APP

External PFM Palpation
Internal Exam (Superficial PFM)
Internal Exam (Deep PFM)

44

Internal Exam

• PFM quality
• Function (contract vs relax vs expansion)
• Strength

• Absent/trace/weak/moderate/strong  vs 0‐5/5
• Endurance and quick contractions
• Coordination – synergy with lumbopelvic core musculature

Lumbopelvic Core Canister

Need for Synergy

• PFM are integral in managing IAP, along with abdominals and 
diaphragm

Hung et al (2010); Arab et al (2010); Yamasoto (2014)

45

Role of Physical Therapy

• Augment medical management
• Restore and/or optimize FUNCTION
• Provide “hands on” treatment

Bradley et al. (2017); Faubion et al (2012); Stein (2018)

Pelvic Physical Therapy

• Male and female PFD

• Urogynecologic

• Urologic
• OB
• Lymphedema
• Dyspareunia/sexual dysfunction
• Defecatory disorders

PT Evaluation

Subjective
• Function of PFM

• Bowel/bladder symptoms
• Sexual function
• Spine/pelvis/hip pain

• Discuss any other pain or MSK concerns/injuries

46

PT Evaluation

Objective
Focused MSK assessment including:
• Posture, gait and movement patterns
• Screen spine, bony pelvis and hips
• Strength/flexibility of larger muscle groups
• Further orthopedic testing as indicated

Sedighimehr et al.(2018); Stein (2018)

PT Evaluation 

• External/internal PFM assessment
• Function
• Motor control
• Reproduction of pain/symptoms

Goals for Pelvic PT

• Restore FUNCTION
• Decrease pain
• Optimize bowel, bladder and sexual functioning
• Independence in home program
• Fitness recommendations

Bradley et al. (2017); Faubion et al (2012); Prathers (2009)

47

PT Interventions

• Physical exam guides treatment, not just diagnosis
• So much more than just KEGELS!

Patient Education (Pelvic Health 101)

• Anatomy
• Bladder norms, behavioral retraining
• Bowel cares
• Sexual functioning, enhancements, modifications/adaptations

Hill (2017); Neels (2016); Mandimika et al (2014) 

Improve Kinesthetic Awareness

Therapist/manual feedback 
Mindfulness
Rehabilitative ultrasound imaging
Biofeedback

• General vs PFM specific

48

Improve Kinesthetic Awareness

Manual Therapy

Joint mobilization (Hips, Pelvis, Thoracolumbar, SI joint)
Internal manual techniques (vaginal/rectal) 
Neural and visceral mobilization
Soft tissue techniques
Eliminate trigger points
Dilator/therawand

Bo et al. (2017); Fitzgerald (2012);  Stein (2018)

Therapeutic Exercise

• Developed per physical exam 
• Hypertonic, overactive                   Downtraining

vs
• Hypotonic, dyscoordination                Up Training

Bo et al. (2017); Cullen et al. (2014)

49

Downtraining

• Relaxation
• Stretching
• Yoga
• Breathing techniques
• Biofeedback
• Physiologic quieting

Cullen et al (2014); Bonnema (2018)

Up Training

• Integrated core strengthening, including Kegels
• Train for specificity
• Neuro‐motor control: Type I (endurance)  and Type II (timing/coordination)

Bump(1991); Lee et al(2008); Devreese(2007); Crotty(2014); Castro(2008); Lamin (2016)

Kegels

• Needs dynamic integration
• 40% performed Kegel incorrectly with verbal cues alone 
• Technique is important!

Bump(1991); Lee et al(2008); Devreese (2007); Crotty (2012)

50

Improvement at skill/function level

Return to activity
Bowel and bladder retraining
Sexual function ‐ Sex should NOT be painful.
Behavioral modifications 
Ergonomics

Home program and Self cares

• Self manual techniques
• Bowel/bladder regimen 
• Exercise prescription
• Sexual modifications/cares
• Heat/ice/relaxation
• Self cares
• Incorporate pelvic floor into their fitness routine

Pelvic PT Stats

• Varying levels of pelvic floor muscle education included in PT DPT 
programs

• PT boards only include incontinence and pregnancy
• Varying backgrounds, education and skill set
• Superior response with seasoned/skilled PT
NOT ALL PELVIC PT’S ARE EQUAL…….

Polackwich (2015)

51

What do all their initials really mean….

• PT
• MPT
• DPT
• WCS
• PRPC
• BCB‐PMD
• OCS

Finding a local pelvic PT

• Herman and Wallace Pelvic Institute
• www.pelvicrehab.com
• APTA – Academy of Pelvic Health  (formerly Section of Women’s Health)
• www.womenshealthapta.org

Review of a PT’s plan of care

• Good vs Bad???
• There is no magic bullet to ensure excellent care
• Let patient results speak for themselves
• Home program is essential

52

Key Points

• PFM work together, not in isolation
• Include functional assessment during PFM exam
• Don’t forget about urogenital triangle
• Pelvic PT can offer much more than just Kegels
• Not all pelvic PT’s are created equal

53

Notes

Recurrent Urinary Tract Infections

Matthew A. Barker, MD

@MA_BARKER_MD
• The University of South Dakota Sanford School of Medicine

• Associate Professor of ObGyn, Internal Medicine, & Neurosciences
• Avera McKennan Hospital & University Health Center

• Director of Female Pelvic Medicine & Reconstructive Surgery
• Avera Medical Group - Urogynecology
• Education:
• BS: Creighton University, Omaha, NE
• MD: The University of South Dakota Sanford School of Medicine
• ObGyn Residency: University of Wisconsin – Madison, WI
• FPMRS Fellowship: Good Samaritan Hospital Cincinnati, OH
• Board Certified
• Obstetrics and Gynecology
• Female Pelvic Medicine and Reconstructive Surgery

Disclosures

• Astellas - Speaker
• AMAG - Speaker
• Allergan - Consulting

54

Learning Objectives

1. Describe the risk factors for recurrent urinary tract infections (UTIs).
2. Identify and develop appropriate antibiotic treatment regimens.
3. Develop strategies to prevent recurrent urinary tract infections.
4. Discuss a standardized approach to acute cystitis.

Recurrent Urinary Tract Infections

• Culture based definition: ≥ 2 UTIs in 6 months or ≥ 3 per year.
• Relapse versus Reinfection
• Acute uncomplicated cystitis occurs in 50-80% of women.
• After single UTI, 30-44% of women will have RUTI; 50% will

have a third episode if they have had 2 UTIs in 6 months.

Gupta BMJ 2013

Risk Factors • Urinary Instrumentation

• Sexual activity • Postmenopausal women
• Diaphragm-spermicide use
• Prior infections • Urinary incontinence
• Recent use of antibiotics • Cystocele
• New sex partner • Elevated urine residual
• UTI before age 15 • UTI before menopause
• Mother with history of UTIs • Non-secretor of certain blood

group antigens

Raz et al. Clin Infect Dis 2000

55

Pathogenesis

• Uropathogens originate in the
rectal flora, colonize the
periurethral area and urethra,
and ascend to the bladder.

• Postmenopausal women:
elevation vaginal pH, loss of
lactobacilli, and increase in
vaginal E. Coli.

Netter Atlas of Human Anatomy, 2nd Ed,1997

Reinfections

• Caused by extraurinary sources
such as vagina or rectum.

• Uropathogenic E. coli (UPEC)
for sessile communities or
biofilms.

• UPEC invade urothelium and
form quiescent intracellular
bacterial reservoirs (QIRS).

Rosen et al. PLoS Med 2007

Different UTI Terminology

• Reinfection: infection occurring after completion of therapy with
a different strain of bacteria.

• Relapse: consecutive infection caused by the same strain of
infection.

• Persistence of bacteria: the persistence of the same strain of
bacteria isolated at the start of treatment.

• Superinfection: the appearance of bacteria during treatment
different from the original isolated organism.

56

Asymptomatic Bacteriuria

Presence of a positive urine culture in a patient without urinary
symptoms.

Diagnosis

Symptoms Lab Testing

• Dysuria • Post void residual
• Frequency, urgency, nocturia, • Urinalysis
• Urine Culture
hematuria & suprapubic pain. • Basic Metabolic Panel
• Urine cytology?
• Flank pain, fever & chills,
tachycarida, and nausea & Imaging
vomiting: pyelonephritis.

Symptoms in Older Women

• Foul odor • Asymptomatic pyuria and asymptomatic
• Feeling ‘ill’ or fatigue bacteriuria highly prevalent especially in
• Altered mental status long term care facilities.
• Incomplete emptying
• Constipation • Symptom Relief:
• Hematuria
• Phenazopyridine 100-200mg TID x 1-2 days
• Ibuprofen 400mg TID x 3 days
• Increase hydration

• Mental status changes in the setting of a positive urine
culture are often inappropriately attributed to UTI.

Bader et al. Postgrad Med 2017

57

Urinary Tract Infections

Uncomplicated UTI Complicated UTI

• Infection in healthy patient • Infection associated with factors that increase
with a structurally and the chances of developing an infection and
functionally normal urinary decrease efficacy of therapy. Urinary tract is
tract. structurally or functionally abnormal.

• Complicating Factors:
• Functional or structural abnormalities
• Recent instrumentation
• Pregnancy
• Diabetes mellitus
• Immunosuppression
• Hospital-acquired infection
• Elderly
• Symptoms > than 7 days at presentation

Schaeffer AJ 2011

Brubaker et al. FPMRS 2018

Urinalysis

58

Chu et al. Am J Obstet Gynecol 2018

Urine Culture

Microbiology

• E. coli causes > 75% of uncomplicated cystitis & pyelonephritis.
• pfaEaorneestceiatarilvolsiesbo,abcacaontcemdtreimSaricotarene(aoScepotat(moKpcmhloeyucbloncsuciiteoyslclaaaccgupqasnulaesircuaetmpidaroeoinnp(fiheaGycerttoiiacoununpdss,B.PErsnotrtteeerouopsc)ro;ocGccorucascmu-s)
• Nosocomial infections: E. coli, Klebsiella, Enterobacter, Citrobacter,

Serraita, Pseudomonas aeruginosa, Providencia, E. faecalis, S
epidermidis
• Sexually Transmitted Diseases; Mycoplasm & Ureaplasm
• Fungal infections

Price et al. IUGJ 2018

59

Expanded Quantitative Urinary Culture
(EQUC)

• EQUC inoculates 100x more urine on diverse types of media,
anaerobic conditions, varying temperatures, and time periods
up to 5 days, with a lower threshold of detection than standard
urine culture at 10 CFU/ml.

• Consider using in RUTI patients with multiple negative standard
urine cultures or symptoms that do not improve with standard
urine culture-directed treatment.

• Risk of false positive cultures with EQUC and studies looking at
treatment algorithms based on EQUC are needed.

Hilt et al. J Clin Microbiol 2014; Jung et al Climacteric 2018

JO4

Microbiology

• E. coli causes > 75% of uncomplicated cystitis & pyelonephritis.
• Enterobacteriaceae (Klebsiella pneumoniae and Proteus); Gram-

positive bacteria (Staphylococcus saprophyticus, Enterococcus
faecalis, and Streoptococcus agalactiae (Group B streoprococcus)
are also common community acquired infections.
• Nosocomial infections: E. coli, Klebsiella, Enterobacter, Citrobacter,
Serraita, Pseudomonas aeruginosa, Providencia, E. faecalis, S
epidermidis
• Fungal infections

Treatment

60

Choosing an Antibiotic…

• Patient’s microbial history. *Always culture.
• Drug tolerance.
• Patient’s health history and comorbidities.
• Cost to the patient.
• Aim at minimizing effects on intestinal and vaginal flora.
• Without treatment 24-42% of uncomplicated UTIs resolve

spontaneously and in absence of effective treatment only 2%
will progress to pyelonephritis.

Bader Postgrad Med 2017

Spectrum of Antimicrobial Activity

Urogynecology and Reconstructive Pelvic Surgery 4th Ed, 2014

Antibiogram

CFT CFT

Gram POSITIVE Organisms Total TMP/S GENT SYN SYN CLINDA ERYTH CIPRO LEVO FD OXA LIN PEN-G VANCO nonmening mening TE
Staph aureus 744 97% 100% 100% 100% 22% 100% 94%
MRSA 372 98% 100% 80% 70% 85% 100% 0% 95%
Staph epidermidis 418 59% 38% 100% 36%
Staph hominis 88 59% 99% 60% 14% 47% 100% 0% 100% 25%
Enterococcus faecalis 638 78% 0% 98% 29%
Enterococcus faecium 42 97% 100% 61% 34% 99% 99% 100% 10% 100%
Enterococcus faecium VRE 92 97% 97% 21% 0%
Streptococcus pnemoniae 123 72% 100% 69% 33% 100% 21% 100% 76%
Streptococcus agalactiae 86 0% 10%
0% 9% 85% 100% 99% 99%

100% 14% 31% 100% 33% 100%

100% 1% 0% 100% 3% 0%

84% 41% 100% 100% 95% 88%

36% 31% 100% 100% 100% 99%

Gram NEGATIVE Organisms Total AMP AMP/SUL CEFAZO CEFTRI GENT CPE CIPRO LEVO PIP/TAZO TOBRA TMP/S MEM CEFTAZ
Citrobacter freundii 90 100% 100% 100% 82%
Enterobacter aerogenes 95 80% 99% 100% 100% 100% 84% 100% 100% 86%
Enterobacter cloacae complex 100% 84%
Escherichia coli 198 84% 100% 95% 97% 100% 82% 100% 98% 100% 99%
Escherichia coli ESBL 2843 100% 86% 100% 0%
Haemophilus influenzae 82% 99% 97% 84% 98% 95%
Klebsiella pneumoniae 115 0% 17% 100% 100%
Klebsiella oxytoca 109 63% 69% 91% 99% 94% 86% 98% 95% 82% 100% 100%
Morganella morganii 556 100%
Proteus mirabilis 112 0% 10% 0% 0% 68% 17% 90% 52% 37% 100% 85%
Pseudomonas aeruginosa 97%
Serratia marcescens 33 72% 100% 70% 89% 91%
210 100% 100%
372 0% 88% 97% 100% 99% 100% 98% 99% 97% 99% 96%
100% 100%
54 0% 54% 36% 100% 100% 100% 100% 97% 99% 96%
67%
3% 3% 0% 91% 70% 97% 82% 70% 100% 91% 61%
91% 85%
82% 90% 76% 97% 90% 100% 93% 83% 100% 90% 90%

1% 0% 1% 91% 81% 95% 99% 0%

0% 98% 98% 93% 89%

AMP = Ampicillin AMP/SUL = Ampicillin/Sulbactam CEFAZO = Cefazolin CFT= Cefotaxime CEFTRI = Ceftriaxone CIPRO = Ciprofloxacin
CLINDA = Clindamycin CPE = Cefepime ERYTH = Erythromycin FD= Nitrofurantoin GENT SYN = Gentamicin synergy LEVO = Levofloxacin

LIN = Linezolid MEM= Meropenem OXA = Oxacillin(equals Methicillin) PEN-G = Penicillin-G PIP/TAZO = Piperacillin/Tazobactam
SYN = Synercid TE= Tetracycline TOBRA = Tobramycin TMP/S Trimethoprim/Sulfa VANCO= Vancomycin

61

Bacterial Resistance

• Understand specific organisms: nitrofurantoin not effective against
Proteus and Pseudomonas; Extended-spectrum beta-lactamases
(ESBL); research your local antibiogram for common resistant
organisms.

• Select antibiotic with a urinary concentration that exceeds the
minimal inhibitory concentration by the widest margin possible, avoid
under dosing and emphasize compliance.

• Resistance increases the longer the antibiotic agent is used.

ESBL-Producing Organisms

• ESBL contains an enzyme that hydrolyzes certain antibiotics
and confers resistance to many beta-lactam antibiotics (PCN,
cephalosporins, and aztreonam).

• Gram-negative bacteria: E. coli, Klebsiella oxytoca, Proteus
species, K. pneumonia, and Enterobacteriacea

• Treatment options: Fosfomycin, nitrofurantoin, and
pivmecillinam (not available in US).

• Involve Infectious Disease Specialists.

Bader et al. Postgrad Med 2017

Brubaker et al. FPMRS 2018

62

Brubaker et al. FPMRS 2018

Treatment for Uncomplicated UTI in
Pregnant Women

Chu et al. Am J Obstet Gynecol 2018

Multidrug-Resistant Organisms (MDROs)

• Bacteria can acquire genes to encode for multiple antibiotic
resistance mechanisms.

• AmpC β-lactamase (Enterobacteriaceae)
• ESBLs (Enterobacteriaceae)
• Carbapenemases (carbapenem-resistant Enterobacteriaceae (CRE))

• Multidrug-resistant Pseudomonas aeruginosa
• Practice good antibiotic stewardship!

• Involve Infectious Disease Specialists and consider combination
therapy.

63

Candida Infections

• Asymptomatic candiduria does not require treatment unless
urinary manipulation or instrumentation is planned.

• Symptomatic candiduria should always be treated.

• Fluconazole 200mg/day for 14days
• Beware of resistant strains of Candida
• Consider IV or intravesical amphotericin B

Prevention

Prevention

• Behavior changes • Treat bowel dysfunction

• Avoid spermicides. • Improve perianal hygiene
• Change contraception (diaphragm
• Antibiotic prophylaxis
and oral contraceptive use)
• Post coital
• Post coital voiding • Intermittent or self-treatment
• Continuous
• Increase fluid intake

• Wipe front to back

• Avoid hot tubs, douching and
tampons

64

Non-Antimicrobial Prophylaxis

• Vaginal Estrogen
• Cranberry

(proanthocyanodins (PACs))
• Probiotics
• D-Mannose
• Ascorbic Acid (Vitamin C)

Beerepoot et al. J Urol 2013

www.myellura.com

Non-Antimicrobial Prophylaxis

• Methenamine hippurate
• Intravesical therapies

(Hyaluronic Acid and
Chondroitin Sulfate)
• Immunostimulants (OM-89)
• Vaccines

Beerepoot et al. J Urol 2013

65

Hooton TM NEJM 2012; Brubaker et al. FPMRS 2018
Hickling Reviews in Urol 2013

Cortes-Penfield NW Infect Dis Clin N AM 2017

66

UTI Pathway

Pathway does not address complicated UTI, which includes
UTI in men or in the presence of urologic abnormality or
urinary catheter.

UTI Pathway - Diagnosis

• First, ask about SYMPTOMS

• Acute cystitis: dysuria, frequency, urgency, suprapubic pain
• Pyelonephritis: fever, flank pain

• If a person has symptoms, obtain a urinalysis (UA) and reflex to
culture

• Repeat UA and culture is not indicated except during pregnancy

• Do not start antibiotics in patients with a positive UA and/or
culture until asking about symptoms

• Exception: pregnant women with asymptomatic bacteruria should be
treated

UTI Pathway - Treatment

• Assess prior urine culture data, as • Pregnant women with acute cystitis OR
previous susceptibility patterns can asymptomatic bacteruria
help guide antibiotic choice. • Avoid fluoroquinolones, tetracyclines,
and trimethoprim-sulfamethoxazole
• Uncomplicated acute cystitis:
• Avoid fluoroquinolones • Select ONE of the following options:
• Cephalexin 500mg PO QID for 7d
• Select ONE of the following options: • Cefdinir 300 mg PO BID for 7d
• Nitrofurantoin 100mg PO BID for 5d • Nitrofurantoin* 100mg PO BID for 7d
• Trimethoprim-sulfamethoxazole 1
DS tablet PO BID for 3d • *Avoid nitrofurantoin during 1st
• Cephalexin 500mg PO QID for 7d trimester and at term (38 – 42 weeks
• Cefdinir 300 mg PO BID for 5d gestation)

• Follow-up urine culture should be
obtained 1 week following completion
of antibiotic for test of cure in pregnant
women. Coordinate care with OB
provider as appropriate.

67

UTI Pathway – Patient Education

• Drink an adequate amount of fluids according to provider
direction.

• Acetaminophen (Tylenol) or NSAID’s as needed for symptom
relief.

• Phenazopyridine may be considered for symptomatic relief of
dysuria.

Office Management

• Develop standing orders or protocols.

• Develop a diagnosis and treatment algorithm with your nursing staff.
• Recognize which patients can utilize home urine tests and self-start

antibiotic regimens.

• Have treatment plan and prevention strategies written out.
• Create UTI specific patient education materials.

Key Points

• Urogynecologic patients are at high risk for RUTIs.
• Treatment regimens are effective and appropriate antibiotic

utilization is key to preventing resistant organisms.
• Performance or Quality Measures:

• Urine culture before initiating antibiotic therapy.
• Discuss prevention strategies.

• AUGS Guidelines: American Urogynecologic Society Best-Practice
Statement: Recurrent Urinary Tract Infection in Adult Women Female
Pelvic Medicine Reconstructive Surgery 2018

68

Notes

OAB
Tips to Maximize Medical

Therapy

Randina Harvey-Springer APRN, CNP

• Undergraduate; Winona State University 1999

• Bachelor of Science in Nursing

• Graduate School; University of Minnesota 2010

• Masters of Science

• National Certification Corporation

• Women’s Health Nurse Practitioner

• Mayo Clinic, Rochester MN 1999-present

• Department of OB/GYN; Division of Urogynecology
• Instructor, College of Medicine Mayo Clinic

Disclosures

• None

69

Learning Objectives

1) Define the impact of over active bladder syndrome (OAB)
2) Understand the work-up for OAB
3) Tips to maximize lifestyle, behavioral/therapy options
4) Tips to maximize medication options

What is OAB?

• Urinary urgency
• Frequency
• Nocturia
• Absence of UTI or obvious pathology
• With or without urinary incontinence
• Multitude of studies quote different rates: 15-45% of the female

population; millions and millions

ICS Fact Sheets; A Background to Urinary and Fecal Incontinence. Published July 2013 available at www.ics.org
Stewart W., Fowke, J., Dmochowski, R. (2016). The Burden of Overactive Bladder on US Public Health. Curr Bladder Dysfunction Rep. March; 11 (1): 8-13.

Burden of OAB

• Interference with ADLs • Expensive

• Decreased physical activity • Pads, medications, loss of income
from decreased work productivity
• OAB attributed to weight gain b/c limited
activity • Long term care placement-caregiver
burden
• Decreased self esteem
• Sleep deprivation
• Increased rates of depression
and/or anxiety • Falls and fractures

• Decreased sexuality • Increased feelings of overall
declining health

Stewart W., Fowke, J., Dmochowski, R. (2016). The Burden of Overactive Bladder on US Public Health. Curr Bladder Dysfunction Rep. March; 11 (1): 8-13.

70

Learning Objectives

1) Define the impact of over active bladder syndrome (OAB)
2) Understand the work-up for OAB
3) Tips to maximize lifestyle, behavioral/therapy options
4) Tips to maximize medication options

Why Women Don’t Seek Care

• Embarrassment
• Failure to see symptoms as abnormal
• Belief that symptoms are self-limited
• Perception of lack of treatment efficacy
• Fear of procedure
• Fear of cost of treatment

Milsom, I. et al. Am J Manag Care. 2000; 6:565

Provider Factors

• Dismisses symptoms as unimportant
• Perceives treatment a ineffective
• Unaware of the differential diagnosis
• Dismisses the impact on quality of life
• Does not consider potential complications

Milsom, I. et al. Am J Manag Care. 2000; 6:565

71

Conditions that May Mimic OAB

• Bladder outlet obstruction • Urinary tract stones

• Carcinoma • Neurogenic

• Compression • diabetic uropathy
• ETOH abuse • spinal cord injury
• Infection • MS, Parkinson’s
• Interstitial cystitis/painful bladder syndrome • stroke
• Dementia

• Medications • OSA and nocturia
•diuretics

• Pelvic floor muscle
• pain, injury

Treatment

• A presumptive diagnosis of OAB can be cased on

• patient history, symptom assessment, voiding diary
• physical examination
• urinalysis

• Initiation of noninvasive treatment may not require an extensive
further workup

Learning Objectives

1) Define the impact of over active bladder syndrome (OAB)
2) Understand the work-up for OAB
3) Tips to maximize lifestyle, behavioral/therapy options
4) Tips to maximize medication options

72

Management of OAB

• Improving OAB symptoms is like putting a puzzle
together:

• Takes time, effort and commitment from patients and providers

Typical Patient
Jane Doe age 60

• Menopausal for 8 years
• BMI: 40
• Symptoms began 10 year ago
• Symptoms include:

• Urgency, frequency, and nocturia
• 5 major leaks in public
• Many small leaks daily while approaching BR
• 3 medium pads/day

Typical Patient
Jane Doe age 60

• BMI: 40
• Medical comorbidities:

• Diabetic; recent HgbA1c; 7.0%. Oral agent
• Hypertension: takes HCTZ 25mg po daily
• Statin therapy
• Thyroid replacement
• Chronic constipation
• Bilateral knee soreness/pain; “arthritis”

• Her overall impression of her health is that she is “healthy”

73

Approach

• Lifestyle changes Lifestyle
• Behavioral and therapy interventions
• Medication interventions

Therapy

Life Style Changes

• Reduction or elimination of dietary bladder irritant
intake

• Total fluid intake/drinking patterns
• Bowel regulation
• Weight loss

74

Lifestyle Change:
Weight management

• Higher waist circumference and/or general obesity is associated
with:

• higher odds of having any urinary incontinence
• among those with OAB, there was a relationship between UUI
• Higher urinary frequency and nocturia

Lai et al. (2018). Relationship Between Central Obesity, General Obesity, Overactive Bladder Syndrome and Urinary Incontinence in Male and Female Patients Seeking
Care for Their Lower Urinary Tracts Symptoms. Journal of Urology. 123, 2019.

Weight loss: Behavioral Tactics

• PRIDE study
• 8% total body weight loss is the target
• 338 participants

• Minimum of 1 UI episode a week
• BMI 25-50

• Either assigned to an intensive 6 month weight loss (intervention) or
a four-session education program (control group)

• Intensive 6 month weight loss program was more effective than
educational control program in decreasing UI

Program to Reduce Incontinence by Diet and Exercise Clinical Trial

Weight Loss: Surgical Approach

• 1 Year success in surgically managed weight loss patients

• Average BMI 51 kg/m2 preoperative to 33 kg/m2 postoperative

• Cure rates
• 41% for SUI
• 38% for OAB
• 48% for MUI

Lai et al. (2018). Relationship Between Central Obesity, General Obesity, Overactive Bladder Syndrome and Urinary Incontinence in Male and Female Patients Seeking
Care for Their Lower Urinary Tracts Symptoms. Journal of Urology. 123, 2019.

75

Approach

• Lifestyle changes Lifestyle
• Behavioral and therapy interventions
• Medication interventions

Therapy

Behavioral/Therapy Interventions:
Pelvic Floor Physical Therapy

• Pelvic floor muscle rehabilitation/pelvic PT

• Urge suppression
• Pelvic floor strength/coordination
• Biofeedback
• ESTIM
• Reiterate dietary changes
• Reiterate bowel program

• Pelvic PT finder https://pelvicrehab.com/

Limitations

• Require motivation and commitment Lifestyle

• Patients need follow up

• In office appointment
• Phone call
• Patient portal message

Therapy

. 2000;48:370-374

76

Learning Objectives

1) Define the impact of over active bladder syndrome (OAB)
2) Understand the work-up for OAB
3) Tips to maximize lifestyle, behavioral/therapy options
4) Tips to maximize medication options

Medication Options

• Topical vaginal atrophy therapies
• Anticholinergic medications
• Beta-adrenergic medication

Estrogen receptors in the bladder and
urethra

• The trigone, demonstrates similar cytological modifications under
hormone stimulation to vaginal cells

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Muscarinic Receptors

• M1: Brain (cortex, hippocampus), salivary glands, sympathetic
ganglia

• M2: Heart, hindbrain, smooth muscle (human detrusor 80%)
• M3: Smooth muscle (human detrusor 20%, salivary glands,

brain eye (lens, iris)
• M4: Brain (forebrain, striatum)
• M5: Brain (substantia nigra), eye

Antimuscarinic Medications

• M-receptor Non-specific:

• M1, M2, M3 oxybutynin (Ditropan, Ditropan XL, Oxytrol,
Gelnique)

• M2, M3 tolterodine (Detrol, Detrol LA)

• M3:

• darfenacin (Enablex)
• fesoterodine (Toviaz)
• solifenacin (Vesicare)
• trospium (Sanctura, Sanctura XR)

Antimuscarinic Medications

• Inhibit muscarinic actions of acetylcholine on autonomic nerve endings
• Common side effects are those of parasympathetic stimulation

dryness: mouth and eyes headache

constipation visual blurring

confusion and hallucinations urinary retention

decreased sweating restlessness

• Translation: slows bladder contractions, encourages bladder filling =
fewer bladder/bathroom problems but will make your mouth dry and your
mind foggy and your bowels slow

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Muscarinic Receptor Sites

CNS Iris/Ciliary Body = Blurred Vision
Lacrimal Gland = Dry Eyes
• Dizziness Salivary Glands = Dry Mouth
• Somnolence
• Impaired Heart = Tachycardia
Gall Bladder
Memory & Cognition Stomach = Dyspepsia

Colon = Constipation

Bladder (detrusor muscle)

Abrams P, Wein AJ. (1998). The Overactive Bladder: A Widespread and Treatable Condition.

Use Caution

• Antimuscarinic medications are contraindicated

• urinary retention/obstruction
• gastric retention/obstruction
• Myasthenia gravis
• Uncontrolled narrow angle glaucoma

• Caution

• memory changes
• controlled narrow angle glaucoma
• renal impairment
• hepatic impairment
• bladder outflow obstruction
• gastrointestinal obstructive disorders
• > 65 yo

Oxytrol Patch

• Available OTC

• $14/box or $28/month

• Steady concentrations are maintained with each patch for up to
96 hours

• Apply to dry, intact skin on the hip, buttock, or abdomen
• Dry mouth and constipation side effects are reduced by a factor

of 10 compared with tablets
• Memory concerns persist

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Oxybutynin

• Longest track record
• Wide range of doses; 5mg-30mg a day.

• No higher than 10-15mg/day in >65 years old

• Small molecule, lipophilic, can cross the BBB
• Oxy-XL more likely to cause memory impairment in the elderly1
• Higher dry mouth compared to Tol-ER

• (30 vs 22%)2

(1) MacDiarmid et al. (2005) J Urol. 174:1301-05
(2) 1Diokno et al. (2003) Mayo Clinic Proceedings 78: 687-95

Tolterodine (Detrol)

• Long tract record of efficacy
• Better tolerated than oxybutynin
• Less impact on cognition when compared to oxybutynin
• Unique metabolic features

• Drug delivers two active metabolites

• 5-HMT and tolterodine

• Potential prolonged Q-T syndrome

Fesoterodine (Toviaz)

• “Next generation tolterodine”
• 8mg/day OK with mild to moderate renal and mild hepatic

impairment
• 4mg/day OK with moderate hepatic impairment
• Large molecular weight, water soluble, neutral
• Tolerated with fluconazole and warfarin
• No prolonged Q-T

.Wyndaele, J. (2012). Overactive Bladder, Differential Diagnosis, and Clinical Utility of fesoterodine. International Journal of General Medicine. 5 943-51

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Trospium (Sanctura)

• Metabolized by…….probably the liver but not fully understood
• No CYT P-450; few drug-drug interactions
• Consider in these patient populations:

• Poly-pharmacy
• Warfarin
• Cardiac problems

• Excreted primarily in stool and urine
• Inconvenient dosing; Must take on empty stomach

• 1 hr before meals or 2 hours after meals

Solifenacin (VESIcare)

• 5mg/day OK for moderate hepatic impairment
• 5mg/day OK for renal impairment (CLcr < 30 mL/min)
• Not recommended for use in patients with severe hepatic

impairment
• Large molecule, neutral and lipophilic
• Has no significant effect on the pharmacokinetics of warfarin
• QT Prolongation

Darifenacin (Enablex)

• Enablex is not recommended for use in patients with severe
hepatic impairment

• Positively charge, large molecule, with low lipophilicity
• Caution should be taken used concomitantly with flecainide,

thioridazine and tricyclic antidepressants

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Drug vs. Drug

Saks, E., and Arya, L. (2009). Pharmacologic Management of Overactive Bladder. The Female Patient. Nov (35) 24-29.

Mirabegron (Myrbetriq)

• Beta-3 Adrenergic Agonist 25 RCTs were included

• mirabegron vs anticholinergics

• Suggest that mirabegron is as effective as anticholinergics in
managing OAB symptoms

• Leads to muscle relaxation and an increase in bladder capacity
• S/E: elevated blood pressure
• Potential for INR increase with those on warfarin

Obloza, A., Kirby, J., Toozs-Hobson, P. (2017). Indirect treatment comparison (ITC) of medical therapies for an overactive bladder. Neurourol Urodynam 2017; 9999: 1–8.

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Combined mirbegron and antimuscarinics

• BESIDE study
• Multicenter study was conducted at 281 centers globally
• 675+ in each of the 3 groups

• Montherapy: solifenacin 5mg, 10 mg monotherapy
• Combined group: solifenacin 5mg + 25mg mirabegron x 4 weeks; then increased to

50mg x 8 weeks

• Statistically significant reduction in incontinence accidents at 4, 8
and 12 weeks in combined group

• CV profile appears safe
• No increase in anticholinergic burden

https://clinicaltrials.gov/ct2/show/results/NCT01908829

Side Effect Remedies

• You found a medication that is helpful in controlling your patient’s
symptoms

• The medication is affordable!
• However, she states her dry mouth is terrible and uncomfortable
• Her constipation is a problem
• What do you do?

OTC Dry Mouth Remedies

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OTC Constipation Remedies

• Walking/moving, fluid, fiber/food
• **Daily fiber** Psyllium
• Stool softeners
• PEG preparations
• Suppositories
• Enema

Dry Eye Remedies

Typical Patient
Jane Doe age 61

• Started on oxybutynin ER 10mg daily
• Started vaginal estrogen
• Worked with pelvic PT for 6 months
• Now has stopped the oxybutynin and doing well
• Current symptoms include:

• Fewer problems with urgency, frequency, and nocturia
• No major leaks anymore
• 1-2 small leaks a week while approaching the bathroom
• 1 small pad per day
• BMI: 36; blood pressure is lower, lower lipids, blood glucose is lower, fewer
constipation problems, sleeps better

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Real World Tips

• Find a medication on her formulary
• Give her 30 days with 1 refill for 2 total months of treatment
• Bring her back for an office visit OR prompt nursing to call with a

standard set of questions

• Reiterate behavioral changes, weight loss goals

• Change medications, consider combined mirabegron +
antimuscarinic

• 1 year follow up is important either face to face or a phone call

Thank You

[email protected]

Appendix

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Cytochrome P450 Drug Metabolism; Possible Drug-Drug
Interactions with Anticholinergic Medications

Ogu, C. and Maxa, J. (2000) Drug Interactions Due to Cytochrome P450. Proc (Bayl Univ Med Cent). October; 13
(4); 421-23.

Cytochrome P450 Drug Metabolism; Possible Drug-Drug
Interactions with Antimuscarinic Medications

C. and Maxa, J. (2000) Drug Interactions Due to Med Cent). October; 13 (4); 421-23.
Ogu, C. and Maxa, J. (2000) Drug Interactions Due to Cytochrome P450. Proc (Bayl Univ Med Cent). October; 13 (4);
421-23.

Reduction in Urinary Urgency

Buser, N., et al. (2012). Efficacy and Adverse Events of Antimuscarinics for Treating Overactive Bladder: Network Meta-analyses. European Urology. 62, pg 1040-60.

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Reduction in Urge Incontinence

Buser, N., et al. (2012). Efficacy and Adverse Events of Antimuscarinics for Treating Overactive Bladder: Network Meta-analyses. European Urology. 62, pg 1040-60.

Anticholinergic Burden Scale

http://www.todaysgeriatricmedicine.com/archive/JA17p8.shtml

BEERS Criteria

• https://dcri.org/beers-criteria-medication-list/

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Notes

Neuromuscular Electrical Stimulation
(NMES)

A Treatment Adjunct for Women with
Pelvic Floor Disorders

Julie Starr FNP, PhD

Julie Starr FNP, PhD

Center for Female Continence and Advanced Pelvic Surgery
University of Missouri, Columbia

[email protected]

• BSN 1987, University of Missouri, Columbia
• MSN, APRN, FNP-C 2008, University of Missouri, Columbia
• PhD Nursing 2017, University of Missouri, Columbia

• Dissertation: Immediate and long-term symptom improvement and change in
quality of life (QOL) in women with symptoms of pelvic floor dysfunction
(PFD) who underwent a course of comprehensive pelvic floor rehabilitation
with an Advanced Practice Nurse (APRN).

Objectives

• Identify indications for NMES of the pelvic floor and bladder
• Understand the NMES equipment and treatment protocols
• Identify procedure and diagnostic codes used for NMES
• Describe clinical outcomes using case studies

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Disclosures

• Clinical Educator for The Prometheus Group

Neuromuscular Electrical Stimulation (NMES)

• Electronic stimulation of muscle fibers

• Vaginal, rectal or external sensor

• NMES

• the artificial means of stimulating muscle activity by exposing the muscle
to electrical current causing a contraction

Mechanisms for NMES
of the Bladder and Pelvic Floor

• Produces a reflex muscle contraction

• No effort on the part of the patient

• Twofold action of NMES

• Contraction of the pelvic floor muscles
• Relaxation and inhibition of bladder activity

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NMES of the Bladder and Pelvic Floor

• Principle of NMES is based on the restoration of normal
physiological reflex mechanisms in abnormal nerves and muscles

• Electrode placement

• Internally (vagina or rectum)
• Activate deep pelvic floor and detrusor muscles
• Preferable to skin surface electrodes

• Externally (skin surface sensors)

• Methods of Stimulation

• Chronic (long-term continuous)
• Short term (in office or with home unit)

NMES as an Adjunct Treatment in
Pelvic Muscle Rehabilitation (PMR)

• Assist with identification and isolation of pelvic muscle
• Increase pelvic muscle contraction strength
• Decrease unwanted or uninhibited detrusor muscle contraction

or bladder overactivity
• Assist with normalizing pelvic muscle relaxation in persons with

pelvic pain or discomfort

NMES Indications

• Stress, urgency or mixed urinary incontinence
• Non obstructive urinary retention
• Urgency or frequency
• Dysuria
• Dyspareunia
• Interstitial cystitis
• Fecal incontinence
• Vaginismus
• Pelvic pain associated with pelvic floor tension myalgia

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