Ultrasound biofeedback in the management of incontinence in the elderly

Investigators: Mrs Santha Tisserevasinghe, Ms Margaret Sherburn, Prof Mary Galea

Recent research has shown ultrasound imaging of the pelvic floor to be a valid and reliable tool for visualising and measuring pelvic floor muscle activity. However ultrasound has not been tested for use as a biofeedback tool during pelvic floor muscle training (PFMT). Tactile feedback during digital vaginal palpation remains the standard clinical tool for pelvic floor muscle biofeedback although it is a qualitative tool. The aim of this study was to compare the effectiveness of visual feedback using transabdominal ultrasound (US) to tactile feedback using internal vaginal palpation (PV) in PFMT for older women with urinary incontinence.

This was a single-blind randomised controlled clinical trial. Twenty women aged 60 to 85 years with stress and/or urgency incontinence were randomly assigned using concealed allocation, to 10 weeks of either conventional physiotherapy (n=10) or ultrasound biofeedback only (n=10). Conventional physiotherapy involved teaching and feedback via internal vaginal palpation (PV) whilst the ultrasound intervention (US) involved visual feedback of PFM contraction using transabdominal ultrasound and no internal vaginal palpation. Both groups received 4 one-hour long sessions of individualised physiotherapy intervention. This included specific and functional PFMT, bladder education, and a home exercise program. Both groups continued with their home program until the follow-up assessment at 3 months post-intervention.

Assessments occurred at baseline (T1), immediately post-intervention at 10 weeks (T2) and 3 months post-intervention follow-up (T3) by a pelvic floor physiotherapist who was blinded as to subject allocation. Successful PFMT was measured by improvement in continence outcomes and an ability to displace the pelvic floor a greater distance as measured on ultrasound. The outcomes measured at all assessments were 1) the volume of urine lost using a 24 hour pad weigh test (PWT), 2) total accidents per week using an accident dairy (AD), 3) displacement of the pelvic floor as imaged on transabdominal ultrasound (USD) 4) and quality of life using King Health Questionnaire (KHQ), at baseline and follow-up only. Compliance to the exercise program and treatment advice was recorded using an exercise diary.

There were no significant differences between the 2 groups at baseline for age, BMI, or parity. There were also no significant differences in the number who reported regular problems with constipation, cystitis, those who exercised regularly or had previously undergone gynaecological surgery. The 2 groups were not significantly different at baseline with respect to mean grams of urine loss measured by the 24 hour pad weigh test, or mean ultrasound displacement measures. However the number of leakage episodes reported in the accident diary was significantly different, with the US group having more leakage episodes.

There was a trend towards improvement for both groups, indicating both feedback methods may be effective for PFMT. Both groups changed similarly, indicating they may be equally effective methods of providing feedback. However, this small study had insufficient power to clearly indicate whether there may be a real difference between the two groups, because of the wide variance in the data.

Visual feedback from ultrasound imaging of the pelvic floor is as effective as tactile feedback from vaginal palpation for PFMT in older women with urinary incontinence as shown by improvement in continence outcomes. Ultrasound may be a useful tool for pelvic floor examination and training in situations where a per vaginum examination is not appropriate.

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