Pessaries Key to Stress Incontinence Management


Expert Analysis from the Annual Meeting of the American Urological Association

WASHINGTON – Trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.

“It's unfortunate, but many women currently manage their incontinence with pads,” said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the meeting.

The mainstay of SUI management is still active pelvic floor muscle training that's taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said. Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. “Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy,” she said.

A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. “This is an incredibly common scenario. [Urinary leakage] is a real barrier to women's participation in high-impact activities and sports,” said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.

Pessaries are widely available and mainly used for prolapse, but there are a variety of “highly effective” incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.

Early discontinuation of pessaries and other inserts “can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there's very high long-term success,” she said.

Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year (Obstet. Gynecol. 2010;115:609–17).

Refitting of pessaries is not uncommon, she noted. (In the ATLAS trial, 47% of the patients assigned to the pessary group needing a refitting, and 92% were ultimately properly fitted.) Minor complications can also occur. In one retrospective study of 273 women fitted with a ring pessary, the rate of minor complications (vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order) was a surprisingly high 56% (BJOG 2009;116:1715–21).

“Women will decide early on if this is the right option for them,” Dr. Lightner said. “And if it's not, they can move on to other therapies.”

Clinical experience over the past 2 decades with urethral inserts has been “somewhat challenging,” she said. Colonization and symptomatic urinary tract infections can occur with frequent or long-term use. Calcification and erosion also can occur, but “mainly with indwelling inserts, and not with episodic use.”

The reported continence rate with use of the FemSoft urethral insert – the only one currently available in the United States – is 93% at 48 months. Early discontinuation occurs in up to 40% of users, and UTIs occur in about one-third of patients. Still, with this “excellent” continence rate, the urethral insert may have a role for women who wish to postpone or avoid surgery, she said.

Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, she emphasized. “It can't be effective it's not done correctly, so I'd have that as part of my physical exam … find out, what can she do with her pelvic floor?”

Dr. Lightner reported that she had no disclosures.

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