The overactive bladder and the role of the pelvic floor muscles

Transcription

1 BJU International (1999), 83, Suppl. 2, The overactive bladder and the role of the pelvic floor muscles E.J. MESSELINK Department of Urology, Academic Medical Centre Amsterdam, The Netherlands Keywords Pelvic floor muscle, overactive bladder, therapy, biofeedback, neurology, psychology, bladder dysfunction Introduction bladder with pelvic floor rehabilitation, both under the supervision of a physiotherapist. In this article, the relationship between PFM function and bladder function is discussed. The overactive pelvic floor seems to play an important role in relation to the symptoms of the over- active bladder. There are few reports on the relationship between the overactive bladder and overactive pelvic floor. Hence, some of the views in this article are based on clinical experience. The overactive bladder is a common disorder of the lower urinary tract; in the Netherlands, a recent survey showed that 10% of the Dutch population 18 years of age (about 1 million people) report symptoms of an overactive bladder [1]. The symptoms of bladder overactivity are urinary frequency (>8 times/24 h), urgency and urge incontinence. According to the ICS definitions, an overactive bladder is diagnosed by urodynamic investigation, i.e. filling cystometry [2]. The disorder is characterized by involuntary detrusor contractions while the patient is trying to suppress them (Fig. 1). If a known neurological disorder is the cause, the condition is classified as hyper-reflexia, and otherwise it is termed detrusor instability. There is still much debate about the classification and value of the cystometric findings [3]. In the treatment of bladder control problems, the pelvic floor muscles (PFMs) play an important role. In the past this therapy was used only for patients with stress incontinence. Recently there has also been a tendency to treat patients with urinary symptoms including an overactive Neurological control In the physiological situation the pelvic floor and the bladder co-operate to fulfil the demands of a normal lower urinary tract cycle. This cycle is primarily under the involuntary control of centres in the spinal and central nervous system. The desire to void is a warning signal that facilitates voiding at a convenient place and time. The neuronal circuitry of the lower urinary tract is still debated; a recent description was provided from the study by Blok et al. [4], using positron emission tomography to image central activity during voiding. Fig. 1. Urodynamic investigation of a 20- year-old women with dysfunctional voiding. Note the pelvic floor muscle action during coughing (red bars at the top of the recording) and during voiding BJU International 31

2 32 E.J. MESSELINK The neuronal circuitry has several elements in common, lems [12]. Respondent conditioning means that anxiety, i.e. the musculature of the lower urinary tract, and the expectations and other external signals are associated sympathetic, parasympathetic and somatic connections. with the feelings of the desire to void. Operantconditioning These elements regulate the storage and voiding phase, mechanisms (see below) can train a person and the end of voiding. To illustrate the role of the pelvic to postpone voiding because they are rewarded for this floor in the lower urinary tract cycle, the scheme by their social environment. Generalization causes more described by Holstege et al. is used (cited in [5]). and unspecific signals to acquire the same emotional The PFMs and the urinary bladder transmit acerent burden as the original signals, and thus influence both information to the lumbosacral cord and the periaquad- the lower urinary tract cycle and the process of voiding. uctal grey matter (PAG), the latter being part of the Another mechanism is trained helplessness, whereby emotional motor system [6]. The pontine micturition patients are convinced of their own inability to manage centre (PMC) receives excitatory information from the their bladder behaviour. For some patients the bladder PAG. In the PMC there are two regions of interest, the problems function as a method to avoid specific situations, m and the l region (medial and lateral region of the e.g. sexual intercourse [13]. Other patients try to pons). An important mechanism is the reciprocal inhibi- obtain special privileges because of their complaints and tory ecect of the m-region and the l-region on each symptoms [14]. other. The m-region is the centre of synergetic micturition, with projections via the sacral intermediolateral cell groups to the bladder and the urethral sphincter. Pelvic floor control The l-region has direct projections on the nucleus of The pelvic floor is a complex of muscular and fascial Onuf and in this way initiates contraction of the PFMs structures forming a structural unit. First, the PFMs and striated sphincter of urethra and anus [7]. provide support for the pelvic organs; second, the pelvic In the normal situation, the PFMs and bladder are coordinated floor plays a role in the process of continence and at the level of the PMC under control of the excretion (both urinary and faecal); and third, it is PAG region. Voluntary control of the lower urinary tract important in sexual functioning. Thus disorders of the cycle can be assessed by contracting the pelvic floor PFMs may lead to bladder control problems, retention, when longer storage is needed. The superomedial part prolapse or sexual dysfunction. Because the pelvic floor of the precentral gyrus projects onto the l-region, is a functional unit it gives rise to symptoms in dicerent resulting in a contraction of the PFMs [8]. The ecect of tracts; thus it is important to take a detailed history and a contraction of the PFMs on the bladder is inhibition of to have a multidisciplinary approach if more than one the detrusor contraction [9]. This reflex mechanism may organ system is involved. The pelvic floor may play a be of sacral origin, but the role of the PMC in this role in the development of bladder symptoms in the child mechanism has been described as inhibition of the l- and the adult. During normal development the child has region on the m-region [10]. During voiding there should learned to manage the bladder by using central control be maximal relaxation of the PFMs. This co-ordinated mechanisms. Some children learn to use other tech- action is also controlled by the PMC. Activation of the niques to prevent bladder control problems or to cope m-region initiates a detrusor contraction and simultaneously inhibits the l-region, relaxing the PFMs. Psychological control The desire to void is a sensation which, in the developing child, is incorporated into daily life so that voiding takes place at an appropriate time and place. Interpreting the desire and taking the right actions are the goal of training during childhood. Problems with training or general physical or psychological problems during training can have a great impact on the results of training, e.g. some women patients report that, when a child, they were taken to the toilet many times because their parents thought they had to void [11]. When children receive a negative sensual input related to voiding they may develop an abnormal voiding pattern. Conditioning is an important psychological mechanism for these prob- with urgency, e.g. some sit on their heel to compress the urethra. Other children use their pelvic floor to diminish the detrusor contraction or to prevent urine loss. Using the PFMs as a primary voluntary mechanism to regulate the lower urinary tract cycle can lead to bladder dysfunction and signs of an overactive bladder; this finally results in an overactive pelvic floor. In the western world, voiding in adults is probably no longer as natural as it was before modern civilization; for many people, the lower urinary tract cycle is dictated by their work or social activities. Many professions have dibculty coping with their lower urinary tract cycle, e.g. cab-drivers, salesmen and waiters. During their work there is little time for voiding so they train themselves to postpone micturition for a long time. The interval between consecutive voids increases, with some voiding only two or three times a day. Their functional bladder capacity can exceed 500 ml and there is often a

3 THE OVERACTIVE BLADDER AND PELVIC FLOOR MUSCLES 33 significant postvoid residual urine volume. Not only do the results are better and achieved earlier [19]. In a they postpone voiding, but they also wish to void whenever long-term study, the initial success rate was 88% but it is convenient. In this situation, voiding may declined to 38% after 6 months [20], and when reviewed, change from an involuntary regulated reflex action to a the proportion responding completely was 10 15%. In voluntarily initiated and most often uncoordinated those patients (50%) who had fewer symptoms, there action of the bladder and PFMs. During voiding the was a 50 75% improvement when compared with their PFMs are not relaxed but instead reflexively contract condition before treatment [21]. through abdominal straining; hence, a dysfunctional voiding pattern develops. As expected, this is a vicious circle, resulting in an overactive pelvic floor with dysfunctional Pelvic floor muscle training voiding and residual urine. PFM training may be important in treating the overactive Theoretically, the development of an overactive pelvic bladder. To determine whether such therapy is ecective floor may induce peripheral and central changes leading and to apply the right form of therapy, it is necessary to to a new system managing and controlling the lower know the status of the PFMs. Three types of pelvic floor urinary tract cycle. This system could be more vulnerable dysfunction can be identified on physical examination, to loss of co-ordination between the detrusor and PFMs, i.e. no voluntary control, voluntary control but impaired and loss of inhibitory signals to the detrusor, leading to strength and/or relaxation, and voluntary control with detrusor overactivity. On the other hand, there may be normal strength and/or relaxation. The dicerent treat- an important role for the central regulation of the lower ment modalities are shown in Table 1. urinary tract cycle. The m-region and the PAG are part When there is no voluntary control, biofeedback (BFB) of the emotional motor system; the ecect of emotional alone or combined with electrotherapy may be a good trauma on the lower urinary tract is well known [15]. therapeutic strategy. When there is voluntary control Psychological, emotional or sexual trauma are frequently but strength or relaxation is impaired, pelvic floor reeducation, seen in patients with symptoms of an overactive bladder including exercises to improve strength or in combination with an overactive pelvic floor [16]. relaxation, is the therapy of choice. If there is voluntary control and good strength/relaxation, conditioning will teach the patient to use the pelvic floor correctly. The Bladder training ability to relax the pelvic floor during a physical examination The overactive bladder can be treated pharmacologically does not exclude an overactive pelvic floor. During with antimuscarinics, oestrogen, and other drugs. It can voiding these patients may be contracting the pelvic also be treated by bladder training programmes and the floor instead of relaxing. In these situations, the history psychological mechanism described for the development can provide clues about the activity pattern of the pelvic of the overactive bladder can be used in such a training floor. The most important feature of PFM rehabilitation programme. One of the earliest training schemes was is training the co-ordination between bladder and pelvic devised by JeCcoate and Frewen [17], who described the floor. Initially, the patient should become aware of the method of postponing voiding in case of urgency and PFMs and incorporate this group of muscles into their frequency by progressively delaying micturition. By body scheme. The patient should be taught the normal observing the interval between separate voids it was function of the PFMs and their interaction with the possible to learn that voiding could be postponed with bladder. In the final stage, the patient should learn how no significant problems (operant conditioning). Because the results of bladder training soon diminish, concomitant cognitive behavioural therapy is advocated. Patients Table 1 Methods of pelvic floor therapy should have more knowledge about their symptoms and Method Components about their urinary tract function [18]. Concomitant psychological counselling may be important when anxi- Pelvic floor rehabilitation Muscle training ety is excessive. The help of a trained psychologist, Bladder training interested in patients with bladder problems, can then Co-ordination training be vital to therapeutic success. Depending on whether Biofeedback Digital Perineometer the psychological factors are related to sexual problems, Pelvic floor EMG a sexologist may be an optional first choice for the Urethral pressure psychological part of the therapy. Urinary flow recording The reported results of bladder training vary greatly; Neuromuscular electrical Pelvic floor muscles Hz they depend on whether detrusor overactivity was present (motor urge) or not (sensory urge). With the latter, stimulation Detrusor muscle 5 10 Hz

4 34 E.J. MESSELINK with an overactive pelvic floor, only improving muscle strength will aggravate the symptoms. Another import- ant precaution is to recognize any association of an overactive pelvic floor and psychological trauma in the history. In our clinical experience, patients with an overactive pelvic floor more often have psychological and especially sexual trauma in their past. This can be unclear at the start of therapy because it may be impossible for the patient to discuss it with the specialist; some patients only recount these experiences after a long time. One opportunity to initiate discussion may be during PFM therapy sessions; when relaxation appears to be a problem, the specialist can then inform the patient that negative experiences in the past may be a factor in the present symptoms. Where such experiences are reported it is obvious that psychological counselling should be ocered to the patient. Based on this knowledge, it seems wise to be careful when performing invasive investigations (e.g. cystoscopy) and using intravaginal or intra-anal treatment devices in such patients. In these situations, this should be discussed with the patient and with the psychologist if appropriate. to manage the pelvic floor and practise this in dicerent daily situations. Biofeedback is important for showing the patients the ecect of their ecorts; patients showing no or poor voluntary control over the pelvic floor can be assisted using BFB. Comparing those using or not using BFB showed that the results were no better but were achieved more quickly in the former. The simplest form of BFB is the provision of information on the action of the pelvic floor as measured digitally by the instructing physiotherapist. This combination of training and feedback is important at the start of training. Neuromuscular electrical stimulation (NMES) can be used to stimulate nerve fibres and muscles, the optimal stimulus frequency being based on the conduction velocity of the targeted nerve fibre type. NMES at Hz can stimulate the PFM through a pudendal nerve reflex loop, which improves re-innervation and converts fastinto slow-twitch fibres. At 5 10 Hz, NMES can also acect the detrusor muscle by reflex inhibition; at this frequency, a pudendal to pelvic nerve reflex is activated. As a result of PFM training, problems were completely resolved in 20% of patients; most patients reported a reduction in urinary symptoms of 50 75% [22]. The results of BFB are reported only in a few studies; in children, the results were classified as good in 68%, improved in 13% and not improved in 29% [23]. In a study on adults, 43% were rendered continent and there was a significant decrease in daytime frequency and nocturia [24]. The results of NMES, reported in a review [25], were 20% dry and 37% significantly improved; other studies report comparable results [26]. Complications of PFM training The future There remains much work in the field of PFMs and the overactive bladder. First, there needs to be a consensus on the classification of pelvic floor disorders. Second, the instruments for measuring pelvic floor function should be more objective and reproducible. Outcome measures should be stated, and clinical, sham-controlled trials of the ebcacy of dicerent treatment options and combinations should be constructed. Another important field of research is the neurological basis for the interaction between the bladder and pelvic floor. The recent results with positron emission tomography should encourage investigators to conduct further trials on these aspects. Combined with this area, more attention must be given to the psychological and sexual aspects of the overactive pelvic floor and bladder. Using the term overactive bladder syndrome rather than overactive bladder may provide a broader view of the complex relations of the bladder, the pelvic floor and the brain in patients with urge, urgency, frequency and urge incontinence. Further investigations are needed and these should be multi- disciplinary. The indications for PFM therapy have increased over recent years; currently, physiotherapy of the PFMs may be applied not only to women with stress incontinence but also in both sexes with symptoms of dysfunctional voiding and an overactive bladder. PFM therapy is a functional approach and is therefore a reasonable option for functional disorders of the lower urinary tract. Restoring normal function is the main goal of PFM therapy. By broadening the indications for PFM therapy, it will become increasingly important that specialists and physiotherapists who treat this type of patient are familiar with the nature of PFM problems and the characteristics of the dicerent treatment modalities. The overactive pelvic floor is a relatively References new indication for PFM therapy and some precautions 1 De overactive blaas. OBce Report Veldkamp 1998 are necessary. The diagnosis of PFM overactivity may 2 Abrams PH, Blaivas JG, Stanton SL, Andersen JT. be dibcult and therefore missed. When applying PFM Standardisation of terminology of lower urinary tract therapy it is important to realize that, in all cases, function. Neurourol Urodynam 1988; 7: control of the PFMs and co-ordination are the primary 3 Artibani W. Diagnosis and significance of idiopathic goals and muscle strengthening the second. In those overactive bladder. Urology 1997; 50: 25 32

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