VOL: 103, ISSUE: 19, PAGE NO: 40
Ian Pomfret, NDNCert, PWT, RGN, is continence adviser
Clare Holden, BSc, MCSP, is specialist continence physiotherapist; both at Chorley and South Ribble Continence Service, Central Lancashire PCT.The NICE guideline on the management of urinary incontinence in women recommends that: 'A trial of supervised pelvi...
The NICE guideline on the management of urinary incontinence in women recommends that: 'A trial of supervised pelvic floor muscle training of at least three months' duration should be offered as a firstline treatment to women with stress or mixed urinary incontinence' (NICE, 2006).
It also recommends that 'routine digital assessment of pelvic floor muscle contraction should be undertaken before the use of supervised pelvic floor muscle training for the treatment of UI'.
The reason for this recommendation is that there is evidence to show that teaching pelvic floor muscle exercises (PFMEs) in the absence of vaginal examination may be ineffective or may actually cause additional physical harm if the woman bears down rather than contracts her pelvic floor muscles (Bump et al, 1991). The action of repeatedly bearing down weakens the pelvic floor muscles and this may lead to a worsening of symptoms.
Specialist continence physiotherapist
Specialist continence physiotherapists have received training that includes anatomy, physiology and muscle rehabilitation. This gives them the skills required to play a vital role in the management of continence, particularly in pelvic floor muscle rehabilitation (Whitehead, 2002).
Some patients with mild symptoms may receive basic pelvic floor muscle advice from a midwife, GP, practice nurse or health visitor. Specialist continence physiotherapists' skills should be used to teach professionals how to assess and teach a correct pelvic floor muscle contraction.
Patients suffering from more significant incontinence or who are unable to perform PFMEs correctly should be referred for specialist advice and/or treatment. Patients with a correct technique can be encouraged to perform PFMEs independently but should be given information on how to access specialist continence physiotherapy if no improvement has occurred within three months or if their symptoms worsen.
Although neither biofeedback nor electrical stimulation are recommended as a routine part of training in the guideline, both should be considered in women who cannot actively contract their pelvic floor muscles (NICE, 2006). An internal electrode can be used to stimulate a contraction and/or increase patient awareness of a contraction (Parsons and Cardozo, 2004).
Biofeedback could also be used for teaching and to facilitate awareness of pelvic floor muscle contraction (Haslam, 2002). The Chartered Society of Physiotherapy (2006) lists therapeutic exercise and the application of electrophysical modalities as core skills of a physiotherapist. It highlights the need to use a specialist physiotherapist in pelvic floor muscle rehabilitation to manage and treat stress and mixed urinary incontinence.
Surgical intervention and PFMEs
According to the NICE guidelines, indirect comparison of the effectiveness of pelvic floor muscle training and surgery in the treatment of stress urinary incontinence suggests that surgery is associated with higher cure rates but greater morbidity. It also suggests that a significant number of women initially treated successfully by pelvic floor muscle training will ultimately undergo surgery and that the development of newer minimal access procedures, for example, tension-free vaginal tapes, with shorter recovery periods may now make surgery a more acceptable option.
However, it should be remembered that many women with a young family or who work full time may not have the family support to undergo surgery. Also, women suffering from urinary incontinence but intending to have more children need an effective management technique, such as PFME, as they will not be suitable for surgery at that time. Many women worry about symptoms getting worse but do not think they are severe enough to warrant surgery.
Also, as there is an increased morbidity associated with surgery, there is a need for easily available techniques such as pelvic floor muscle rehabilitation prior to, instead of, or as an adjunct to surgery.
Consent to vaginal examination
While welcomed as a statement of good practice, the NICE guidance may cause problems for male healthcare professionals. A study identified that 82% of female patients seen in primary care would refuse a vaginal examination by a male nurse or male physiotherapist (Haslam et al, 2000).
The study was conducted in a continence service that had a male (nurse) continence adviser. During assessment on female patients, this adviser did not perform vaginal examinations, relying on female colleagues or on examinations performed by medical staff (of either gender).
Anecdotally, it was assumed that female patients would object to vaginal examinations by male nurses and physiotherapists and the study confirmed this assumption (Haslam et al, 2000).
Another problem was the question of chaperones. It was found that 95% of female patients seen in primary care wanted a female chaperone present during an examination carried out by a male nurse, physiotherapist or doctor (Haslam et al, 2000). This has implications for staffing levels and costs.
The NHS Clinical Governance Support Team (2005) advises that: 'A chaperone is present as a safeguard for all parties (patient and practitioners) and is a witness to continuing consent of the procedure. However, a chaperone cannot be a guarantee of protection for either the examiner or examinee. Protecting the patient from vulnerability and embarrassment means that the chaperone would usually be of the same sex as the patient.'
The problem was resolved at our PCT by developing a multiprofessional continence team incorporating a female specialist continence physiotherapist. While the appointment was not solely on a gender basis, it provided an opportunity to develop specialist physiotherapy services in a PCT continence service (Pomfret, 2002; 2001).
There may be other male and female practitioners who have developed other methods. However, this multiprofessional model of care has proven very effective and resolved the issues around the acceptability of male healthcare professionals conducting vaginal examinations.
PFMEs play an important part in treating female urinary incontinence. It is important to assess that a patient is carrying out the procedure correctly. Continence teams must have appropriately trained staff so that they can provide a full programme of PFMEs without compromising the privacy and dignity of women presenting for treatment.
NICE guidance relating to Pelvic Floor Muscle Exercises
- Routine digital assessment of pelvic floor muscle contraction should be undertaken before the use of supervised pelvic floor muscle training for the treatment of urinary incontinence (UI)
- A trial of supervised pelvic floor muscle training of at least three months' duration should be offered as firstline treatment to women with stress or mixed UI
- Pelvic floor muscle training programmes should comprise at least eight contractions performed three times per day
- If pelvic floor muscle programmes are beneficial, they should be continued
- Perineometry or pelvic floor electromyography as biofeedback should not be used as a routine part of pelvic floor muscle training
- Electrical stimulation should not routinely be used to treat those with overactive bladder
- Electrical stimulation should not routinely be used in combination with pelvic floor muscle training
- Electrical stimulation and/or biofeedback should be considered in women who cannot contract pelvic floor muscles to aid motivation and adherence to therapy