academic half-day: family medicine residency program management of stress incontinence: pessary use...

Academic Half-Day: Family Medicine

Residency Program

Management of Stress Incontinence: Pessary UseGrace 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

• 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 urethro-vesicular 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

• 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

Constipation, straining

Smoking

Coughing

Aging

Associated Factors

Having babies

Gaining weight

Associated FactorsLifting heavy things, impact activities

Heredity

Some surgeriesChronic DiseasesMedications

Stress Incontinence

Pelvic Muscle Exercises

Pessary

HealthyBladderHabits

Treatment Options for SI

Surgery

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 RingCovered Ring Shaatz

Gellhorn Cube 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

• 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

• 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 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