm circumference, and calf circumference), and chronic disease status (hypertension, diabetes mellitus, chronic respiratory disease, heart disease, and urinary incontinence). Data analysis included univariate and multivariate logistic regression to identify the main factors affecting mortality.

RESULTS

In 2011 (baseline), the mean age of the participants was 80.46 years (SD = 7.08) and most were female (73.6%). At the 24-month follow-up, 94 (34.1%) of the participants had died. The major factors affecting mortality were as follows: cognitive dysfunction (OR = 3.12, 95% CI [1.41, 6.90]), mid-arm circumference (< 22.5 cm; OR = 2.32, 95% CI [1.35, 3.96]), and urinary incontinence (OR = 2.04, 95% CI [1.16, 3.61]).

CONCLUSIONS

According to the findings, special attention is needed at the end of life to improve the quality of life of older adults with cognitive dysfunction, malnutrition (low mid-arm circumference), and urinary incontinence who reside in long-term care facilities.

Continence: Bowel and Bladder and Physical Function Decline in Women

Purpose of review

The purpose of this article is to review the various forms of incontinence, highlight their impact on older women, and to explore current literature regarding the link between physical activity, physical function, and incontinence.

Recent findings

Both urinary and fecal incontinence become more prevalent with age, and are associated with significant morbidity. In parallel, there is a well-established decline in physical function that occurs with age. Furthermore, incontinence has a bidirectional relationship with physical function decline. Given the known link between increasing physical activity and preserved physical function, there is an emerging body of literature seeking to determine whether increases in physical activity may also improve incontinence outcomes. We review some recent data on this topic.

Summary

Continence and physical function are two closely linked entities. Further research is needed to determine whether interventions that increase physical activity might result in improved continence outcomes.

Prevalence and Risk Factors of Urinary Incontinence in Frail Elderly Females

Background/Purpose. Urinary incontinence (UI) is an important geriatric health problem, and it is linked to frailty syndrome. We had conducted a study to detect the prevalence and risk factors of UI and its effect on quality of life (QOL) among frail elderly females living in Cairo, Egypt. Methods. We carried out a cross-sectional study on 130 frail elderly females sixty years and older, attending Ain Shams Geriatrics Hospital, Cairo, Egypt. Each patient gave oral consent and then was subjected to history taking, full clinical examination, diagnosis of frailty (clinical frailty scale), assessment of UI by the Arabic version of International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF), assessment of QOL by using the Arabic version of Incontinence Impact Questionnaire Short Form (IIQ-7 SF), and complete urine analysis. Results. The prevalence of UI among the studied population was 80%. Mixed UI was the most prevalent type. UI was significantly associated with older age, functional impairment, multiparity, osteoarthritis, stroke, vaginal prolapse, and laxative use. All IIQ-7 subscales were higher (worse health-related QOL) for women with mixed UI. Conclusion. Urinary incontinence is prevalent in frail elderly females. Mixed UI, compared with other types, has a significant negative impact on all domains of quality of life.

Managing Urinary Incontinence

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers. This article is the second of two that provide an update on urinary incontinence and its management in older adults. It includes an informational tear sheet-Information for Family Caregivers-that contains links to the instructional videos. To use this series, nurses should read the articles first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

Urinary Incontinence in Older Adults

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aim to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers. This article is the first of two that provide an update on urinary incontinence and its management in older adults. The second article will contain an informational tear sheet-Information for Family Caregivers-that contains links to the instructional videos. To use this series, nurses should read the articles first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. In this article, the videos can be found in Resources for Nurses.

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.

Management of Overactive Bladder in Older Women

PURPOSE OF REVIEW

This review will highlight our current understanding of age-related changes in bladder function and propose important clinical considerations in the management of overactive bladder (OAB) specific to older women.

RECENT FINDINGS

Frailty, functional and cognitive impairment, multimorbidity, polypharmacy, estrogen deficiency, and remaining life expectancy are important clinical factors to consider and may impact OAB symptom management in older women. Third-line therapies, particularly PTNS, may be preferable over second-line therapy in some cases. Due to the complexity within this population, the standard treatment algorithms may not be applicable, thus a broader, more holistic focus is recommended when managing OAB in older women.