Impact of menopausal status on the outcome of pelvic

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physiotherapy in women with urinary incontinence. Christiana Campani Nygaard ... Department of Obstetric and Gynecology, General Hospital of. Nikaia, Athens ... Estrogens play an important role in lower urinary tract func- tion throughout the ...
Int Urogynecol J DOI 10.1007/s00192-013-2179-7

ORIGINAL ARTICLE

Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence Christiana Campani Nygaard & Cornelia Betschart & Ahmed A. Hafez & Erica Lewis & Ilias Chasiotis & Stergios K. Doumouchtsis

Received: 19 December 2012 / Accepted: 12 February 2013 # The International Urogynecological Association 2013

Abstract Introduction and hypothesis The purpose of this study was to evaluate the effectiveness of pelvic floor muscle training in pre- and postmenopausal women using a quality-of-life questionnaire. Methods We retrospectively reviewed the medical records of 96 patients with urinary incontinence who participated in a pelvic floor muscle-training (PFMT) program at the Physiotherapy Department in a London University Hospital between January 2010 and August 2011. Results A period of supervised PFMT resulted in significant improvement in symptoms of stress urinary incontinence, urge urinary incontinence, urgency, frequency, and nocturia, irrespective of menopausal status.

C. C. Nygaard (*) Departament of Gynaecology, Pontifícia Universidade Católica do Rio Grande do Sul, St George´s Healthcare NHS Trust, Porto Alegre, Brazil e-mail: [email protected] C. Betschart Department of Gynecology, University Hospital Zurich Zurich, Switzerland A. A. Hafez Faculty of Health and Social Care Sciences, Kingston University, St. George’s University of London, London, UK E. Lewis St George’s Healthcare NHS Trust, London, UK I. Chasiotis Department of Obstetric and Gynecology, General Hospital of Nikaia, Athens, Greece S. K. Doumouchtsis St George’s Healthcare NHS Trust / St George’s University of London, London, UK

Conclusions Pre- and postmenopausal women experience similar outcomes in relation to urinary symptoms following a short-term supervised PFMT. Keywords Pelvic floor muscle training . Premenopausal . Postmenopausal . Urinary incontinence Abbreviations UI PFMT PFM SUI UUI QOL ICIQ-FLUTS

OAB HRT BMI

Urinary incontinence Pelvic floor muscle training Pelvic floor muscle Stress urinary incontinence Urge urinary incontinence Quality-of-life questionnaire International Consultation on Incontinence Modular Questionnaire/Female Lower Urinary Tract Symptoms Overactive bladder Hormonal replacement therapy Body mass index

Introduction Urinary incontinence (UI) is a common condition, with approximately 10 % of women experiencing urine leakage at least once a week, with a significant impact on quality of life (QOL) [1]. Current guidelines recommend conservative management, defined as interventions that do not involve treatment with drugs or surgery, as a first-line therapy [2, 3]. A trial of pelvic floor muscle training (PFMT) of at least 3 months should be offered, with reasonably frequent appointments [3, 4]. It has been reported that women receiving regular supervision are more likely to comply and report improvement than women doing PFMT with little or no supervision [4].

Int Urogynecol J

PFMT is based on principles of strengthening the muscular components of the urethral closure mechanism. Intensive strength training may build up structural support of the pelvis by permanently elevating the levator plate to a higher position inside the pelvis. It also enhances hypertrophy and stiffness of connective tissues [5–7]. The bladder neck receives support from a strong, toned PFM, which limits its downward movement during effort and exertion, preventing stress urinary incontinence (SUI) [8]. PFM contraction stimulates sympathetic nerve fibers of the internal urethral sphincter, decreases detrusor muscle tone, and suppresses detrusor contraction , which prevents urinary urgency incontinence (UUI) [8]. Female genital and urinary tracts share a common embryologic origin arising from the urogenital sinus. Both are sensitive to the effect of female “sex” steroid hormones. Estrogens play an important role in lower urinary tract function throughout the adult lifespan. Estrogen deficiency after menopause causes atrophic changes to the urogenital tract and is associated with urinary symptoms [9]. Estrogens also increase urethral closure pressure, urethral blood flow, αadrenergic receptor sensitivity, and improve cellular maturation in both the urethra and vagina [10]. As the tissues involved in the female urinary continence mechanism are estrogen sensitive, it is possible that estrogen deficiency after menopause may be an etiological factor in the development or progress of UI. The condition may improve with the use of local estrogen treatment [11]. However, a systematic review of the literature reveals little evidence from trials on the period after estrogen treatment had finished [12]. In addition, no evidence is available regarding long-term effects of this therapy. Conversely, in the same review, systemic hormone replacement therapy using conjugated estrogen showed it may even worsen incontinence [11]. Thus, evidence does not favor a beneficial effect on SUI with the use of local estrogen therapy [12]. Our hypothesis is that estrogen status may be an important contributing factor to the effectiveness of pelvic floor physiotherapy. Therefore, the aim of this study was to evaluate and compare the effectiveness of PFMT in improving bladder symptoms in pre- and postmenopausal woman.

Materials and methods This was a retrospective study designed to evaluate the effectiveness of PFMT in pre- and postmenopausal patients with UI. The primary outcome measure was the assessment of bladder symptoms before and after a period of supervised and standardized PFMT. All women who attended the Physiotherapy Department in a London University Hospital with UI between January 2010 and August 2011, who participated in a specific PFMT program, and who completed the questionnaire were included (n=47 pre- and n=35 postmenopausal women). The

one-to-one PFMT sessions were conducted in ambulatory hospital settings and supplemented by an individually instructed and progressively adapted home exercise program. Education on pelvic floor and bladder function was offered to all patients. In addition, patients were instructed about the correct PFM activation assessed by digital vaginal palpation in order to empower their ability to incorporate PFMT in routine daily life. Women with overactive bladder (OAB) symptoms were instructed to gradually prolong voiding intervals and alter drinking and voiding behavior, as recommended. Patients who had difficulties contracting PFM were supported by electromyography biofeedback during office sessions to help them recognize the right technique for muscle contraction [3]. Symptoms were assessed based on results of the validated International Consultation on Incontinence Modular Questionnaire/Female Lower Urinary Tract Symptoms (ICIQFLUTS) questionnaire [13]. Each answer in the questionnaire corresponds to a numerical value (0, 1, 2, 3, or 4), depending on the intensity of each symptom, where the greater the number, the more severe and troubling the symptom. Changes in symptoms with training were estimated according to changes in these scores. The questionnaire is composed of 12 items, but we particularly focused on OAB symptoms, such as frequency of micturition, nocturia, urgency, urinary urgency incontinence (UUI), and SUI. To control for varying age of menopause onset and the possibility of gradual changes over that critical period, 14 women between the ages of 45 and 55 years were excluded. This would remove perimenopausal women from our cohort. Menopause occurs at a median age of 51.4 years. The menopausal transition, or perimenopause, begins on average 4 years before the final menstrual period and occurs on average at 47 years. It includes a number of physiological changes and marked hormonal fluctuations [14, 15]. We decided to avoid using data for any patient in this age category. Patients >55 years were accepted as postmenopausal, and patients