Pelvic floor symptoms improve similarly after pessary and behavioral treatment for stress incontinence.
ABSTRACT The objective of this study was to determine if differences exist in pelvic symptom distress and impact on women randomized to pessary versus behavioral therapy for treatment of stress urinary incontinence (SUI).
Change in symptom and condition-specific health-related quality-of-life (HRQOL) measures were compared between pessary and behavioral groups 3 months after randomization in the Ambulatory Treatments for Leakage Associated With Stress Incontinence trial. Four hundred forty-six women with symptoms of SUI were randomized to continence pessary, behavioral therapy (pelvic floor muscle training and continence strategies) or combination therapy. Validated measures utilized included urinary, prolapse, and colorectal scales of the Pelvic Floor Distress Inventory; urinary, prolapse, and colorectal scales of the Pelvic Floor Impact Questionnaire; and Stress and Urge scales of the Questionnaire for Urinary Incontinence Diagnosis. Student t test and analysis of variance were used to compare scores within and between groups.
Mean age of participants was 49.8 (SD, 11.9) years; 84% were white, and 10% were African American. One hundred forty-nine were randomized to pessary, and 146 to behavioral therapy. Baseline symptoms and HRQOL scores were significantly reduced within treatment arms at 3 months after randomization, but there was no statistically significant difference between groups.
There was no difference in pelvic floor symptom bother and HRQOL between the pessary and behavioral therapy arms in women undergoing conservative treatment for SUI. Individualized preference issues should be considered in the approach to the nonsurgical treatment of SUI.
Full-textDOI: · Available from: David D Rahn, May 29, 2015
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ABSTRACT: Stress urinary incontinence (SUI) is a common and bothersome problem for women. Sling surgery is the mainstay of surgical treatment of SUI. A review of PubMed literature using the following keywords was performed: stress urinary incontinence, women, sling, midurethral sling, mini-sling, outcomes, and complications. Literature within the last 10 years, systematic reviews, and meta-analyses were given preference. Slings placed at the bladder neck and the midurethra each corrects a particular anatomic weakness, as described in the "hammock hypothesis" and the "integral theory," respectively. At present, the literature suggests that the autologous bladder neck sling (BNS) and retropubic midurethral sling (MUS) have similar success rates, while the retropubic MUS appears to be more successful than the transobturator approach. The literature supporting single-incision mini-sling (SIMS) is still in the early stages and data to support its use over another MUS is absent. Each approach is associated with unique complications and adverse outcomes. While both BNS and MUS are effective in improving SUI in women, the ultimate choice of material and approach should be based both on surgeon experience and patient preference. Detailed informed consent discussion prior to any sling surgery cannot be overemphasized.Minerva medica 08/2014; 105(4):263-274. · 1.20 Impact Factor
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ABSTRACT: OBJECTIVE: To determine the muscles comprising the minimal levator hiatus. DESIGN: Cross-sectional study. SETTING: The University of Oklahoma Health Sciences Center, USA. POPULATION: Eight female fresh frozen pelves and 80 nulliparouswomen. METHODS: Three-dimensional endovaginal ultrasound was performed in eight fresh frozen female pelves. The structures of the levator hiatus were tagged with needles and the cadavers were dissected to identify the tagged structures. A group of 80 nullipara underwent 3D endovaginal ultrasound, and the minimal levator hiatus area, puborectalis area, and anorectal angle were assessed, and normal values were obtained. MAIN OUTCOME MEASURES: Anatomic borders of minimal levator hiatus and normality in pelvic floor measurements. RESULTS: The pubococcygeus forms the inner lateral border and anterior attachment of the minimal levator hiatus to the pubic bone. The puboanalis fibres are immediately lateral to pubococcygeus attachments. There are variable contributions of the puborectalis fibres lateral to the puboanalis attachment. The posterior border of the minimal levator hiatus is formed by the levator plate. Eighty community-dwelling nulliparous women underwent 3D endovaginal ultrasound. The median age was 47 years (range 22-70 years). The mean of minimal levator hiatus and puborectalis hiatus areas were 13.4 cm(2) (±1.89 cm(2) SD) and 14.8 cm(2) (±2.16 cm(2) SD). The mean anorectal and levator plate descent angles were 156° (±10.04° SD) and 15.9° (±8.28° SD). CONCLUSION: Anterior and lateral borders of the minimal levator hiatus are formed mostly by pubococcygeus. The puborectalis, pubococcygeus, and iliococcygeus form the bulk of the levator plate.BJOG An International Journal of Obstetrics & Gynaecology 11/2012; DOI:10.1111/1471-0528.12055 · 3.86 Impact Factor
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ABSTRACT: Pelvic floor muscle training (PFMT) is a first-line conservative treatment for urinary incontinence in women. Other active treatments include: physical therapies (e.g. vaginal cones); behavioural therapies (e.g. bladder training); electrical or magnetic stimulation; mechanical devices (e.g. continence pessaries); drug therapies (e.g. anticholinergics (solifenacin, oxybutynin, etc.) and duloxetine); and surgical interventions including sling procedures and colposuspension. This systematic review evaluated the effects of adding PFMT to any other active treatment for urinary incontinence in women OBJECTIVES: To compare the effects of pelvic floor muscle training combined with another active treatment versus the same active treatment alone in the management of women with urinary incontinence. We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 28 February 2013), EMBASE (January 1947 to 2013 Week 9), CINAHL (January 1982 to 5 March 2013), ClinicalTrials.gov (searched 30 May 2013), WHO ICTRP (searched 3 June 2013) and the reference lists of relevant articles. We included randomised or quasi-randomised trials with two or more arms in women with clinical or urodynamic evidence of stress urinary incontinence, urgency urinary incontinence or mixed urinary incontinence. One arm of the trial included PFMT added to another active treatment; the other arm included the same active treatment alone. Two review authors independently assessed trials for eligibility and methodological quality and resolved any disagreement by discussion or consultation with a third party. We extracted and processed data in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Other potential sources of bias we incorporated into the 'Risk of bias' tables were ethical approval, conflict of interest and funding source. Eleven trials met the eligibility criteria for inclusion, comprising women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI), and they compared PFMT added to another active treatment (494 women) with the same active treatment alone (490 women). The pre-specified comparisons were reported by single trials except electrical stimulation which was reported by two trials. However, the two trials reporting electrical stimulation could not be pooled as one of the trials did not report any relevant data. We considered the included trials to be at unclear risk of bias for most of the domains, predominantly due to the lack of adequate information in a number of trials. This affected our rating of the quality of evidence. The majority of the trials did not report the primary outcomes specified in the review (cure/improvement, quality of life) or measured the outcomes in different ways. Effect estimates from small, single trials across a number of comparisons were indeterminate for key outcomes relating to symptoms and we rated the quality of evidence, using the GRADE approach, as either low or very low. There was moderate-quality evidence from a single trial investigating women with SUI, UUI or MUI that a higher proportion of women who received a combination of PFMT and heat and steam generating sheet reported cure compared to those who received the sheet alone: 19/37 (51%) versus 8/37 (22%) with a risk ratio (RR) of 2.38, 95% confidence interval (CI) 1.19 to 4.73). More women reported cure or improvement of incontinence in another trial comparing PFMT added to vaginal cones to vaginal cones alone: 14/15 (93%) versus 14/19 (75%), but this was not statistically significant (RR 1.27, 95% CI 0.94 to 1.71). We judged the quality of the evidence to be very low. Only one trial evaluating PFMT when added to drug therapy provided information about adverse events (RR 0.84, 95% CI 0.45 to 1.60; very low-quality evidence).With regard to condition-specific quality of life, there were no statistically significant differences between women (with SUI, UUI or MUI) who received PFMT added to bladder training and those who received bladder training alone at three months after treatment either on the Incontinence Impact Questionnaire-Revised scale (mean difference (MD) -5.90, 95% CI -35.53 to 23.73) or on the Urogenital Distress Inventory scale (MD -18.90, 95% CI -37.92 to 0.12). A similar pattern of results was observed between women with SUI who received PFMT plus either a continence pessary or duloxetine and those who received the continence pessary or duloxetine alone. In all these comparisons, the quality of the evidence for the reported critical outcomes ranged from moderate to very low. This systematic review found insufficient evidence to state whether or not there were additional effects of adding PFMT to other active treatment when compared with the same active treatment alone for urinary incontinence (SUI, UUI or MUI) in women. These results should be interpreted with caution as most of the comparisons were investigated in small, single trials. None of the trials in this review were large enough to provide reliable evidence. Also, none of the included trials reported data on adverse events associated with the PFMT regimen, thereby making it very difficult to evaluate the safety of PFMT.Cochrane database of systematic reviews (Online) 11/2013; 11(11):CD010551. DOI:10.1002/14651858.CD010551.pub2 · 5.94 Impact Factor