Diagnosis and Management of Complex Pelvic Floor Disorders in Women

• What is first-line treatment for the complaints of urgency, frequency, and incontinence?

In an older patient with complaints of urgency, frequency, and incontinence, dietary and behavioral modifications as well as pelvic floor physical therapy are considered first-line minimally invasive treatments.

Dietary irritants such as coffee, tea, soda, and other caffeinated beverages can contribute to worsening of symptoms [8]. A randomized study measuring the effects of caffeine noted a significant reduction in urgency and frequency of voids and in symptom scores with reduction of caffeine use [9]. Some elderly patients are reluctant to change their lifestyle, but even small changes can significantly improve their urgency symptoms.

Timed voiding is an effective method for bladder retraining, which can be critical for managing symptoms both alone and as an adjunct to other interventions. Studies of behavioral therapy show significant improvement in urgency, frequency, and incontinence episodes. In a study by Wyman and Fanti, patients participating in bladder training and Kegel exercises noted a 57% decrease in incontinence episodes and 54% decrease in urine loss without medications [10]. Burgio et al compared behavioral therapy to anticholinergic medication administration. After 4 sessions over 8 weeks they reported 81% reduction in incontinence episodes compared to 69% in the drug group and 39% in the placebo group [11].

Elderly patients may take several medications, some of which can affect urine volume and timing of urine production. Diuretics given later in the day can increase nighttime urine production and worsen nocturia. Similarly, lower extremity edema can increase nocturnal urine volumes when the patient reclines. Compressive stockings and leg elevation 2-3 hours prior to bedtime will help evenly distribute fluids and decrease reabsorption when supine at night.

Pelvic Floor Physical Therapy

Pelvic floor physical therapy (PFPT) can be an effective treatment for OAB, SUI, and pelvic organ prolapse. PFPT is used as an urge suppression strategy for OAB by teaching patients how to contract their pelvic muscles to occlude the urethra and prevent leakage during a detrusor contraction. Strategies to help suppress urge and manage stress situations can reduce incontinence episodes up to 60% to 80% [12]. Behavioral programs can include bladder diaries, scheduled voiding, delayed voiding, double voiding, fluid management, and caffeine reduction. When combined with PFPT they can be very effective in the management of OAB symptoms and incontinence. The BE-DRI study showed that combined behavioral training and drug therapy yielded better outcomes over time in OAB symptoms, patient distress and treatment satisfaction than drug therapy alone [13]. PFPT is considered a first-line treatment for OAB and is a noninvasive and effective treatment for these symptoms [14].

Pelvic floor programs for SUI aim to teach pelvic floor muscle contraction to help prevent stress leakage and use a variety of methods including biofeedback and personalized training programs. A recent Cochrane review included 18 studies of PFPT for incontinence. They concluded that there was high quality evidence that PFPT was associated with cure and moderate evidence for improvement in SUI [15]. In a study comparing surgery versus PFPT at 1 year, subjective improvement in the surgery group was 91% compared to 64% in the PFPT group. While PFPT was not as effective as surgery, over 50% had improvement. PFPT remains an effective noninvasive option that should be considered, particularly in an older patient [16].