Urinary incontinence is defined as an
involuntary urine leakage under the definition of International Continence
Society and is classified into stress-type, urgency-type, mixed-type, and
overflow-type. Stress urinary incontinence (SUI) is involuntary urine leakage
when abdominal pressure increases, such as cough, sneezing, and straining. Its
major pathogenesis can be largely explained by two mechanisms; hypermobility of
bladder neck and urethra when abdominal pressure increases due to postpartum
weakening of pelvic muscle and pelvic atony in women; and deficiency of
urethral sphincter itself.
Decline in quality of life and expenditure of
medical bill due to urinary incontinence can give a great influence in women’s
social life. Prevalence of female urinary incontinence is 30~40% in younger
women, increases in middle aged women up to 30~50%, and stays at such level in
older women. In regard to type of urinary incontinence, SUI is most common with
49%, second most common is mixed-type urinary incontinence with 29% and third
most common is urgency-type urinary incontinence with 21%. As for prevalence in
Korea, 24.4-41.2% complained of urinary incontinence when analyzing 1,000 or
more women. Of those, SUI constituted 48.8%, mixed-type 41.6%, and urgency-type
7.7%, in which prevalence of SUI was the highest. Influence of urinary
incontinence is not to be overlooked in socio-economical and individual
aspects. Though there are not much data in Korea, based on data from western
countries, more than 1.1 million patients in the U.S visited hospital for
urinary incontinence as their chief complaints in year 2000 alone, and the
amount spent in its diagnosis and treatment was 19.5 billion dollars, which is
safe to say that it caused more socioeconomical loss than any other chronic
diseases. Analysis of individual patients revealed that women with severe
urinary incontinence showed more severe depression, negative thoughts and lower
satisfaction in quality of life, which induced various physical and
psychological disorders.
SUI is majorly due to weakening of pelvic
musculature and urethral sphincter and when some severe SUI symptoms arise to a
certain level, surgical treatment is mostly conducted in Korea. But when
symptom of the patient is not severe, or patient refuses the surgery due to
health status, there are some conservative treatments to improve symptoms.
Conservative treatments of SUI include modification of life style, behavior
therapy, and pelvic floor muscle exercise (PFME). Modification of life style is
to alleviate symptoms of urinary incontinence by modifying chronic
constipation, obesity, smoking, and caffeine intake, but its scientific
evidence is weak to routinely approve such approach. Behavior therapy includes
bladder training and education of voiding mechanism and is mostly effective in
urgency-type urinary incontinence. Though it has been reported that it
decreased around 50% of urinary incontinence in treatment of SUI, its effects
in clinical practice is restrictive as the patient’s motive in therapy is crucial.
PFME, among treatment of SUI, was first
proposed by Dr. Arnold Kegel in 1948 for prevention and treatment of
post-partum urinary incontinence and various modifications have been attempted
to improve its therapeutic effect. Theological background of PFME is to
increase muscular capacity with exercise and support pelvic organ structurally,
preventing descent of bladder neck and urethra with quick pelvic floor muscle
contraction when abdominal pressure abruptly increases. To be more specific, it
is to enhance passive urinary continence by placing pelvic organ with
reinforcing and hypertrophying pubococcygeus muscle among anal elevating
muscles and active urinary continence of bladder neck and urethra with
repetitive contraction exercise. In order for PFME to be effective, selection
of appropriate patients is crucial. PFME has no side effect and does not affect
other treatment so it can be utilized as primary treatment of SUI. However, it
is more effective in patients with less severe symptoms, patients receiving
estrogen therapy after menopause, patients with normal body weight, and
patients with no history of previous urinary incontinence surgery. The most
important point is that patient must recognize contraction and relaxation of
pelvic muscle from education. To be said, muscles other than pelvic floor
muscles like abdominal or buttock muscles should not contract, and only pelvic
floor muscles should be selectively contracted and relaxed for its maximum
effect. There is no standard guideline on training frequency or repetition of
PFME, but International Continence Society recommends 8 to 10 repetition with 6
to 8 seconds of contraction each time exercised 3 to 4 times a week. As for
duration, it is recommended to be continued for at least 15 to 20 weeks. In recent
meta-analysis, PFME showed cure rate of 56%, which showed improvement in cure
rate of 8 times than control group and overall improvement rate of 17 times
than the control group. Therefore, it can be effective as a primary treatment
for SUI in optimal patient group.
Among PFME methods, 4 methods are commonly
used in order to increase cognition of pelvic floor in patients and increase
exercise outcome. Vaginal cone uses heavier vaginal cone stage by stage for
patient to exercise while identifying pelvic floor muscle and has been approved
of its effect from meta-analysis. In some cases, electrical stimulation and
extracorporeal magnetic therapy can be conducted simultaneously with PFME, but
the protocol has not yet been established and there are many negative opinions
on its long-term effect.
Biofeedback includes all methods that give
direct audiovisual stimuli to patient during exercise and modifying cognition
and contraction of pelvic floor muscle. About 30% of patients were incapable of
contracting pelvic floor muscles adequately when they heard PFME method via
literature or verbal instruction, and biofeedback was introduced to supplement
such problem and enhance its effect. In conclusion, it is to give feedback to
patients by showing electromusculography or sphincter pressure as audiovisual
cues and train them repeatedly until they can selectively control the proper
muscle. Though there is no standard guideline on biofeedback in PFME,
continuous education is recommended after education of 30 minutes or longer, 2
or more times a week, for more than 1 month. In regard to simultaneous
treatment of biofeedback in PFME, there are many conflicting reports on its
significance in therapeutic effect, but it is recognized to be helpful in
faster relief of urinary incontinence. Previous studies found PFME with
biofeedback to be more effective in improvement of pelvic floor muscle
contraction than PFME alone, whereas one study reported PFME with biofeedback
to be more effective in improving pelvic floor muscle contraction, but with no
additional benefit of average decrease in urinary incontinence. From analysis
of 10 randomized studies, PFME with biofeedback was reported to be no more
effective than PFME alone, but recent meta-analysis reported PFME with
biofeedback to have some more advantage in improvement rate than PFME alone. In
addition, one recent study reported that PFME with biofeedback alleviated SUI
symptoms in earlier stage with use of new biofeedback device that uses
vibration.
Such result of PFME treatment with biofeedback
is facilitating many portable biofeedback PFME devices to be sold in market so
that home training would be possible, rather than in hospital. Such portable
devices use various biofeedback methods and increase outcome of PFME with improvement
of probe mechanism. The most typical method would be to measure intra-vaginal
pressure with intra-vaginal probe when the patient is conducting PFME and
provide feedback after assessing whether patient is conducting PFME properly,
which is clinically safe and shows great effect in relief and treatment of
urinary incontinence. Such portable biofeedback devices are clinically safe and
show great effect in relief and treatment of urinary incontinence. These
devices also help achieve improvements in sexual function.
Seong-Jin Jeong, M.D.
Professor of Urology, Seoul National
University Bundang Hospital