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