Nonsurgical Therapies for Women with Pelvic Floor Disorders

Raymond T. Foster, Sr., M.D., M.S., M.H.Sc.Assistant Professor of Obstetrics and Gynecology

Director, Missouri Center for Female Continence and Advanced Pelvic Surgery

University of Missouri School of Medicine

Columbia, Missouri

Topics for Discussion

Why not surgery?Obstructed defecationPelvic organ prolapseOveractive bladderUrge incontinenceUrgency/frequencyNocturia

Stress incontinenceLevator spasmCase Presentations

Why not surgery?

Shull, BL et al., A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments, Am J Obstet Gynecol, 183: 1365-73, 2000

Bleeding• Shull et al reported their

experience with 302 patients undergoing transvaginal surgery, including USVS

• Mean EBL: 243mL

• 1% rate of blood transfusion

Why not surgery?

Bleeding

• SSLF is generally associated with a higher rate of bleeding complications (compared with other vaginal procedures for apical support)

• In one study of elderly women (≥80), hemorrhage was noted in 28% of 25 subjects

• The largest problem with bleeding during SSLF is the associated risk to the rectum and pudendal nerve during attempts to control bleeding

• Optimal strategy for bleeding control includes packing and vascular clips from the vaginal approach, with or without interventional radiology techniques

Nieminen, E., and Heinonen, P.K., Sacrospinous ligament fixation for massive genital prolapse in women aged over 80 years, BJOG, 108: 817-821, 2001Barksdale, P.A., et al., An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault, Obstet Gynecol, 91: 715-718, 1998

Why not surgery?

Bleeding• Obesity has been studied as a risk factor for

hemorrhage

• Isik-Akbay et al., compared surgical complications in 189 obese patients undergoing TAH versus 180 obese women having a TVH

• Both groups had a 13% transfusion rate

• The authors concluded that obesity is a risk factor for hemorrhage during pelvic surgery, regardless of approach

Isik-Akbay, E.F., et al., Hysterectomy in obese women: a comparison of abdominal and vaginal routes, Obstet Gynecol, 104: 710-714, 2004

Why not surgery?

Bleeding• Most MIS case series report a 1-3%

rate of excessive bleeding

• Abouassaley et al. reported their experience with 241 midurethral sling procedures

• 2.5% intraoperative hemorrhage (16 patients)

• 1.9% developed a clinically significant pelvic hematoma

Abouassaly, R., et al., Complications of tension-free vaginal tape surgery: a multi-institutional review, BJU Int, 94: 110-113, 2004

TVT video

Why not surgery?

Injury to the Lower Urinary Tract

• 224 consecutive patients undergoing transvaginal, pelvic reconstructive/urogynecologic surgery

• 4% rate of otherwise unrecognized injury to the lower urinary tract

• Among 144 patients undergoing vaginal hysterectomy, 11 (7.6%) had injury to the lower urinary tract detected by cystoscopy

• Concurrent prolapse surgery was an independent risk factor for urinary tract injury

bladder video

Why not surgery?

• Graft material problems• Infection• DVT• Nerve injury

Obstructed Defecation

Mechanical Functional

RectocelePerineal RectoceleEnteroceleRectal prolapse

Neurologic disorderPelvic floor dysenergiaLevator spasm

Obstructed Defecation

Prolapse Animation

Pelvic Floor Rehabilitative Therapy

One recently published meta-analysis showed that pelvic floor rehabilitative therapy was superior to various other treatments (laxatives, placebo, sham training, and botox) (OR: 3.657; 95% CI:2.127–6.290, P < 0.001)

Enck P, Van Der Voort IR, and Klosterhalfen S; Biofeedback therapy in fecal incontinence and Constipation, Neurogastroenterol Motil (2009) 21, 1133–1141

22 patients with constipation related to pelvic floor dysenergia were enrolled in a prospective case series to undergo pelvic floor rehabilitative therapy. Symptom severity decreased after physical therapy (2.1±0.7 vs. 1.3±0.9, P=0.007). Quality of life also improved significantly (2.6±0.8 vs. 1.5±1.0, P=0.007).

Lewicky-Gaupp C, Morgan DM, Chey WD, Muellerleile P, and Fenner DE; Successful Physical Therapy for Constipation Related to Puborectalis Dyssynergia Improves Symptom Severity and Quality of Life, Dis Col Rect (2008) 51, 1686-1691

Pelvic Organ Prolapse

BLS Interviews

Bladder Control in Women

V

B

R

PVPu

Pu > Pv Continence

Pu ↓↓Intrinsic

Extrinsic Pv ↑↑

Pu ↓↓ and Pv↑↑

Stress

Urge

Mixed

Myogenic

Neurogenic

Idiopathic

Bladder Control in Women

↑Pu

Bladder Control in Women

↓Pv

Behavior Modification•Timed voiding•Squeeze before you sneeze•Quick flicks•Fluid moderation in the evening•Avoid bladder irritants

• Alcohol• Caffeine• Chocolate

Bladder Control Therapy

Levator Spasm

Ethel

• 90 y/o G4P3• OAB complaints

for 2 years• Worsened

symptoms with recent sacroplasty

Ethel

• Stress incontinence• OAB symptoms worse at night• Wears a depends diaper AND a large

poise pad (this ensemble changed 5/day)

Ethel

• 4 UTI’s in the past year• Drinks 3 glasses of water, 2 glasses of juice, 1 cup

of coffee and 1 soda on an average day• Uses Miralax daily and strains to have 1 or 2 BM’s

per day• 24 hour pad weight: 803g• Bladder diary: 16 voids/24 hrs• Nocturia X4

Ethel

• PMH: HTN, anemia, hernia, sinusitis, GERD, hypothyroidism, Raynaud’s syndrome, IBS-C

• PSH: sacroplasty, cholecystectomy, appendectomy, hysterectomy, and BSO

Ethel

Diagnoses• Rectocele (stage II)• Defecatory dysfunction• Urogenital atrophy• Urgency/frequency• Nocturia• Urge incontinence• Stress incontinence• UTI• Recurrent UTI’s

Ethel

Treatment Plan• Bowel regimen• Premarin cream• Treat UTI (fosfomycin)• Prophylactic Abx for recurrent UTI

(trimethoprim)• Pelvic floor rehabilitative therapy• Imipramine QHS

Ethel

Clinical Outcome• Patient reported 100% improvement after 5 sessions

of pelvic floor therapy. • She voids 7-8/day and 2/night.• Her daytime incontinence completely resolved and

she leaks only drops during the night.• She wears a panty liner for peace of mind.• She remains on Trimethoprim at bedtime.• She remains on Imipramine QHS• She takes Oxybutynin only occasionally when going

out

Ethel

Clinical Outcome cont.• She continues with Premarin vaginal cream 1 x week• She continues to do pelvic floor exercises 4 x day • She takes Metamucil daily and reports 1-2 bowel

movements per day without straining• She just returned from a vacation with her family in

which they drove over 500 miles in the car

Anne

• 70 y/o G2 P2002• c/o stress incontinence,

urgency/frequency, urge incontinence and nocturia

• Symptoms bothersome over last 6-8 months

Anne

• On an average day she drinks 5-6 glasses of water, 1 glass of juice, 1 glass of milk, 2 cups of coffee, 1 glass of tea and 1 soda

• Her bladder diary indicates she voids 7 x in 24 hours

• Her 24 hour output averages 3400cc

Anne

• Completely healthy with no PMH/PSH• 2 term vaginal deliveries with

maximum birth weight of 8 lbs., 15 oz.

Anne

Diagnoses• Stage II cystocele• Stage II rectocele• Nocturia• Urodynamic stress incontinence• Urge incontinence• Urogenital atrophy• Defecatory dysfunction

Anne

Treatment• Bowel regimen to treat defecatory

dysfunction• Premarin vaginal cream for urogenital

atrophy • Moderate fluids, especially in the

evening• Pelvic floor therapy for urge and stress

incontinence

Anne

Clinical Outcome• Patient reports 85% improvement in her

symptoms after 6 sessions of pelvic floor therapy• Her urge incontinence has resolved and she

continues with mild stress incontinence 2-3 x month

• She continues on Premarin vaginal cream 1 x week for urogenital atrophy

• She continues with pelvic floor exercises and urge suppression techniqes daily

• She continues to moderate her caffeine intake

Anne

Clinical Outcome cont.• Anne was pleased with her results

but her best friend’s bladder was limiting her (Anne’s) lifestyle.

• Her friend completed a course of pelvic floor therapy

• They have just returned from two weeks in Italy and reported complete bladder control and no anxiety about being on a tour bus all day

Questions