October 8th, 2014
Pelvic Physical Therapy Distance Journal Club
Description: This
guideline from the American College of Physicians (ACP) presents the available
evidence on the nonsurgical (pharmacologic and nonpharmacologic) treatment of
UI in women in the primary care setting.
Nonpharmacologic Treatments for UI
1)
PFMT
a.
Instruction on the voluntary contraction of
pelvic floor muscles
2)
PFMT with biofeedback using vaginal EMG
a.
PFMT with vaginal probe
3)
Bladder training
a.
Behavioral therapy that includes extending the
time between voiding
4)
Continence service
a.
Treatment program involving nurses and
clinicians trained in identifying, diagnosing and appropriately treatment
patients with UI
Methods: This
guideline is based on a systemic evidence review that addressed 13 questions
related to the diagnosis and nonsurgical management of UI. The literature search included
English-language studies published between 1990-2013. This guideline focuses on treatments most
relevant to primary care clinicians.
Diagnosis:
Because most women with UI do not report it to their physicians, physicians
should proactively ask female patients about bothersome UI symptoms as part of
a routine review of systems.
Treatment:
Complete continence (defined as reducing UI by greater than or equal to 50%)
and QOL were the primary outcomes assessed in the systematic review to evaluate the effectiveness of non-pharmacologic
and pharmacologic treatments:
1)
Stress UI: Nonpharmacologic treatment
a.
PFMT vs No Active Treatment
i.
PFMT is an effective UI treatment compared with
no active treatment.
b.
PFMT with Biofeedback using a vaginal prove vs
No Active Treatment
i.
Improved UI with this treatment vs no active
treatment
2)
Urgency UI: Nonpharmacologic treatment
a.
Bladder training vs No active treatment
i.
Insufficient evidence for assessment
3)
Mixed UI: Nonpharmacologic Treatment
a.
PFMT vs No active treatment
i.
Increased continence rates with PFMT compared
with no active treatment
b.
PFMT plus bladder training vs No Active
Treatment
i.
Continence achieved with PFMT and bladder
training compared with no active treatment
c.
Continence Services vs No active treatment
i.
No statistically significant improvement
d.
Weight Loss and Physical Activity vs No Active
Treatment
i.
Weight loss and exercise improved UI in obese
women
4)
Stress UI: Pharmacologic Treatment
5)
Urgency UI: Pharmacologic Treatment with
Antimuscarinics
6)
Urgency UI: Pharmacologic Treatment with
B3-Andrenoceptor Agonists
7)
Urgency UI: Other Pharmacologic Treatment
8)
Urgency UI: Comparative Effectiveness of
Pharmacologic Treatments
9)
Comparative Effectiveness of Pharmacologic
Versus Nonpharmacologic Treamtents
10)
Role of Patient Characteristics on Outcomes of Pharmacologic Treatments
a.
Age
b.
Race
c.
Baseline Frequency of UI
d.
Prior Treatment Response
e.
Concomitant Treatments
f.
Obesity
11)
Adverse Effects
a.
Nonpharmacologic Treatments
b.
Pharmacologic Treatments
Recommendations:
1)
ACP recommends first-line treatment with PFMT in
women with stress UI
2)
ACP recommends bladder training in women with
urgency UI
3)
ACP recommends PFMT with bladder training in
women with mixed UI
4)
ACP recommends against treatment with systemic
pharmacologic therapy for stress UI
5)
ACP recommends pharmacologic treatment in women
with urgency UI if bladder training was unsuccessful
6)
ACP recommends weight loss and exercise for
obese women with UI
Discussion:
1)
“Clinical research always is going to lag behind
clinic practice. You have to think of it first.
Then you try something based on the best available research, what your
clinical judgment is telling you, what’s going on in the patient’s world and
what’s important to him/her. You put all
of that together to come up with the best solution. You want PTs to use the existing evidence as
a springboard to further innovation.”
Mary Massery (PTinMotion May 2014)
2)
Incorporating technology into treatment:
a.
Apps
i.
Kegel Kat
ii.
Bladder tracHer apps (multiple available)
iii.
Myfitnesspal
b.
Online resources:
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