Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain.

BACKGROUND: The rehabilitation of post-prostatectomy urinary incontinence has traditionally focused on pelvic floor strengthening exercise. The goal of this study was to determine whether an individualized pelvic physical therapy (PT) program aimed at normalizing both underactive and overactive pelvic floor dysfunction (PFD) can result in improvement in post-prostatectomy stress urinary incontinence (SUI) and pelvic pain. METHODS: A retrospective chart review of 136 patients with post-prostatectomy SUI and treated with pelvic PT. Patients were identified as having either underactive, overactive, or mixed-type PFD and treated accordingly with a tailored program to normalize pelvic floor function. Outcomes including decrease in SUI as measured in pad usage per day and pain rated on the numeric pain rating scale. RESULTS: Twenty five patients were found to have underactive PFD and were treated with strengthening. Thirteen patients had overactive PFD and were treated with relaxation training. Ninety eight patients had mixed-type PFD and were treated with a combination of relaxation training followed by strengthening. Patients demonstrated statistically significant decrease in pad usage per day (p < 0.001), decreased pelvic pain (p < 0.001), and increased pelvic floor strength (p = 0.049), even in patients who received predominantly pelvic floor relaxation training to normalize pelvic floor overactivity. CONCLUSIONS: A majority of post-prostatectomy men with SUI have pelvic floor overactivity in addition to pelvic floor underactivity. An individualized pelvic PT program aimed at normalizing pelvic floor function (as opposed to a pure Kegel strengthening program) can be helpful in reducing SUI and pelvic pain.

A new bladder-emptying method in females with neurogenic bladder: A randomized, phase II trial.

AIM: To evaluate the performance of the new device compared with clean intermittent catheterization (CIC). METHODS: From March 2015 to March 2018, patients who were admitted to the urologic outpatient clinic. A new intraurethral self-retaining device (ISRD) was made of medical grade silicone and it was inspired by similar catheters that use sliding disks to adjust or fix tubes used to drain the bladder. Patients were randomized into two groups (experimental group [GI]-ISRD vs control group [GII]-CIC). The evaluation was performed at the time of enrollment and 6 months after treatment. Intervention was initiated from the antisepsis of the perineal region and subsequent introduction of the device through the external urethral meatus. The primary outcome was quality of life (QOL). Urinary tract infections (UTIs) episodes, data on urodynamic parameters, adverse effects and number of diapers per day. RESULTS: A total of 177 subjects were analyzed. We found a significant improvement on QOL analysis in the ISRD group (P < .01). ISRD group presented an important reduction (two episodes after ISRD use) on number of UTIs (P < .01) and diaper use, and significant improvement on bladder capacity (80 mL of the average improvement) (P < .01) and compliance (P = .01). Among all registered serious adverse effects, ISRD presented with lower proportion. CONCLUSIONS: The new device has shown to be a safe and promising alternative for adequate emptying of the neurogenic bladder in female patients. Our study has a limitation that is related to a limited period of observation.

Impact of the lack of integrated care for older people with urinary incontinence and their family caregivers: results from a qualitative pilot study in two large areas of the Marche Region.

OBJECTIVES: Urinary incontinence (UI) may have a severe impact on older people and on their family caregivers' quality of life, especially when support services are scanty or inadequate. This study investigated the support needs and expectations of community-dwelling older people with UI and their family caregivers in the Marche Region (Central Italy). METHODS: Face-to-face semi-structured interviews were carried out to eight over-60-year-old patients with UI, four family caregivers, two representatives of the Regional Health System and two pharmacists. RESULTS: Findings show that the insufficient supply and low quality of continence products and the lack of integrated care services negatively affects the well-being of both older people and family caregivers. DISCUSSION: Integrated care services and a standardized system for the periodic assessment of sufferers and a more customized service delivery, including the possibility of choosing brand and type of products for users, may improve the current provision in this Italian Region.

Outcome and complications of adjustable continence therapy (ProACTTM ) in the treatment of urinary incontinence after transurethral resection of the prostate: A multicenter study.

AIM: To evaluate the outcome of adjustable continence balloons in the treatment of stress urinary incontinence (SUI) after transurethral resection of the prostate (TURP). METHODS: In two tertiary centers, adjustable continence balloons were implanted in 29 patients with post-TURP SUI between 2007 and 2018. Endpoints of this retrospective multicenter study were patient-reported changes in pad count and complications. Dry was defined as no pad or one security pad. RESULTS: Preoperative urinary incontinence was mild in 7 (24%), moderate in 12 (41%), and severe in 10 (35%) patients. The median follow-up duration was 21 (interquartile range [IQR], 11-43) months. Within 30 days postoperatively, a Clavien-Dindo grade less than or equal to II complication occurred in 24% of the patients. Reintervention rate was 24%. Six and 12 months after implantation, the International Prostate Symptom Score (IPSS) quality-of-life item improved significantly from 5 (IQR, 5-6) preoperatively to 3 (IQR, 1-4.5) and 1 (IQR, 0-3), respectively. At last visit (median 21 months after implantation), the outcome on continence had improved in 76% of the patients, including, 45% dry patients. After a median follow-up of 28 months (IQR, 13-63; N = 23), all but one patient reported improvement on the Patient Global Impression of Improvement (PGI-I) scale. In detail, 10 patients reported "very much better" condition compared with before the implantation, 10 patients "much better," two patients "a little better," and one patient "no change." Daily pad use decreased from three (IQR, 2-5) to one (IQR, 0-2) pads/day (P < 0.001). CONCLUSIONS: This is hitherto, the first study reporting results of adjustable continence balloons in the treatment of post-TURP SUI. The therapy was found to be safe and efficient. The majority of our study population reported improvement on their condition and greater than or equal to 50% reduction in daily pad use.

A Pragmatic Randomized Controlled Trial Examining the Impact of the Retzius-sparing Approach on Early Urinary Continence Recovery After Robot-assisted Radical Prostatectomy.

BACKGROUND: Retzius-sparing (posterior) robot-assisted radical prostatectomy (RARP) may expedite postoperative urinary continence recovery. OBJECTIVE: To compare the short-term (≤3 mo) urinary continence (UC), urinary function (UF), and UF-related bother outcomes of posterior RARP compared with standard anterior approach RARP. DESIGN, SETTING, AND PARTICIPANTS: A total of 120 patients aged 40-75 yr with low-intermediate-risk prostate cancer (per the National Comprehensive Cancer Network guidelines) underwent primary RARP at a tertiary care institution. INTERVENTION: Eligible men were randomized to receive either posterior (n=60) or anterior (n=60) RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES: Primary outcome was UC (defined as 0 pads/one security liner per day) 1 week after catheter removal. Secondary outcomes were short-term (≤3 mo) UC recovery, and UF and UF-related bother scores (measured by the International Prostate Symptom Score [IPSS] and IPSS quality-of-life scores, respectively) assessed at 1 and 2 wk, and 1 and 3 mo following catheter removal. Continence outcomes were objectively verified using 24-hr pad weights. UC recovery was analyzed using Kaplan-Meier method and Cox proportional hazards regression; UF and UF-related bother outcomes were compared using linear generalized estimating equations (GEEs). Perioperative complications, positive surgical margin, and biochemical recurrence-free survival (BCRFS) represent secondary outcomes reported in the study. RESULTS AND LIMITATIONS: Compared with 48% in the anterior arm, 71% men undergoing posterior RARP were continent 1 wk after catheter removal (p=0.01); corresponding median 24-h pad weights were 25 and 5g (p=0.001). Median time to continence in posterior versus anterior RARP was 2 and 8 d postcatheter removal, respectively (log-rank p=0.02); results were confirmed on multivariable regression analyses. GEE analyses showed that UF-related bother (but not UF) scores were significantly lower in the posterior versus anterior RARP group at 1 wk, 2 wk, and 1 mo on GEE analyses. Incidence of postoperative complications (12% anterior vs 18% posterior) and probability of BCRFS (0.91 vs 0.91) were comparable in the two arms. CONCLUSIONS: In this single-center randomized study, the Retzius-sparing approach of RARP resulted in earlier recovery of UC and lower UF-related bother compared with standard RARP. These results require long-term validation and reproduction by other centers, as well as studies on men with high-risk localized disease. PATIENT SUMMARY: In our hands, men with low-intermediate-risk prostate cancer undergoing Retzius-sparing robot-assisted radical prostatectomy (RARP) had earlier recovery of urinary continence and lower urinary function-related bother than those undergoing standard RARP.

Quantifying patient improvement following sacral neuromodulation: is it time for a new scoring system for fecal incontinence?

BACKGROUND: The Cleveland Clinic Florida Fecal Incontinence score is widely used to assess the severity of fecal incontinence. OBJECTIVE: We hypothesized that the Cleveland Clinic Fecal Florida Incontinence score is useful at establishing baseline disease severity, but it may underestimate the response to treatment following sacral neuromodulation because of the large number of patients who still wear a pad despite improved continence, as well as the inability to track improvements in urgency. DATA SOURCES: Data were obtained from prospectively maintained database of patients treated with sacral neuromodulation for fecal incontinence at 2 institutions beginning in 2011. DESIGN: A retrospective review of the individual components of Cleveland Clinic Fecal Florida Incontinence scores in response to treatment with sacral neuromodulation was performed. SETTINGS: The study was conducted at 1 academic medical center and 1 community medical center. PATIENTS: One hundred twenty-one consecutive patients were treated with sacral neuromodulation for fecal incontinence. INTERVENTIONS: No interventions occurred. MAIN OUTCOME MEASURES: Individual components of posttreatment Cleveland Clinic Florida Fecal Incontinence scores and subjective improvement in fecal urgency were the primary outcomes measured. RESULTS: The median preoperative Cleveland Clinic Fecal Florida Incontinence score of 14 decreased to 3 (interquartile range, 2-4) at 12 months. Of the patients, 66.1% reported still wearing a pad after the procedure. The reason for wearing a pad was residual fecal incontinence (41%), habit despite normal continence (35.3%), and urinary incontinence with complete fecal continence (23.5%). Of patients who report wearing a pad, 59% have falsely elevated Cleveland Clinic Fecal Florida Incontinence scores owing to wearing a pad despite complete fecal continence. Additionally, 96.3% of patients reported improvement in fecal urgency. LIMITATIONS: This retrospective study did not include a comparison with an alternative scoring system. CONCLUSIONS: Although the Cleveland Clinic Fecal Florida Incontinence score is a validated scale, which is simple to use for baseline disease severity, it may underestimate patient response to treatment. Additionally, it does not capture improvement in urgency. The ideal scoring system would be easy to use in clinical practice, and would account for improvement in fecal urgency.

The efficacy and safety of electroacupuncture for women with pure stress urinary incontinence: study protocol for a multicenter randomized controlled trial.

BACKGROUND: Although available evidence relating to its effectiveness is weak, acupuncture is used as an alternative therapy for stress urinary incontinence. We report a protocol of a randomized controlled trial using electroacupuncture (the passing of a weak current between inserted acupuncture needles) to treat women with pure stress urinary incontinence. METHODS/DESIGN: This is a large-scale multicenter subject-blinded randomized controlled trial. A total of 500 women with pure stress urinary incontinence will be randomly assigned to two groups: a treatment group and a control group. The treatment group will receive electroacupuncture with deep needling at acupuncture points BL33 and BL35. The control group will receive sham electroacupuncture with non-penetrating needling at sham locations for the acupuncture points of BL33 and BL35. Participants will be given three sessions a week for 6 weeks. A 24-week-long follow-up will be conducted. The primary outcome will be the change in amount of urine leakage at the sixth week from a baseline measured by a 1-h pad test. The secondary outcomes include: the 72-h incontinence episode frequency based on a 72-h bladder diary; the score of International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form; the degree of urinary incontinence based on a 72-h bladder diary; self-assessment of the therapeutic effect; weekly consumption of pads; application of other treatments for stress urinary incontinence; and subgroup analysis stratified by incontinence severity. The safety of electroacupuncture will also be assessed. DISCUSSION: This trial will help to identify whether electroacupuncture is effective for stress urinary incontinence, and, if so, whether it is a therapeutic effect rather than a placebo effect. TRIAL REGISTRATION: Clinical Trials.gov NCT01784172.

Cost-effectiveness analysis of solifenacin versus oxybutynin immediate-release in the treatment of patients with overactive bladder in the United Kingdom.

OBJECTIVE: To carry out a cost-utility analysis comparing initial treatment with solifenacin 5 mg/day vs oxybutynin immediate-release (IR) 15 mg/day for the treatment of patients with overactive bladder (OAB) from the perspective of the U.K. National Health Service (NHS). METHODS: A Markov model with six health states was developed to follow a cohort of OAB patients treated with either solifenacin or oxybutynin during a 1-year period. Costs and utilities were accumulated as patients transited through the health states in the model and a drop-out state. Some of the solifenacin patients were titrated from 5 mg to 10 mg/day at 8 weeks. A proportion of drop-out patients were assumed to continue treatment with tolterodine ER. Utility values were obtained from a Swedish study and pad use was based on a multinational clinical trial. Adherence rates for individual treatments were derived from a U.K. database study. For pad use and utility values, the drop-out state was split between those patients who were no longer receiving treatment and those on second-line therapy. Patients on second-line therapy who drop-out were referred for a specialist visit. Results were expressed in terms of incremental cost-utility ratios. RESULTS: Total annual costs for solifenacin and oxybutynin were £504.30 and £364.19, respectively. First-line drug use represents 49% and 4% of costs and pad use represent 23% and 40% of costs for solifenacin and oxybutynin, respectively. Differences between cumulative utilities were small but were greater for solifenacin (0.7020 vs. 0.6907). The baseline incremental cost-effectiveness ratio was £12,309/QALY. CONCLUSION: Under the baseline assumptions, solifenacin would appear to be cost-effective with an incremental cost-utility of less than £20,000/QALY. However, small differences in utility between the alternatives and the large number of drop-outs means that the results are sensitive to small adjustments in the values of utilities assigned to the drop-out state.

The effects of posterior tibial nerve stimulation on refractory overactive bladder syndrome and bladder circulation.

AIM: We aimed to evaluate if posterior tibial nerve stimulation (PTNS) exerts its effects on overactive bladder symptoms through changes in bladder circulation. MATERIALS AND METHODS: Eighteen women who applied to Istanbul Medical Faculty with symptoms of urgency, frequency±urge incontinence and did not respond to anticholinergic treatment and behavioral modification were enrolled in the study. Weekly PTNS in 30-min sessions for 12 weeks was performed. Urogynecologic symptom assessment, 1-h pad test, bladder diary, King's Health Questionnaire (KHQ), and transvaginal Doppler ultrasonography were performed before and after treatment. RESULTS: Ten patients (55.5%) were cured, five (27.8%) improved, and no effect was observed in three (16.7%). No significant change was observed in systolic and diastolic flow rate, pulsatility index, resistive index, systolic/diastolic ratio and average flow rate. Significant decrease in frequency, urgency, urge incontinence, pad test results and increase in fluid intake was observed. There was a significant improvement in physical limitations and sleeping/energy domains of KHQ. No significant change was observed in urodynamics. CONCLUSIONS: PTNS does not have any effect on the bladder circulation despite positive effects on bladder diary, pad test, and quality of life in overactive bladder syndrome.

Highlights in the minimally invasive treatment of SUI in women.

OBJECTIVE: Treatment of stress urinary incontinence consists of a wide range of options, from conservative therapies like lifestyle changes, medication, pelvic floor muscles exercises, electro-stimulation, to minimally invasive procedures--injection of collagen, suburethral slings TVT/TOT and last but not least, invasive surgical treatment reserved for recurrent and complex cases. Among the latest minimally invasive procedures reported in literature, the injection of intra-and perisphincterian of autologous stem cell (mioblasts and/or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscles). MATERIAL AND METHOD: On October 18, 2010, in 'Fundeni' Clinical Institute of Uronephrology and Renal Transplantation was performed the first stem cell implantation procedure in the urethral sphincter, in Romania. RESULTS: Assessment at 6 weeks, the quality of life questionnaires, micturition diary and clinical examination revealed a stunning decrease of urine loss from 6 pads/day at one per day, which significantly improved the patient's quality of life. CONCLUSIONS: Stem-cell-mioblasts therapy may represent in the future an every-day intervention in the urologist's armamentarium. The effectiveness of this treatment can change the course of therapy and last but not least, the accessibility to urological evaluation of patients with stress urinary incontinence. Clinical and urodynamic evaluations will continue and will be future scientific topics.

Efficacy of the InVance™ male sling in treating stress urinary incontinence: a three-year experience from a single centre.

INTRODUCTION: The aim of this study was to evaluate the efficacy of the InVance™ male sling in treating stress urinary incontinence. PATIENTS AND METHODS: We retrospectively reviewed operative logs from a single surgeon of 43 patients treated over a 3-year period (Feb. 2004 to Nov. 2006) for stress incontinence by implantation of a male bulbourethral bone-anchoring sling (InVance™). The mean follow-up time was 24.2 months (range 4-38). Radical prostatectomy was the most common cause of incontinence in this group (33/ 43 cases; 76.7%). Efficacy was evaluated objectively in terms of the number of pads used per day, while subjective patient satisfaction was also recorded. We also investigated a possible correlation between preoperative parameters and outcome. RESULTS: Twenty-two patients (51.2%) were cured (totally dry: 30.2%; the remainder: 1 pad per day), while 8 (18.6%) patients improved but still required two pads per day. Overall, 30 of 43 patients (69.6%) were satisfied with the outcome of the operation. Postoperative infection was the most common complication (11.6%). The severity of preoperative incontinence correlated with the outcome of the operation, with mild incontinence giving better results. CONCLUSIONS: The bone-anchored male sling is an effective and minimally invasive treatment for mild-to-moderate male urinary incontinence.

A double-blind randomized controlled trial of electromagnetic stimulation of the pelvic floor vs sham therapy in the treatment of women with stress urinary incontinence.

OBJECTIVE: To compare the efficacy of extracorporeal electromagnetic stimulation (ES) of the pelvic floor for treating stress urinary incontinence (SUI) vs sham ES. PATIENTS AND METHODS: In all, 70 women with urodynamically confirmed SUI were randomized to receive active (35) or sham (35) ES. The NeoControl chair (NeoTonus, Marietta, GA, USA) was used, and treatment consisted of three sessions per week for 6 weeks. data were collected before and after treatment on all women, including a 20-min provocative pad-test with a predetermined bladder volume (primary outcome measure), a 3-day bladder diary and 24 h pad-test. Circumvaginal muscle (CVM) rating score, perineometry using two separate instruments and video-urodynamics were also used, and the Urinary Incontinence Quality of Life Scale (I-QOL) and King's Health Questionnaires. Patients were fully re-evaluated 8 weeks after treatment, and the bladder diary, pad-test and questionnaires were repeated at 6 months. The urotherapist and physician were unaware to which treatment group the patient was assigned. RESULTS: In the overall group of 70 patients there were significant improvements in each of the primary and secondary outcome measures at 8 weeks. There were also significant improvements in primary and secondary outcome measures in the active treatment group when compared with baseline measures. At 8 weeks, there were improvements in the mean (sd) values for the 20-min pad-test, of 39.5 (5.1) vs 19.4 (4.6) g (P < 0.001); the 24-h pad-test, of 24.0 (4.7) vs 10.1 (3.1) g (P < 0.01); the number of pads/day, of 0.9 (0.1) vs 0.6 (0.1) (P < 0.01), the I-QOL score, of 63.7 (2.8) vs 71.2 (3.3) (P < 0.001); and King's Health Questionnaire score, of 9.6 (0.8) vs 6.9 (0.7) (P < 0.001). However, these improvements were not statistically significant when compared with the sham-treatment group. In those patients on active treatment who had a poor pelvic floor contraction at the initial assessment (defined by the CVM score and perineometry), there was a significant reduction (P < 0.05) in the 20-min pad-test leakage when compared with the sham-treatment group. CONCLUSIONS: ES was no more effective overall than sham treatment in this patient group. However, in those women who were unable to generate adequate pelvic floor muscle contractions, there was an objective improvement in provocative pad testing when compared to sham treatment.

[Impact of global postural reeducation for treatment of female stress urinary incontinence]. / Impacto da reeducação postural global no tratamento da incontinência urinária de esforço feminina.

OBJECTIVE: To evaluate the effect of global postural reeducation (GPR) on stress urinary incontinence (SUI) and quality of life in SUI female patients METHODS: The study design was a prospective non-randomized clinical trial. Twenty-six patients with symptoms of SUI were selected from the Urogynecology Outpatient Clinics of the State University of Campinas (Unicamp), state of São Paulo, Brazil. Age ranged from 23 to 72 years old (mean 50.8). All women were submitted to anamnesis, physical exam, postural evaluation and urodynamic testing. Patients were treated by the GPR in individual 50 minute sessions weekly for three months and twice a month for the next three months. All patients were re-evaluated at the end of treatment and six months later by means of General Impression of Improvement, Incontinence Impact, General Perception of Health, Functional Evaluation of the Pelvic Floor, Number of Leaking Episodes and Pad Use. RESULTS: At the end of treatment 4 (16%) of the patients were cured, 18 (72%) had improved significantly and 3 (12%) failed. At 6 months, 6 (24%) were cured, 16 (64%) improved and 3 (12%) failed (p<0.001). Quality of Life questionnaires presented significant improvement (p<0.05) in all domains, with emphasis on General Perception of Health, Incontinence Impact and number of leaking episodes. The Functional Evaluation of the Pelvic Floor and Pad Use also presented significant (p<0.001) improvement. CONCLUSION: These results may demonstrate that GPR is an efficient alternative for treatment of stress urinary incontinence.

Impacto da reeducação postural global no tratamento da incontinência urinária de esforço feminina / Impact of global postural reeducation for treatment of female stress urinary incontinence

OBJETIVO: Avaliar os efeitos da reeducação postural global (RPG) nos sintomas de incontinência urinária de esforço (IUE) e a qualidade de vida em um grupo de mulheres incontinentes. MÉTODOS: Ensaio clínico aberto, tipo antes e depois, prospectivo, não randomizado. Foram selecionadas 26 mulheres com queixa clínica e estudo urodinâmico compatível com IUE, do Ambulatório de Uroginecologia do Hospital das Clínicas da UNICAMP. A idade média foi de 50,76 anos (23 a 72 anos). Todas as mulheres foram avaliadas por anamnese, exames clínicos e uroginecológico, avaliação postural. Todas foram submetidas a tratamento com RPG, em sessões individuais de 50 minutos semanais por três meses e quinzenais por mais três meses. As pacientes foram submetidas a posturas de alongamento propostas pela técnica, em que se coloca em tensão as cadeias musculares responsáveis pela postura estática e estrutura do corpo. O trabalho ativo da paciente nas correções, aliado à atuação do fisioterapeuta, levam ao reequilíbrio das tensões musculares e reestruturação do corpo, o que pode favorecer as funções, especificamente as relacionadas ao assoalho pélvico. Ao término do tratamento, e após seis meses, as pacientes foram reavaliadas através do questionário de impressão geral de melhora, dos domínios relacionados à IUE do King's Health Questinnaire: impacto da incontinência, em que se avaliam os prejuízos na qualidade de vida; percepção geral da saúde, qual a classificação que a paciente dá para sua saúde no momento e a presença do sintoma de perda por esforço; avaliação funcional do assoalho pélvico (AFA) e número de trocas de protetores diários. RESULTADOS: No término do tratamento, quatro pacientes (16 por cento) estavam curadas, dezoito (72 por cento) melhoraram significativamente e três (12 por cento) falharam. Após seis meses, seis pacientes (24 por cento) estavam curadas, 16 (64 por cento) melhoraram e três (12 por cento) falharam (p <0,001). Ao avaliarmos a qualidade de vida das pacientes, observamos melhora significativa (p <0,05) em todos os domínios questionados, destacando-se percepção geral da saúde, impacto da incontinência e número de episódios de perda. A avaliação do funcional do assoalho pélvico (AFA) e do teste do absorvente (número de troca/dia) também mostrou melhora significativa (p<0,001) nos diferentes tempos de coleta. CONCLUSÃO: Os resultados mostram que a RPG pode ser uma alternativa para o tratamento da IUE.

OBJECTIVE: To evaluate the effect of global postural reeducation (GPR) on stress urinary incontinence (SUI) and quality of life in SUI female patients METHODS: The study design was a prospective non-randomized clinical trial. Twenty-six patients with symptoms of SUI were selected from the Urogynecology Outpatient Clinics of the State University of Campinas (Unicamp), state of São Paulo, Brazil. Age ranged from 23 to 72 years old (mean 50.8). All women were submitted to anamnesis, physical exam, postural evaluation and urodynamic testing. Patients were treated by the GPR in individual 50 minute sessions weekly for three months and twice a month for the next three months. All patients were re-evaluated at the end of treatment and six months later by means of General Impression of Improvement, Incontinence Impact, General Perception of Health, Functional Evaluation of the Pelvic Floor, Number of Leaking Episodes and Pad Use. RESULTS: At the end of treatment 4 (16 percent) of the patients were cured, 18 (72 percent) had improved significantly and 3 (12 percent) failed. At 6 months, 6 (24 percent) were cured, 16 (64 percent) improved and 3 (12 percent) failed (p<0.001). Quality of Life questionnaires presented significant improvement (p<0.05) in all domains, with emphasis on General Perception of Health, Incontinence Impact and number of leaking episodes. The Functional Evaluation of the Pelvic Floor and Pad Use also presented significant (p<0.001) improvement. CONCLUSION: These results may demonstrate that GPR is an efficient alternative for treatment of stress urinary incontinence.

National audit of continence care for older people: management of urinary incontinence.

INTRODUCTION: the Department of Health report 'Good practice in continence services' highlights the need for proper assessment and management of urinary incontinence. The National Service Framework for Older People required service providers to establish integrated continence services by April 2004. A national audit was conducted to assess the quality of continence care for older people and whether these requirements have been met. METHOD: the audit studied incontinent individuals of 65 years and over. Each site returned data on organisational structure and the process of 20 patients' care. Data were submitted via the internet, and all were anonymous. RESULTS: the national audit was conducted across England, Wales and Northern Ireland. Data on the care of patients/residents with bladder problems were returned by 141/326 (43%) of primary care trusts (PCT), by 159/196 (81%) of secondary care trusts (involving 198 hospitals) and by 29/309 (9%) of invited care homes. In all 58% of PCT, 48% of hospitals and 74% of care homes reported that integrated continence services existed in their area. Whilst basic provision of care appeared to be in place, the audit identified deficiencies in the organisation of services, and in the assessment and management of urinary incontinence in the elderly. CONCLUSION: the results of this audit indicate that the requirement for integrated continence services has not yet been met. Assessment and care by professionals directly looking after the older person were often lacking. There is an urgent need to re-establish the fundamentals of continence care into the practice of medical and nursing staff and action needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice.

Neuromuscular electrical stimulation and the treatment of lower urinary tract dysfunction in multiple sclerosis--a double blind, placebo controlled, randomised clinical trial.

AIMS: Lower urinary tract dysfunction affects up to 75% of the multiple sclerosis population. Results from our recent Pilot Study (McClurg et al., 2006) indicated that a combined programme of pelvic floor muscle training, electromyography biofeedback and neuromuscular electrical stimulation modalities may alleviate some of the distressing symptoms within this population. This clinical trial aimed to evaluate further the efficacy of these interventions and to establish the benefit of neuromuscular electrical stimulation above and beyond that of EMG biofeedback and pelvic floor muscle training. METHODS: 74 multiple sclerosis patients who presented with lower urinary tract dysfunction were randomly allocated to one of two groups - Group 1 received Pelvic Floor Muscle Training, Electromyography Biofeedback and Placebo Neuromuscular Electrical Stimulation (n=37), and Group 2 which received Pelvic Floor Muscle Training, Electromyography Biofeedback, and Active Neuromuscular Electrical Stimulation (n=37). Treatment was for nine weeks with outcome measures recorded at weeks 0, 9, 16 and 24. The Primary Outcome Measure was the number of leakage episodes. Within group analysis was by Paired Samples t-test. Group differences were analysed using Repeated Measures Analysis of Variance and Post-hoc tests were used to determine the significance of differences between Groups at each time point. RESULTS: The mean number of incontinence episodes were reduced in Group 2 by 85% (p=0.001) whereas in Group 1 a lesser reduction of 47% (p=0.001) was observed. However, there was a statistically superior benefit in Group 2 when compared to Group 1 (p=0.0028). This superior benefit was evident in all other outcome measures. CONCLUSIONS: The addition of Active Neuromuscular Electrical Stimulation to a programme of Pelvic Floor Muscle Training and Electromyography Biofeedback should be considered as a first-line option in alleviating some of the symptoms of lower urinary tract dysfunction associated with multiple sclerosis.

[Stress urinary incontinence in women--current treatment alternatives]. / Stressinkontinens hos kvinner--aktuell behandling.

BACKGROUND: Stress urinary incontinence in women occurs frequently. This paper gives a review of current treatment alternatives. MATERIAL AND METHODS: The paper is based on the report from the 3 rd International Consultation on Incontinence, the Cochrane database, a PubMed search, and my own clinical experience as a urogynaecologist. RESULTS: General practitioners may initiate conservative treatment without extensive evaluation. The first line treatment is pelvic floor muscle exercises (8-12 strong contractions X 3 every other day). Motivation and compliance are extremely important. Electrostimulation and treatment with vaginal cones are other options with comparable efficacy. Weight reduction (5-10%) may improve the condition significantly. Medical treatment with duloxetine tablets has recently become available. The efficacy of duloxetine is similar to that for pelvic floor exercise. Currently the most commonly used surgical procedures are midurethral retropubic or transobturatoric tension free vaginal tape, which are often done as day surgery and have lower morbidity than older procedures. Approximately 90% of the patients are satisfied with the results, and they continue to be so over time. Stress incontinence surgery is associated with complications such as de novo urge incontinence, impaired bladder emptying, recurrent urinary tract infections, pain and genital prolapse, but the risk is probably lower with tension free vaginal tape than with the older surgical methods. INTERPRETATION: Conservative treatment may reduce incontinence in many patients; it is simple, inexpensive and without risk of complications and is therefore the primary treatment option. Surgical treatment may cure the incontinence permanently, but there is a risk of permanent complications.