Pelvic organ prolapse with urinary incontinence

 

Irena Nurkic outlines a case where clinical reasoning, including with the client’s narrative, was used to formulate the diagnoses, which then guided the multidisciplinary team management. 

Pelvic organ prolapse (POP) is defined as ‘clinically evident descent of’ the uterus/cervix (vaginal vault/cuff), anterior and/or posterior vaginal walls or compartments (Haylen et al 2016, p672). POP diagnosis incorporates symptoms and signs, obtained on clinical examination +/– relevant investigations.

A vaginal bulge sensed, seen and/or palpated by a woman is a common prolapse-specific symptom (Haylen et al 2016, Dumoulin et al 2017) often impacting her physical/exercise ability and participation in social events (Sung et al 2014).

Furthermore, a variety of pelvic floor (PF) symptoms are reported by women with POP affecting their bladder, bowel and/ or sexual function. Emotional distress and poor body/genital image in women with POP are recognised mental health issues (Sung et al 2014).

Consequently, POP negatively impacts women’s wellbeing and quality of life (QoL) (Touza et al 2018).

The aetiology of POP and associated pelvic floor disorders (PFD) is multifactorial. The woman’s PF functional reserve founded on genetics and individual development with growth depletes and recovers at different rates throughout her lifespan (DeLancey et al 2008).

Events such as obstetric injury, obesity, constipation and repetitive increases in intra-abdominal pressure (IAP) impact the PF and reduce the functional reserve, unmasking the POP and other PFD symptoms through the lifespan.

Targeted questioning and condition- specific patient-reported outcome measures (PROMs) are recommended as standardised tools assessing the symptoms, physical, social and mental health, including QoL (Sung et al 2014, Castro-Diaz et al 2017, AUGS 2017).

Clinical examination starts with exclusion of abdominal/pelvic pathology by medical staff to avoid serious mismanagement.

Evidence of prolapse is obtained on vaginal examination (VE) using POP Quantification (POP-Q) assessment of the vaginal support (Haylen et al 2016, Bump et al 1996).

The POP-Q assessment in lying and/or standing positions measures the level of descent (POP stage 0–4) in relation to hymen, genital hiatus/ perineal body length on Valsalva (indicating perineal descent/laxity) and total vaginal length necessary for pessary and surgical treatments.

Physiotherapy examination of POP and PFD incorporates examination of the whole person (functional +/– neurological status, body mass index (BMI), posture). 

Digital VE of pelvic floor muscles (PFM) includes assessment of structure (tone, levator ani (LA) hiatus, its integrity/defects), and function, using the PERFECT scheme (Laycock & Jerwood 2001) along with assessing the quality of contraction and relaxation.

Trans-perineal (TP) and/or trans- abdominal (TA) real-time ultrasound (RTUS) assessment are optional evaluations of PFM function (TA) (Thompson et al 2006) and POP displacement (TP) (Haylen et al 2016).

Ancillary investigations (discussed below) are recommended in the presence of other PFD, such as urinary incontinence (UI) (AUGS 2017).

Conservative management is the recommended first-line treatment for POP and UI (Dumoulin et al 2017). Pelvic floor muscle training (PFMT) is supported by level I evidence for POP and UI management (Dumoulin et al 2017).

However, only weak evidence supports other conservative interventions such as:

  • lifestyle modifications and support pessaries for POP
  • fluid and caffeine intake modification, and voiding/bladder training regimens for UI (Dumoulin et al 2017).

POP and UI are typically seen in clinical practice.

Presenting case

A 66-year-old woman was referred by a gynaecologist for ‘management of urgency urinary incontinence; presenting with anterior vaginal compartment prolapse; declined pessary and surgery’.

She presented with a normal BMI, complaining firstly of ‘leakage of urine’ (‘I can’t stop it. I have to go to the toilet urgently, but it floods before I get there’) worsening over several years. She was worried about social impact (‘If I had someone living with me, it would be so embarrassing’). For years she had leakage with cough/sneeze, which resolved 12 months ago.

Secondly, she reported a 12-month history of ‘heaviness and dropping feeling in the vagina’—the gynaecologist diagnosed ‘prolapse of my bladder’.

The client refused support pessary. ‘What if I meet someone and want to have sex with [them]?’ was her explanation. She declined surgery because of the ‘mesh problems’.

She was concerned her leakage and prolapse would worsen over time and was keen to do PFMT—she started independently over the last three months but was unsure if she was doing it correctly.

The client was widowed, living alone and was concerned about finding a partner ‘while having all these problems’. She had no previous sexual dysfunction.

She looked after her grandchildren (age five and one) 2–3 times per week including overnight stays while her daughter worked (‘Love them, but they tire me’). She had no trouble sleeping but slept 9–10 hours when tired. Her life stress was rated ‘low to moderate, mostly because of my health problems’.

She swam twice a week and walked 2–3 times per week with a friend, but walking was sporadic during the last 6–8 months due to discomfort with the prolapse.

A retired hairdresser, she nursed and cared for her father for two years and suffered a depression episode last year after he died.

She reported general anxiety, occasional low blood pressure, gastric reflux, thyroid ‘nodules but normal function’, hip osteoarthritis, and no surgical history. Her only medication was Losec.

She reported menopause at age 54 and two vaginal deliveries, the first one vacuum-assisted with a tear. There were no bowel issues, past or present. The client reported ‘no urine infection’, as tested by the referring gynaecologist.

Clinical findings and reasoning

Focused questioning on initial assessment clarified the client’s problems further. Her goals and preliminary hypotheses on the presenting issues/conditions were formulated.

The chosen PROMs were selected for their relevance to the client’s goals, easiness to implement and sound psychometric properties, specifically:

  • ICIQ-UI SF (Avery et al 2004) assessing symptoms and impact of UI 
  • POP-SS (Hagen et al 2009) being sensitive to change following PFM training
  • NRS (0–10) assessing impact of symptoms (bother) more sensitively than verbal rating scale (Willimsons & Hoggart 2005).

The preliminary hypotheses were based on the client’s symptoms matching the POP and urgency urinary incontinence (UUI) terminology/definitions (Haylen et al 2016, Haylen et al 2010). UUI has been defined as ‘involuntary loss of urine associated with urgency’ (Haylen et al 2010, p5), with urgency being a ‘sudden, compelling desire to pass urine which is difficult to defer’ (Haylen et al 2010, p6).

Abnormal pathology relevant to vaginal bulge was presumably excluded by the referring gynaecologist. Additionally, the client’s obstetric history, post-menopausal status, age, nursing at the onset of POP symptoms, with ongoing lifting of grandchildren, are associated with POP/ PFD (DeLancey et al 2008, Castro-Diaz et al 2017).

Nocturnal polyuria (NP) defined as ‘excessive production of urine during the individual’s main sleep period’ (Hashim et al 2019, p501) was suspected as an underlying issue of UUI occurring with first- morning void because of the client’s age, possible postural hypotension, long sleep period in the absence of nocturia (sleep issues?) and no other daytime UUI (Hashim et al 2019, Oelke et al 2017).

A bladder diary was necessary to quantify/confirm NP (Hashim et al 2019).

POP was a suspected cause of bladder outlet obstruction (BOO) and voiding dysfunction (VD) (Haylen et al 2016). Post- void residual (PVR) testing was required to test this hypothesis (Haylen et al 2016, Haylen et al 2010).

Initially, PFM function was assessed using transabdominal real-time ultrasound (TARTUS). Observed PFM contraction/ elevation firstly resulted in depression of PF and bearing down as the client engaged upper abdominal muscles and diaphragmatic bracing (breath-holding) (Thompson et al 2006).

Re-training, using TARTUS and self-monitoring with hands on the upper and lower abdomen for biofeedback, achieved isolated PFM contraction and relaxation with reportedly good proprioception. Clinical assessments challenging preliminary hypotheses ensued.

Unequivocally, POP was confirmed, with PFM impairments and dysfunction. Hypervolemia due to peripheral oedema was excluded; however, other NP causes required further investigation (Oelke et al 2017). VD required uroflowmetry and urodynamics testing to identify its cause (bladder, urethra, sphincters) (Haylen et al 2010).

Three-day bladder diary (3DBD) is the recommended assessment of urinary habits (Castro-Diaz et al 2017, Haylen et al 2010). The client confirmed the accuracy of her 3DBD and reported often falling asleep on the sofa in the early evenings then going to bed without voiding before night-time.

Newly diagnosed global and NP were quantified and confirmed.

TANGO Nocturia Screen (Bower et al 2017) identified comorbidities: the client scored 4/6 items in sleep, 1/5 in urinary (urgency) and 2/4 in wellbeing categories.

Pathophysiology of global and NP (Hashim et al 2019, Oelke et al 2017) includes serious health problems (diabetes mellitus, diabetes insipidus, renal insufficiency, cardiac insufficiency, obstructive sleep apnoea), which required further investigation by the medical team, rather than physiotherapy, therefore they are not discussed from hereon.

Similarly, underactive bladder, referred to as ‘symptom-based correlate of detrusor underactivity (DUA)’ (Osman et al 2018, p633), is indicated by the impaired daytime bladder sensation (reported as absent or ‘mild’ during 3DBD interpretation), large bladder capacity allowing for no nocturia and slow/prolonged voiding in the absence of significant PVR.

DUA requires urodynamic clarification and urology/uro-gynaecology management, hence, will not be discussed beyond this point (Osman et al 2018).

Urgency with voided volumes >900ml and UUI with a voided volume of 1280ml could be argued as expected due to extreme volumes. It is unclear if urgency/ UUI at such volumes is normal/protective or pathological. Interestingly, subsequent random bladder scans in the clinic suggested periods of reduced diuresis during the day—small volumes (130–160ml) measured 2–3 hours post-void.

Lower limb reflexes, muscle strength and sensation were tested to excluded neurological contribution. No other symptoms/ signs suggested neurological issues.

Management goals, aligned with the client’s goals, included:

  • elimination of UI
  • reduction of POP symptoms allowing a return to walking, minding grandchildren
  • postponement/avoidance of surgery
  • voiding symptoms optimisation to ‘no bother’ and timely, effortless voiding with insignificant PVR
  • increase the client’s confidence to engage in a romantic/sexual relationship
  • prevention of bladder overstretch injury and PFD in the long term.

Assessment findings and presenting conditions were explained to the client against her symptoms, using illustrations/ models and handouts to inform and justify proposed management. Individualised education targeted identified gaps and/or misconceptions in her knowledge.

It included anatomy of PFM, pelvic organs and their role relevant to support and urinary functions; explanation of POP  and incontinence/voiding issues and contributing factors. Client understanding can improve adherence with management (Frawley et al 2015).

Vaginal oestrogen is recommended for women with vaginal atrophy and POP and it may improve UI (NICE 2019). The client was encouraged to discuss vaginal oestrogen with her GP. Admittedly, a prescription was given by the gynaecologist, but never used due to her poor understanding of its benefits. 

Management of UI aimed to reduce excessive bladder volumes, therefore to reduce NP. The client was advised to:

  • cease fluid intake 2–3 hours prior to night-time
  • void before night-time and if woken up at night
  • void immediately upon waking up (then attend to grandchildren) (Oelke et al 2017).

Using non-alarming language, the client was advised a further medical assessment of polyuria was needed.

Limited level I evidence suggests bladder training may be effective in the treatment of UUI in women (Dumoulin et al 2017). Voiding ‘just-in-case’ without straining was encouraged if no voids for four hours.

The client was advised to increase her awareness of bladder-filling sensation, correlate it to fluid intake, expected/actual voided volumes, and to self-monitor. The advice was intended to minimise chronic bladder overstretch injury. 

Current VD symptoms were explained in the likely context of bladder overstretch/ detrusor inefficiency with insignificant PVR.

However, a trial of different voiding positions and double voiding without straining was advised to assess its impact on voiding symptoms. Improvement in initiation and in voiding speed at the start of voiding was reported on leaning forward.

Lifestyle interventions for POP aim to reduce the impact of exacerbating modifiable factors causing rises in IAP impacting on PF/POP. There is limited evidence supporting these interventions (Dumoulin et al 2017); however, the client’s prolapse- provoking activities suggest the need for their modification.

The client was invited to identify her ‘prolapse-unfriendly’ activities (‘lifting youngest grandchild, washing basket, walking >15min’) and to propose and adopt modifications, including activity pacing. She was encouraged to maintain optimal BMI and prevent constipation as potential contributors to POP (Dumoulin et al 2017, DeLancey et al 2008).

Her preferred exercises (swimming, walking) were reinforced with trialling walking in the morning when PFM were non-fatigued and POP less symptomatic. Despite success with this, time flexibility to walk with her friend made this unsustainable.

Until POP improvements were achieved, the client continued swimming. Significant variations in IAP rises with different exercises have been reported (Tian et al 2018), therefore POP symptom self-monitoring during and post-exercise was encouraged if a new exercise regimen started.

PFMT is the mainstay conservative treatment for POP and UI founded on level I evidence (Dumoulin et al 2017). Following re-training of correct, isolated PFM exercise technique, strength training in gravity- assisted and gravity-eliminated positions commenced.

Progression of PFMT included exercising in upright positions and PFM activation with exercises relevant to lifting (lean forward, squat, step forward/reach). A range of repetitions, sets and positions was prescribed to allow for PFM fatigue.

Despite a lack of strong evidence for pessary use (Dumoulin et al 2017), high patient satisfaction rates (Lamers et al 2011) and immediate relief of bulge symptoms (Cheung et al 2016) allowing a return to walking/lifting warranted a pessary trial in this client.

Her perception of pessary was clarified before informed counselling on pessary benefits, risks and long-term follow-up requirements was done. The opportunity to touch/handle pessaries and ask questions was provided (Neumann et al 2012).

Her concern about sexual intercourse with pessary was addressed. This positively framed, non-coercing education, supported by a pessary information handout (Neumann et al 2012), made the client re- consider pessary fitting.

At the follow-up gynaecology review, she consented and was successfully fitted with a size 4 ring pessary. She was advised to return to a nurse-led pessary clinic if there were any problems. No self- care option was given/discussed. There were no urinary or bowel changes post-pessary fitting.

Outcomes

Her UI with first-morning void reduced to 1–2 episodes per week, while her VD remained unchanged but was less bothersome. She achieved her POP-related goals.

Discussion

The client continues physiotherapy. Unfortunately, as she achieved benefits from pessary use, her adherence to PFMT reduced.

PFMT up to six months has been demonstrated to reduce POP symptoms frequency (74 vs 31%) and bother (67 vs 42%) compared to the control group (Braekken et al 2010). Similarly, one-to-one PFMT significantly reduces POP-SS score at 12 months compared to lifestyle advice/no PFMT (p=0.0053) (Hagen et al 2014).

Although long-term pessary use is possible (Lone et al 2011), the client may have to rely on her PFM if pessary complications necessitate rest from it, justifying the continuation of intensive PFMT (Braekken et al 2010).

The evidence for PFM pre-contraction before and during activities rising the IAP, ‘the knack’ manoeuvre, exists for management of stress urinary incontinence (SUI) only (Miller et al 1998). Its effectiveness in reducing POP in this client was demonstrated in supine with cough.

Client-reported effectiveness in controlling the ‘bulge dropping’ symptom ‘sometimes’ with lifting her grandchild pre-pessary fitting, justified its place in PFMT/HEP with the aim to achieve automatic pre-recruitment.

Improvements in SUI with POP worsening, and unmasking of SUI with pessary fitting can happen (Dumoulin et al 2017, Neumann et al 2012). Interestingly, post-pessary fitting, no SUI occurred, possibly due to the effects of vaginal oestrogen and PFMT.

Even though physiotherapists have a limited role in NP management, it is important to identify and quantify its presence. Communication of supporting evidence to the GP/specialist is imperative as serious health conditions may be unmasked (Oelke et al 2017).

This client’s UUI was associated with NP. Treating her incontinence as UUI is inappropriate and dangerous. Excessive bladder volumes, leading to overstretch bladder injury, need swift management, which was not reflected in clinical practice.

The client’s GP and gynaecologist were informed about polyuria/UI; however, only the GP engaged (urine and blood tests showed no abnormalities). Subsequently, the client was referred to a geriatrician.

Urology/uro-gynaecology involvement is still necessary to obtain a full clinical picture and manage urinary problems. Similarly, optimisation of services for pessary management is needed. Trained and competent physiotherapists, nurses and GPs co-managing with specialists is the way to achieve this (Neumann et al 2012). 

Workplace restrictions in this physiotherapy practice meant the client’s pessary had to be managed by a gynaecologist.

The pessary self-care, recommended to increase the adherence to pessary use and reduce adverse events (Neumann et al 2012), will be taught, pending approval from the gynaecologist.

The importance of assessing the client’s narrative in a busy clinical practice was demonstrated by her willingness to re-trial vaginal oestrogen and pessary—both treatments leading to prolapse-relevant goal attainment.

Limitations of this report are related to ongoing management—final outcomes are unknown. The client’s NP and UI are under investigation. The gynaecologist’s approval for pessary self-care is pending. The client has not attempted sexual intercourse yet.

On reflection, the client’s narrative/ story hinted at prolapse-related body/ genital image issues. A standardised questionnaire would have provided a full assessment and a PROM to guide the treatment. Similarly,

TPRTUS pre-pessary and post-pessary fitting can provide insight into the anatomical position of prolapse and organs, which can be related to symptoms. Repeated 3DBD to assist further management was not possible post- pessary fitting—the client was increasingly busy.

Finally, the client’s attitude towards surgery in general needs evaluation and informed counselling, as she may require surgery in the future (Coolen et al 2018).

Conclusion

This case highlights the importance of clinical reasoning-guided management of UI and POP. Particularly, focused education derived from evaluation of the client’s narrative led her to re-consider initially rejected treatments for POP, and to attain her goals.

Similarly, the significance of clinical reasoning in the assessment of UI helped identify polyuria requiring referral to medical/specialist care. The outlined treatment options may not be applicable to all clients, but the principles of management can be followed.

>> Email inmotion@australian.physio for references. The client provided consent for her case to be published.  

Note: due to page restrictions, some figures describing pelvic floor muscle training have been omitted. 

Irena Nurkic, APAM, MACP, is a registrar undertaking Fellowship of the Australian College of Physiotherapists by Clinical Specialisation in the women’s, men’s and pelvic health discipline. Irena is a senior physiotherapist at Royal Perth Hospital in the area of continence and sexual health, and is a lecturer and clinical tutor in the postgraduate Continence and Women’s Health Physiotherapy Course at Curtin University. 

 

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