Søren Brostrøm

Pelvic floor muscle training in the prevention and treatment of urinary incontinence in women – what is the evidence?

Many women suffer from urinary incontinence (UI). During and after pregnancy, women are advised to perform pelvic floor muscle training (PFMT) to prevent the development of UI. In established UI, PFMT is prescribed routinely as first‐line treatment. Published studies are small, underpowered and of uneven methodological quality. Variations in study populations, intervention types and outcome measures make comparisons difficult. While further studies are needed, the available evidence suggests a lack of long‐term efficacy of peripartum PFMT. In established UI, there seems to be a modest immediate response to PFMT. Based on the available evidence, we believe that a critical reappraisal of PFMT is needed, and judgments on the place of PFMT in current clinical practice should be reserved until further evidence, including cost‐benefit analyses, has unequivocally demonstrated a clinically relevant efficacy.

Morbidity of urodynamic investigation in healthy women.

Abstract: The morbidity of diagnostic catheterization in healthy women has never been described. In order to further elucidate the natural history of postcystometry bacteriuria we studied a group of healthy women without lower urinary tract symptoms. Thirty female volunteers aged 39–72 years underwent urine sampling prior to and at day 3 after invasive urodynamic evaluation. One case of asymptomatic bacteriuria was detected among pretest samples. On post-test sampling 10 of 29 cultures were positive. With a cut-off level of >105 CFU/ml only 2 cases could be classified as significant bacteriuria. Only 1 was symptomatic. The remaining 29 women had no symptoms following the examination. Thus the incidence of lower urinary tract infection was 3.3% following repeated diagnostic catheterization. We concluded that although bacteriuria is common after diagnostic catheterization, it is essentially asymptomatic.

Low-Pressure Urethra in Women: What does it mean and what can it be used for?

The term low-pressure urethra (LPU) has gained widespread popularity as an indicator of intrinsic sphincter deficiency (ISD) and a predictor of poor outcome of conventional bladder neck suspension operations in women with stress incontinence. However, LPU is not a well-defined term and the utility of this parameter remains unclear. Urethral pressure depends on age of the patient, the technique and circumstances of measurement, such as type and caliber of catheter, position of the patient and bladder volume etc. [1]. A variety of pressure parameters can be measured [2]; those in common use have been defined by the Standardization Committee of the ICS [3]. Maximum urethral pressure (MUP), like maximum urethral closure pressure (MUCP), declines as a function of age and values below 20 cmH2O may occur in continent women [4,5]. Both MUP and MUCP are reduced in stress incontinent women. However, because the overlap between the values of continence and incontinence is so great, it has been impossible to define a cutoff level that allows us to distinguish between women with and those without stress incontinence [4,6]. In patients with stress incontinence there is a consistent decline in MUP/MUCP from mild to severe grades of incontinence [6,7]. In 1976 McGuire et al. [8] reported that low urethral pressure was a common factor associated with surgical failure. LPU was defined as a MUP less than 20 cmH2O measured with a perfusion catheter. Values obtained in the standing position and at 100 ml bladder volumes were used for comparative purposes. In 1987 Sand et al. [9] reported that LPU was a factor in failed retropubic urethropexy. In this study LPU was defined as a MUCP of 20 cmH2O or lower. Urethral pressure was measured in the sitting position at maximal cystometric capacity. The authors did not provide detailed information on the urethral profilometry technique used. Thus different pressure parameters, techniques and circumstances of measurement have been used to determinate LPU. Although a cutoff level of 20 cmH2O has been used in most studies, LPU is not a well-defined term. The term ‘intrinsic urethral sphincteric deficiency’ (ISD) has been defined by the Agency for Health Care Policy and Research (AHCPR) as a cause of genuine stress incontinence: ‘. . . which may be due to congenital sphincter weakness such as myelomeningocele or epispadias or may be acquired after prostatectomy, trauma, radiation, or sacral cord lesion. In this condition, the urethral sphincter is unable to coapt and generates enough resistance to retain urine in the bladder, especially during stress maneuvers. In women, ISD is commonly associated with multiple anti-incontinence procedures. Patients with ISD often leak continuously or with minimal exertion [10].’ This is a broad clinical definition which includes various pathophysiological conditions, such as the malfunctioning fibrotic rigid urethra. MUCP < 20 cmH2O has been used arbitrarily as an indicator of ISD [11], although other cutoff levels, such as 30 cmH2O, have also been used [12]. MUP and MUCP may provide gross measures of sphincteric strength [6,7] but they do not yield any pathophysiological information [13]. A stiff fibrotic urethra (rigid tube) is only slightly distensible, which means that the pressure/crossOwnership and Copyright Springer-Verlag Limited Int Urogynecol J (2002) 13:215–217 International Urogynecology Journal

Validation of the Pelvic Floor Distress Inventory-20 and the Pelvic Floor Impact Questionnaire-7 in Danish women with pelvic organ prolapse

To translate the Pelvic Floor Distress Inventory‐20 (PFDI‐20) and the Pelvic Floor Impact Questionnaire‐7 (PFIQ‐7) and to evaluate their psychometric properties in Danish women with symptomatic pelvic organ prolapse.

Motor evoked potentials from the striated urethral sphincter and puborectal muscle: reproducibility of latencies

OBJECTIVE Transcranial magnetic stimulation can be used to test the motor efferents to the pelvic floor muscles. The aim of the present study was to assess the long-term test-retest reproducibility of pelvic floor MEPs. METHODS Eighteen healthy women without evidence of neurological or lower urinary diseases had serial measurements of pelvic floor MEPs with a mean test-retest interval of 39 weeks. Cortical and spinal transcutaneous magnetic stimulations were applied. Evoked potentials were recorded with concentric needle electrodes placed in the striated urethral sphincter and the puborectal muscle by a transvaginal route. Responses from the abductor hallucis were also recorded for comparison. Stimulations were performed with relaxed pelvic floor and with tonic contraction (facilitated responses). Students t test was applied and mean latencies were plotted against differences to analyze test-retest variability. RESULTS There were no systematic effects of time or other variables that might differ between trials for all subjects. However, the means vs. differences plots revealed a large scatter of intra-individual test-retest values. The poor reproducibility was common for all tested pelvic floor muscles and modalities. CONCLUSIONS The clinical use of pelvic floor MEPs is questionable.

The 12‐month effects of structured lifestyle advice and pelvic floor muscle training for pelvic organ prolapse

We evaluated the 12‐month effects of adding pelvic floor muscle training to a lifestyle advice program in women with symptomatic pelvic organ prolapse stage II–III and the number of women who had sought further treatment.

Use of antibiotics for urinary tract infection in women undergoing surgery for urinary incontinence: a cohort study

Objective To describe the use of antibiotics for urinary tract infection (UTI) before and after surgery for urinary incontinence (UI); and for those with use of antibiotics before surgery, to estimate the risk of treatment for a postoperative UTI, relative to those without use of antibiotics before surgery. Design A historical population-based cohort study. Setting Denmark. Participants Women (age ≥18 years) with a primary surgical procedure for UI from the county of Funen and the Region of Southern Denmark from 1996 throughout 2010. Data on redeemed prescriptions of antibiotics ±365 days from the date of surgery were extracted from a prescription database. Main outcome measures Use of antibiotics for UTI in relation to UI surgery, and the risk of being a postoperative user of antibiotics for UTI among preoperative users. Results A total of 2151 women had a primary surgical procedure for UI; of these 496 (23.1%) were preoperative users of antibiotics for UTI. Among preoperative users, 129 (26%) and 215 (43.3%) also redeemed prescriptions of antibiotics for UTI within 0–60 and 61–365 days after surgery, respectively. Among preoperative non-users, 182 (11.0%) and 235 (14.2%) redeemed prescriptions within 0–60 and 61–365 days after surgery, respectively. Presurgery exposure to antibiotics for UTI was a strong risk factor for postoperative treatment for UTI, both within 0–60 days (adjusted OR, aOR=2.6 (95% CI 2.0 to 3.5)) and within 61–365 days (aOR=4.5 (95% CI 3.5 to 5.7)). Conclusions 1 in 4 women undergoing surgery for UI was treated for UTI before surgery, and half of them had a continuing tendency to UTIs after surgery. Use of antibiotics for UTI before surgery was a strong risk factor for antibiotic use after surgery. In women not using antibiotics for UTI before surgery only a minor proportion initiated use after surgery.

Use of symptom-relieving drugs before and after surgery for urinary incontinence in women: a cohort study

Objective To describe the use of symptom-relieving drugs (antimuscarinic drugs or duloxetine) before and after surgery for urinary incontinence (UI); and for those with use of antimuscarinic drugs or duloxetine before surgery, to estimate the risk of being a postoperative user, relative to those without use before surgery. Design A historical population-based cohort study. Setting Denmark. Participants Women ≥18 years with a first-time surgical procedure for UI from the county of Funen, Denmark between 1 January 1996 and 31 December 2006, extended to the Region of Southern Denmark from 1 January 2007 to the end of 2010. For these women, data on redeemed prescriptions ±365 days of date of surgery were extracted. Main outcome measures Effect of preoperative use of antimuscarinic drugs or duloxetine on the risk of being a postoperative user of these drugs. Results Of 2151 women with a first-time surgical procedure for UI, 358 (16.6%) were preoperative users of antimuscarinic drugs or duloxetine and 1793 were not (83.4%). A total of 110 (30.7%) of the preoperative users also redeemed prescriptions for these drugs within 0–60 days after surgery, and 152 (42.5%) of the preoperative users redeemed prescriptions for these drugs within 61–365 days after surgery. Among preoperative non-users, 25 (1.4%) and 145 (8.1%) redeemed prescriptions within 0–60 and 61–365 days after surgery, respectively. Presurgery exposure to antimuscarinic drugs or duloxetine was a strong risk factor of postoperative drug use, both within 0–60 days (adjusted OR=33.0, 95% CI 20.0 to 54.7) and 61–365 days (OR=7.2, 95% CI 5.4 to 9.6). Conclusions A substantial number of women will continue to be prescribed symptom-relieving drugs after surgery for UI within a year of follow-up. Only a minority of preoperative non-users initiated usage of symptom-relieving drugs after surgery. Compared with other factors included in the regression model, preoperative use of antimuscarinic drugs or duloxetine was the strongest risk factor for postoperative use.

The evidence on pelvic floor muscle training (PFMT) in women with urinary incontinence

1. Wilson D, Hay-Smith J, Berghmans B. Adult conservative management. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence, vol. 1, pp. 255 312. 3rd international consultation on incontinence, 28 30 June, 2004, Monaco. Paris, France: Health Publications Ltd, 2005. pp. 855 964 (chap 15). 2. Welsh A. Urinary incontinence the management of urinary incontinence in women. National Collaborating Centre for Women’s and Children’s Health. The National Institute for Health and Clinical Excellence. London: RCOG Press, Royal College of Obstetricians and Gynaecologists, 2006. 3. Hay-Smith EJC, Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. The Cochrane Collaboration. The Cochrane Library; 2006, Issue 1, Art. No.: CD005654. DOI: 10.1002/14651858.CD005654. 4. Hay-Smith J, Mørkved S, Fairbrother KA, Herbison GP. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. The Cochrane Library, 2008, Issue 4, Art. No.: CD007471. DOI: 10.1002/14651858.CD007471. 5. Brostrøm S, Lose G. Pelvic floor muscle training in the prevention and treatment of urinary incontinence in women what is the evidence? Acta Obstet Gynecol. 2008;/87:/384 402. 6. Meyer S, Hohlfeld P, Achtari C, DeGrandi P. Pelvic floor education after vaginal delivery. Obstet Gynecol. 2001;97: 673 7. 7. Stothers L. A randomized controlled trial to evaluate intrapartum pelvic floor exercise as a method of preventing urinary incontinence [Abstract]. J Urol. 2002;167:106 7. 8. Gorbea Chavez V, Velazquez S, Kunhardt Rasch JR. Effect of pelvic floor exercise during pregnancy and puerperium on prevention of urinary stress incontinence. Ginecolog Obstet Mex. 2004;/72:/628 36. 9. Mørkved S, Bø K. Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one year follow-up. BJOG. 2000;/107:/1022 8. 10. Bø K, Hagen RH, Kvarstein B, Jørgensen J, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. Effects of two different degrees of pelvic floor muscle exercises. Neurourol Urodyn. 1990;/9:/489 502. 11. Wong K, Fung B, Fung LCW, Ma S. Pelvic floor exercises in the treatment of stress urinary incontinence in Hong Kong Chinese women. ICS 27th annual meeting, pp. 62 63. 1997, Yokohama, Japan. 12. Ward K, Hilton P. Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow-up. BJOG. 2008;/115:/226 33. 13. Herbert RD, Bø K. Analysing effects of quality of interventions in systematic reviews. BMJ. 2005;/331:/507 9. 14. Woldringh C, van den Wijngaart M, Albers-Heitner P, Nijeholt AA, Lagro-Jansse T. Pelvic floor muscle training is not effective in women with UI in pregnancy: a randomised clinical trial. Int Urogynecol J Pelvic Floor Dysfunct. 2007;/ 18:/383 90.

Which nonsurgical options are effective for the treatment of female urinary incontinence

In this study sponsored by the US federal government, Shamliyan et al. extracted data from 96 randomized controlled trials and 3 meta-analyses, and reviewed the evidence of nonsurgical treatment for female urinary incontinence (UI). Pelvic-floor muscle training alone, or in combination with bladder training, was found to be effective in improving UI compared with standard care. Generalizing the clinical relevance of these studies, however, was difficult because of heterogeneity between the trials. Anticholinergic agents were also moderately effective, but adverse effects were frequent. Additionally, slight improvements on subjective variables were noted with duloxetine, but adverse effects were numerous, and some were serious. The aim of conservative treatment for UI is often to improve quality of life rather than cure the disorder; if women are properly counseled, conservative therapies have a valuable place in the management of UI.