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#346 Stress Urinary Incontinence: Pelvic floor exercises or pessary?


CLINICAL QUESTION
QUESTION CLINIQUE
How effective are pelvic floor exercises or pessaries for stress urinary incontinence?


BOTTOM LINE
RÉSULTAT FINAL
Pelvic floor exercises increase the proportion of women with symptom improvement (74% versus 11%) and patient satisfaction (71% versus 13%) compared to control over 1-6 months. Pessaries may reduce incontinence episodes compared to no treatment based on one small, 2-week study. Exercise may be slightly better than pessary at three months (example: more patients without bothersome symptoms) with less vaginal discharge at 12 months.



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EVIDENCE
DONNÉES PROBANTES
  • Results statistically different unless indicated. Focusing on systematic reviews from the last 10 years.
  • Pelvic floor exercises:
    • Largest systematic review, 18 randomized controlled trials (RCTs), 26-133 women, compared to no treatment/control.1 At 6-24 weeks:
      • Self-reported cure/improvement: 74% versus 11% (control), number needed to treat (NNT)=2.
      • Leakage (example baseline: 1-2 episodes/day):2 Reduced by one episode/day over control.
      • Patient satisfaction: 71% versus 13% (control), NNT=2.
    • Other systematic reviews and newer RCTs report similar.3-9
  • Pessaries:
    • Meta-analyses10-11 did not combine RCTs.
    • RCT, 55 women, pessary versus no treatment.12 After two weeks:
      • Total incontinence episodes reduced: 32% versus 7.6% (control).
      • Satisfaction (scale 0-100, higher=better): 60 versus 5 (control).
      • Limitations: Industry funded; baseline incontinence episodes imbalanced: 36 versus 58 (control) in two weeks before trial.
    • RCT, 446 women, pelvic floor exercises versus pessary:13
      • At 3 months:
        • Proportion without bothersome symptoms: 49% versus 33% (pessary), NNT=7.
        • Improved/much improved: Not different.
        • Satisfaction: 54% versus 50% (pessary), NNT=27.
        • Withdrawals due to adverse effects: No difference.
      • At 12 months:
        • No difference in above outcomes.
        • Vaginal discharge: 6% versus 16% (pessary), NNT=10.
      • Exercise plus pessary versus exercise alone: No difference.
      • Limitations: Pessary dropouts higher at 3 months, no different at 12 months.
    • Limitations: RCTs unblinded and outcomes often subjective.12,13

CONTEXT
CONTEXTE
  • Pelvic floor exercises considered first-line.14
    • If supervised programs inaccessible, can provide written information15 or video16 to patients.
    • At least 8 contractions three times daily recommended.14
  • Pessaries:
    • Can last 5-10 years and be fitted in primary care.17,18
      • ~10-40% women have unsuccessful first fittings.13,19
    • Cost:17 $50-150.


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Author(s)
Auteur(s)
  • Samantha Moe PharmD
  • Anthony Train MBChB MSc CCFP

1. Dumoulin C, Cacciari LP, Hay-Smith EJC. Cochrane Database Syst Rev. 2018: CD005654.

2. Asklund I, Nyström E, Sjöström M, et al. Neurourol Urodyn. 2017; 36(5):1369-76.

3. Stenzelius K, Molander U, Odeberg J. Age Ageing. 2015; 5:736-44.

4. Moroni RM, Magnani PS, Haddad JM, et al. Rev Bras Ginecol Obstet. 2016; 38(2):97-111.

5. Nie XF, Ouyang YQ, Wang L, et al. Int J Gynaecol Obstet. 2017; 138(3):250-5.

6. Garcia-Sanchez E, Avila-Gandia V, Lopez-Roman J, et al. Int J Environ Res Public Health. 2019; 16(22).

7. Okayama H, Ninomiya S, Naito K, et al. Int Urogynecol J. 2019: 7:1093-99.

8. Al Belushi ZI, Al Kiyumi MH, AlMazuri AA, et al. Neurourol Urodyn. 2020; 39:5:1557-1566.

9. Kamali S, Ozengin N, Topcuoglu MA. Women Health. 2023; 63(6): 473-83.

10. Lipp A, Shaw C, Glavind K. Cochrane Database Syst Rev. 2014; CD001756.

11. Ayeleke Ro, Hay-Smith EJC, Omar MI. Cochrane Database Syst Rev. 2015: CD010551.

12. Cornu JN, Mouly S, Amarenco G, et al. Int Urogynecol J. 2012; 23(12): 1727-34.

13. Richter HE, Burgio KL, Brubaker L, et al. Obstet Gynecol. 2010; 115(3): 609-17.

14. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management. Available at: https://www.nice.org.uk/guidance/ng123/chapter/Recommendations#non-surgical-management-of-urinary-incontinence. Accessed May 5, 2023.

15. The Canadian Continence Foundation. Incontinence Treatments. Available at: https://www.canadiancontinence.ca/EN/treatment.php.

16. MDConversation. Pelvic Floor Muscle Training. Available at: https://www.youtube.com/watch?v=AuG7ZaKcH60. Accessed on July 2, 2023.

17. Ontario Health. Ont Health Technol Assess Ser. 2021; 21(3): 1-155.

18. Bordman R, Telner D, Jackson B, et al. Can Fam Physician. 2007; 53(3): 485-7.

19. Harvey MA, Lemieux MC, Robert M, et al. JOGC. 2021; 411: 255-66.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.