By Chiara Ghetti, MD

Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis

Dr. Ghetti reports no financial relationships relevant to this field of study.

Synopsis: Pelvic floor physical therapy with myofascial release techniques improves urinary symptoms and provides an alternate option to medications and more invasive therapies.

Source: Adams SR, et al. Pelvic floor physical therapy as primary treatment of pelvic floor disorders with urinary urgency and frequency-predominant symptoms. Female Pelvic Med Reconstr Surg 2015;21:252-256.

The objective of this study was to assess the efficacy of pelvic floor physical therapy (PFPT) as primary treatment for urinary urgency and frequency symptoms. This was a case series study of 36 women with urinary urgency and frequency completing 10 weeks of PFPT. The main outcome measures used to assess symptom improvement were the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) and Patient Global Impression of Improvement (PGI-I). Women were excluded if their diagnosis included stress incontinence or stress predominant-mixed incontinence, if they had previous surgical treatment for urinary incontinence, if they had undergone PFPT within 1 month of presentation, if they were taking or wanted to initiate anticholinergic medication for incontinence, or if they did not wish to try PFPT as a management option.

Of the 57 women enrolled over 18 months, 31 completed 10 weeks of PFPT. Participants were referred to one physical therapy group practice, all of which endorsed similar treatment philosophies and modalities. All subjects were taught about healthy bladder habits and fluid management. Subjects were also educated about pelvic floor anatomy and function and normal bladder function (in relationship to urge and voiding). Subjects were taught urge suppression techniques and exercises to facilitate pelvic floor muscle release and improved pelvic floor coordination. PFPT included external trunk and lower extremity connective tissue manipulation and intravaginal myofascial release techniques. Relevant findings from postural, movement, and lumbopelvic-hip examination were addressed on an individual basis using standard physical therapy interventions. Electrical stimulation and traditional Kegels for strengthening or urinary urge suppression were excluded interventions.

Women enrolled had overactive bladder (OAB) with the following primary diagnoses: urge-predominant mixed urinary incontinence (12; 33.3%), urgency/frequency symptoms (10; 27.8%), urgency urinary incontinence (2; 5.6%), and painful bladder syndrome (12; 33.3%). After completing PFPT, women reported significant decreases in the urinary and prolapse symptoms subscales of the PFDI-20. In addition, 62.5% of subjects reported their symptoms were “much better” or “very much better” by the PGI-I.

COMMENTARY

Urinary urgency and frequency symptoms significantly affect the quality of life of millions of women and lead to significant psychological distress.1 Urgency and frequency urinary complaints are common in a spectrum of diagnoses, including OAB, urge-predominant mixed urinary incontinence, or painful bladder syndrome. Incontinence, pain, and pressure symptoms can commonly be associated with symptoms of urgency and frequency. Treatment options for urinary symptoms include behavioral modification, pharmacologic treatment, sacral or peripheral neuromodulation, and intravesical botulinum toxin. Pelvic floor physical therapy is often overlooked as a therapeutic approach in the treatment of patients with urinary urgency and frequency symptoms. Several studies have demonstrated the efficacy of pelvic floor muscle training in stress and mixed urinary incontinence; however, the data for efficacy of PFPT for OAB are limited.2

In a prior issue we reviewed a paper on PFPT and levator myalgia. The current study further highlights the important relationship between pelvic floor muscles and pelvic floor symptoms, in this case specifically urinary symptoms. This is a topic that is near and dear to my practice. My clinical experience has repeatedly shown that women with urinary symptoms of urgency and frequency show dramatic improvement with behavioral changes and by addressing pelvic floor muscle dysfunction with physical therapy and myofascial release.

This study attempts to assess urinary symptom improvement in subjects with urgency and frequency symptoms who chose PFPT as a therapeutic option. The study design was a case series. Subjects who met enrollment criteria were assessed before and after their chosen treatment of PFPT as a therapeutic option. This study lacked a comparative group that did not undergo PFPT or who underwent basic education alone but the outcomes are still valuable. This would have been a stronger study as a randomized intervention trial with a control group. In addition, this study does not determine the duration of effect of PFPT, the need for further physical therapy, or the addition of other treatment modalities. Despite these flaws, the data demonstrated that many women had improvement in pelvic floor symptom after PFPT, which is consistent with what I see in practice. PFPT is a feasible therapeutic option for urinary symptoms that may have the ability to impact a large number of women.

REFERENCES

  1. Stewart WF, et al. Prevalence and burden of overactive bladder in the United States. World J Urol 2003;20:327-336.
  2. Berghmans LC, et al. Conservative treatment of urge urinary incontinence in women: A systematic review of randomized clinical trials. BJU Int 2000;85:254-263.