1. 排尿障礙治療中心 版權所有 Conservative Treatment of Stress Urinary Incontinence Hann-Chorng Kuo. M.D. Department of Urology Buddhist Tzu Chi General Hospital, Hualien, Taiwan

2. 排尿障礙治療中心 版權所有 Pathophysiology of Stress urinary incontinence Intrinsic sphincteric deficiency Intrinsic sphincteric deficiency Defects in extrinsic continence mechanism Defects in extrinsic continence mechanism Defects of attachments to archus tendineus fascia pelvis Defects of attachments to archus tendineus fascia pelvis Defects of attachments to levator ani Defects of attachments to levator ani Damage or degenerative change of endopelvic fascia Damage or degenerative change of endopelvic fascia Pelvic floor muscle relaxation Pelvic floor muscle relaxation Damage of anococcygeal ligaments Damage of anococcygeal ligaments Urethrovesical facilitative reflex (detrusor overactivity ?) Urethrovesical facilitative reflex (detrusor overactivity ?)

3. 排尿障礙治療中心 版權所有 Damage of continence mechanism

4. 排尿障礙治療中心 版權所有 Hypermobility of Bladder Neck

5. 排尿障礙治療中心 版權所有 Factors Influencing Continence Bladder neck Bladder neck Urethral smooth muscle Urethral smooth muscle External urethral sphincter External urethral sphincter Pelvic floor musculatures Pelvic floor musculatures Connective tissue and collagen Connective tissue and collagen Intact neurological innervation Intact neurological innervation

6. 排尿障礙治療中心 版權所有 Conservative management of Stress incontinence Weight reduction Weight reduction Stop smoking Stop smoking Reduced caffeine intake Reduced caffeine intake Decrease fluid intake Decrease fluid intake Resolving chronic straining and constipation Resolving chronic straining and constipation Prevent heavy exertion or exercise Prevent heavy exertion or exercise

7. 排尿障礙治療中心 版權所有 Physical Therapies for Stress Incontinence Bladder retraining Pelvic floor muscle exercises Vaginal cones Biofeedback Functional electrical stimulation

8. 排尿障礙治療中心 版權所有 Pelvic floor muscle training (PFMT) Kegel 1948 Kegel 1948 Effective PFM contractions increase urethral resistance, increase activated motor units, frequency of excitation, and muscle volume Effective PFM contractions increase urethral resistance, increase activated motor units, frequency of excitation, and muscle volume Repeat PFMT may reflexly inhibit detrusor contractions Repeat PFMT may reflexly inhibit detrusor contractions Successful PFMT depends on ability to perform a correct contraction, 50% women failed to do PFMT Successful PFMT depends on ability to perform a correct contraction, 50% women failed to do PFMT

9. 排尿障礙治療中心 版權所有 ICS recommended Ideal PFMT Program Three sets of 8 to 12 slow velocity maximal contractions Sustained for 6 to 8 seconds each Performed 3 to 4 times a week Continued for at least 15 to 20 weeks

10. 排尿障礙治療中心 版權所有 Correct PMF contraction Co-contraction of related muscles should be discouraged Co-contraction of related muscles should be discouraged Use of voluntary PFMC prior to anticipated increased intra-abdominal pressure Use of voluntary PFMC prior to anticipated increased intra-abdominal pressure Near maximal contractions are the most significant factor in increasing strength Near maximal contractions are the most significant factor in increasing strength Prevent muscle fatigue with vigorous exercise Prevent muscle fatigue with vigorous exercise Assessed by a specialist for correct PFMC Assessed by a specialist for correct PFMC

11. 排尿障礙治療中心 版權所有 Effects of PFMT in Incontinence A meta-analysis of 10 studies concluded improvement ranges from 61 to 85% A meta-analysis of 10 studies concluded improvement ranges from 61 to 85% Cure ranges from3 to 38% Cure ranges from3 to 38% Severity of urine loss decreases by 61 to 82% in women who leaks after PFMT Severity of urine loss decreases by 61 to 82% in women who leaks after PFMT In 23 women with repeat training for 5 years, 14 were satisfied with current condition, 15 were continent, a high durability was noted In 23 women with repeat training for 5 years, 14 were satisfied with current condition, 15 were continent, a high durability was noted

12. 排尿障礙治療中心 版權所有 Combination of PFMT with other Physical therapies For a woman with stress, urge, and mixed incontinence, PFMT is better than no treatment For a woman with stress, urge, and mixed incontinence, PFMT is better than no treatment Combined PFMT with electrical stimulation Combined PFMT with electrical stimulation PFMT with biofeedback PFMT with biofeedback PFMT with intravaginal resistance devises PFMT with intravaginal resistance devises No consistent data proves that combination therapies are better than PFMT alone, but can be used as an initial training for women who cannot perform VPFC No consistent data proves that combination therapies are better than PFMT alone, but can be used as an initial training for women who cannot perform VPFC

13. 排尿障礙治療中心 版權所有

16. Effects of Conservative Treatment Increased maximal cystometric capacity Fewer detrusor contractions Less incontinence episodes Expected cure/improvement rates 65-75% About 50% of patients avoid surgery

17. 排尿障礙治療中心 版權所有 Predictive Factors for a Successful Physiotherapy Low patient age and presence of estrogen Absence of detrusor instability Absence of intrinsic sphincteric deficiency Low urethral hypermobility Good compliance with treatment

18. 排尿障礙治療中心 版權所有 Postulated Physiological Changes after PFMT Press urethra against pubis symphysis Increase activated motor units and muscle volume Build a structural support for urethra Reflexic inhibition of detrusor contractions

19. 排尿障礙治療中心 版權所有 Reported Urodynamic Findings in PFMT Increased in MUCP (Wilson 1987, Bo 1990, Elia 1993) Increased in MUCP and FPL (Benevenuti 1987) No changes in MUCP or FPL (Ferguson 1990, Meyer 1992, Burns 1993) No changes in all urodynamic parameters (McClish 1991, Elser 1999)

20. 排尿障礙治療中心 版權所有 Videourodynamics in Evaluation of PFMT Determine abdominal leak point pressure Measure bladder base descent during straining Measure bladder base elevation during PME Educate patient to perform an effective PME

21. 排尿障礙治療中心 版權所有

23. Dynamic Urethral Pressure Profilometry Resting UPP – Maximal urethral closure pressure – Functional profile length Stress UPP – Pressure transmission ratio PFMT UPP – Maximal pelvic floor muscle contractions Concomitant recording Pves and Pabd

24. 排尿障礙治療中心 版權所有

28. 陰道壓力儀

29. 排尿障礙治療中心 版權所有

30. Materials and Methods 40 women with GSI with/out frequency urgency Gr. 3 or 4 cystocele and pure ISD were excluded Structured 12-week PFMT with biofeedback Videourodynamic study and UPP study Abdominal leak point pressure determination Compare the parameters between successful and failed treatment groups

31. 排尿障礙治療中心 版權所有 PFMT Program A 12- week structured treatment course Performed by a trained nurse specialist Involve a gradual home exercise and 6 office biofeedback sessions 15 sustained 10-second contractions, 3 timed daily Results assessed by subjective satisfaction and improvement rate

32. 排尿障礙治療中心 版權所有 Abdominal Muscle EMG Recording

33. 排尿障礙治療中心 版權所有 Correct Pelvic Floor Muscle Contractions No Abdominal muscle contractions

34. 排尿障礙治療中心 版權所有 PFM Contractions with Abdominal muscle contractions

35. 排尿障礙治療中心 版權所有 PFMT 2 weeks, Weak Contractions

36. 排尿障礙治療中心 版權所有 PFMT 6 weeks Strengthening

37. 排尿障礙治療中心 版權所有 Strengthened PFM after 3 M training

38. 排尿障礙治療中心 版權所有 Results of PFMT Cure or improvement in 22 patients (55%) Treatment failure in 18 patients (45%) Mean age 45 ± 12 and 47 ± 15 years (p>0.05) of successful and failed treatment group

39. 排尿障礙治療中心 版權所有 Urodynamic Changes after PFMT Increase in first sensation, full sensation and cystometric capacity No change in MUCP, PTR, and FPL Significant increase in pelvic floor contraction pressure in PFC - UPP Successfully treated patients had more changes ALPP changed little in patients with persistent UI

40. 排尿障礙治療中心 版權所有 The Urodynamic Parameters after Pelvic Floor Muscle Training (I) Pre-treatmentPost-treatmentStatistics (p value) Qmax (mL/s)Total22.6 ± 13.020.9 ± 10.20.390 Successful26.0 ± 10.7723.4 ± 10.70.236 Failure18.3 ± 14.917.8 ± 9.20.881 Voided volumeTotal340.5 ± 123.4386.1 ± 152.90.240 Successful395.4 ± 69.8414.1 ± 176.30.780 Failure273.3 ± 144.5351.9 ± 119.40.021 FSF (mL)Total101.0 ± 26.8128.2 ± 41.60.025 Successful96.1 ± 21.1136.4 ± 45.80.027 Failure107.0 ± 32.7118.1 ± 35.70.484 FS (mL)Total189.0 ± 47.5229.5 ± 46.90.006 Successful190.4 ± 51.4245.0 ± 47.40.015 Failure187.3 ± 45.2210.4 ± 40.90.218

41. 排尿障礙治療中心 版權所有 The Urodynamic Parameters after Pelvic Floor Muscle Training (II) Pre-treatmentPost-treatmentStatistics (p value) Cystometric Capacity (mL) Total288.2 ± 83.8338.0 ± 96.10.050 Successful303.0 ± 82.9377.8 ± 100.60.086 Failure270.1 ± 86.0289.3 ± 66.80.376 Compliance (mL / cmH 2 O) Total63.8 ± 69.7138.3 ±170.30.069 Successful58.7 ± 53.0190.4 ± 208.00.045 Failure70.0 ± 89.174.7 ± 80.40.914 Pdet (cmH 2 O)Total22.5 ± 9.021.9 ± 10.30.777 Successful21.5 ± 8.918.3 ± 8.30.328 Failure23.8 ± 9.526.2 ± 11.30.465 LPP(cmH 2 O)Total111.7 ± 43.9113.9 ± 20.70,816 Successful122.3 ± 44.9109.3 ± 23.30.518 Failure99.6 ± 42.8119.3 ± 17.40.233

42. 排尿障礙治療中心 版權所有 The Urodynamic Parameters after Pelvic Floor Muscle Training (III) Pre-treatmentPost-treatmentStatistics (p value) MUCP (cmH 2 O) Total75.4 ± 30.270.5 ± 23.90.304 Successful72.5 ± 24.376.9 ± 23.60.393 Failure78.9 ± 37.562.7 ± 23.30.047 FPL (mm)Total34.5 ± 4.5936.6 ± 4.90.300 Successful34.4 ± 4.936.3 ± 5.10.089 Failure34.8 ± 4.436.9 ± 5.00.198 PTR (%)Total47.9 ± 15.150.8 ± 10.20.486 Successful51.6 ± 17.450.2 ± 9.90.847 Failure43.4 ± 11.151.7 ± 11.10.049 PFC (cmH 2 O)Total15.7 ± 13.423.0 ± 22.20.043 Successful20.5 ± 12.536.0 ± 21.20.009 Failure9.9 ± 12.77.1 ± 9.60.051

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45. Bladder Base Changes after PFMT Less bladder neck descent after PFMT Increased bladder neck elevation after PFMT Both successfully and failure treated patients had significant reduction of BN descent after PFMT BN descent and increase of BN elevation after PFMT

46. 排尿障礙治療中心 版權所有 The Urodynamic Parameter after Pelvic Floor Muscle Training ( Ⅳ ) Pre-treatmentPost-treatmentStatistics (p value) Resting BN position (cm) Total1.40 ± 0.741.65 ± 1.130.304 Successful1.14 ± 0.951.54 ± 1.210.213 Failure1.72 ± 1.201.77 ± 1.060.886 Straining BN position (cm) Total2.79 ± 1.782.29 ± 1.470.138 Successful2.55 ± 1.562.18 ± 1.530.372 Failure3.13 ± 2.122.44 ± 1.450.270 BN descent (cm) Total1.45 ± 1.010.68 ± 0.490.000 Successful1.31 ± 1.190.59 ± 0.370.031 Failure1.61 ± 0.780.78 ± 0.620.004 BN elevated PFMT (cm) Total0.83 ± 0.491.40 ± 0.740.000 Successful1.14 ± 0.321.91 ± 0.440.000 Failure0.44 ± 0.390.78 ± 0.510.022

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51. Prediction for a Successful PFMT Young age, fewer pad changes, less urethral incompetence, higher MUCP A greater voluntary BN elevation on PME A greater PFM contractility Pretreatment BN position and BN descent does not affect outcome of PFMT

52. 排尿障礙治療中心 版權所有

54. Results of PFMT for SUI PFM can be strengthened by a 12-week PFMT program Effective PFMT increases Pura during voluntary contractions Strengthened PFM do not change BN resting position Strengthened PFM reduce BN descent on straining 55% of SUI patients have benefit from PFMT

55. 排尿障礙治療中心 版權所有 Pelvic floor muscle training for Stress urinary incontinence An improved hammock effect after PFMT can be achieved No effect of PFMT on intrinsic continence mechanism Patients with ISD might not benefit from PFMT Patients with low cortical control of PFM have unfavorable results Good patient intention and compliance are the utmost important

56. 排尿障礙治療中心 版權所有 Electrical Stimulation for SUI Transvaginal ES has been used for genuine SUI, urge and mixed urinary incontinence Transvaginal ES has been used for genuine SUI, urge and mixed urinary incontinence Reported efficacy ranges 35 to70% Reported efficacy ranges 35 to70% A placebo-controlled study revealed after 15- week treatment course, pad usage diminished by >50% in 62% women compared to 19% in sham device, incontinence episode reduced >50% in 48% women compared to 13% in sham device A placebo-controlled study revealed after 15- week treatment course, pad usage diminished by >50% in 62% women compared to 19% in sham device, incontinence episode reduced >50% in 48% women compared to 13% in sham device

57. 排尿障礙治療中心 版權所有 Transvaginal electrical simulator

58. 排尿障礙治療中心 版權所有 Transvaginal electrical stimulation for Urge incontinence Leach reported 6% after long period of stimulation Leach reported 6% after long period of stimulation McGuire observed improvement in 93% women with urge incontinence McGuire observed improvement in 93% women with urge incontinence Plevnik found 52% improved (30% cured) in pure urge incontinence Plevnik found 52% improved (30% cured) in pure urge incontinence Brubaker used 20 Hz frequency current and cured 49% with urodynamic DI Brubaker used 20 Hz frequency current and cured 49% with urodynamic DI Smith found ES reduced urine loss by 50% in 20women Smith found ES reduced urine loss by 50% in 20women Sand reported 38% success rate in 20 women with DI Sand reported 38% success rate in 20 women with DI

59. 排尿障礙治療中心 版權所有 Transvaginal electrical stimulation Low frequency (20 Hz) was applied Low frequency (20 Hz) was applied Contrasting data of effects on genuine SUI Contrasting data of effects on genuine SUI Transvaginal ES is effective in urge UI Transvaginal ES is effective in urge UI First line treatment for women with pure urge incontinence First line treatment for women with pure urge incontinence For the women with mixed type UI who does not wish to undergo PME or surgery For the women with mixed type UI who does not wish to undergo PME or surgery

60. 排尿障礙治療中心 版權所有 Other Non-surgical Therapies for Incontinence Vaginal cones are a method of biofeedback Vaginal cones are a method of biofeedback 70% (19/27) with mild SUI had complete or >50% improvement after vaginal cone therapy, 7/50 with severe SUI had similar success rate 70% (19/27) with mild SUI had complete or >50% improvement after vaginal cone therapy, 7/50 with severe SUI had similar success rate Electrostimulation of pudendal nerve (prolonged pudendal nerve conduction velocity in 97% SUI) is effective in 62% with SUI and 20% were dry Electrostimulation of pudendal nerve (prolonged pudendal nerve conduction velocity in 97% SUI) is effective in 62% with SUI and 20% were dry Electromagnetic stimulation Electromagnetic stimulation

61. 排尿障礙治療中心 版權所有 Multiple purposes Electrostimulator and Biofeedback

62. 排尿障礙治療中心 版權所有 Patient visualization & biofeedback

63. 排尿障礙治療中心 版權所有 Cystometry biofeedback for urge incontinence For women who failed electrical stimulation, were intolerant to anticholinergics, For women who failed electrical stimulation, were intolerant to anticholinergics, Urodynamic detrusor overactivity was proven Urodynamic detrusor overactivity was proven Performed several voluntary PFMC at episodes of DI while watching CMG tracing and EMG activity Performed several voluntary PFMC at episodes of DI while watching CMG tracing and EMG activity Try to inhibit urge incontinence as longer duration as possible at home Try to inhibit urge incontinence as longer duration as possible at home

64. 排尿障礙治療中心 版權所有 Detrusor overactivity and CMG biofeedback

65. 排尿障礙治療中心 版權所有 Biofeedback to inhibit detrusor instability