Pelvic organ prolapse (POP) and urinary incontinence (UI) are common problems experienced by women of all ages. With the publication of Seizing the opportunity to improve patient care: Pelvic floor services in 2021 and beyond (Pelvic Floor Society, 2021) comes recognition of how common pelvic floor disorders are, but how little investment has been put into these services. Such publications highlight the need for services to be provided which encourage women to come forward to be assessed and treated. This article, the second in a two-part series, discusses conservative treatments for UI and POP, which should be considered as first-line options where possible (National Institute for Health and Care Excellence [NICE], 2021).  
Following on from the previous article in this two-part series, which looked at the assessment of women with urinary incontinence and pelvic organ prolapse, this article discusses the most common conservative treatments available for women presenting with symptoms of:  
  • Stress incontinence  
  • Overactive bladder (OAB)  
  • Pelvic organ prolapse. 
 Table 1 outlines the treatments available for women with these symptoms, which can be started in primary care. 
Condition Conservative treatments
Stress incontinence Pelvic floor exercises (PFE), intravaginal devices, Squeezy app, electrical stimulation and biofeedback, medications
Overactive bladder Bladder retraining, fluid advice, PFE, medications
Pelvic organ prolapse PFE, vaginal pessaries
Table 1. Treatments available.

STRESS INCONTINENCE  


Stress incontinence has been defined by the International Continence Society (ICS, 2018) as: the complaint of any involuntary loss of urine or physical exertion (e.g. sporting activities) or on sneezing or coughing.  

Pelvic floor exercises (PFE) improve pelvic floor muscle strength, endurance, power and relaxation (Bo, 2017) and should be tried as first-line treatment for women presenting with symptoms of stress incontinence. The National Institute for Health and Care Excellence (NICE, 2019) suggests that women should receive three months of PFE. Women should be advised to do eight contractions three times a day and should continue with the treatment if improvement is noted.  

PFE can be undertaken by the patient at home or supervised by a pelvic health physiotherapist or specialist nurse (Bo, 2017). It is essential that women are refereed to check their technique if they are not sure they are doing it correctly. Mazur-Baily et al (2020) reported that 70% of women with pelvic floor dysfunction are unable to perform a correct pelvic floor contraction. Physiotherapists will be able to assess the patient’s ability to contract their muscle and advise accordingly, setting a regimen specifically designed for them. Regular feedback sessions can then be arranged to monitor progress and keep the patient motivated.  

There are a number of excellent patient resources that staff can give out to patients to explain how to do pelvic floor exercises correctly. The International Urogynecological Association (IUGA) has an excellent range which can be printed from their website — www.yourpelvicfloor.org/leaflets/. The Pelvic and Obstetric and Gynaecological Physiotherapy (POGP) website (https://pogp.csp.org.uk/publications/pelvic-floormuscle-exercises-women) also has a number of excellent patient information leaflets about pelvic floor exercises. 

Those who want to start their PFE before seeing a specialist can download Squeezy: NHS pelvic floor app (Sudol et al, 2019). This app provides excellent feedback from patients. Squeezy comes pre-set with an exercise plan that follows NICE guidelines (2019b). All the patient needs to do is to set reminders so that they can easily remember to do their exercises throughout the day. There are visual guides and pre-set programmes, which can be tailored to a patient’s needs once they have seen a physiotherapist.  


Intravaginal devices  


Intravaginal devices can be considered to support the bladder neck and reduce urinary leakage. They give additional support to the pelvic floor and help to relieve symptoms (NICE, 2021). They have become more popular since the suspension of mesh surgery (Stewart, 2019), as women look for alternatives to surgical management. Women can self-manage these devices and use them when suits their symptoms the most, i.e. they can be inserted before an exercise class, or if going out dancing for the evening. It is advisable that patients are supported by a clinician when using this type of device, such as a pelvic health physiotherapist, and are informed of cleaning, removing and reinserting the devices and potential problems which may be experienced. For example, some women who have atrophic vaginal tissues may find that they bleed when the device is inserted, and so a healthcare professional would be able to advise what should be done to prevent this from happening. Figures 1–3 are examples of intravaginal devices available. These can be bought from companies directly or prescribed on FP10s.  

Figure 1. Uresta intravaginal device.

Figure 2. Diveen and applicator intravaginal device. 

Figure 3. Contiform intravaginal device. 

Electrical stimulation and biofeedback  


These treatments are not recommended as first line but may be suggested by a pelvic health physiotherapist to augment pelvic floor exercises following assessment, or lack of progress with treatment. 

Electrical stimulation is often used in women with little or no pelvic floor contraction. Some women are unable to contract their muscles at all, so this can be used to show them which muscles they need to contract.  

Biofeedback, where a patient is able to visualise her feedback, can also be used by a specialist with specialised equipment.  
▶ Biofeedback...

A probe, which is attached to a biofeedback machine, is inserted into the vagina. When the patient squeezes the probe with their pelvic floor muscles, the patient can see the pressure increase during the squeeze on the machine’s screen. This is positive feedback, which aims to encourage the patient to do their exercises more regularly to notice improvement the next time they use the machine. It can also be used to encourage people who find it difficult to contract their pelvic floor muscle because they can see any movement on the screen. 

Medications to treat stress urinary incontinence  


Duloxetine remains the only drug currently licensed to treat stress urinary incontinence. NICE/British National Formulary (BNF) (NICE/BNF, 2022) online suggest that patients are started on 20mg twice daily for two weeks, as a lower dose can reduce side-effects, and be increased to 40mg twice daily if needed. A review of the medication is suggested two to four weeks after starting treatment. Nausea is the most common adverse event and the main cause for discontinuation, so women should be advised of this before starting any treatment (Noble, 2018). NICE recommends that duloxetine is not routinely offered to women as a second-line treatment. However, it may be used and offered if surgery is declined by the patient or if it is not a suitable treatment option (NICE, 2019b).  

Prevention  


It is important to educate women and try to prevent symptoms worsening. Advice on reducing constipation (straining weakens the pelvic floor muscle which may have an impact on symptoms), avoiding heavy lifting and some specific types of exercise can help with this. Again, if unsure, refer the patient to a physiotherapist. 
 

Referral for surgery  


Patients who have not noticed satisfactory improvement in their symptoms should be referred to secondary care for advice on alternative treatments. Women of child bearing age are advised to complete their families before a referral is made for surgical management (Table 2), as future pregnancies may negate any surgery performed.  

OVERACTIVE BLADDER (OAB)  


There are a number of treatments which can be tried to help improve symptoms of an OAB. The most common symptoms are urinary frequency, urgency, urgency incontinence and nocturia (Fontaine et al, 2021). OAB can be wet or dry, which means that women can have OAB symptoms with or without urinary leakage, most commonly in the form of urgency incontinence. Most of the treatments require the patient to be motivated and wanting to improve their symptoms. DeMaagd and Davenport (2012) have suggested that patients who are motivated and follow a regimen for up to three months experience beneficial effects.  

The author feels it is vital for healthcare professionals to ensure that patients understand why they are being asked to undertake a specific intervention and the benefits they should notice if they engage fully. Brucker et al (2020) agree with this, stating that patients with OAB should receive education on normal bladder function and benefits and risks of treatment. The clinician and patient should then discuss the patient’s treatment goals and expectations.  

When simple, conservative treatments do not provide the symptom improvement and quality of life changes that the woman wants, referral to secondary care should be considered.  

It is important to remember that OAB is a chronic condition and available treatment options may improve, but not cure symptoms, leading to dissatisfaction and high rates of discontinuation of medications. Dhaliwal and Wagg (2016) suggest that adherence to medication is markedly worse in those with OAB than other chronic medical conditions, and that many people discontinue therapy prematurely.  

Bladder retraining  


Bladder retraining aims to increase the length of time between voids with the intention of increasing bladder capacity and reducing urinary urgency and urgency incontinence (Ostle, 2016). Patients should be advised to try and ‘hold on’ when they feel the urge to go to the toilet and try not to rush straight away. This can be achieved by teaching patients urge suppression techniques, such as perineal pressure and distraction (Rantell, 2015). NICE (2019b) suggests that women with urgency or mixed urinary incontinence are offered bladder training lasting for a minimum of six weeks as first-line treatment.  
 

Fluid advice  


NICE (2017) recommends a reduction in caffeine to improve overactive bladder symptoms. Caffeinated drinks such as tea, coffee, hot chocolate and green tea are high in caffeine and are known to irritate the bladder, which will make those experiencing symptoms of OAB worse. Patients should be advised to drink decaffeinated drinks (which do still contain some caffeine) or caffeine-free drinks. Rantell (2015) suggests that women should be advised to aim to drink 1.5 litres of fluid a day. This may need to be increased if they are overweight, they are exercising a lot, or it is hot. Not drinking enough often increases urinary urgency and urinary frequency because the urine produced is strong and concentrated, which can irritate the bladder increasing the number of times needed to go to the toilet. Carbonated and citrus drinks can also affect bladder function and increase urinary urgency and frequency. Patients should be advised to avoid them or water down citrus drinks, such as orange juice, if they affect their symptoms.  

Women who are experiencing nocturia should be advised to restrict what they drink from earlier in the evening and not to take a drink to bed with them.  

Diuretics are also known be a cause of incontinence and should be avoided where possible, particularly in the elderly (Fontaine et al, 2021).  

Pelvic floor exercises  


The aim of pelvic floor muscle (PFM) training in patients with OAB symptoms is to inhibit detrusor contraction through a PFM contraction (Brucker et al, 2020). Fontaine et al (2021) state that in motivated patients this can prove to be efficacious with urinary leakage reduced by 50–80%, with up to 30% of patients becoming dry. Patients should be referred to a pelvic health physiotherapist to ensure that they are doing PFE correctly (see stress incontinence section).  
 

Bladder diaries  


In the author’s clinical experience, bladder diaries are a useful tool for someone who is embarking on bladder training and changes to fluid intake. Healthcare professionals should suggest that women complete a diary for a couple of days before starting bladder training, and then six weeks into treatment to see what changes have been made to their symptoms. Changes are often small and looking back at previous diaries will show patients the improvement they have made, which will help with maintaining motivation. NICE (2013) suggests that a bladder diary should be completed for a minimum of three days. This should cover variations in normal activities, i.e. a day at work and a day at home.  
 

Medications to treat OAB  


If women do not achieve an acceptable benefit from doing bladder retraining, the combination of an OAB medicine with bladder training should be considered if frequency remains a troublesome symptom (NICE, 2019b). Patients who are started on medications should be offered a review of the medications four weeks after starting them (NICE, 2019), or earlier if there are any adverse events or problems, such as a dry mouth, blurred vision or constipation, or if they have any queries about their medications after starting taking them. Patients should be advised of the side-effects of any medications started. Antimuscarinics can cause a number of potential side-effects, which patients should be warned of before starting them to ensure that they have given informed consent (Table 3). Patient compliance with antimuscarinic therapy is often poor due to intolerable side-effects, with Chappel et al (2017) stating that discontinuation rates are up to 85% over 12 months. Table 4 details medications available to treat OAB symptoms.  
  • • Urodynamics  
  • • Bulking agents such as bulkamid or macroplastique 
  • • Colposuspension — open or laparoscopic 
  • • Autologous fascial sling. 
Table 2. Secondary care options.  
  • • Dry mouth  
  • • Constipation 
  • • Blurred vision 
  • • Dizziness 
  • • Drowsiness 
  • • Dyspepsia 
  • • Headache 
  • • Nausea 
  • • Palpitations 
  • • Urinary retention. 
Table 3. Side-effects of antimuscarinic medications. (NICE/BNF 2022) 

Table 4. Medications available for OAB. (Adapted from NICE, 2019)
Patients should also be advised that antimuscarinic agents may take several weeks to achieve an initial treatment effect.  

Mirabegron should also be considered if medications are needed to improve OAB symptoms. Mirabegron is a beta-3-adrenergic-receptor agonist. Common side-effects include hypertension, headache, and urinary tract infection (UTI). Patients who suffer with constipation should be considered for mirabegron instead of an antimuscarinic, as they are likely to exacerbate this problem. Persistence and adherence with mirabegron is statistically superior to other antimuscarinics in a large UK primary care population (Chappel et al, 2013).  

If antimuscarinics alone do not improve symptoms sufficiently, combination therapy of solifenacin and mirabegron can be considered. Brucker et al (2021) state that combination therapy increased the efficacy of solifenacin without increasing antimuscarinic side-effects.  

If there is no significant symptom improvement after trying conservative treatments and medications, referral to secondary care should be considered (Table 5).  
  • • Urodynamics — simple, video, ambulatory 
  • • Percutaneous tibial nerve stimulation (PTNS) 
  • • Botulinum toxin injections 
  • • Sacral nerve stimulation (SNS) 
  • • Augmentation cystoplasty 

Table 5. Onward referral when conservative treatments have failed. (Ostle, 2016) 

PELVIC ORGAN PROLAPSE  


Pelvic organ prolapse is one of the most common medical disorders, occurring in one in two parous women (Stewart, 2019). POP can be treated or managed in three ways, namely:  
  • Pelvic floor exercises  
  • Vaginal pessary  
  • Surgical management (Chung and Kim, 2018).  
Okeahialam et al (2022) suggest that pelvic floor exercises are considered as first-line treatment and that four months of pelvic floor exercises should be considered for women with a vaginal prolapse which does not extend greater than 1cm below the hymen on straining. NICE (2021) also suggests that vaginal pessaries should be considered for women suffering with symptomatic POP.  
 

Vaginal pessaries  


These are plastic/silicone devices which are inserted into the vagina to support and take away symptoms of a POP, such as heaviness or a bulge in the vagina (UKCS, 2021). A number of different types of pessaries are available depending upon the type and severity of prolapse. Zeiger et al (2021) suggest that vaginal pessaries have a high level of patient satisfaction, improved vaginal and sexual symptoms, quality of life and mental health, so should be considered when managing POP.  

Fitting a vaginal pessary can be ‘hit and miss’ in spite of the experience of the clinician (UKCS, 2021). Sometimes previous surgery can affect the shape of the vagina, which means that it is difficult to hold the pessary in place. Some women find vaginal pessaries uncomfortable and are unable to tolerate them, these women should be offered a different type or size of pessary to see if the fit is better. Other women would rather opt for surgical management of their prolapse instead of trying a vaginal pessary because of previous negative experience of a friend or family member. When considering a vaginal pessary, women should be counselled about the benefits in symptom improvement. As well as improving the symptoms of a bulge in the vagina, having a vaginal pessary can improve bladder function and have a significant impact on quality of life. They should also be advised that, on average, it takes 2–3 fittings until the correct size/shape of pessary is found (Jones and Harmanli, 2010).  

Ring pessaries are the most commonly used in primary care. These can be fitted by nurses or GPs. A number of things should be discussed with the patient before a pessary is inserted (Table 6) to ensure that informed consent is obtained before the pessary is trialled. Patients should also be told about potential complications associated with the risk of vaginal pessaries (Table 7). It should be stressed that complications with vaginal pessaries are rare (Jones and Harmanli, 2010), provided that the pessaries are the correct size, fitted properly, and changed as per guidelines.
 
▶ Practice point

Ring pessaries are used to support mild-to-moderate POP. More supportive pessaries, such as Gellhorn and POPY™ pessaries, should be considered if the rings do not support the prolapse effectively or are not held in place. 
  • • The pessary will need changing every four to six months   
  • • An increase in vaginal discharge may be noticed 
  • • The first pessary may come out, often when opening bowels or sitting on the toilet. Sometimes it takes a few fittings to get the correct size and type 
  • • Any vaginal bleeding should be reported immediately to the clinician 
  • • Topical vaginal oestrogen may be considered to help re-oestrogenise the vaginal tissues and reduce complications, such as ulceration of tissues and bleeding 
  • • Self-management pessaries can be considered to enable independence with care/ prolapse management. 

Table 6. Things to inform women of in discussions about vaginal pessaries 
  • • Increased vaginal discharge 
  • • Odour 
  • • Bleeding 
  • • Pessary getting stuck 
  • • Irritation in the vagina 
  • • Pain 
  • • Erosion.   

Table 7. Complications of vaginal pessaries 

Changing the pessary  


Following removal of the vaginal pessary, the condition of vaginal tissues should be checked using a speculum. Atrophic tissues should be noted and a topical vaginal oestrogen in the form of a cream or pessary tablet should be considered (Bulchandani et al, 2014). The pessary device should be left out if there is evidence of bleeding and/ or ulceration, which will allow for the tissues to heal (Stewart, 2019). If the woman is post-menopausal, has a womb and notices vaginal bleeding when she has a pessary, she should be referred to secondary care on the two-week wait pathway for assessment of endometrial thickness and screening for possible endometrial cancer. An endometrial biopsy should be considered to exclude coexisting endometrial cancer (Vanichtantikul et al, 2017).  

The most common cause for vaginal bleeding in women who have a vaginal pessary is atrophic vaginitis (Figure 4) — this is when the tissues in the vagina lack oestrogen and become dry and thin. This may cause bleeding (Domoney, 2014), as the pessary rubs inside the vagina as the patient moves around.  


Figure 4. Atrophic vaginal tissues.  

Training in pessary management  


A freedom of information request sent to all hospitals in the UK concluded that there was no agreed guideline or standard for training healthcare professionals about pessary management (Dwyer et al, 2021). The UK Continence Society (UKCS) published an excellent guideline in March 2021 (UKCS Guideline), which provides patient information, guidelines for pessary management, flow charts detailing the fitting of different types of vaginal pessaries, trouble shooting and a comprehensive training document. These standards and guidelines were produced by a multidisciplinary team, including patients, with the aim of improving patient care and management of people using a vaginal pessary to manage their POP.  

WEIGHT LOSS  


NICE (2019b) advises that women with a body mass index (BMI) of over 30kgm2 who experience symptoms of urinary incontinence, OAB and POP should lose weight. The guidance states that women with pelvic floor dysfunction should not wait until they have lost weight but should start other treatments to improve their symptoms (such as pelvic floor exercises) at the same time as a weight loss programme (NICE, 2019b). Faiena et al (2015) agree with NICE and suggest that obesity is a significant, adjustable and reversible risk factor for incontinence. Pomian et al (2016) state that reduction of BMI has a positive impact on the symptoms of urinary incontinence. However, weight loss is often difficult. It requires the person to be motivated and support from a healthcare professional is often needed to set realistic goals and weight loss efforts (Dicker et al, 2021).  

Women should be supported in their attempt to lose weight and understand the general health benefits as well as the impact it could have on their bladder symptoms or pelvic organ prolapse (Stewart, 2019). The NHS has a digital, online 12-week behavioural and lifestyle programme, which supports adults living with obesity to manage their weight and improve their health (www.england.nhs.uk/digital-weight-management/). Local clinical commissioning groups (CCGs) often have similar programmes, which patients can be referred to or enrolled on.  

CONCLUSION  


There are many simple treatments available which can be started in primary care to treat those presenting with symptoms of stress incontinence, OAB and POP. Patient motivation and an understanding of their problem is vital in noticing symptom improvement. Women should only be referred to secondary care once they have undertaken conservative options, which have not improved symptoms to a satisfactory level. Healthcare professionals in primary care, such as GPNs, should use every opportunity available to ask women about problems and ensure that women are told about pelvic floor exercises with the aim of preventing problems developing in the future. Detecting and treating symptoms early will increase symptom improvement and, as a consequence, patient satisfaction.  
Key points 
  • • Conservative treatments should be considered for urinary incontinence and pelvic organ prolapse as first-line options where possible, and are easily started in primary care   
  • • Patient motivation and an understanding of their problem is vital in noticing symptom improvement  
  • • Women should only be referred to secondary care once they have undertaken conservative options 
  • • Healthcare professionals in primary care, such as GPNs, should use every opportunity available to ask women about problems and ensure that women are told about pelvic floor exercises with the aim of preventing problems developing in the future 
  • • Detecting and treating symptoms early will increase symptom improvement and, as a consequence, patient satisfaction.  

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This piece was first published in the Journal of General Practice Nursing. To cite this article use: Stewart E (2022) Treatments for female urinary incontinence and pelvic organ prolapse. J Gen Pract Nurs 8(1): 47-53 


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