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 defecation
Pelvic organ prolapse
Overactive bladder
Urge incontinence
Urgency/frequency
Nocturia
Stress incontinence
Levator spasm
Case Presentations
Why not surgery?
Bleeding
• Shull et al reported their
experience with 302 patients
undergoing transvaginal surgery,
including USVS
• Mean EBL: 243mL
• 1% rate of blood transfusion
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
Why not surgery?
• SSLF is generally associated with a higher rate of
bleeding complications (compared with other
vaginal procedures for apical support)
Bleeding
• 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, 2001
Barksdale, 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
Rectocele
Perineal Rectocele
Enterocele
Rectal prolapse
Functional
Neurologic disorder
Pelvic floor dysenergia
Levator spasm
Obstructed Defecation
Prolapse Animation
Pelvic Floor Rehabilitative Therapy
22 patients with constipation related to pelvic
Onedysenergia
recently published
meta-analysis
showed that
floor
were enrolled
in a prospective
pelvic
floorto
rehabilitative
therapy
wasrehabilitative
superior to
case
series
undergo pelvic
floor
various Symptom
other treatments
(laxatives,
placebo,
sham
therapy.
severity
decreased
after
training, and botox) (OR: 3.657; 95% CI:
physical therapy (2.1±0.7 vs. 1.3±0.9, P=0.007).
2.127–6.290, P < 0.001)
Quality of life also improved significantly
(2.6±0.8 vs. 1.5±1.0, P=0.007).
Enck
P, Van Der C,
Voort
IR, and
Klosterhalfen
S; Biofeedback
therapy
fecal
Lewicky-Gaupp
Morgan
DM,
Chey WD, Muellerleile
P, and
FennerinDE;
incontinence
and Constipation,
Neurogastroenterol
(2009) 21,
Successful Physical
Therapy for Constipation
RelatedMotil
to Puborectalis
1133–1141
Dyssynergia Improves Symptom Severity and Quality of Life, Dis Col Rect
(2008) 51, 1686-1691
Pelvic Organ Prolapse
BLS Interviews
Bladder Control in Women
Pu
PV
B
Pu > Pv
Continence
Intrinsic
Myogenic
Pu ↓↓
Stress
Extrinsic
Neurogenic
RP ↑↑
Urge
V
Idiopathic
v
Pu ↓↓ and Pv↑↑
Mixed
Bladder Control in Women
↑Pu
Bladder Control in Women
↓Pv
Bladder Control Therapy
Behavior Modification
•Timed voiding
•Squeeze before you sneeze
•Quick flicks
•Fluid moderation in the evening
•Avoid bladder irritants
•Alcohol
•Caffeine
•Chocolate
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
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•
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•
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•
Diagnoses
Rectocele (stage II)
Defecatory dysfunction
Urogenital atrophy
Urgency/frequency
Nocturia
Urge incontinence
Stress incontinence
UTI
Recurrent UTI’s
Ethel
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•
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Treatment Plan
Bowel regimen
Premarin cream
Treat UTI (fosfomycin)
Prophylactic Abx for recurrent UTI
(trimethoprim)
Pelvic floor rehabilitative therapy
Imipramine QHS
Ethel
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•
•
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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
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•
•
•
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Diagnoses
Stage II cystocele
Stage II rectocele
Nocturia
Urodynamic stress incontinence
Urge incontinence
Urogenital atrophy
Defecatory dysfunction
Anne
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•
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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