Fourth International Consultation On Incontinence (ICI) - Adult Conservative Management Committee Highlights

Main Category: Urology / Nephrology
Article Date: 24 Jul 2008 - 2:00 PDT

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Jean Hay Smith, MD, and Ingrid Nygaard, MD, Committee Chairs

PARIS, FRANCE (UroToday.com) - Dr. Hay Smith presented this committee's findings on conservative management of UI in women and men and POP in women. Dr. Hay Smith noted that the group also examined other LUTS and the affect of aging on conservative management, but these issues will be addressed only in the full written report. He began by defining conservative management as any intervention that does not involve pharmacotherapy or surgical management. It is generally a first-line therapy at the primary care level and is usually "simple" and "low-cost".

In women, weight loss in morbidly to moderately obese women achieved a Grade A recommendation and caffeine restriction received a Grade B recommendation. Both of these were changes from the previous consultation, as was the Grade C recommendation for exercise. Fluid restriction in women with high baseline fluid intake levels received a Grade D (expert opinion) recommendation. Pelvic floor exercises (PFE) was the subject of numerous citations in the presentation.

In two specific cases (primiparous women who are continent at 18 weeks and women with persistent UI after delivery), a Grade A recommendation was given for PFE. PFE for women following delivery of larger babies or after forceps delivery is also advised (Grade B), as is physiotherapist PFE for primiparous women between 12 and 20 weeks gestation (Grade B). For all women with SUI, urge UI and mixed incontinence, PFE is a good first-line treatment (Grade A), and physician directed/supervised treatment is superior to self-directed treatment (Grade A). Clinic or home-based biofeedback does not appear to be of benefit (Grade A, B). A grade recommendation was given for using vaginal cones for SUI (Grade A), although adding cones to PFE does not add benefit (Grade B).

Several different types of electrical stimulation therapies received Grade B recommendations for treatment of DO and SUI, although there does not appear to be any additional benefit when added to PFE. Magnetic stimulation has generally fallen out of favor and the committee recommended its use only in the setting of clinical trials. Bladder training was addressed next a given a Grade A recommendation as first-line therapy, and the committee suggested that more physician or nurse supervision may be helpful, although this was only at the level of expert opinion (Grade D). A new finding since the previous consultation involved the use of duloxetine vs. PFE for SUI. It was not clear that PFE was superior, although Dr. Hay Smith noted that the duration of PFE (12 weeks) was probably too short to see the full effect. Women on duloxetine had superior quality-of-life scores, although it was noted this might be due to the mood enhancing effects of the drug.

The presentation then switched to the discussion of conservative treatments for men. Several new Grade B recommendations were given including using PFE before or after radical prostatectomy to assist in return of continence. The evidence was equivocal as to whether or not digital rectal exam or biofeedback is superior to written and verbal instructions. Electrical stimulation does not add anything to PFE alone.

In the area of treatment of POP, the committee concluded that obesity, certain occupations involving heavy lifting, constipation and anemia increase the risk for POP (Grade C). PFE can improve POP severity (Grade B) and may prevent POP (Grade C). PFE before prolapse surgery can improve LUT symptoms and QoL measures (Grade C). In one trial, the Gellhorn pessary and ring pessary were found to be essentially equivalent in the conservative treatment of POP (Grade B).

Overall, the committee concluded that the evidence supports conservative therapies as a first-line therapy for men and women with UI and women with POP. Dr. Hay Smith identified numerous research priorities in these fields, including conservative therapies in primary prevention, cost-effectiveness of different treatments and patient adherence.

Moderated by Christopher Chapple, MD, and Willie Davila, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.

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