Case-Based Review

Diagnosis and Management of Complex Pelvic Floor Disorders in Women

Journal of Clinical Outcomes Management. 2015 June;22(6)

References

1. Nygaard I, Barber MD, Burgio KL, et al; Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311–6.

2. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186:1160–6.

3. Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J 2013;24:1783–90.

4. Zhang C, Hai T, Yu L, et al. Association between occupational stress and risk of overactive bladder and other lower urinary tract symptoms: a cross-sectional study of female nurses in China. Neurourol Urodyn 2013;32:254–60.

5. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 2003;189:372–7.

6. Baessler K, Maher C. Pelvic organ prolapse surgery and bladder function. Int Urogynecol J 2013;24:1843–52.

7. Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–7.

8. Lohsiriwat S, Hirunsai M, Chaiyaprasithi B. Effect of caffeine on bladder function in patients with overactive bladder symptoms. Urol Ann 2011;3:14–8.

9. Wells MJ, Jamieson K, Markham TC, et al. The effect of caffeinated versus decaffeinated drinks on overactive bladder: a double-blind, randomized, crossover study. J Wound Ostomy Continence Nurs 2014;41:371–8.

10. Fantl JA, Wyman JF, McClish DK, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA 1991;265:609–13.

11. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998;280:1995–2000.

12. Burgio KL. Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training. Curr Urol Rep 2013;14:457–64.

13. Burgio KL, Kraus SR, Menefee S, et al; Urinary Incontinence Treatment Network. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med 2008;149:161–9.

14. Gormley EA, Lightner DJ, Faraday M, Vasavada SP. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment. J Urol 2015;193:1572–80.

15. Dumoulin C, Hay-Smith J, Habée-Séguin GM, Mercier J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: A short version Cochrane systematic review with meta-analysis. Neurourol Urodyn 2015;34:300–8.

16. Labrie J, Berghmans BL, Fischer K, et al. Surgery versus physiotherapy for stress urinary incontinence. N Engl J Med 2013;369:1124–33.

17. Braekken IH, Majida M, Engh ME, Bø K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol 2010;203:170.e1–7.

18. Hagen S, Stark D, Glazener C, et al; POPPY Trial Collaborators. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet 2014;383:796–806.

19. Alperin M, Khan A, Dubina E, et al. Patterns of pessary care and outcomes for medicare beneficiaries with pelvic organ prolapse. Female Pelvic Med Reconstr Surg 2013;19:142-7.

20. Lamers BH, Broekman BM, Milani AL. Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Int Urogynecol J 2011;22:637–44.

21. Richter HE, Burgio KL, Brubaker L, et al; Pelvic Floor Disorders Network. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010;115:609–17.

22. Wood LN, Anger JT. Urinary incontinence in women. BMJ 2014;349:g4531.

23. FDA Safety Communication. Update on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Available at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm262435.htm.

24. Barber MD, Brubaker L, Burgio KL, Meikle SF; Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014;311:1023–34.

25. Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol 2001;185:1299–304.

26. Chmielewski L, Walters MD, Weber AM, Barber MD. Reanalysis of a randomized trial of 3 techniques of anterior colporrhaphy using clinically relevan tdefinitions of success. Am J Obstet Gynecol 2011;205:69.e1–8.

27. Altman D, Väyrynen T, Engh ME, et al; Nordic Transvaginal Mesh Group. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med 2011;364:1826–36. Erratum in: N Engl J Med 2013;368:394.

28. Delancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;187:93–8.

29. Clemons JL, Myers DL, Aguilar VC, Arya LA. Vaginal paravaginal repair with an AlloDerm graft. Am J Obstet Gynecol 2003;189:1612–8.

30. Gomelsky A, Rudy DC, Dmochowski RR. Porcine dermis interposition graft for repair of high grade anterior compartment defects with or without concomitant pelvic organ prolapse procedures. J Urol 2004;171:1581–4.

31. Handel LN, Frenkl TL, Kim YH. Results of cystocele repair: a comparison of traditional anterior colporrhaphy, polypropylene mesh and porcine dermis. J Urol 2007;178:153–6.

32. Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 2013;309:2016–24.

33. Sirls LT, McLennan GP, Killinger KA, et al. Exploring predictors of mesh exposure after vaginal prolapse repair. Female Pelvic Med Reconstr Surg 2013;19:206–9.

34. Hsiao KC, Latchamsetty K, Govier FE, et al. Comparison of laparoscopic and abdominal sacrocolpopexy for the treatment of vaginal vault prolapse. J Endourol 2007;21:926–30.

35. Anger JT, Mueller ER, Tarnay C, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014;123:5–12.

36. Wei JT, Nygaard I, Richter HE, et al; Pelvic Floor Disorders Network. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012;366:2358–67.

37. Wai CY, Curto TM, Zyczynski HM, et al; Urinary Incontinence Treatment Network. Patient satisfaction after midurethral sling surgery for stress urinary incontinence. Obstet Gynecol 2013;121:1009–16.

38. Kenton K, Stoddard AM, Zyczynski H, et al. 5-year longitudinal followup after retropubic and transobturator mid urethral slings. J Urol 2015;193:203–10.

39. Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD, McClinton S. Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev 2012;2:CD003881.

40. Chapple CR, Kaplan SA, Mitcheson D, et al. Randomized double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron, a β(3)-adrenoceptor agonist, in overactive bladder. Eur Urol 2013;63:296–305.

41. Nitti VW, Auerbach S, Martin N, et al. Results of a randomized phase III trial of mirabegron in patients with overactive bladder. J Urol 2013;189:1388–95.

42. Dmochowski RR, Newman DK. Impact of overactive bladder on women in the United States: results of a national survey. Curr Med Res Opin 2007;23:65–76.

43. Benner JS, Nichol MB, Rovner ES, et al. Patient-reported reasons for discontinuing overactive bladder medication. BJU Int 2010;105:1276–82.

44. Apostolidis A, Dasgupta P, Fowler CJ. Proposed mechanism for the efficacy of injected botulinum toxin in the treatment of human detrusor overactivity. Eur Urol 2006;49:644–50.

45. Nitti VW, Dmochowski R, Herschorn S, et al; EMBARK Study Group. OnabotulinumtoxinA for the treatment of patients with overactive bladder and urinary incontinence: results of a phase 3, randomized, placebo controlled trial. J Urol 2013;189:2186–93.

46. Dmochowski R, Chapple C, Nitti VW, et al. Efficacy and safety of onabotulinumtoxinA for idiopathic overactive bladder: a double-blind, placebo controlled, randomized, dose ranging trial. J Urol 2010;184:2416–22.

47. Visco AG, Brubaker L, Richter HE, et al; Pelvic Floor Disorders Network. Anticholinergic versus botulinum toxin A comparison trial for the treatment of bothersome urge urinary incontinence: ABC trial. Contemp Clin Trials 2012;33:184–96.

48. Chapple C, Sievert KD, MacDiarmid S, et al. OnabotulinumtoxinA 100 U significantly improves all idiopathic overactive bladder symptoms and quality of life in patients with overactive bladder and urinary incontinence: a randomised, double-blind, placebo-controlled trial. Eur Urol 2013;64:249–56.

49. Osborn DJ, Kaufman MR, Mock S, et al. Urinary retention rates after intravesical onabotulinumtoxinA injection for idiopathic overactive bladder in clinical practice and predictors of this outcome. Neurourol Urodyn 2014 Jun 29.

50. Rovner E. Chapter 6: Practical aspects of administration of onabotulinumtoxinA. Neurourol Urodyn 2014;33 Suppl 3:S32–7.

51. Duthie JB, Vincent M, Herbison GP, et al. Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane Database Syst Rev 2011;(12):CD005493.

52. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol 2007;178:2029–34.

53. Al-zahrani AA, Elzayat EA, Gajewski JB. Long-term outcome and surgical interventions after sacral neuromodulation implant for lower urinary tract symptoms: 14-year experience at 1 center. J Urol 2011;185:981–6.

54. Groen J, Blok BF, Bosch JL. Sacral neuromodulation as treatment for refractory idiopathic urge urinary incontinence: 5-year results of a longitudinal study in 60 women. J Urol 2011;186:954–9.

55. Carey M, Fynes M, Murray C, Maher C. Sacral nerve root stimulation for lower urinary tract dysfunction: overcoming the problem of lead migration. BJU Int 2001;87:15–8.

56. Everaert K, Kerckhaert W, Caluwaerts H, et al. A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation. Eur Urol 2004;45:649–54.

57. Staskin DR, Peters KM, MacDiarmid S, et al. Percutaneous tibial nerve stimulation: a clinically and cost effective addition to the overactive bladder algorithm of care. Curr Urol Rep 2012;13:327–34.

58. Peters KM, Carrico DJ, Wooldridge LS, et al. Percutaneous tibial nerve stimulation for the long-term treatment of overactive bladder: 3-year results of the STEP study. J Urol 2013;189:2194–201.

59. Peters KM, Carrico DJ, Perez-Marrero RA, et al. Randomized trial of percutaneous tibial nerve stimulation versus Sham efficacy in the treatment of overactive bladder syndrome: results from the SUmiT trial. J Urol 2010;183:1438–43.

60. Peters KM, Macdiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol 2009;182:1055–61.

61. Finazzi-Agrò E, Petta F, Sciobica F, et al. Percutaneous tibial nerve stimulation effects on detrusor overactivity incontinence are not due to a placebo effect: a randomized, double-blind, placebo controlled trial. J Urol 2010;184:2001–6.

62. Yoong W, Shah P, Dadswell R, Green L. Sustained effectiveness of percutaneous tibial nerve stimulation for overactive bladder syndrome: 2-year follow-up of positive responders. Int Urogynecol J 2013;24:795–9.

To evaluate long-term efficacy and safety, 36-month results of 29 positive responders of the initial SUmiT trial was reported [59]. In addition, a maintenance regimen was developed so patients received PTNS at tapering intervals over a 3-month period followed by a personalized treatment plan to sustain subjective improvement in their symptoms. With an average of 1 treatment a month, symptom severity scores and health related quality of life scores were statistically significant for improvement at each tested time-point. Yoong et al followed patients for 2 years following initial treatment with PTNS and confirmed a durable improvement in nocturia, frequency, urgency incontinence and symptom scores with a longer median length between treatments of 64 days [62].

PTNS is office-based, has few side effects, and avoids an implantable device. In addition, continuous stimulation is not necessary and a decreased treatment frequency is needed over time. Limitations include the time commitment that is required for both the initial treatment phase and the maintenance phase. Logistical concerns of weekly and monthly office visits or arranging for transportation can limit treatment.

Additional Treatment

The patient received injection of 100 U of Botox in the office. At her 2-week follow up appointment, her PVR was 90 mL and she was already seeing improvement in her incontinence episodes. At 6 weeks she was wearing 1 pad per day but using it mainly for protection. She still notices urgency, particularly if she drinks more than 1 cup of coffee in the morning, but overall she reports significant improvement in her symptoms. She has no complaints of a vaginal bulge and on exam has a grade 1 distal rectocele and no SUI with a full bladder. The physician discussed need for continued yearly examinations and repeat injections due to the duration of action of Botox.

Conclusion

This case demonstrates the complex step-wise management strategy of a patient with pelvic organ prolapse and voiding dysfunction. Interventions directed at patient bother and recognition of the various modalities and timing of treatment are essential to provide the greatest chance of positive treatment outcomes and patient satisfaction.

Corresponding author: Jaimie M Bartley, DO, 3601 W. 13 Mile Rd., Royal Oak, MI 48073.

Financial disclosures: None.