Academic Half-Day:
Family Medicine
Residency Program
Management of Stress
Incontinence: Pessary Use
Grace Neustaedter MN RN NCA
CNS Pelvic Floor Clinic, Calgary
July 2015
Faculty/Presenter Disclosure
• Faculty: Grace Neustaedter
• Relationships with commercial interests: None
Objectives
• To better understand the pathophysiology
of stress incontinence (SI) (vs urge
incontinence)
• To be aware of treatment options for SI
• To understand the use of pessaries for
management of SI
• To be aware of appropriate referrals to the
PFC
Stress Incontinence
• “ The complaint of involuntary leakage on
effort or exertion, or on sneezing or
coughing”
International Continence Society 2002
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Bladder muscle is relaxed, not contracting
Three sub-types
Tends to start at a younger age
May occur with OAB = mixed incontinence
Sub-types of SI
• Type 1: SI caused by urethral
hypermobility – loss of posterior urethrovesicular angle
• Type 2: SI caused by urethral
hypermobility with loss of posterior angle
and anterior support
• Type 3: SI caused by intrinsic sphincter
deficiency – a malfunction of musculature
within urethra (loss of innervation, trauma)
Features of Pure SI
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Void normal # times (6-8 X in 24 hours)
No night-time problems
Normal bladder capacity (350 – 650 mls)
Can hold for long time
Leaks only with increased abdominal
pressure on bladder
• Common in younger population, worsens
with age
Examination
• Visual exam of perineum
• Spread labia, have patient bear down and
cough and watch for leakage
• Vaginal exam – manually hold finger along
anterior wall, feel movement of UV
junction with bearing down/coughing
• Or – when standing or jumping (over
sheet/towel)
Differentiate SI from OAB
• Voiding diary useful to determine # of
voids (can pick up OAB if frequent voids)
• Frequency & severity of leakage
• # pads during day/night
• UD exams objectively verifies SI and OAB
• Cystoscopy – can visualize mobility of
bladder neck
Associated Factors for SI
Smoking
Constipation,
straining
Coughing
Associated Factors
Aging
Having babies
Gaining weight
Associated Factors
Lifting heavy things,
impact activities
Heredity
Some surgeries
Chronic Diseases
Medications
Treatment Options for SI
Stress Incontinence
Healthy
Bladder
Habits
Surgery
Pelvic Muscle
Exercises
Pessary
Healthy Bladder Habits
All conservative treatment options for SI
designed to increase urethral resistance or
decrease activities that actively aggravate
pressure on bladder or urethra
Chance of success - if surgery eventually
done - is enhanced if conservative
therapies are followed
Reduction of Bladder Irritants
• DO NOT have direct effect on urethral
resistance - indirectly improve ability to
control leakage by helping bladder relax
and nor further aggravate symptoms
• 6 – 8 cups non-irritating fluids (avoid
caffeine, acidic juices/fruits, alcohol,
cigarettes, spicy foods)
Bowel & Bladder Habits
• Constipation huge issue – bowels full of
hard stool & straining, pushing
FIBER 25 – 35 grams daily
Fluid intake 6-8 glasses water
• Regular emptying of bladder, q 3-4 hours
• Don’t push to pee, relax
• Double voiding, lean forward
Impact Activities, Weights
• Modifications may be necessary
• Lighter weights, more repetitions, closer to
body
• Cross-fit controversy
• Pelvic floor-SAFE exercises
• www.pelvicfloorfirst.org.au
Pelvic Floor Muscle Training
(PFMT)
• Goal – to become part of lifestyle, to
functional use
• Start with awareness and strengthening
• BOTH lift (tighten) and relax
• Recommend sets of 10 (fast or slow)
• 3+ sets daily
• Takes 2-3 months to notice improvement
• Pelvic floor physiotherapy very helpful
Pessary for Stress
Incontinence
Knob of
pessary
sits here
Pessaries for SI
For stress urinary incontinence
Selection of Pessary for SI
• Fit is important – slight room, not too tight
• Often – go up a size or two in first few
weeks
• Knob should remain in center (12 o’clock)
• If any prolapse also present, can help with
that
• Can use for years – no issues if cared for
Pessaries Used for
Incontinence
• Stress Incontinence – supports UV junction
• Urge Incontinence – stabilizes bladder,
especially with prolapse
• May be used only for certain physical
activity (part-time)
• May be used for incontinence and prolapse
• Varied results
Insertion/Removal
• Most can do on own, some require a
doctor/nurse to remove & insert
• Video clip
edit clip1.1.wmv
Pessaries for Prolapse
• 50% + women experience prolapse
• Can be mild – no symptoms, bothersome
or severe
• Treatment not necessary if mild – BUT –
prevent from worsening (weight, activity,
constipation, PFMT, etc)
• If treatment required – pessary or surgery
Types of Prolapse
• Prolapse clip
edit clip 1.wmv
Prolapse
Types of Prolapse Pessaries
Open Ring
Gellhorn
Covered Ring
Cube
Shaatz
Donut – rarely use
Surgeries for SI – Midurethral
Taping Procedures
Surgeries for SI
• Mid-Urethral taping procedures – TVT,
TVTO
• Will not be done if patients wants more
children
• Can be done in combination with prolapse
surgeries
• Does NOT work for urge incontinence
(may worsen urgency)
Bulking Agents for SI
• Expensive; may be covered by insurance
plans
• Can be effective, seems to decrease with
time
• Bulkamid being used
• May need > 1 treatment
Bulking Agents
Pelvic Floor Clinic
www.albertahealthservices.ca/calgarypelvicfloorclinic.asp
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Women’s Health Centre
Multidisciplinary team
Focus on patient education and engagement
Accept referrals for
i. bladder issues
ii. pelvic organ prolapse
iii. bowel evacuation
disorders
Current Clinic Team Members
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RNs (9)
NP
LPNs (3)
GP
Urogynecologists (5)
Physiotherapists
Roles
• RNs – teaching, assessment, conservative
treatments, pessary fittings & f/u
• GP and NP – OAB, medications
• LPNs – Physicians support (clinics, testing)
• UGs – primarily surgical
• Physiotherapy – internal referrals only for
MSK issues
• UDS, cystoscopy, SNS
Clinic Website
www.albertahealthservices.ca/calgarypelvicfloorclinic.asp
• Online workshops
• Handouts
• Links to other resources
Friday Morning at the Medical
School (FMMS)
• Prolapse & Pessaries
• Half day of didactic presentation and
hands-on at PFC
• Yearly – spring
• Through CME office
References
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Abrams et al (2002). The standardization of terminology of lower urinary track function: report from the
standardization sub-committee of the International Continence Society. Neurourology & Urodynamics
21
Carls, C. (2007). The prevalence of stress urinary incontinence in high school and college-age female
athletes in the Midwest:implications for education and prevention. Urologic Nursing 27 (1),
Doughty, D. (2000). Urinary and Fecal Incontinence: Nursing Management, 2nd Edition, Chapter 4,
Getliffe, K. & Dolman, M. (2003). Promoting Continence: A Clinical Research
Resource, 2nd Edition,
Chapter 3
Haslam, J. (2007). Vaginal cones in stress incontinence treatment. NursingTimes 104 (5)
Herbruck, L. (2008). Stress urinary incontinence: an overview of diagnosis and treatment options.
Urologic Nursing, 26 (3),
Komesu, et al. (2008). Restoration of continence by pessaries: magnetic resonance imaging
assessment of mechanism of action. AmericanJournal of Obstetrics and Gynecology 198:
Laycock, J. & Haslam, J. (2002). Therapeutic Management of Incontinence and Pelvic Pain: Pelvic
Organ Disorders.
Palmer, M. (1996). Urinary Continence: Assessment and Promotion, Maryland, USA: Aspen
Publishers Inc.
Murphy, M. & Wasson, C. (2003). Pelvic Health & Childbirth: What Every Woman Needs to Know, New
York, USA: Prometheus Books.
Retzky, S. & Rogers, R. (1996). Urinary incontinence in women. Clinical Symposia Ciba 2.
education and prevention. Urologic Nursing