Urogynecology: Evidence-Based Clinical Practice 2nd ed.

6. Conservative Therapy of Urodynamic Stress Incontinence

Kate H. Moore1

(1)

Department Obstetrics & Gynaecology, St George Hospital, Kogarah, New South Wales, Australia

Abstract

When starting a patient on a conservative treatment program for stress incontinence, you must check whether there are uncorrected precipitating factors.

Managing Chronic Cough and Obesity

When starting a patient on a conservative treatment program for stress incontinence, you must check whether there are uncorrected precipitating factors.

It is demoralizing for the patient to work hard on a pelvic floor muscle training program if she has uncorrected chronic cough. We often see patients with chronic sinusitis, nasal polyps, postnasal drip, or asthma/chronic bronchitis, who have never seen an ENT surgeon or had optimal asthma therapy and so on.

Many general practitioners have had no training in managing incontinence during their undergraduate years. They may not realize that in the last 20 years, major advances have been made in conservative continence therapy, but we cannot achieve cure in the presence of an unrelenting cough. Hence, the urogynecologist may need to refer such patients to the appropriate ENT surgeon or respiratory physician.

Similarly, marked obesity should be reduced whenever possible. A large randomized controlled trial in 2010 showed that obese women who lost 10 % of their body weight were significantly likely to achieve at least a 70 % reduction in the frequency of incontinence [35]. Increases in body mass index relate directly to increased risk of incontinence [31].

In women with truncal distribution of fat, serum insulin levels may reveal insulin resistance, which warrant referral to an endocrinologist for metformin therapy to enhance weight loss [12].

By striving for reasonable weight loss, you may convert a patient from someone who needs surgery, with the attendant risks in the obese, into a woman who can achieve cure from a conservative program. In our unit, we do not routinely offer continence surgery to an obese woman without a serious trial of weight loss, because the weight loss may obviate the need for surgery and anesthesia (and the well-known surgical complication of detrusor overactivity or voiding difficulty; see Chap. 9).

Having said this, some obese women are trapped in a vicious circle. They need to exercise in order to lose weight, but whenever they exercise, they leak much more urine than in daily life. In this scenario, we usually strike a deal with the patient. If they can start the process and lose even 5 %, then we will offer surgery if supervised pelvic floor training does not achieve major benefit.

Treatment of Constipation

Uncorrected constipation (with chronic straining to defecate) is an acknowledged risk factor for stress incontinence. Patients need to learn how to manage this problem before they can expect a conservative program to work.

Further information is provided in Chap. 8 on obstructed defecation, but in essence management is as follows:

·               Colorectal surgeons recommend the use of bulking agents such as Metamucil, psyllium husks (from which Metamucil is manufactured), or Movicol.

Normacol granules are better tolerated by some patients.

·               A dessert spoon of psyllium husks or Metamucil should be dissolved in 400 ml of water in order to achieve a moist stool that is easily passed. Putting these substances onto the cornflakes in the morning is of no benefit, they must be dissolved in a plentiful amount of water!

·               A lubricating substance, such as Agarol or lactulose, can be added, to lubricate the bolus of stool as it moves down the gut.

·               In cases where the call to stool is felt, but the bolus of feces cannot be evacuated, then rectal glycerin suppositories are inserted to encourage defecation in this circumstance.

Simply getting the patient to eat a large juicy orange with three to four prunes first thing in the morning, with dilute hot tea, then sitting and relaxing on the toilet can be remarkably helpful.

·               Regular use of Senokot is now considered unwise, although intermittent doses help if all else fails. Studies by colorectal surgeons indicate that this agent stimulates the nerves of the gut to increase peristalsis and may induce a state of dependence. Eventually, the colonic nerves may become refractory.

Treatment of Postmenopausal Urogenital Atrophy

We all know that incontinence is more common as age advances, with a peak at the menopause. Because estrogen receptors are known to occur in the urethra, estrogen therapy should give benefit, by thickening the urethral epithelium, improving mucosal coaptation, and enhancing vascular tone in the periurethral vessels.

The Cochrane meta-analysis on use of estrogens for incontinence in 2002 analyzed both systemic and topical estrogen data. They concluded that topical estrogen has about a 50 % benefit for incontinence compared to a 25 % benefit for patients on placebo [23]. Systemic estrogen therapy (HRT) is no longer recommended, as two large trials have shown that stress incontinence was worsened in those on HRT compared with those on placebo [1418]. The most recent Cochrane review [8] concluded that four small trials of vaginal estrogen revealed a significant benefit (RR 0.74, 95 % CI 0.64–0.68) for improvement or cure of incontinence.

The objective benefit of topical vaginal estrogen cream in stress incontinence has received little study. In four small open (nonrandomized, noncontrolled) studies, three showed significant increase in urethral function tests, and one showed subjective benefit for continence (20 % dry, 55 % major benefit) [10]. A fifth study showed cure or major benefit on pad testing in 12 % of patients versus 0 % of controls (for review see Moore [24]).

Practical Advice for Patients

Many elderly women dislike the vaginal applicator that accompanies oestriol cream (Ovestin). It is cumbersome for those with arthritis, and many do not like inserting the applicator all the way into their vagina and then having to wash it. Some patients stop using it for these reasons (and the first two complaints apply to Vagifem tablets). We encourage patients to put a small amount on their finger and apply it around and just inside the vagina, last thing at night before sleep. Most women find this much more acceptable than using a messy applicator.

Many women ask whether the use of vaginal oestrogens will increase the risk of breast cancer. In general, the blood levels of oestriol are well below the menopausal levels (90 picomol/l) in women on Ovestin cream. However, a small study of women on Vagifem tablets [20] suggested caution in those on aromatase inhibitors to suppress early breast cancer.

Starting a Home-Based Pelvic Floor Muscle Training Program

The first step in starting a pelvic floor muscle (PFM) training program should be done during the physical examination (see Fig. 6.1). That is, palpate the PFM digitally; make sure the patient can contract the correct muscle. Discourage her from:

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Figure 6.1

Assessing the pelvic floor muscles

·               Contracting the gluteal muscles (lifting buttocks off the bed)

·               Contracting the adductor muscles (tightening thighs together)

·               Contracting the abdominal muscles (bearing down on the pelvic floor)

Contracting these muscles will not help and may make leakage worse.

Once the patient can contract the PFM correctly, ask her to squeeze as hard as she can, then count up to a maximum of 10 s. Observe when the muscle starts to fatigue, and stop the count there, for example, 6 s.

After the patient has gotten dressed, explain to her that the PFM is a muscle running from the pubic bone to the tail bone, with three openings in it (urethra, vagina, anus). We find it helpful to show a diagram such as that shown in Fig. 6.2, inasmuch as many patients do not understand this basic anatomy. Explain that the PFM is a postural muscle, like the erector spinae of the back. Think of the weight lifter who goes to the gymnasium. He usually has a very erect posture because of the strong resting tone of his large back muscles, but he can also lift heavy weights. The woman needs to train her PFM gradually, over 12–24 weeks, to increase the resting tone of the muscle, and it will also hypertrophy. Then the patient can train to squeeze the muscle against the “load” of coughing or sneezing.

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Figure 6.2

Diagram of the pelvic floor muscle (Reprinted with permission from Swash [32]. Copyright 1990, John Wiley & Sons Limited)

The Role of the Nurse Continence Advisor

The assessment and basic explanation of the PFM (as above) are a task that any registrar or clinician should be able to carry out, as it only takes 1 min during the physical exam and 3 or 4 min of explanation time.

The following description of how to start a PFM training program may be too time consuming within the confines of a busy outpatient clinic. In this case, the patient should be referred to a nurse continence advisor (NCA) for the detailed training given below.

A physiotherapist (physical therapist) will also carry out this type of training program, but in some countries, the NCA is more readily available within a public hospital, with no cost to the patient. Referral to a physiotherapist can therefore be reserved for patients with a weak pelvic floor muscle, who may need electrical stimulation therapy, described later, especially if this incurs a cost.

·               First, the woman must contract the muscle as hard as possible for as long as she can, up to her maximum when fatigue is noted (e.g., 3 s).

·               Then rest the muscle for 5 s to let oxygen back into the muscle.

·               Explain that just squeezing the muscle over and over without this oxygen break will cause it to tire out, not strengthen.

·               To make it easy to remember, we usually set a program that builds up numerically from her 3-s maximum, for example, 3-s squeeze, 4 squeezes per “set” or group, and 5 sets per day.

·               In this example, she would perform 20 contractions per day.

·               The five sets per day should be spread out over the day, not done all at once in the morning (because this causes fatigue also).

·               To help remember this, we would give five red adhesive dots to be placed around the house in places that are visited at different times of the day (near the toothbrush, kettle, telephone, television remote control, etc.). See Fig. 6.3.

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Figure 6.3

Written PFM training program for a patient with an initial pelvic floor contraction of only 3-s duration, who is to do four contractions per set and five sets per day (five red dots given)

After the patient has strengthened her PFM for 3–4 weeks, she should then learn how to contract the muscle just before a cough or sneeze. This technique, called “the knack,” has been shown on pad testing to reduce leakage by up to 60 %/day [22].

In subsequent visits, the nurse continence advisor reiterates the initial explanation and upgrades the program (makes it harder). If a patient is sent to physiotherapy, the first visit always includes this type of explanation, with upgrading at follow-up. Even if the main complaint is urge incontinence, the PFM is used to defer micturition, so patients need to know how to contract it.

Who Should Be Referred for Physiotherapy?

If a woman cannot contract her PFM at the initial examination (or can only manage a weak flicker) despite your best efforts to help her locate the muscle, then she definitely needs referral to a pelvic floor physiotherapist (a physiotherapist who has undergone subspecialty training). She will assess the patient vaginally, use additional methods to help her identify the muscle, then move on to biofeedback or electrostimulation or both (see below for details).

The question then becomes the following: do women who can contract their muscles need a supervised training program, or can they practice at home with equally good results? This leads into the question, what form of PFM training is most effective?

In the last 30 years, many publications have considered this question. One problem is that the outcome measures used by the different authors varied greatly. Table 6.1 summarizes the results. The term “hospital PFMT” indicates that patients attended a pelvic floor physiotherapist weekly or monthly and had regular supervision of their training program.

Table 6.1

Objective results after pelvic floor muscle training for stress incontinence

Authors

N

Treatment

Results

Wilson et al. [34]

15

Home PFME

Pads/24 h 11 % benefit

45

Hospital PFME

Pads/24 h 54 % benefit

Jolleys [19]

65

Home PFME

48 % subjectively dry

56

Control

0 % subjectively dry

Henalla et al. [17]

25

Hospital PFME

65 % cure/marked benefit pad test

24

Control

0 % cure/marked benefit pad test

Burns et al. [6]

38

Hospital PFME

54 % reduction leaks/week FVC

40

Control

9 % worse leaks/week FVC

Bo et al. [3]

26

Home PFME

Pad test change NS

26

Hospital PFME

Pad test 27 g fell to 7.1 g/h

Bo and Talseth [4]

23

Hospital PFME

75 % dry on urodynamic cough test at 5 year

Wells et al. [33]

82

Hospital PFME

27 % dry on wetting diary

75

Phenylpropanolamine

14 % dry on wetting diary

Mouritsen et al. [27]

100

Hospital PFME

47 % dry pad test at 12 months

Cammu et al. [7]

52

Hospital PFME

25 % dry on FVC

O’Brien et al. [28]

292

Home PFME

29 % no longer using pads

132

Control

No benefit

Lagro-Janssen et al. [21]

53

Home PFME

Leaks/week 19.6, fell to 7.2/week

57

Control

Leaks/week 21, worse, to 23/week

Hahn et al. [15]

170

Hospital PFME

35 % dry on stress test

30

Control

0 % change in controls

Seim et al. [30]

96

Hospital PFME

48-h pad test 28 g fell to 10 g

Bo et al. [5]

25

Hospital PFME

44 % dry, pad test at 6 months

30

Control

6 % dry, pad test at 6 months

The duration of follow-up in these trials also varied a great deal. Nevertheless, it can be seen that supervised PFM training yields generally higher success rates (average about 50 % cure, range 25–75 %), compared to a home-based program (29 % cure).

Another problem with this table of results is that the severity of leakage at baseline was seldom taken into account. Stratified randomization was rare (so that mild and severe patients could be distributed equally into both treatment arms). A study in which only patients with mild to moderate incontinence (on 1-h pad test) were recruited (with stratified randomization) showed that 65 % of those with mild incontinence were cured, compared to a 35 % cure rate for moderate incontinence [25]. In this pragmatic trial, only patients with a weak pelvic floor were referred for subspecialty physiotherapy. In those with a good contraction strength at baseline, a nurse continence advisor supervised their training.

A meta-analysis [2] and the recent Cochrane review [9] both emphasized poor standardization of outcome measures and follow-up duration but concluded that PFM training is clearly superior to no treatment and a supervised program gives better results than a home-based program.

What Does the Physiotherapist Do That Increases Efficacy?

Basically, the pelvic floor physiotherapist has three techniques:

·               To act as a personal trainer, just as for an athlete:

·                      To reexamine the PFM at regular intervals to check strength and increase the difficulty of the training program

·                      To evaluate the frequency volume chart with the patient regularly and see whether leakage is really declining

·                      To remind the patient to perform “the knack” as they often forget

·                      To increase motivation by positive verbal feedback (as results improve)

·               To use some form of “biofeedback” technique such as:

·                      A graduated perineometer, to show contraction strength (Fig. 6.4)

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Figure 6.4

Perineometer. Used to measure strength of the PFM contraction

·                      Verbal biofeedback during digital examination, asking the patient to contract harder or for a longer duration

·                      Vaginal weighted cones that the patient wears in the vagina for 20 min twice daily, with steady increase in the cone weights (Fig. 6.5)

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Figure 6.5

Vaginal cones. Used to teach patients how to contract the PFM

·                      Mechanical or auditory biofeedback, such as a vaginal pressure transducer that conveys increased pressure by an increased auditory or visual signal

·               To employ electrostimulation therapy when the patient has a weak or absent PFM contraction, which may comprise:

·                      Trans-vaginal electrostimulation, also called faradism (Fig. 6.6)

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Figure 6.6

Intravaginal electrostimulation device

·                      Trans-suprapubic electrostimulation, or interferential therapy, now seldom used

The Efficacy of Physiotherapy Techniques

For a detailed analysis of this issue, the reader should consult a dedicated text, such as Pelvic Floor Re-education [29]. Nevertheless, some conclusions can be made. The first item of physiotherapy training above (acting as a personal trainer to enhance performance and gradually increase the difficulty of the training) is clearly efficacious, as shown in Table 6.1 regarding home training versus supervised training.

Biofeedback is quite controversial. The following statements are evidence based. In a compact book such as this, it is not practical to cite all evidence.

Use of the perineometer aids the patient by measuring the degree of improvement in pelvic floor muscle strength. This does not always translate into improved continence, unless the patient uses her PFM during cough or other episodes of raised intra-abdominal pressure (the knack).

Use of vaginal weighted cones provides a variable degree of enhanced efficacy. In some studies, they give major benefit; in other studies, the benefit over PFM training is not statistically significant. The Cochrane meta-analysis found that cone therapy is better than no treatment and similar to PFMT alone, with no clearly significant benefit gained from adding cones to a PFMT program. We find that a patient’s attitude towards a self-inserted vaginal device is very important. Some women find them a useful aid; others cannot accept the idea of inserting a cone into their vagina. They are “another option” for women having difficulty with simple PFM training who do not want surgery.

Use of auditory or visual biofeedback techniques to enhance the woman’s appreciation of her PFM strength is now known to enhance PFMT. Women who were given biofeedback had a significantly greater likelihood of noting cured or improved continence (risk ratio 0.75, CI 0.66–0.86 [9]). Such devices are often quite expensive. Some physiotherapists use biofeedback at the first visit to help women identify their PFM, but do not always use it at follow-up visits [13].

Use of electrostimulation is physiologically attractive. The skeletal muscle of the PFM is given a regular electrical stimulus, which causes a tetanic (maximal strength) contraction. In our experience, electrostimulation is very useful for the woman who simply cannot contract her PFM at the first visit. Once she can feel it contracting, she should be given a detailed PFM training program to use between the electrostimulation visits. Unfortunately, most studies of this technique do not specifically select women who are unable to contract the PFM and do not give a PFM training program for use between electrostimulation visits. Many of the studies are very small (n  =  20–30 in either arm), so that they are “underpowered” to achieve a significant result. Definition of “cure” is variable and not clearly reported.

The International Consultation on Incontinence (ICI) recently concluded that “There is insufficient evidence to judge whether electrical stimulation is better than no treatment for women with urodynamic stress incontinence.” [16]

Extracorporeal Electromagnetic Chair Stimulation Therapy

This is an alternative form of electrostimulation therapy that avoids the need for a vaginal probe. Patients sit fully clothed on a chair that contains a magnetic coil under the seat. A randomized controlled trial using a sham chair showed that, in women who were unable to contract their pelvic floor muscle at the first visit, the active chair therapy produced a significant reduction in leakage on pad test (p<0.05) compared with sham chair [11].

What to Do if Conservative Therapy Fails but Patient Does Not Want Surgery

Prior to the 1990s, such patients were left with the main option of using continence pads. In the last decade, several bioengineering companies have taken up the challenge to develop mechanical devices that can correct incontinence.

The first of these was the bladder neck support prosthesis (Introl, Fig. 6.7), which is shaped like a prolapse ring pessary but has two prongs that sit in the retropubic space and cradle the urethra. Clinical trials indicate that 62 % of those who can be fitted become continent (see Moore [24]). The device is difficult to fit in those with multiple previous failed continence surgeries but is well suited to those without previous surgery who mainly leak during sporting activities. It is also useful for patients with coexistent prolapse. Availability is limited at present due to manufacturing problems, but it is likely to return.

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Figure 6.7

Introl device (top left), continence dish (top right), and two sizes of Contiform (bottom)

The same inventor went on to develop a simpler device, Contiform, that is shaped like a hollow tampon (Fig. 6.7). Initially, this device was only available in three sizes and gave a highly significant reduction in incontinence, but the “cure” rate on pad testing was only 22 % Morris and Moore [26]. Subsequently, a fourth size has been manufactured which yielded improved efficacy, 51 % dry on pad testing [1]. This device does not treat prolapse but is useful in patients who mainly leak with sporting activities and do not want surgery. The continence dish is used in a similar way in the USA and Australia.

Conclusions

PFM training needs to be tailored to the individual woman. Stress incontinence is not life threatening, and patients know this. Do not recommend a therapy that the patient feels uncomfortable with, as her compliance will be poor. In order to provide the best results, discuss the options with the patient, and let her select that with which she thinks she can comply.

The caveat to this advice is that patients should also understand the risks of surgery, should they not respond to conservative therapy. If a woman understands that current continence surgery has a 5–6 % risk of developing overactive bladder and a 1–2 % risk of voiding difficulty, then their interest in and compliance with conservative therapy may be enhanced. Urogynecologists must always remember that our first duty is “to do no harm,” and PFM training has no complications.

References

1.

Allen WA, Leek H, Isurieta A, Moore KH. Update: the Contiform intravaginal device in four sizes for treatment of stress incontinence. Int J Urogynaecol. 2008;20:1085–93.

2.

Berghmans LC, Hendriks HJ, Bo K, et al. Conservative treatment of genuine stress incontinence in women: a systematic review of randomized clinical trials. BJU Int. 1998;82:181–91.CrossRef

3.

Bo K, Hagen RH, Kvarstein B, Jorgensen J, Larson S. Pelvic floor muscle exercise for treatment of female stress urinary incontinence. III: effects of two different degrees of pelvic floor muscle exercises. Neurourol Urodyn. 1990;9:489–502.CrossRef

4.

Bo K, Talseth T. Five year follow up of pelvic floor muscle exercise for treatment of stress urinary incontinence, clinical and urodynamic assessment. Neurourol Urodyn. 1995;14:374–6.

5.

Bo K, Talseth T, Holme I. Single blind randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ. 1999;318:487–93.PubMedCrossRef

6.

Burns P, Pranikoff K, Nochajski M, Desotelle P, Harwood M. Treatment of stress incontinence with pelvic floor exercises and biofeedback. J Am Geriatr Soc. 1990;38:341–4.PubMed

7.

Cammu H, Van Hylen M, Derde MP, Debruyne R, Amy JJ. Pelvic physiotherapy in genuine stress incontinence. Urology. 1991;38:332–7.PubMedCrossRef

8.

Cody JD, Richardson K, Moehrer B, Hextall A, Glazener CMA. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev. 2009;Issue 4. Art.No.:CD001405. doi: 10.1002/14651858.CD001405.pub2.

9.

Dumoulin C, Hay-Smith EJ. Pelvic floor muscle training versus no treatment, or inactive control treatments for urinary incontinence in women. Cochrane Database Syst Rev. 2010. doi: 10.1002/14651858.CD005654.pub2.

10.

Fantl JA, Cardozo L, McClish DK, the Hormones and Urogenital Therapy Committee. Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis. Obstet Gynecol. 1994;83:12–8.PubMed

11.

Gilling PJ, Wilson LC, Westenberg AM, et al. A double-blind randomized controlled trial of electromagnetic stimulation of the pelvic floor vs sham therapy in the treatment of women with stress urinary incontinence. BJU Int. 2009;103:1386–90.PubMedCrossRef

12.

Glueck CJ, Aregawi D, Agloria M, Winiarska M, Sieve L, Wang P. Sustainability of 8 % weight loss, reduction of insulin resistance, and amelioration of atherogenic-metabolic risk factors over 4 years by metformin-diet in women with polycystic ovary syndrome. Metabolism. 2006;55:1582–9.PubMedCrossRef

13.

Goode PS, Burgio KL, Locher JL, et al. Effect of behavioural training with or without pelvic floor electrical stimulation on stress in continence in women. A randomized controlled trial. JAMA. 2003;290:345–52.PubMedCrossRef

14.

Grady D, Brown JS, Vittinghoff E. HERS Research Group. Postmenopausal hormones and incontinence; the Heart and Estrogen/Progestin Replacement Study. Obstet Gynecol. 2001;97:116–20.PubMedCrossRef

15.

Hahn I, Milson J, Fall M, Eklund P. Long term results of pelvic floor training in female stress urinary incontinence. Br J Urol. 1993;72:421–7.PubMedCrossRef

16.

Hay Smith J, Berghmans K, Burgio C, et al. Adult conservative management. In: Abrams P, Cardoza L, Khoury S, Wein A, editors. Incontinence, report of 4th international consultation on incontinence. Plymouth: Health Publications Ltd; 2009. p. 1025–120.

17.

Henalla SM, Hutchins CJ, Robinson P, MacVicar J. Nonoperative methods in the treatment of female genuine stress incontinence of urine. Obstet Gynecol. 1989;9:222–5.

18.

Jackson RA, Vittinghof E, Kanaya AM, et al. Urinary incontinence in elderly women: findings from the health aging and body composition study. Obstet Gynecol. 2004;104:301–7.PubMedCrossRef

19.

Jolleys J. Diagnosis and management of female urinary incontinence in general practice. J R Coll Gen Pract. 1989;39:277–9.PubMedCentralPubMed

20.

Kendall A, Dowsett M, Folkerd E, Smith I. Caution: vaginal estradiol appears to be contraindicated in postmenopausal women on adjuvant aromatase inhibitors. Ann Oncol. 2005;17:584–7.CrossRef

21.

Lagro-Janssen ALM, Debruyne FMJ, Smits AJA, Van Weel C. The effects of treatment of urinary incontinence in general practice. Fam Pract. 1992;9:284–9.PubMedCrossRef

22.

Miller J, Aston-Miller JA, DeLancey JOL. The knack: use of precisely timed pelvic muscle contraction can reduce leakage in SUI. Neurourol Urodyn. 1996;15:392–3.

23.

Moehrer B, et al. Oestrogens for urinary incontinence (review). Cochrane Database Syst Rev. 2003:CD001405. doi: 10.1002/14651858.CD.

24.

Moore KH. Conservative therapy for incontinence. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000;14:251–89.PubMedCrossRef

25.

Moore KH, O’Sullivan RJ, Simons A, Prashar S, Anderson P, Louey M. Randomized controlled trial of nurse continence advisor therapy versus standard urogynaecology regime for conservative incontinence treatment: efficacy, costs and two year follow up. BJOG. 2003;110:649–57.PubMedCrossRef

26.

Morris A, Moore KH. The contiform incontinence device – efficacy and patient acceptability. Int Urogynecol J. 2003;14:412–7.CrossRef

27.

Mouritsen L, Frimodt-Moller C and Moller M. Long term effect of pelvic floor Exersizes on Female Urinary Incontinence. Brit J Urol. 1991;68:32–37.CrossRef

28.

O’Brien J, Austin M, Sethi P, O’Boyle P. Urinary incontinence: prevalence, need for treatment, and effectiveness of intervention by nurse. Br Med J. 1991;303:1308–12.CrossRef

29.

Schuessler B, Norton PA, Stanton SL, et al. Pelvic floor reeducation: principles and practice. 2nd ed. London: Springer; 2008.

30.

Seim A, Siversen B, Eriksen BC, Hunskar S. Treatment of urinary incontinence in women in general practice: an observational study. Br Med J. 1996;312:1459–62.CrossRef

31.

Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol. 2009;186(6 Suppl):S2–7.CrossRef

32.

Swash M. The neurogenic hypothesis of stress incontinence. In: Neurobiology of incontinence, no. 151 CIBA foundation symposium. New York: John Wiley and Sons; 1990. p. 160.

33.

Wells TJ, Brink MPH, Diokno AC, Wolfe R, Gillis GL. Pelvic muscle exercise for stress urinary incontinence in elderly women. J Am Geriatr Soc. 1991;39:785–91.PubMed

34.

Wilson PD, Al Samarrai T, Deakein M, Kolbe E, Brown ADG. An objective assessment of physiotherapy for female genuine stress incontinence. Br J Obstet Gynaecol. 1987;94:575–82.PubMedCrossRef

35.

Wing RR, Creasman JM, West DS, et al. Improving urinary incontinence in overweight and obese women through modest weight loss. Obstet Gynecol. 2010;116:284–92.PubMedCentralPubMedCrossRef