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Detrusor Instability and its Treatment
Detrusor Instability and its Treatment MARGARET NORWOOD MCSP
Senior Physiotherapist in Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford
b y Words: Detrusor instability, frequency/volumecharts, anticholinergic drugs, bladder training, pelvic floor exercises. SWIItnary: Physiotherapy treatment of incontinence has been focused on the symptom of stress incontinence. Research projects have been camed out into its effectiveness. Many patients experience symptoms of severe frequency, nocturia, urgency and urge incontinence. A few experience enuresis. These symptoms often cause more distress and greater disruption of lifestyle than leaking on coughing and exercise, and may be due to detrusor instability. This has been diagnosed in up to 37% of women attending an incontinence clinic after urodynamic assessment. The etiology of detrusor instability is not clear and its treatment is difficult and often unsatisfactory. The aim of this paper is to examine the physical and psychological factors which may be involved in this complex condition, together with the usual treatment by anticholinergic drugs. Physiotherapy treatment using frequency/ volume charts, pelvic floor exercises and bladder training is discussed. Two case studies are included.
Bladder volume (mll
400
Fig 1: Normal cystometrogram
loo
1
Biography: Margaret Norwood qualifed from King's College Hospital
School of Physiotherapy in 1%3. She is a member of the Association of Chartered Physiotherapists in Obstetrics and Gynaecology, and has been a member of its education committee and a part I course leader. She is at present involved in a research project into the treatment of detrusor instability, and hopes to publish the results of this when it is completed.
I
Bladder volume (ml)
400
Fig 2: Spontaneous detrusor instability
Sometimes a contraction only happens on provocation. Cough instability may be confused with stress incontinence. The patient may have a desire t o void immediately after the cough and prior t o leakage. In genuine stress incontinence no such desire is felt (Abrams, 1988).
Introduction DETRUSOR instability describes a condition of unknown etiology, in which the detrusor muscle contracts not only during voiding but at other times. These contractions can be diagnosed only by urodynamic investigation, but may be suspected when the symptoms of urgency, urge incontinence, frequency and nocturia are present. A single contraction may produce the feeling of urgency. Urge incontinence usually happens with a powerful contraction, facilitated by urethral relaxation. Another effect of unstable contractions is t o limit the functional bladder capacity, and this produces symptoms of frequency and nocturia. (The alternative term used for the same condition is unstable bladder - Bates et a/, 1970.) Detrusor instability is defined as being present when involuntary rises in detrusor pressure exceeding 15 cm of water are observed during bladder filling (International Continence Society Standardisation Committee, 1977). ~
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Bladder volume (ml)
400
Fig 3: Provocation (cough) instability
Unstable contractions are phasic and followed by relaxation. Sometimes there is a gradual rise in pressure due to the bladder exhibiting low compliance, but the detrusor
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~Ysiotherapy,August 1990. vd 76. no 8
439
remains stable. The bladder fails t o stretch readily t o allow a normal bladder capacity of 4 5 0 ml. In some patients reduced detrusor compliance may be accompanied by instability or progress to it (Elder and Stephenson, 1980).
Bladder volume (mll
400
Fig 4: Low compliance
Bladder volume (mll
400
Fig 5: Low compliance and detrusor instability
Bladder instability is an important phenomenon because of its frequent occurrence and the embarrassment of the symptoms it produces. It is estimated that 10% of the population aged 2 0 t o 5 0 years may be affected, although some are unsymptomatic (Turner-Warwick, 1975). It is very common in children, being normal under the age of three years, ie prior to gaining full bladder control. It is often present over the age of 70. It was seen in more than 50% of men of this age group by Abrams and Fenely (1978). and 3 0 % of women of the same age group. Women under that age, who show a higher incidence than men, may also be experiencing stress incontinence, and it is this group whose symptoms need careful evaluation, particularly if surgery is contemplated. Haylen e t a / (1989) showed that of 494 women referred t o a urodynamic clinic who complained of stress incontinence, only 2 % presented with it as their only symptom. Results of urodynamic studies showed 59% had stress incontinence, 9 % detrusor instability, and 12% a combination of both. A higher incidence of detrusoi instability was found by Cordozo (1984). Haylen eta/ (1989)argue that all patients who are to haw bladder neck surgery, should have urodynamic investigatior prior to it. Beck e t a / (1976) state that surgery should nevei be the first line of treatment for detrusor instability Hodgkinson e t a / (1963) showed that only 26% of womer with bladder instability who were treated with surger) gained any improvement.
3iology A single cause of detrusor instability cannot be clearly dentified and the etiology appears to be a complex of known 3nd unknown factors (Beck er a/, 1976). Unstable contractions were reported in association with :ertain neurological disorders (Rose, 1931; Kolb eta/, 1936). iyperreflexia is the term used to describe an unstable Aadder of neuropathic etiology (International Continence Society, 1980) to differentiate it from detrusor instability, without recognisable neurological disability. Some people have a family history of difficulty with urinary zontrol. It is not clear if this is some idiopathic weakness 3r a learned pattern of frequency due to overanxiety about micturition. Mundy (1985) suggests that someone who ?ever learns or uses the ability to hold urine under normal 5rcumstances will be unable to do so when forced to. Men who develop the condition often do so as a response to outflow obstruction, caused by an enlarged prostate. Women have fewer problems with obstruction, but some postulate that minor urethral problems may cause the letrusor to become unstable (Lowe, 1977). Mahoney e t a / 11980) state that instability is not uncommon in multiparous women with weakness of the pelvic floor. Turner-Warwick and Brown (1979) suggest that because some women with instability are continent, impairment of the distal sphincter mechanism is present in those who are incontinent. Some women develop detrusor instability following surgery to the bladder neck. The incidence following surgery for incontinence has been given as 70% of failure (Bates et a/, 1970). Detrusor instability is sometimes subject to spontaneous exacerbation and remission. This factor together with the lack of precise understanding of the etiology of the condition leads some to argue that most if not all patients have a psychological cause for their problem (Frewen, 1978). Certainly Hafner et a/ (1977) demonstrated a strong correlation between psychological disorder and the symptoms of frequency, urgency and urge incontinence, but these are sometimes present without bladder instability. In a later study Frewen (1980) found an emotive etiology in only 20% of cases where detrusor instability had been diagnosed. Abrams (1980) states that this etiological factor is currently regarded as less important. Neurophysiology The greatest difficulty in understanding the cause and nature of detrusor instability lies in the inadequacy of knowledge and understanding of the neurological control of the bladder, bladder neck, and internal urethral sphincter under autonomic control, and the role of the straited muscle providing the external sphincter mechanism, which is under voluntary control. Blaivas (1982) concludes that anatomically separate neural centres control the activity of the detrusor muscle and the external urethral sphincter. There is still argument over whether voiding is the result of a segmental sacral reflex arc that is facilitated and inhibited by supraspinal neurological pathways, or a long-routed reflex that is integrated at higher central nervous system levels. The first theory proposed by Denny-Brown and Robertson (19331, and popularised by McLellan (19391 and Lapides (19701, suggested that the detrusor reflex centre is simply a local sacral reflex, mediated entirely by the pelvic and pudendal nerves, that it is intrinsically hyperactive and dependant on tonic inhibitory impulses from the cerebral cortex.
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Physiotherapy, August 1990, vd 76, no 8
This theory was challenged by Bradley et a/ (1974) and De-Groat eta/ (1979) who deny the simple segmental sacral detrusor reflex. They believe that voluntary control of voiding is accomplished by connections between the frontal cortex and the micturition centre in the rostra1 pons. They also conclude that during bladder filling, receptors in the external sphincter cause afferent discharge along the pudendal nerve, which synapse in the pudendal nucleus. Efferent pudendal discharge causes increasing external sphincter contraction until micturition reflex occurs. Voluntary control of the external sphincter is achieved by corticospinal pathways connecting the frontal cortex with the pudendal nucleus. Most of these conclusions were reached from research on cats, so it is necessary t o be careful in extrapolating to the human situation. Some research has been carried out on patients. Blaivas (1982) used his data to suggest that they 'strongly suggest that co-ordinated voiding is not a simple sacral reflex but requires integration at a higher neurological level'. The role of the external sphincter was examined. One group of patients with neurological lesions above the pons were able to void synergistically; 'in each instance complete relaxation of the external sphincter preceded the detrusor contraction'. Lowe (1977) reported a decrease in urethral pressure preceding an unstable detrusor contraction by five seconds in 85% of women with detrusor instability. In Blaivas' group nearly half those with neurological lesions had voluntary control of the external sphincter. Once aware of the detrusor contraction they could inhibit voiding momentarily by contracting the sphincter, but they could not abolish the detrusor contraction voluntarily. However, in a different group without neurological problems, he found that some patients who had involuntary detrusor contractions which they perceived as an urge to void, although unable to inhibit the onset of a contraction, once aware of it were able to abort it by contracting the external sphincter. 'This was followed by cessation of the bladder contraction within several seconds.' Certainly Mahoney e t a / (1980) believe that tonic inhibition comes from peripheral reflexes originating in the striated muscle of the pelvic floor and perineum, and that it is this which maintains the normal balanced function of the sacral micturition centre. These muscles which include the striated urethral sphincter are innervated by motor neurones originating in the pudendal nucleus, located close to the sacral micturition reflex centre, S2 t o S4. They also believe all cerebral influence is facilitative and not inhibitory, but that conscious 'wilful' inhibition in addition t o that from the voluntary contraction of the pelvic floor is possible, but the neurological pathways responsible are unknown. Vereecken and Verduyn (1970) established that normally, during bladder filling, pelvic floor EMG activity gradually increases with bladder volume. Mayo (1981) found that in women with detrusor instability 58% showed a decrease in pelvic floor activity during bladder filling.
Assessment with Frequencylvolume Charts The patients' recording of timing and volume of fluid intake and output is indespensable for the objective assessment of the symptoms of frequency of micturition and nocturia. It also shows clearly the pattern of micturition, bladder capacity and the correlation of input and output with frequency. Unfortunately it cannot monitor urgency. This frequencylvolume chart is always completed prior to a urodynamic assessment, and the recordings discussed
physiorherapy, August 1990. vol76, no 8
Nith the patient before a full history is taken. Mundy (1985) Ielieves it is perfectly reasonable to begin treatment on the Ibjective evidence provided by a completed frequency1 iolume chart accompanied by a careful history, and reserve irodynamic study for those who fail t o respond. The proviso given is that outflow obstruction in men should be excluded 'irst. If treatment is by medication, unnecessary use of drugs night result. If active treatment is prescribed, in the form )f bladder training and/or pelvic floor exercises there is no ,isk of side effects. A normal frequencylvolume chart shows a frequency rate )f seven or less in 2 4 hours, occasional or no nocturia, at east one voided volume of 4 5 0 m l (usually the first in the norningl, most other volumes similar to each other, and a otal output of 1,200 to 2,200 ml each day. Frequencylvolume charts
Time
fluid
inrake
Urine voideo Time
lmll
fluid
Urine voided Time
inrake
(mil
Normal
5.45 am 615am
Tea x 2
10.15am Coffee 12.30pm Tea 4pm 5.30pm 7pm
Tea Water Coffee
10.30 pm 11 om Horlicks Total
Wednesday
Tuesday
Monday
450 6 am 615am 9 am 350 10.15am 10.30 am 12.30pm 1.30pm 400 4pm 350 7pm 8.30pm 400 111om 1,950
Tea x 2 Coffee Soup Tea Tea x 2 Coffee Cocoa Horlicks
I
470 5.30 am 6.15am 310 9.30 am 10.15 am 260 12.30pm 250 1.30pm 4pm
Total
Tea
Coffee Orange
Coffee Tea Orange Tea Coffee Orange
150 80 50 90 100 100 140 140 120 70 130 150 50 200 140 90 90 1,890
Tea x 2
Squash Tea Tea x 2
Tea Coffee Orange
Coffee Tea Orange Tea Coffee Orange
130 150 50 80 100 90 120 140 140 60 150 100 80 150 120 90 120 1,890
500 300
350 300 250 300
2,000
2,040 3.30am 710am 8am 9.30am 1015am 11.05am 11.30am 12.10pm 12.50am 1.15pm 2.50pm 3.40pm 4.40pm 5.20pm 715pm 8.45pm 11pm
Urine voided (mll
Coffee
300 6 . 4 5 ~ m Coffee 250 10.15 pm Horlicks 300 11 om
Detrusor instability
6.50 am 7.55am 8.35 am 9.40 am 10.05 am 10.45am 11.20am 11.50am 12.15am 1 pm 2.40pm 3.45pm 4.30pm 5.50pm 7.05pm 9pm 10.55pm
fluid intake
410 am 6.40am 8.10 am 9.15 am loam 10.50am 11.20am 1210pm 1.10 pm 2 Pm 3.15pm 4.20pm 5.10pm 7.15pm 19pm
I
Tea Coffee Orange Tea Tea Orange Tea Coffee Orange
170 90 160 140 100 90 90 120 100 50 160 90 100 150 200 120 1,930
Typically, a patient with detrusor instability will void very variable volumes of urine at greatly different intervals, and the pattern may vary from day to day. (This is the reason for a chart to be kept initially for seven days.) Frequency rate may be ten to 30 times in 2 4 hours, sometimes more. Some of the voided volumes will be very low, and the largest voided volume often less than 4 5 0 ml. The patients may feel that having t o void into a plastic measuring jug and record their urine output for a week is difficult. For this reason it is important t o explain the usefulness of a completed chart not only t o the medical team, but to the patients themselves. It can reveal the relationship of symptoms to quantity or cafieine content
441
of intake, location (greater frequency at work or home) or other individual factors. The incidence of leakage can also be recorded if the patients are aware when it occurs. If the patients do not feel it happening, the need to wear a pad and the number of changes necessary in 24 hours is an alternative guide.
when medication is withdrawn. The treatment is passive, the patient gains no understanding of her condition or feeling of control over it. This is only achieved by combining treatment with bladder training, or pelvic floor exercises and bladder training. Bladder Training
Treatment of Detrusor Instability
Jeffcoate and Francis (1966) first described 'bladder discipline'. Patients with urge incontinence were hospitalised for three weeks. They underwent urethral dilation, received anticholinergic drugs, and were taught to void very strictly by the clock, gradually increasing the time intervals between voiding, wen though it was uncomfortable or leakage occurred. They showed that 67% of patients were cured, and 22% improved. Later, Frewen (1972) became the exponent of this form of treatment. He claimed a cure rate of 80% for detrusor instability using bladder training and inhibitory drugs for hospitalised patients. He was criticised for lack of urodynamic evaluation. He rectified this in 1978, and after three months showed a cure rate of 82%. Most patients were admitted to hospital initially for two weeks, but ten were treated as out-patients. In evaluating Frewen's regime, Elder and Stephenson (1980) compared the effect of bladder training on patients with low compliance, detrusor instability, and those with urge incontinence but stable bladders. At three months, symptoms were markedly improved or cured in 86% of patients. However, reduced compliance was the only detrusor abnormality which was reversible. The only long-term study of bladder training has shown a disappointingly high relapse rate after three years (Holmes et a/, 1983). Bladder training involves the patients in their own treatment. It is only possible with full explanation, discussion and use of frequencylvolume charts. Most patients with detrusor instability are very highly motivated to participate in bladder training, but need strong support and encouragement while undertaking it, particularly if they do so as outpatients. Frewen (1972) believes it is this psychological support which is the essential key to a successful outcome. Frequency is often an acquired habit, arising from the fear of allowing the bladder to fill normally. Patients with detrusor instability often void before leaving home, work or known location or on seeing a lavatory, even though they have felt no desire to micturate. They have to learn to break this habit. The only way that patients can postpone voiding when they do feel urgency is by contracting the muscles of the pelvic floor. This factor seems to have been ignored when teaching bladder training.
The lack of understanding about the cause of detrusor instability is reflected in the wide range of treatments tried. Those most commonly used are bladder training, drugs, and bladder training plus drugs. Other methods are electrical pelvic floor stimulation, biofeedback, surgical procedures (denervation or bladder distension), hypnosis, acupuncture, and transcutaneous nerve stimulation. Irecommendmethods of treatment which includevoluntary pelvic floor exercises plus bladder training; ' or for severe symptoms, pelvic f loor exercises, bladder training and drugs. Drug Treatment , Two problems arise when prescribing medication for detriisor instability. The first is the lack of knowledge about the pathophysiology of the condition. The second is that of giving adequate doses without producing unacceptable side effects. Many drugs have been used to treat the condition (Andersson and Ulmsten, 1980; Applebaum, 1980). They may act either on the nervous system or the muscle. Those acting on the nervous system may act centrally or peripherally. The anticholinergic drugs are the most popular. They produce their effect by competitive blockade of receptor sites. The following drugs have anticholinergic effects and have been used with effect for some patients with detrusor instability: propantheline bromide, emepronium bromide, and oxybutynin chloride. The last of these is thought to have an additional muscle relaxant property, but Abrams (1984) doubts if the dosage required to produce muscle relaxation would be tolerated, due to the anticholinergic side effects on the same doses. These side effects are - dry mouth, eyesight difficulties, nausea, constipation and urinary retention. Drugs are now being used which have a dual effect. Andersson and Ulmsten (1980) state that treatment with anticholinergics is often ineffective. They have a low and variable absorption rate. Drugs inhibiting bladder contractions by anticholinergic and calcium entry blocking action have the advantage of being well absorbed from the gastro-intestinal tract. Drugs selectively inhibiting calcium influx are effective because calcium entry plays an important part in the activation of smooth muscle (Formanetal, 1978). Trials of one drug with the dual effect, terodiline (Micturin), found a small but significant reduction in frequency of micturition in the treatment of detrusor instability (Gerstenberg et a/, 1986; Andersen et a/, 19881. It eliminated unstable contractions in nearly 50% of patients, but failed to do so in 50%. However, Peters (1984) and Fischer-Rasmussen (1984) showed that 50% of large groups of women treated with terodiline experienced side effects, and these were severe for 12% of patients. The side effects of the anticholinergic property predominated over those of the calcium antagonist agent which were: hypotension, palpitations, headache, and facial flushing. Even when drugs are effective in reducing frequency of micturition slightly, the effect is not always permanent
442
Rationale for Trestment of Detrucror Instability by Rdvic Floor Exercises Combined with Bladder Training Mayo (19811states that 'with regard to detrusor instability, because pelvic floor relaxation appears to be the initiating event and because pelvic floor contraction is known to inhibit detrusor contraction by reflex mechanisms, an attempt to improve pelvic floor control would be more logical than a direct attack on the detrusor'. The effectiveness of electrical stimulation of the pelvic floor muscles in abolishing unstable detrusor contractions has been shown (Godec eta/, 1975 Teague and Merill, 1977; Fall etal, 1987). The same effect is produced by voluntary pelvic floor contractions (Mahoney 8t a/, 1977; Blaivas, 19_8_2_),..
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P h W o h W y , August 1990. vd 76, no 8
Different methods of treatment using electrical stimulation of the pelvic floor muscles have been found to be effective in the treatment of detrusor instability. Fall et a/ (1986) showed 87% of patients showed improvement after using an intravaginal device at home (Contelle), but some patients experienced a recurrence of symptoms within a few weeks of discontinuing treatment. Using a device for anal electrical stimulation (Incontan) Erikson and Mjqlnerod (1987) found that 45% of patients with detrusor instability had a stable bladder after treatment. Bladder volume was decreased, both at first desire t o void, and at maximum cystometric capacity. Laycock (1988) describes the use of interferential therapy in the treatment of incontinence, and states: ‘A combined treatment with pelvic floor exercises is recommended‘. She included treatment of patients with detrusor instability. Harrison (1976) found that active pelvic floor exercises could be well taught during digital vaginal examination, by getting the patient t o squeeze on to the t w o gloved fingers inserted, while keeping the glutei, abdominals and adductors
History
Case History 1
‘Jane‘ was a divorced mother of three teenage children. She was 4 5 years old, at 105 kg heavily overweight, and worked as a driver. She had had a hysterectomy and anterior repair 14 years previously, but her incontinence had gradually become worse and was severely distressing t o her and causing her anxiety in relation to her ability t o maintain her job. She was referred for urodynamic assessment prior to consideration of future colposuspension. Presenting Symptoms Severe urgency and urge incontinence. Severe frequency and nocturia. Her frequencylvolume chart showed a frequency rate of 16 in 2 4 hours, related to an average daily total volume voided 2,450 ml. Nocturia averaged three each night. The largest volume voided was 400 ml. 0 Severe leaking on coughing, sneezing and exercise. Stress incontinence was demonstrated when lying and in standing. Continuously wet, requiring three large sanitary pad changes per day. Urodynamic Findings Gross detrusor instability and gross stress incontinence. The patient had a severe cystocoele and moderate rectocoele. Treatment
It was decided to try to stabilise the bladder and encourage weight loss prior to surgery. Cetiprin (emepronium bromide) and physiotherapy were prescribed. On Examination The cystocoele and rectocoele were seen clearly during vaginal examination. Only very weak pelvic floor contractions were felt during digital examination, and this registered a reading of four on a Bourne perineometer’.
‘The Bourne perineometer is available only from the manufacturer, Doncast, 56 Chaldon Common Road, Chaldon, Caterham, Surrey CR3 5DD (tel 0883 3427821. Prices from €139 to €187 all inclusive of post and packing.
relaxed. This made electrical stimulation unnecessary, except for a few patients with sensory loss. Electrical stimulation of the pelvic floor muscles has been used for the treatment of stress incontinence. However, in a comparative study Wilson e t a / (1987) found that the teaching of voluntary pelvic floor exercises, encouraged by weekly follow-up visits for six weeks, was just as effective as either faradism and pelvic floor exercises or interferential therapy and pelvic floor exercises, in curing genuine stress incontinence. No equivalent study for treating detrusor instability has been made. When treating stress incontinence with faradism and pelvic floor exercises Scott et a/ (1971) recommended reeducation of the bladder to decrease frequency. Montgomery and Shepherd (1983) noticed that pelvic floor exercises decreased frequency of micturition, in addition to stress incontinence. The following t w o case histories illustrate some of the problems involved in the treatment of detrusor instability, but also the possibility of effective treatment by a physiotherapist. Physiotherapy Treatment Aims 1. To give the patient an understanding of her urinary problems. 2. To reduce symptoms of urgency, urge incontinence, frequency and stress incontinence. 3. To encourage weight loss. 4. To help the patient regain confidence in her bladder control. 5. To prepare the patient for possible surgery. Physiotherapy Management Jane was pleased t o co-operate fully with the physiotherapist, and very highly motivated indeed t o participate fully in her own treatment. The results of the urodynamic findings were fully discussed with her, and the relationship of her symptoms t o detrusor instability and stress incontinence explained. The functional anatomy of the pelvic floor was taught, together with information about the inhibitory effect of pelvic floor contractions on unstable detrusor contractions. She was taught how to contract the pelvic floor muscles while keeping the abdominal, gluteal and adductor muscle groups relaxed, in lying, sitting and standing. Instructions for home exercises were given. Pelvic floor exercises were to be done half-hourly initially, in any position where they could be felt effectively, concentrating on closing and lifting the back passage and vagina, and gradually progressing the height of the lift and number of seconds held from t w o t o ten. The aim of increasing the strength of the pelvic floor was related to setting a goal of improving the perineometer reading. Progress Chart Symptoms
1st visit
After 2 weeks
After 6 weeks
After 3 months
Nocturia Stress incontinence Frequency Urgency Pads, daily
3-4
1
0-1
Occasional
Severe 16 Severe 3
Reduced 12 Reduced 1-2
Occasional 8 Reduced 1
Occasional 6-7 Slight Occasional
Perineometer
4
7
10
16+ +
443
Progress The use of a three-day frequencylvolume chart prior t o each follow-up visit, and the perineometer, gave an objective measurement of improvement. This patient made such good progress it was decided to stop the medication after six weeks, as she was obviously continuing her pelvic floor exercises vigorously. As the strength of the muscles increased, she was encouraged t o carry out some contractions quickly, and if she suddenly experienced urgency. This gave her confidence that she could delay voiding, and she began t o refrain from passing urine at every possible opportunity. The overweight was discussed and she was referred t o her GP for advice. This was reinforced by the physiotherapist after explanation of the way in which excessive weight increases pressure on the pelvic floor, and the reluctance of surgeons t o operate until weight was lost. Jane decided that although she still leaked if she coughed
Case History 2 History 'May' was a quiet woman of 46 years, dressed rather dowdily. She was married, with t w o children, and her husband always brought her for treatment. She complained of urinary symptoms since her hysterectomy three years previously. She worked as a cook and found conditions at work aggravated her symptoms which she found embarrassing. She was slightly overweight at 7 5 kg.
Physiotherapy liea tmen t Aims
1. To give the patient an understanding of her urinary symptoms. 2. To reduce the symptoms of urgency, urge incontinence, leaking in response to hearing or feeling water, enuresis, and frequency. 3. To encourage weight loss. 4. To help the patient regain confidence in control of her bladder. Physiotherapy Management
Presenting Symptoms 0 Extreme urgency and urge incontinence. 0 Leaking on hearing a tap running, putting her hands in
water, coughing and sneezing. 0 Occasional enuresis. 0 Slight frequency, nine in 2 4 hours, related t o total average daily volume voided 1,863 mi. Urodynamic Findings Gross detrusor instability, no stress incontinence (detrusor instability exhibited on bladder filling and on provocation tests, ie coughing). The largest volume voided was only 300 mi, ie functional bladder capacity was reduced. Treatment Terodiline (Micturin), 25 mg per day, and physiotherapy were prescribed. On Examination
No prolapse was present. The perineometer reading was 14, ie very high (the limit is 16).
Conclusion Detrusor instability is poorly understood and its treatment difficult. Drugs are not always effective and only reduce frequency slightly. They often cause side effects, and do not give the patient an understanding of their condition or any feeling of control over it. Electrical stimulation of the pelvic floor may be frightening for the patient, uses a lot of physiotherapist's time, and is not usually necessary t o teach a patient active pelvic floor exercises. Bladder training can be effective, but is difficult if the pelvic floor is weak.
444
or sneezed suddenly, and stress incontinence could still be demonstrated after treatment, she would not go ahead with surgery at that time. Although we were as delighted with the outcome as she was, the presence of the cystocoele remained; and as it was severe, the problem of stress incontinence would continue. During the course of treatment Jane seemed very keen t o discuss the depressing effect of her symptoms, and the decrease in symptoms was accompanied by a visible increase in self-confidence and more positive feelings about herself, her job and family. At the end of treatment not only had her symptoms decreased but her chart showed a large increase in the largest volume voided - 6 5 0 ml (from 400 ml initially). Jane was advised t o continue pelvic floor exercises four-hourly or if experiencing urgency, but t o increase the frequency of contractions if symptoms returned. The possibility of the need for surgery at a later date was emphasised, together with the advisability of weight reduction.
It took time to gain May's confidence as she was shy. Once this was achieved, she welcomed the opportunity to talk about her situation and showed a quiet determination t o overcome her problem herself. It became obvious that her husband was helpful and encouraged her. The management was the same as for Jane, but pelvic floor contractions were related t o urgency (and urine) earlier as the pelvic floor was already strong. After the first week May complained of feeling continuously 'dizzy' and discontinued the medication, when this symptom disappeared.
Outcome May's frequency had reduced to six in 2 4 hours, and her largest volume voided increased t o 400 m l (from 300 ml), ie her bladder capacity had increased. All her other urinary symptoms had been alleviated, apart from slight leaking on sneezing. On her final visit, she had lost half a stone in weight, was dressed more smartly and seemed confident about her regain of bladder control. in a recent group of 17 women with detrusor instability being studied, 12 registered an initial perineometer reading of 2-4, ie had very weak pelvic floor muscles. Active treatment involving the patients' understanding, high motivation, and co-operation t o achieve relief of symptoms, seems preferable t o treatment where patients are passive. The treatment of women with detrusor instability by a specialist physiotherapist using frequency/volume charts, active pelvic floor exercises and, if necessary, bladder training, can be effective for some patients in reducing symptoms and increasing confidence in bladder control. It makes good use of a physiotherapist's time and skills. Evaluation of this method has not yet been completed.
ACKNOWLEDGMENTS I would like to thank Professor Sir A C Turnbull, Mr K A McCallum, Mr H Williams, Miss B M Couldrey, Mrs C Boyd and Mrs A Hill for all their assistance.
REFERENCES Abrams, P (1988). 'Update on drugs and the lower urinary tract', International Congress and Symposium Series 140, Royal Society of Medicine Services, London. Abrams, P (1984). 'Bladder Instability: Concept, clinical associations and treatment', Scandinavian Journal of Urology and Nephrology Supplementum 87, 7-12. Abrams, P and Fenely R C (1978). 'The significance of the symptoms associated with bladder flow obstruction', Urology International, 33, 171-174. Andersen, J R, Lose, C, Nbrgaard, M, Stimpel, H and Andersen, J T (1988). 'Terodiline, emepronium bromide or placebo for treatment of female detrusor overactivity?' British Journal of Urology, 58, 129-133. Andersson, K E and Ulmsten, U (1980). 'Drug treatment of the overactive detrusor', Acta Pharmacologica et Toxicologica, 46, 1, 7. Applebaum, S N (1980). 'Pharmacological agents in micturitional disorders', Urology, 16, 555-568. Bates, C P, Whiteside, C G and Turner-Warwick, R T (1970). 'Synchronous cine/pressure/flow cysturethrograph with special reference to stress and urge incontinence', British Journal of Urology, 42, 714-723. Beck, R P, Arnusch, D and King, C (1976). 'Results of treating 210 patients with detrusor overactivity incontinence of urine', American Journal of Obstetrics and Gynaecology, 125, 593- 596. Blaivas J G (1982). 'The neurophysiology of micturition', Journal of Urology, 127, 958-963. Bradley, W E, Timm, G Wand Scott, F B (1974). 'Innervation of the detrusor muscle and urethra', Urological Clinics of North America, 1, 3. Cardozo, L (1984). Pathophysiology of Clinical Conditions, chapter 17 'Detrusor instability'. De-Groat, W C, Booth, A M, Krier, J, Milne, R J, Morgan, C and Nandelhaft, 1 (1979). Integrative Functions of the Autonomic Nervous System, Biomedical Press, Amsterdam, chap 4. Denny-Brown, D and Robertson, E G (19331. 'On the physiology of micturition', Brain, 56, 149. Elder, D D and Stephenson, T P (1980). 'An assessment of the Frewen regime in the treatment of detrusor dysfunction in females', British Journal of Urology, 52, 467-471. Erikson, B C and Mjglnerod, 0 K (1987). 'Changes in urodynamic measurements after successful anal electrostimulation in female urinary incontinence', British Journal of Urology, 59, 45 -49. Fall, M, Erlandson, B-E, Sundin, T and Waagstein, F (1987). 'Intravaginal electrical stimulation: Clinical experiment on bladder inhibition', Scandinavian Journal of Urology and Nephrology Supplement 44. 41 -47. Fall, M, Ahlstrom, K, Carlsson, C-A, Ek, A, Erlandson, B-E, Frankenberg, S and Mattiason, A (1986). 'Contelle: Pelvic floor stimulator for female stress-urge incontinence', Urology, 27, 3, 282- 287. Fischer-Rasmussen,W (1984). 'Evaluation of long-term safety and clinical benefit of Terodiline in women with urgencyhrge incontinence. A multicentre study', Scandinavian Journal of Urology and Nephrology Supplement 87, 35-47. Forman, A, Andersson, K E, Henriksson, L, Rud, T and Ulmsten, U (1978). 'Effects of nifedipine on the smooth muscle of the human urinary tract', Acta Pharmacologica et Toxicologica, 43, 111. Frewen, W K (1972).'Urgency incontinence', Journal of Obstetrics and Gynaecology of the British Commonwealth, 79, 77-79. Frewen, W K (1978). 'An objective assessment of the unstable bladder of psychosomatic origin', British Journal of Urology, 50, 246-249. Frewen, W K (19801. 'The management of urgency and frequency of micturition', British Journal of Urology, 52, 367-369.
Physiotherapy,August 1990. vd 76, no 8
Gerstenberg, T C, Klavskov, P, Ramirez, D and Hald, D (1986). 'Terodiline in the treatment of women with urgency and motor urge incontinence,' British Journal of Urology, 58, 129-133. Godec, C, Cass, A and Ayala, G F (1975). 'Bladder inhibition with functional electrical stimulation', Urology, 6, 6 6 3 - 666. Hafner, R I, Stanton, S Land Guy, J (1977). 'Study of women with urgency', British Journal of Urology, 49, 211-214. Harrison, S M (1976). Cash's Textbook of General Medical and Surgical Conditions for Physiotherapists, Faber and Faber, London, 159-160. Haylen, B T, Suthurst, J R and Frazer, M I (1989). 'Is the investigation of stress incontinence really necessary?' British Journal of Urology, 64, 147-149. Hodgkinson, C P, Ayers, M A and Drukker, B H (1963). 'Dyssynergic detrusor dysfuction in the apparently normal female', American Journal of Obstetrics and Gynaecology, 87, 717-730. Holmes, D M, Ston, A Rand Bary, P R (1983). 'Bladder training three years on', British Journal of Urology, 55, 660-664. International Continence Society Standardisation Committee (19771. 'The standardisation of terminology related to the lower urinary tract: 1st report', Scandinavian Journal of Urology and Nephrology, 11, 193-196. International Continence Society (1980). 'The fourth report on the standardisation of the terminology of lower urinary tract function', International Journal of Urology, 53, 333-335. Kolb, L G,Dees, J E and Langworthy, D R (19361. 'Behaviour of the human bladder freed from cerebral control', Journal of Urology, 36, 577-597. Jeffcoate, T N A and Francis, W J A (1966). 'Urgency incontinence in the female', American Journal of Obstetrics and Gynaecology, 94, 604-618. Lapides, J (1970). Neuromuscular Vesical and Urethral Dysfunction in Urology, W B Saunders, Philadelphia, vol 2, chap 33. Laycock, J and Green, R J (1988). 'Interferential therapy in the treatment of incontinence', Physiotherapy, 74, 4, 161-168. Lowe, J A (1977). 'Urethral behaviour during the involuntary detrusor contraction', Acta Obstetrica et Gynecologica Scandinavica, 128, 32-42. McLennan, F C (1939). The Neurogenic Bladder, Charles C Thomas, Spingfield, Illinois, pp 57 and 116. Mahoney, D T, Laferte, R 0 and Blais, D J (1977). 'Integral storage and voiding reflexes', Urology, 9, 1, 95. Mahoney, D T, Laferte, R 0 and Blais, D J (19801. 'Incontinence of urine due to instability of micturition reflexes', Urology, 15, 3, 229-239. Mayo, M E (1981). 'Pelvic floor function in women with detrusor instability', Progress in Clinical and Biological Research, 78, 91-99. Montgomery, E and Shepherd, A M (1983). 'Electrical stimulation and graded pelvic floor exercises for genuine stress incontinence', Physiotherapy, 69, 4, 112. Mundy, A R (1985). 'The unstable bladder', Urological Clinics of North America, 12, 2, 317-320. Peters, D (1984). 'Terodiline in the treatment of urinary frequency and motor urge incontinence', Scandinavian Journal of Urology and Nephrology Supplement 87, 21-33. Rose, D K (1931). 'Clinical application of bladder physiology', Journal of Urology, 26, 91-105. Scott, B 0, Green, V M and Couldrey, B M (1971). 'Pelvic faradism', Physiotherapy, 57, 7, 322-325. Teague, C T and Merill, D C (1977). 'Electric pelvic floor stimulation', Investigative Urology, 15, 65-69. Turner-Warwick, R T (19751. Communication to the 8th International Continence Society Meeting. Turner-Warwick, R and Brown, A D G (1979). 'A urodynamic evaluation of urinary incontinence in the female and its treatment', Urological Clinics of North America, 6, 203. Vereecken R Land Verduyn, H (19701. 'The electrical activity of the paraurethral and perineal muscles in normal and pathological conditions', British Journal of Urology, 42, 457. Wilson, F D, Samarrai, T A, Deakin, M, Kolbe, E and Brown, A D (19871. 'An objective assessment of physiotherapy for female genuine stress incontinence', British Journal of Obstetrics and Gynaecology, 94, 575-582.
445
Senior Physiotherapist in Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford
b y Words: Detrusor instability, frequency/volumecharts, anticholinergic drugs, bladder training, pelvic floor exercises. SWIItnary: Physiotherapy treatment of incontinence has been focused on the symptom of stress incontinence. Research projects have been camed out into its effectiveness. Many patients experience symptoms of severe frequency, nocturia, urgency and urge incontinence. A few experience enuresis. These symptoms often cause more distress and greater disruption of lifestyle than leaking on coughing and exercise, and may be due to detrusor instability. This has been diagnosed in up to 37% of women attending an incontinence clinic after urodynamic assessment. The etiology of detrusor instability is not clear and its treatment is difficult and often unsatisfactory. The aim of this paper is to examine the physical and psychological factors which may be involved in this complex condition, together with the usual treatment by anticholinergic drugs. Physiotherapy treatment using frequency/ volume charts, pelvic floor exercises and bladder training is discussed. Two case studies are included.
Bladder volume (mll
400
Fig 1: Normal cystometrogram
loo
1
Biography: Margaret Norwood qualifed from King's College Hospital
School of Physiotherapy in 1%3. She is a member of the Association of Chartered Physiotherapists in Obstetrics and Gynaecology, and has been a member of its education committee and a part I course leader. She is at present involved in a research project into the treatment of detrusor instability, and hopes to publish the results of this when it is completed.
I
Bladder volume (ml)
400
Fig 2: Spontaneous detrusor instability
Sometimes a contraction only happens on provocation. Cough instability may be confused with stress incontinence. The patient may have a desire t o void immediately after the cough and prior t o leakage. In genuine stress incontinence no such desire is felt (Abrams, 1988).
Introduction DETRUSOR instability describes a condition of unknown etiology, in which the detrusor muscle contracts not only during voiding but at other times. These contractions can be diagnosed only by urodynamic investigation, but may be suspected when the symptoms of urgency, urge incontinence, frequency and nocturia are present. A single contraction may produce the feeling of urgency. Urge incontinence usually happens with a powerful contraction, facilitated by urethral relaxation. Another effect of unstable contractions is t o limit the functional bladder capacity, and this produces symptoms of frequency and nocturia. (The alternative term used for the same condition is unstable bladder - Bates et a/, 1970.) Detrusor instability is defined as being present when involuntary rises in detrusor pressure exceeding 15 cm of water are observed during bladder filling (International Continence Society Standardisation Committee, 1977). ~
I
Bladder volume (ml)
400
Fig 3: Provocation (cough) instability
Unstable contractions are phasic and followed by relaxation. Sometimes there is a gradual rise in pressure due to the bladder exhibiting low compliance, but the detrusor
~~
~Ysiotherapy,August 1990. vd 76. no 8
439
remains stable. The bladder fails t o stretch readily t o allow a normal bladder capacity of 4 5 0 ml. In some patients reduced detrusor compliance may be accompanied by instability or progress to it (Elder and Stephenson, 1980).
Bladder volume (mll
400
Fig 4: Low compliance
Bladder volume (mll
400
Fig 5: Low compliance and detrusor instability
Bladder instability is an important phenomenon because of its frequent occurrence and the embarrassment of the symptoms it produces. It is estimated that 10% of the population aged 2 0 t o 5 0 years may be affected, although some are unsymptomatic (Turner-Warwick, 1975). It is very common in children, being normal under the age of three years, ie prior to gaining full bladder control. It is often present over the age of 70. It was seen in more than 50% of men of this age group by Abrams and Fenely (1978). and 3 0 % of women of the same age group. Women under that age, who show a higher incidence than men, may also be experiencing stress incontinence, and it is this group whose symptoms need careful evaluation, particularly if surgery is contemplated. Haylen e t a / (1989) showed that of 494 women referred t o a urodynamic clinic who complained of stress incontinence, only 2 % presented with it as their only symptom. Results of urodynamic studies showed 59% had stress incontinence, 9 % detrusor instability, and 12% a combination of both. A higher incidence of detrusoi instability was found by Cordozo (1984). Haylen eta/ (1989)argue that all patients who are to haw bladder neck surgery, should have urodynamic investigatior prior to it. Beck e t a / (1976) state that surgery should nevei be the first line of treatment for detrusor instability Hodgkinson e t a / (1963) showed that only 26% of womer with bladder instability who were treated with surger) gained any improvement.
3iology A single cause of detrusor instability cannot be clearly dentified and the etiology appears to be a complex of known 3nd unknown factors (Beck er a/, 1976). Unstable contractions were reported in association with :ertain neurological disorders (Rose, 1931; Kolb eta/, 1936). iyperreflexia is the term used to describe an unstable Aadder of neuropathic etiology (International Continence Society, 1980) to differentiate it from detrusor instability, without recognisable neurological disability. Some people have a family history of difficulty with urinary zontrol. It is not clear if this is some idiopathic weakness 3r a learned pattern of frequency due to overanxiety about micturition. Mundy (1985) suggests that someone who ?ever learns or uses the ability to hold urine under normal 5rcumstances will be unable to do so when forced to. Men who develop the condition often do so as a response to outflow obstruction, caused by an enlarged prostate. Women have fewer problems with obstruction, but some postulate that minor urethral problems may cause the letrusor to become unstable (Lowe, 1977). Mahoney e t a / 11980) state that instability is not uncommon in multiparous women with weakness of the pelvic floor. Turner-Warwick and Brown (1979) suggest that because some women with instability are continent, impairment of the distal sphincter mechanism is present in those who are incontinent. Some women develop detrusor instability following surgery to the bladder neck. The incidence following surgery for incontinence has been given as 70% of failure (Bates et a/, 1970). Detrusor instability is sometimes subject to spontaneous exacerbation and remission. This factor together with the lack of precise understanding of the etiology of the condition leads some to argue that most if not all patients have a psychological cause for their problem (Frewen, 1978). Certainly Hafner et a/ (1977) demonstrated a strong correlation between psychological disorder and the symptoms of frequency, urgency and urge incontinence, but these are sometimes present without bladder instability. In a later study Frewen (1980) found an emotive etiology in only 20% of cases where detrusor instability had been diagnosed. Abrams (1980) states that this etiological factor is currently regarded as less important. Neurophysiology The greatest difficulty in understanding the cause and nature of detrusor instability lies in the inadequacy of knowledge and understanding of the neurological control of the bladder, bladder neck, and internal urethral sphincter under autonomic control, and the role of the straited muscle providing the external sphincter mechanism, which is under voluntary control. Blaivas (1982) concludes that anatomically separate neural centres control the activity of the detrusor muscle and the external urethral sphincter. There is still argument over whether voiding is the result of a segmental sacral reflex arc that is facilitated and inhibited by supraspinal neurological pathways, or a long-routed reflex that is integrated at higher central nervous system levels. The first theory proposed by Denny-Brown and Robertson (19331, and popularised by McLellan (19391 and Lapides (19701, suggested that the detrusor reflex centre is simply a local sacral reflex, mediated entirely by the pelvic and pudendal nerves, that it is intrinsically hyperactive and dependant on tonic inhibitory impulses from the cerebral cortex.
~
440
Physiotherapy, August 1990, vd 76, no 8
This theory was challenged by Bradley et a/ (1974) and De-Groat eta/ (1979) who deny the simple segmental sacral detrusor reflex. They believe that voluntary control of voiding is accomplished by connections between the frontal cortex and the micturition centre in the rostra1 pons. They also conclude that during bladder filling, receptors in the external sphincter cause afferent discharge along the pudendal nerve, which synapse in the pudendal nucleus. Efferent pudendal discharge causes increasing external sphincter contraction until micturition reflex occurs. Voluntary control of the external sphincter is achieved by corticospinal pathways connecting the frontal cortex with the pudendal nucleus. Most of these conclusions were reached from research on cats, so it is necessary t o be careful in extrapolating to the human situation. Some research has been carried out on patients. Blaivas (1982) used his data to suggest that they 'strongly suggest that co-ordinated voiding is not a simple sacral reflex but requires integration at a higher neurological level'. The role of the external sphincter was examined. One group of patients with neurological lesions above the pons were able to void synergistically; 'in each instance complete relaxation of the external sphincter preceded the detrusor contraction'. Lowe (1977) reported a decrease in urethral pressure preceding an unstable detrusor contraction by five seconds in 85% of women with detrusor instability. In Blaivas' group nearly half those with neurological lesions had voluntary control of the external sphincter. Once aware of the detrusor contraction they could inhibit voiding momentarily by contracting the sphincter, but they could not abolish the detrusor contraction voluntarily. However, in a different group without neurological problems, he found that some patients who had involuntary detrusor contractions which they perceived as an urge to void, although unable to inhibit the onset of a contraction, once aware of it were able to abort it by contracting the external sphincter. 'This was followed by cessation of the bladder contraction within several seconds.' Certainly Mahoney e t a / (1980) believe that tonic inhibition comes from peripheral reflexes originating in the striated muscle of the pelvic floor and perineum, and that it is this which maintains the normal balanced function of the sacral micturition centre. These muscles which include the striated urethral sphincter are innervated by motor neurones originating in the pudendal nucleus, located close to the sacral micturition reflex centre, S2 t o S4. They also believe all cerebral influence is facilitative and not inhibitory, but that conscious 'wilful' inhibition in addition t o that from the voluntary contraction of the pelvic floor is possible, but the neurological pathways responsible are unknown. Vereecken and Verduyn (1970) established that normally, during bladder filling, pelvic floor EMG activity gradually increases with bladder volume. Mayo (1981) found that in women with detrusor instability 58% showed a decrease in pelvic floor activity during bladder filling.
Assessment with Frequencylvolume Charts The patients' recording of timing and volume of fluid intake and output is indespensable for the objective assessment of the symptoms of frequency of micturition and nocturia. It also shows clearly the pattern of micturition, bladder capacity and the correlation of input and output with frequency. Unfortunately it cannot monitor urgency. This frequencylvolume chart is always completed prior to a urodynamic assessment, and the recordings discussed
physiorherapy, August 1990. vol76, no 8
Nith the patient before a full history is taken. Mundy (1985) Ielieves it is perfectly reasonable to begin treatment on the Ibjective evidence provided by a completed frequency1 iolume chart accompanied by a careful history, and reserve irodynamic study for those who fail t o respond. The proviso given is that outflow obstruction in men should be excluded 'irst. If treatment is by medication, unnecessary use of drugs night result. If active treatment is prescribed, in the form )f bladder training and/or pelvic floor exercises there is no ,isk of side effects. A normal frequencylvolume chart shows a frequency rate )f seven or less in 2 4 hours, occasional or no nocturia, at east one voided volume of 4 5 0 m l (usually the first in the norningl, most other volumes similar to each other, and a otal output of 1,200 to 2,200 ml each day. Frequencylvolume charts
Time
fluid
inrake
Urine voideo Time
lmll
fluid
Urine voided Time
inrake
(mil
Normal
5.45 am 615am
Tea x 2
10.15am Coffee 12.30pm Tea 4pm 5.30pm 7pm
Tea Water Coffee
10.30 pm 11 om Horlicks Total
Wednesday
Tuesday
Monday
450 6 am 615am 9 am 350 10.15am 10.30 am 12.30pm 1.30pm 400 4pm 350 7pm 8.30pm 400 111om 1,950
Tea x 2 Coffee Soup Tea Tea x 2 Coffee Cocoa Horlicks
I
470 5.30 am 6.15am 310 9.30 am 10.15 am 260 12.30pm 250 1.30pm 4pm
Total
Tea
Coffee Orange
Coffee Tea Orange Tea Coffee Orange
150 80 50 90 100 100 140 140 120 70 130 150 50 200 140 90 90 1,890
Tea x 2
Squash Tea Tea x 2
Tea Coffee Orange
Coffee Tea Orange Tea Coffee Orange
130 150 50 80 100 90 120 140 140 60 150 100 80 150 120 90 120 1,890
500 300
350 300 250 300
2,000
2,040 3.30am 710am 8am 9.30am 1015am 11.05am 11.30am 12.10pm 12.50am 1.15pm 2.50pm 3.40pm 4.40pm 5.20pm 715pm 8.45pm 11pm
Urine voided (mll
Coffee
300 6 . 4 5 ~ m Coffee 250 10.15 pm Horlicks 300 11 om
Detrusor instability
6.50 am 7.55am 8.35 am 9.40 am 10.05 am 10.45am 11.20am 11.50am 12.15am 1 pm 2.40pm 3.45pm 4.30pm 5.50pm 7.05pm 9pm 10.55pm
fluid intake
410 am 6.40am 8.10 am 9.15 am loam 10.50am 11.20am 1210pm 1.10 pm 2 Pm 3.15pm 4.20pm 5.10pm 7.15pm 19pm
I
Tea Coffee Orange Tea Tea Orange Tea Coffee Orange
170 90 160 140 100 90 90 120 100 50 160 90 100 150 200 120 1,930
Typically, a patient with detrusor instability will void very variable volumes of urine at greatly different intervals, and the pattern may vary from day to day. (This is the reason for a chart to be kept initially for seven days.) Frequency rate may be ten to 30 times in 2 4 hours, sometimes more. Some of the voided volumes will be very low, and the largest voided volume often less than 4 5 0 ml. The patients may feel that having t o void into a plastic measuring jug and record their urine output for a week is difficult. For this reason it is important t o explain the usefulness of a completed chart not only t o the medical team, but to the patients themselves. It can reveal the relationship of symptoms to quantity or cafieine content
441
of intake, location (greater frequency at work or home) or other individual factors. The incidence of leakage can also be recorded if the patients are aware when it occurs. If the patients do not feel it happening, the need to wear a pad and the number of changes necessary in 24 hours is an alternative guide.
when medication is withdrawn. The treatment is passive, the patient gains no understanding of her condition or feeling of control over it. This is only achieved by combining treatment with bladder training, or pelvic floor exercises and bladder training. Bladder Training
Treatment of Detrusor Instability
Jeffcoate and Francis (1966) first described 'bladder discipline'. Patients with urge incontinence were hospitalised for three weeks. They underwent urethral dilation, received anticholinergic drugs, and were taught to void very strictly by the clock, gradually increasing the time intervals between voiding, wen though it was uncomfortable or leakage occurred. They showed that 67% of patients were cured, and 22% improved. Later, Frewen (1972) became the exponent of this form of treatment. He claimed a cure rate of 80% for detrusor instability using bladder training and inhibitory drugs for hospitalised patients. He was criticised for lack of urodynamic evaluation. He rectified this in 1978, and after three months showed a cure rate of 82%. Most patients were admitted to hospital initially for two weeks, but ten were treated as out-patients. In evaluating Frewen's regime, Elder and Stephenson (1980) compared the effect of bladder training on patients with low compliance, detrusor instability, and those with urge incontinence but stable bladders. At three months, symptoms were markedly improved or cured in 86% of patients. However, reduced compliance was the only detrusor abnormality which was reversible. The only long-term study of bladder training has shown a disappointingly high relapse rate after three years (Holmes et a/, 1983). Bladder training involves the patients in their own treatment. It is only possible with full explanation, discussion and use of frequencylvolume charts. Most patients with detrusor instability are very highly motivated to participate in bladder training, but need strong support and encouragement while undertaking it, particularly if they do so as outpatients. Frewen (1972) believes it is this psychological support which is the essential key to a successful outcome. Frequency is often an acquired habit, arising from the fear of allowing the bladder to fill normally. Patients with detrusor instability often void before leaving home, work or known location or on seeing a lavatory, even though they have felt no desire to micturate. They have to learn to break this habit. The only way that patients can postpone voiding when they do feel urgency is by contracting the muscles of the pelvic floor. This factor seems to have been ignored when teaching bladder training.
The lack of understanding about the cause of detrusor instability is reflected in the wide range of treatments tried. Those most commonly used are bladder training, drugs, and bladder training plus drugs. Other methods are electrical pelvic floor stimulation, biofeedback, surgical procedures (denervation or bladder distension), hypnosis, acupuncture, and transcutaneous nerve stimulation. Irecommendmethods of treatment which includevoluntary pelvic floor exercises plus bladder training; ' or for severe symptoms, pelvic f loor exercises, bladder training and drugs. Drug Treatment , Two problems arise when prescribing medication for detriisor instability. The first is the lack of knowledge about the pathophysiology of the condition. The second is that of giving adequate doses without producing unacceptable side effects. Many drugs have been used to treat the condition (Andersson and Ulmsten, 1980; Applebaum, 1980). They may act either on the nervous system or the muscle. Those acting on the nervous system may act centrally or peripherally. The anticholinergic drugs are the most popular. They produce their effect by competitive blockade of receptor sites. The following drugs have anticholinergic effects and have been used with effect for some patients with detrusor instability: propantheline bromide, emepronium bromide, and oxybutynin chloride. The last of these is thought to have an additional muscle relaxant property, but Abrams (1984) doubts if the dosage required to produce muscle relaxation would be tolerated, due to the anticholinergic side effects on the same doses. These side effects are - dry mouth, eyesight difficulties, nausea, constipation and urinary retention. Drugs are now being used which have a dual effect. Andersson and Ulmsten (1980) state that treatment with anticholinergics is often ineffective. They have a low and variable absorption rate. Drugs inhibiting bladder contractions by anticholinergic and calcium entry blocking action have the advantage of being well absorbed from the gastro-intestinal tract. Drugs selectively inhibiting calcium influx are effective because calcium entry plays an important part in the activation of smooth muscle (Formanetal, 1978). Trials of one drug with the dual effect, terodiline (Micturin), found a small but significant reduction in frequency of micturition in the treatment of detrusor instability (Gerstenberg et a/, 1986; Andersen et a/, 19881. It eliminated unstable contractions in nearly 50% of patients, but failed to do so in 50%. However, Peters (1984) and Fischer-Rasmussen (1984) showed that 50% of large groups of women treated with terodiline experienced side effects, and these were severe for 12% of patients. The side effects of the anticholinergic property predominated over those of the calcium antagonist agent which were: hypotension, palpitations, headache, and facial flushing. Even when drugs are effective in reducing frequency of micturition slightly, the effect is not always permanent
442
Rationale for Trestment of Detrucror Instability by Rdvic Floor Exercises Combined with Bladder Training Mayo (19811states that 'with regard to detrusor instability, because pelvic floor relaxation appears to be the initiating event and because pelvic floor contraction is known to inhibit detrusor contraction by reflex mechanisms, an attempt to improve pelvic floor control would be more logical than a direct attack on the detrusor'. The effectiveness of electrical stimulation of the pelvic floor muscles in abolishing unstable detrusor contractions has been shown (Godec eta/, 1975 Teague and Merill, 1977; Fall etal, 1987). The same effect is produced by voluntary pelvic floor contractions (Mahoney 8t a/, 1977; Blaivas, 19_8_2_),..
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P h W o h W y , August 1990. vd 76, no 8
Different methods of treatment using electrical stimulation of the pelvic floor muscles have been found to be effective in the treatment of detrusor instability. Fall et a/ (1986) showed 87% of patients showed improvement after using an intravaginal device at home (Contelle), but some patients experienced a recurrence of symptoms within a few weeks of discontinuing treatment. Using a device for anal electrical stimulation (Incontan) Erikson and Mjqlnerod (1987) found that 45% of patients with detrusor instability had a stable bladder after treatment. Bladder volume was decreased, both at first desire t o void, and at maximum cystometric capacity. Laycock (1988) describes the use of interferential therapy in the treatment of incontinence, and states: ‘A combined treatment with pelvic floor exercises is recommended‘. She included treatment of patients with detrusor instability. Harrison (1976) found that active pelvic floor exercises could be well taught during digital vaginal examination, by getting the patient t o squeeze on to the t w o gloved fingers inserted, while keeping the glutei, abdominals and adductors
History
Case History 1
‘Jane‘ was a divorced mother of three teenage children. She was 4 5 years old, at 105 kg heavily overweight, and worked as a driver. She had had a hysterectomy and anterior repair 14 years previously, but her incontinence had gradually become worse and was severely distressing t o her and causing her anxiety in relation to her ability t o maintain her job. She was referred for urodynamic assessment prior to consideration of future colposuspension. Presenting Symptoms Severe urgency and urge incontinence. Severe frequency and nocturia. Her frequencylvolume chart showed a frequency rate of 16 in 2 4 hours, related to an average daily total volume voided 2,450 ml. Nocturia averaged three each night. The largest volume voided was 400 ml. 0 Severe leaking on coughing, sneezing and exercise. Stress incontinence was demonstrated when lying and in standing. Continuously wet, requiring three large sanitary pad changes per day. Urodynamic Findings Gross detrusor instability and gross stress incontinence. The patient had a severe cystocoele and moderate rectocoele. Treatment
It was decided to try to stabilise the bladder and encourage weight loss prior to surgery. Cetiprin (emepronium bromide) and physiotherapy were prescribed. On Examination The cystocoele and rectocoele were seen clearly during vaginal examination. Only very weak pelvic floor contractions were felt during digital examination, and this registered a reading of four on a Bourne perineometer’.
‘The Bourne perineometer is available only from the manufacturer, Doncast, 56 Chaldon Common Road, Chaldon, Caterham, Surrey CR3 5DD (tel 0883 3427821. Prices from €139 to €187 all inclusive of post and packing.
relaxed. This made electrical stimulation unnecessary, except for a few patients with sensory loss. Electrical stimulation of the pelvic floor muscles has been used for the treatment of stress incontinence. However, in a comparative study Wilson e t a / (1987) found that the teaching of voluntary pelvic floor exercises, encouraged by weekly follow-up visits for six weeks, was just as effective as either faradism and pelvic floor exercises or interferential therapy and pelvic floor exercises, in curing genuine stress incontinence. No equivalent study for treating detrusor instability has been made. When treating stress incontinence with faradism and pelvic floor exercises Scott et a/ (1971) recommended reeducation of the bladder to decrease frequency. Montgomery and Shepherd (1983) noticed that pelvic floor exercises decreased frequency of micturition, in addition to stress incontinence. The following t w o case histories illustrate some of the problems involved in the treatment of detrusor instability, but also the possibility of effective treatment by a physiotherapist. Physiotherapy Treatment Aims 1. To give the patient an understanding of her urinary problems. 2. To reduce symptoms of urgency, urge incontinence, frequency and stress incontinence. 3. To encourage weight loss. 4. To help the patient regain confidence in her bladder control. 5. To prepare the patient for possible surgery. Physiotherapy Management Jane was pleased t o co-operate fully with the physiotherapist, and very highly motivated indeed t o participate fully in her own treatment. The results of the urodynamic findings were fully discussed with her, and the relationship of her symptoms t o detrusor instability and stress incontinence explained. The functional anatomy of the pelvic floor was taught, together with information about the inhibitory effect of pelvic floor contractions on unstable detrusor contractions. She was taught how to contract the pelvic floor muscles while keeping the abdominal, gluteal and adductor muscle groups relaxed, in lying, sitting and standing. Instructions for home exercises were given. Pelvic floor exercises were to be done half-hourly initially, in any position where they could be felt effectively, concentrating on closing and lifting the back passage and vagina, and gradually progressing the height of the lift and number of seconds held from t w o t o ten. The aim of increasing the strength of the pelvic floor was related to setting a goal of improving the perineometer reading. Progress Chart Symptoms
1st visit
After 2 weeks
After 6 weeks
After 3 months
Nocturia Stress incontinence Frequency Urgency Pads, daily
3-4
1
0-1
Occasional
Severe 16 Severe 3
Reduced 12 Reduced 1-2
Occasional 8 Reduced 1
Occasional 6-7 Slight Occasional
Perineometer
4
7
10
16+ +
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Progress The use of a three-day frequencylvolume chart prior t o each follow-up visit, and the perineometer, gave an objective measurement of improvement. This patient made such good progress it was decided to stop the medication after six weeks, as she was obviously continuing her pelvic floor exercises vigorously. As the strength of the muscles increased, she was encouraged t o carry out some contractions quickly, and if she suddenly experienced urgency. This gave her confidence that she could delay voiding, and she began t o refrain from passing urine at every possible opportunity. The overweight was discussed and she was referred t o her GP for advice. This was reinforced by the physiotherapist after explanation of the way in which excessive weight increases pressure on the pelvic floor, and the reluctance of surgeons t o operate until weight was lost. Jane decided that although she still leaked if she coughed
Case History 2 History 'May' was a quiet woman of 46 years, dressed rather dowdily. She was married, with t w o children, and her husband always brought her for treatment. She complained of urinary symptoms since her hysterectomy three years previously. She worked as a cook and found conditions at work aggravated her symptoms which she found embarrassing. She was slightly overweight at 7 5 kg.
Physiotherapy liea tmen t Aims
1. To give the patient an understanding of her urinary symptoms. 2. To reduce the symptoms of urgency, urge incontinence, leaking in response to hearing or feeling water, enuresis, and frequency. 3. To encourage weight loss. 4. To help the patient regain confidence in control of her bladder. Physiotherapy Management
Presenting Symptoms 0 Extreme urgency and urge incontinence. 0 Leaking on hearing a tap running, putting her hands in
water, coughing and sneezing. 0 Occasional enuresis. 0 Slight frequency, nine in 2 4 hours, related t o total average daily volume voided 1,863 mi. Urodynamic Findings Gross detrusor instability, no stress incontinence (detrusor instability exhibited on bladder filling and on provocation tests, ie coughing). The largest volume voided was only 300 mi, ie functional bladder capacity was reduced. Treatment Terodiline (Micturin), 25 mg per day, and physiotherapy were prescribed. On Examination
No prolapse was present. The perineometer reading was 14, ie very high (the limit is 16).
Conclusion Detrusor instability is poorly understood and its treatment difficult. Drugs are not always effective and only reduce frequency slightly. They often cause side effects, and do not give the patient an understanding of their condition or any feeling of control over it. Electrical stimulation of the pelvic floor may be frightening for the patient, uses a lot of physiotherapist's time, and is not usually necessary t o teach a patient active pelvic floor exercises. Bladder training can be effective, but is difficult if the pelvic floor is weak.
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or sneezed suddenly, and stress incontinence could still be demonstrated after treatment, she would not go ahead with surgery at that time. Although we were as delighted with the outcome as she was, the presence of the cystocoele remained; and as it was severe, the problem of stress incontinence would continue. During the course of treatment Jane seemed very keen t o discuss the depressing effect of her symptoms, and the decrease in symptoms was accompanied by a visible increase in self-confidence and more positive feelings about herself, her job and family. At the end of treatment not only had her symptoms decreased but her chart showed a large increase in the largest volume voided - 6 5 0 ml (from 400 ml initially). Jane was advised t o continue pelvic floor exercises four-hourly or if experiencing urgency, but t o increase the frequency of contractions if symptoms returned. The possibility of the need for surgery at a later date was emphasised, together with the advisability of weight reduction.
It took time to gain May's confidence as she was shy. Once this was achieved, she welcomed the opportunity to talk about her situation and showed a quiet determination t o overcome her problem herself. It became obvious that her husband was helpful and encouraged her. The management was the same as for Jane, but pelvic floor contractions were related t o urgency (and urine) earlier as the pelvic floor was already strong. After the first week May complained of feeling continuously 'dizzy' and discontinued the medication, when this symptom disappeared.
Outcome May's frequency had reduced to six in 2 4 hours, and her largest volume voided increased t o 400 m l (from 300 ml), ie her bladder capacity had increased. All her other urinary symptoms had been alleviated, apart from slight leaking on sneezing. On her final visit, she had lost half a stone in weight, was dressed more smartly and seemed confident about her regain of bladder control. in a recent group of 17 women with detrusor instability being studied, 12 registered an initial perineometer reading of 2-4, ie had very weak pelvic floor muscles. Active treatment involving the patients' understanding, high motivation, and co-operation t o achieve relief of symptoms, seems preferable t o treatment where patients are passive. The treatment of women with detrusor instability by a specialist physiotherapist using frequency/volume charts, active pelvic floor exercises and, if necessary, bladder training, can be effective for some patients in reducing symptoms and increasing confidence in bladder control. It makes good use of a physiotherapist's time and skills. Evaluation of this method has not yet been completed.
ACKNOWLEDGMENTS I would like to thank Professor Sir A C Turnbull, Mr K A McCallum, Mr H Williams, Miss B M Couldrey, Mrs C Boyd and Mrs A Hill for all their assistance.
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