Stress urinary incontinence: A closer look at nonsurgical therapies
This pervasive condition has spawned a host of treatments, from conservative measures like pelvic floor rehabilitation to cutting-edge modalities such as radiofrequency therapy. In this discussion, a panel of experts compares the less invasive options and offers pearls on evaluating and counseling patients and selecting appropriate treatments.
I can’t agree enough about the importance of a physiotherapist, whether that happens to be a physical therapist or your nurse or someone else who takes the time to instruct the patient on how to isolate and contract the pelvic floor muscles. It really takes a team of people to address pelvic floor dysfunction, so that’s where we direct our focus.
SAND: Any other tips to give patients about pelvic floor rehabilitation?
LUBER: Yes. It’s a good idea to stress the importance of moderation. If a sedentary person suddenly decided to rehabilitate the muscles of her arms and set about doing 100 curls with 40-lb weights, the next day she would barely be able to brush her teeth; her arm function would be worse than it was on day 1. And if one of our patients decided to focus on the muscles of her pelvic floor and began with a similarly overzealous program, she might actually report that her stress incontinence had worsened. So we do need to warn patients that the pelvic floor muscles can become extremely debilitated and advise them to start rehabilitation slowly.
MYERS: I agree. Otherwise muscle fatigue develops.
SAND: Let’s talk a few moments about pelvic floor rehabilitation following surgery. Do you recommend it to your patients—or is it only useful as an alternative or prelude to surgery?
DAVILA: I think it is very important. Once an incontinence operation is finished, there is a tendency to think the job is done. That is an incorrect attitude. We see the patient at 3 months, 6 months, and yearly to make sure she is doing her Kegels. While the importance of postoperative Kegel exercises and biofeedback has not been studied in depth, I think they are key to maintaining the success of our surgical interventions.
MYERS: I agree. I think it’s a major weakness of our field that we don’t promote pelvic floor exercises postoperatively. After orthopedic procedures, physical therapy frequently is used, since there is an understanding that the muscles as well as the ligaments need to be rehabilitated. This concept needs to be addressed in pelvic floor reconstructive surgeries as well.
SAND: But we have absolutely no data.
MYERS: We should start to obtain it.
SAND: One of the things that concerns me greatly about postoperative Kegels is the fact that patients don’t do them properly. If a woman is doing the Valsalva maneuver or increasing her intra-abdominal pressure instead of contracting the levators, she may actually undermine the surgery rather than promote its effect. That’s the other side of using Kegel exercise therapy postoperatively.
—Dr. Sand
DAVILA: But at the 6- or 8-week visit, you simply do an exam to see if she can perform a Kegel properly. I tell my patients, “We’re going to do the best surgery we can do. Then you have to take care of your repair.”That means avoiding straining and limiting lifting to 5 lb or so during the healing phase, doing pelvic floor exercises after 6 weeks, and remaining careful about lifting on a long-term basis.
If a patient cannot contract her pelvic floor muscles at the postoperative visit, we send her to our physiotherapist. Frequently, 1 or 2 visits are enough for the patient to learn to perform Kegels.
I do agree that if the patient is performing the Valsalva maneuver instead of contracting her muscles, she can do more damage than good. But proper patient selection and instruction should take care of that.
MYERS: If a patient is doing the Valsalva maneuver every time I ask her to do a Kegel, I tell her not to do them at all. I say: “You are going to need additional help with this for the next 6 to 8 weeks. If you want to maximize your muscle strength, this is something that will be for your benefit.”
As I said before, I think pelvic floor rehabilitation is a very important component of incontinence treatment. Some investigators have emphasized ligament supports and fascial supports to control incontinence, and other investigators emphasize muscular support. It is probably a combination of both.
SAND: I have a different view. Although I would like to believe that stabilizing the pelvic floor will help protect the connectivetissue supports or the “imitation”supports we have instituted surgically, I don’t see the justification for getting all these patients to do pelvic floor therapy without good data demonstrating that fact.
