Efficiency of a pelvic floor exerciser for the treatment of stress incontinence in women

Prof. H Enzelsberger; Ch. Kurz; I. Michl


 

 


 

Urinary incontinence in women is an important social medical and hygene problem for women in all age groups. Almost half of all post-menopausal women suffer from at least mild urinary incontinence. The bladder and the urethra work together in procuring a normal filling and voiding mechanism. The most important function of the urethra is its ability to close – the state of inhibited function of the urethra is called urinary incontinence.

 

The pelvic floor muscle plays a central role in the treatment of urinary incontinence. The pelvic floor muscle is the only muscle which is in a position to elevate the contracted urinary tract. The muscles of the urethra together with the adjecent sceletal muscles of the pelvic floor work together to allow the movement of in part voluntary and in a part involuntary closing and opening necessary to facilitate normal voiding and closing of the urinary tract. In patients who suffer from acute urinary incontinence the urethra is typically shorter than in healthy  subjects. The strengthening of the levator muscles which are an essential part of the pelvic floor muscle group can be effectively shown with a perineometer according to Kegel. However it is important to note that no major anatomical damages may be present to allow for the pelvic floor exercises to take effect. For instance in the case of an enlarged cystocele or in the case of a decensus the exercises of the pelvic floor can not result in an improvement in the condition. In these cases alternative treatment methods such as surgery combined with physical therapy are needed.

 

Furthermore different approaches exist for the conservative therapies of the pelvic floor which are only one treatment alternative next to medication and surgery.

 

Pelvic floor therapy is defined as the repeated voluntary contraction of specific pelvic floor muscles. These exercises require that the patient develops a sense of control over the correct muscles and an ability to relax adjecent muscle groups. Muscle control is important to facilitate these exercises and to strengthen muscels which are either damaged from vaginal deliveries or which are chronically weak.

The exercises specifically target the diaphragma urigenitale and the m levator ani.

 

The goal of the present study was to explore and measure the possible improvement of patients with urinary stress incontinence when they perform home exercises of the pelvic floor against a resistance. This type of exercise allows a faster muscle build up in comparison to the traditional isometric exercises which are performed without any resistance.

 

 

Material and Methods

 

20 pre and post-menpausal patients of the uro-gynecological station of the University women´s clinic for child delivery and gynecology with stress incontinece of the first and second degree were recruited for this study between October 1993 and March 1994. Each of the recruited participants participated in a second clinical evaluation which followed the diagnosis of incontinence to determine neurolgical status and to perform urodynamic testing.

 

After patients consent was obtained, a cystho-urethrotonomtry was performed with the Millar Microtip transducer method with a simultanous measurement of bladder pressure and anal pressur (Stetham-element) in half horizontal position of the patient.

 

The descriptive statistics of the patients are shown in table 1. Subsequently the patients were instructed to use the recently patented device to perform pelvic floor contractions against an adjusteable resistance.

 

The patients learned the exercises together with a physician and the performed the exercises in an unsupervised setting at home during a duration of 4 weeks. Patients were instructed to perform the exercises at least twice per day and had to present themselves for weekly check-ups. The pressure in the sensor was adjusted depending on the individual progress of the patients.

 

 

The pelvic floor exerciser

 

The exerciser has a total length of 95mm of which only a length of 65 mm can be inserted while the remainder functions as a handle which doctors or patients can use to control insertion manually. The top of the inserteable part is a 40mm wide head which is based on an inflatable portion of 35mm in length and of 32 mm width in relaxed state. When the sensor is inflated the width of the sensor can increase up to 55mm when the maximum sensor pressure of 300mm/hg is applied. A tube is connecting the airchamber in the sensor with a pressure display as well with a pump which can be used to increase the pressure and a valve which can be used to decrease the pressure in the sensor.

 

The display shows two types of pressures. First the base pressure which is set after insertion of the sensor and second the minimal pressure differential which the patient ought to achieve for the device to register a successful contraction. Thus the goal for the patient is to increase the pressure in the sensor more that the set differential pressur ein addition to the base pressure. For instance at a base pressure of 100 and a goal pressure of 10 mm/hg the patient has to achieve a pressure of 110 mm/hg to register a successful contraction. As soon as a successful contraction registers the device produces a pieping sound which informs the patient that the correct muscles were contracted and that the goal pressure was achieved.

 

The exercises are performed by inserting the sensor into the vagina until the vulva is adjacent to the inflateable portion of the sensor. Then the patient increases the pressure in the sensor until she feels a slight pressure from the incresed sensor size. Then the base pressure is set and the patient begins to exercise at the base pressure by excerting voluntary movements of the pelvic floor against the sensor. The patients were instructed to perform to sets of 30 contractions each day over a period of 4 weeks. The contractions were supposed to be performed in 2 sets, one in the morning and one in the evening. The statistical analysis of the results was performed with a Wilcoxon test.

 

 

Results and discussion

 

The data of the patients were summarized in table 1. The mean age of participants was 52.3 years. 5 women had uterusexstirpation and 3 women had colporraphia anterior. At the time of the follow up exams it was found that 9 women (45%) improved to a point were they did not find further surgical tratment as necessary. Another 6 women (30%) reported subjective improvements in their voiding patterns. 5 patients (25%) did not report any subjective improvement after the exercise regimen was completed.

 

The aforementioned critaria of inclusion guaranteed that no patients who could not potentially benefit from the exercises were included in this study. 75% of the patients reported at least some improvement after 4 weeks of exercises in their voiding pattern. Allthough the exercises also resulted in anatomical improvemets such as length of the urethra, these improvemets were statistically insignificant, which could be a function of the small sample or the relatively short observation period.

 

The observation started with 27 patients of whom 7 patients were lost due to this patients´ lack of compliance with the requiremnts of the study (daily exercises, keeping of records, weekly check-ups). It was the goal of this prospective study to evaluate the efficacy of pelvic floor exercise with a pelvic floor exerciser in a female population with moderate urinary stress incontinence.

 

 

 

 

 

 

 

 

 

 

 

 

Table 1:

 

Patient data

 

 

 

N

20

Age

52,3 years

Weight

69,2 kg

Parity

1,9

Pre-surgeries (Vag./Plast.)

5/3

Psychological strain

existing

Stress incontinence

20

Cystocele I-II

9

Hormonal status (FSH)

41,1

 

 

 

 

Clinical and urodynamic parameter before and after pelvic floor muscle training with pelvic floor muscle trainer

 

 

Parameter

Before

After

Cystmetrie

 

 

First urge (ml)

130,5

135,2

Imp. Urge (ml)

310,8

340,4

Pads (n)

5

2

 

 

 

Urethra profile

 

 

FUL (mm)

23,8

26,5

UVDR max. (cm H2O)

42,2

50,1

DepQ

0,6

0,4

 

 

 

Uroflow

 

 

Spontaneous miction (ml)

295,7

315,2

Miction time (sec)

20,5

18,6

Rest urine (ml)

1

1