Overactive bladder and urinary incontinence: A multitherapy approach to treatment

Monotherapy options 

There are many pharmaceutical agents available for treating overactive bladder. However, while anticholinergics can be valuable tools, many patients become noncompliant as a result of negative side effects, cost, or lack of response to the medication.

Behavior modification, including lifestyle changes, bladder training, pelvic floor muscle training, and pelvic floor muscle rehabilitation are time-consuming. Furthermore, these treatment options cannot be rushed, as brochures and pamphlets are often inadequate, and counseling and explanation by trained personnel are essential. Accordingly, if scheduling does not allow adequate time for these patients, it is best to refer them to a continence center or continence therapist.

Surgical treatment options for stress incontinence, such as bladder-suspension procedures, are usually reserved for patients refractory to more conservative methods. Bulking agents injected into the periurethral tissue can increase urinary flow resistance within the urethra for intrinsic sphincter deficiency. The fact that they may need to be repeated every year or two makes it a less appealing option for some patients. Sacral nerve stimulator implants, which involve the placement of electrodes along the nerve and their connection to an implantable pulse generator, are an option for patients with urge frequency and urge incontinence. Within the confines of today's medicine, clinicians tend to treat urinary incontinence or overactive bladder with monotherapy. If a patient does not respond well to a particular therapy, another one is tried. This approach is time-consuming and frustrating for both the health care provider and the patient. A more comprehensive approach to conservative therapy would therefore provide the best patient outcomes and satisfaction.

Comprehensive pelvic floor rehabilitation with stimulation 

Comprehensive pelvic floor rehabilitation with stimulation involves a multitherapy approach. It combines behavioral interventions, patient-specific pelvic floor exercises, diagnosis-specific pelvic floor stimulation, and perhaps medications. As this approach provides patients with the knowledge and tools to fully participate in their own recoveries, they are better equipped to continue achieving long-term success in treatment. Pelvic floor rehabilitation and stimulation (PFRS) therapy is used in both female and male patients with stress incontinence, urge incontinence, mixed incontinence, and overactive bladder. The primary goals are to increase pelvic floor muscle strength (i.e. levator ani), enhance the external urethral sphincter closure pressure, and inhibit involuntary detrusor contractions and urgency. It is also used with fecal incontinence, mild pelvic descent, irritative voiding, pelvic pain, dyspareunia, and prostadynia patients.

Patient requirements, selection, and evaluation 

All patients must have a clinical assessment. This evaluation must include EMG tracings and anorectal manometry readings measured simultaneously (see Figure 1). Doing so allows the clinician to observe the muscle's ability to initiate and maintain a physical contraction (per manometry) as compared to the actual firing of motor units (per EMG potentials). Patients require at least partial innervation of the pelvic floor muscle with sensory perception in the pelvic region. Cognitive awareness is essential for the therapy to succeed. Patients must participate in and comply with the exercises, behavior changes, and treatments. A prior urodynamic study is helpful, but not mandatory, in forming a treatment plan. A three-day voiding diary and a bladder questionnaire may be used when assessing anticipated behavioral changes. Proper evaluation of pelvic floor function and strength is needed for the clinician to properly prescribe the correct number and type of pelvic floor exercises.

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Figure 1. Anorectal manometry sensor (top).

A vaginal/rectal EMG sensor (see Figure 2) measures the electrical activity of the pelvic floor muscle during both the relaxation and contraction phases. This allows the clinician to differentiate between pelvic floor muscle weakness and spasm, which are treated differently, as described in the section, “Treatment plan” within the review of Electrical stimulation. Abdominal, gluteal and thigh muscle use are monitored and factored into overall muscle strength, as illustrated in the tracings of Figure 3. After her initial visit, this patient was assigned the following exercises: Hold for 4 seconds, relax for 4 seconds, repeat 4 more times, and do four sets each day. Patients with a resting spasm on EMG often show low strength, poor endurance and early fatigue on manometry. As the pelvic floor muscle resting spasm decreases or is corrected, manometry readings increase. Individuals with weak PFMs are initially capable of only one-to-three second contractions and suffer from early fatigue on manometry. They often continue to activate motor unit action potentials on EMG for a full ten seconds. As shown in Figure 4, our patient's tracings have changed and improved, indicating an improvement in her condition. She can now hold for 10 seconds, relax for 10 seconds, and repeat 14 times in a row doing 4 sets per day. She is fully continent without complaints of pelvic pain or dyspareunia. It is optimal to measure the EMG and manometry simultaneously so as to make comparisons between the two. With male patients this is not possible and the manometry should always be measured first to ascertain fatigue. The exercises prescribed for these patients must be based on the muscle's physical ability rather than on its action potential. We use the CTS 2000 by Prometheus to evaluate, monitor, and treat our patients.

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Figure 2. Vaginal/rectal EMG sensor (bottom).

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Figure 3. Patient's initial visit for mixed incontinence and pelvic pain. In Figure 3A, a resting spasm is noted (arrow) and the pelvic floor muscle action potential lasts 6–8 seconds (EMG A, blue tracing). Definite abdominal use is noted (EMG B, pink tracing). In Figure 3B, on manometry, the PFM is weak and not able to sustain a contraction for the entire action potential seen on the EMG. Fatigue is noted at repetition number 3.

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Figure 4. Same patient after three months and six rehabilitation therapy sessions. The EMG and manometry tracings match closely: one firing and the other holding for 10 seconds. Later, fatigue is noted on the EMG at repetition 11 or 12. There is no abdominal use. The resting state is well within normal limits.

Treatment plan 

Better patient understanding of the condition and treatment process will result in better patient compliance and outcomes. For that reason, the first visit entails an in-depth history of the problem(s) as well as patient teaching.

Pelvic floor exercises are the most important aspect of any pelvic floor rehabilitation with stimulation (PFRS) program. For this reason, ensuring proper technique is essential. Patients should not hold their breath, bear down, or engage their abdominal, gluteal, or thigh muscles. The exercise prescription is based on the manometry tracing. It is also based on an overload principle of +2, meaning the patient is instructed to contract and sustain a holding contraction for 2 seconds longer than the previously noted interpretation of muscle endurance. Furthermore, the number of repetitions assigned for each set of contractions is 2 more than fatigue repetition seen on manometry. The prescribed exercise sets should be completed at least four times a day.

The holding exercises target the slow twitch fibers of the pelvic floor muscle. These slow twitch fibers account for approximately 80% of the muscle. As the patient progresses, quick flicks, i.e., one-second contractions of the PFM done in succession, are introduced to target the fast twitch fibers, which account for the remaining 20% and respond to sudden increases in intra-abdominal pressure such as sneezing. Behavioral interventions are determined by the patient's history, voiding diary, and bladder questionnaire. Areas including foods, fluids, caffeine consumption, control of constipation, and smoking cessation are discussed with the patient at the appropriate times throughout the therapy visits. Bladder training begins once the patient has gained enough PFM strength to suppress detrusor urges.

Electrical stimulation is used for a number of reasons within a PFM rehabilitation program. Stimulation improves the PFM function and strength, reduces resting spasm, restores reflex activity through pudendal nerve pathway excitation, and inhibits involuntary detrusor contractions by stimulating the detrusor inhibition reflex. Pelvic floor muscle weakness is treated with intermittent electrical stimulation of 5 seconds on, 5 seconds off. Reducing pelvic floor muscle resting spasm is best accomplished using a regimen of continuous stimulation in order to fatigue the muscle, reestablish correct work-rest values, and improve the overall function of the muscle. Table 2 summarizes indications and contraindications for pelvic floor muscle stimulation.

TABLE 2. Indications and contraindications for pelvic floor muscle stimulation

	Indications	Contraindications
	Pelvic floor muscle weakness	Pacemakers
	Frequency/Urgency	Metal IUD
	Decreased bladder capacity	Vaginal or urinary infection
	Voiding dysfunction
	Pelvic pain	Pregnancy
	Pelvic floor prolapse	Dementia
	Urge incontinence	Denervation of pelvic floor
	Stress incontinence
	Prostadynia
	Post prostatectomy incontinence

Patient scheduling 

The initial evaluation should be followed by three weekly visits. Thereafter, follow-up visits are scheduled based upon interpretation of muscle studies. A typical follow-up schedule might be weekly ×3, two weeks, 3 weeks, monthly, 2–3 months. At each follow-up visit, the EMG and manometry readings are compared with those of previous appointments. Appropriate modifications are made to the exercise prescription and behavior modification components. Pelvic floor muscle electrical stimulation is administered at most visits based on the muscle and medical diagnoses. If by the third weekly visit there is no improvement, the patient should be evaluated further. However, most patients begin experiencing symptom improvement within the first couple of weeks.

Progressive scheduling is likely to result in better outcomes at the completion of therapy. It also allows the clinician to assess whether a patient requires regularly scheduled stimulation treatments in order to control symptoms. If so, prescribing a home stimulation unit is a logical next step. Sacral neuromodulation may also be an option for those urge and frequency incontinence patients that respond well to PFM stimulation but are not home unit candidates.

Outcomes 

To date, no research study has been done to show the outcomes of combining all these noninvasive alternative therapies. However, studies do support the use of pelvic floor muscle exercises, behavior modification, and bladder training methods, and PFM stimulation with and without exercise. Results vary greatly depending on the study design.

Results from two separate private clinics using pelvic floor rehabilitation and stimulation therapy as described in this article show it to be quite successful. In a retrospective review of 45 female PFRS patients seen three or more times in a Hays, KS clinic, 47% of patients (21/45) showed 100% improvement; 22% (10/45) improved between 90% and 99%; and 18% (8/45) improved by 75%–89%. Improvement rates were reported as either objective (percent improvement in pad count or number of incontinence episodes) or subjective (the patients' perception of her overall improvement since the initial visit), whichever was greater. At another clinic in Salisbury, North Carolina, a retrospective chart review revealed similar results. Twenty five percent (42/167 patients) who completed a full schedule of pelvic floor rehabilitation and stimulation therapy reported themselves 100% improved; 86/167, or 51 percent, reported improvements between 90%–99%; 27/167 or 16% related an improvement between 75%–89%; 12 patients had less than 75% improvement, 10 of whom obtained a home unit to help maintain their symptoms in control. Subjective improvement was based on the patient's perception of overall improvement since beginning PFRS therapy. The patient is asked at each visit to rate his or her improvement on a scale of 0–10 with 0 being no improvement and 10 being 100% improved.

Discussion 

Urinary incontinence and overactive bladder are two very common and troublesome disorders. Most treatments use a monotherapy approach. However, pelvic floor rehabilitation and stimulation, which uses a comprehensive therapy, shows promise for patients with urinary incontinence, overactive bladder, and many other diagnoses related to the bladder, bowel, pelvis, and prostate. The combination of EMG and manometry helps prescribe the appropriate number and type of pelvic floor exercises as well as more specific stimulation needs. When combined with behavior modification, urge suppression, bladder training, and medications as needed this multitherapy approach should offer the best opportunity for achieving optimal results. Further research needs to be completed to assess the success of such a program at one and five years.