1
English version
1.1
Introduction
Some lower urinary tract dysfunctions remain unexplained after urodynamic testing. Functional etiology is then considered. A comprehensive care combining muscular training and behavioral and cognitive therapy (BCT) can be proposed before a more invasive investigation.
In our practice, this approach is mainly applied to patients who complain of urgency-reformulation frequency with leakages.
We present our experience in 3 cases of women complaining of that syndrome with variable degrees of severity.
1.2
Patients
1.2.1
Case #1
Woman aged 66, who had daytime and night-time frequency with important leakages occurring at urgency. Urodynamic testing was close to normal except a delayed first desire to void (190 mL).
1.2.2
Case # 2
Woman aged 62, who had daytime and night-time frequency. During cystometry a rapid progression of desire was observed but functional bladder capacity was normal. She did not have much leakages.
1.2.3
Case # 3
Woman aged 43 who had daytime frequency with large leakages. Urodynamic testing was normal.
1.3
Methods
Initially 10 sessions (45 min duration) of treatment were offered to every patient. Sessions took place once a week except the last 2 that were 2 or 3 weeks apart. If necessary, additional booster sessions were also allowed.
The goal of the treatment was to manage urgency. Therefore, an appropriate treatment program including urgency-coping strategies was offered.
General principles were information, highlighting of inappropriate behavior, re-learning (increase of the delay between voiding and of the number of voiding at normal desire), reformulation, activity exposure and problem solving.
Used tools during session were relaxation, muscular training (feeling, steadiness, duration) of perinea, and abdominal breathing.
Learned techniques were simulated at home (training), then applied in urgency condition (activity exposure). Each patient fulfilled daily voiding diary; a planning of drinks was established jointly with the physiotherapist.
Evaluation was performed initially and during the last session using the discomfort visual analog scale (VAS) and the French score measurement of urinary disability (MHU) obtained from questioning (items are urgency, frequency, dysuria, stress incontinence).
All sessions were conducted by the same physiotherapist.
1.4
Results
The number of proposed sessions (10) could be reduced (7: case #3) or greatly increased (20: case #1) depending on the response to treatment ( Table 1 ).
| Case #1 (66 years) 20 sessions | Case #2 (62 years) 9 sessions | Case #3 (43 years) 7 sessions | ||||
|---|---|---|---|---|---|---|
| Initial | End | Initial | End | Initial | End | |
| Daytime frequency | 11 | 7 | 10 | 7 | 11 | 7 |
| Night-time frequency | 5 | 3 | 3 | 2 | 1 | 0 |
| Daytime voiding interval | 0.5 h | 1 h | 0.5 h | 2.5 h | 0.5 h | 2 h |
| Voiding delay after strong desire | < 1 min | 5 min → 15 min | 5 min | 60 min | 5 min → 10 min | 15 min → 60 min |
| Daytime leakages | 7–30/weeks ++/+++ | 5–10/weeks +/+++ | 1–2/weeks +/++ | 1/2 weeks + | 7–8/weeks ++/+++ | 3–4/months +/++ |
| Night-time leakage | 35/w ++/+++ | 14/w +/++ | 0 | 0 | 0 | 0 |
| % of voidings at normal desire | 0 | 30 | 0 | 33 | 0 | 50 |
| VAS/10 | 6.8 | 5.1 | 4.5 | 2.5 | 8 | 5.1 |
| MHU/28 | 11 | 7 | 7 | 2 | 7 | 3 |
In these 3 cases improvement was observed:
- •
in urinary functional symptoms: increased daytime voiding interval (case #2: from 0.5 hour to 2.5 hours), decreased daytime leakages (case #3: from 7–8 per week to 3–4 per month) and recurrence of voiding at normal desire (from 30% in case #1 to 50% in case #3) ( Table 1 );
- •
in quantization scores: comparing the less improved case (#1) and the more improved (#2) the range of improvement was (25% to 44%) in VAS and (36% to 71%) in MHU
1.5
Discussion
The aim of this paper is to describe a non-usual method of treatment of functional urinary disorders. This diagnosis is rarely made in primary care office and in most cases after urological examination and urodynamics.
The first question we can ask ourselves is how many sessions are needed to obtain significant results. If in a first approach 10 sessions are proposed, the number of sessions does not only depend of improvement but also of socio-professional constraints. An alternative is proposed: reproducing the spacing and training sessions at home. The observed high number of sessions required for case #1 results from the severity of incontinence and the low ability of the patient to assimilate instructions.
The usual frequency is chosen to give the woman time to incorporate new habits and verify their sustainable acquisition.
Other parameters essential for significant results are attendance and regularity of training, and acceptance of coping strategies. Therefore, one can reproach this method for being time-consuming.
Recall that educational aspect (habits related to urinary sphere: drinking, feeding, precautionary voiding, removal of avoidance behavior) is used to make the patient more active and self-dependent.
The limitation of this study is the lack of evaluation of the results at middle- and long-term.
1.6
Conclusion
Comprehensive care combining muscular training and behavioral and cognitive therapy applied to patients with functional urinary dysfunction leads to significant improvement without invasiveness. Good results are conditioned by targeted medical indication and investment of the patient between sessions. That method appears as a good alternative before considering invasive investigations and/or heavy medical treatment (sacral nerve stimulation, botulinum toxin…).
1.7
Consent
Written informed consents were obtained from the patients for publication of this case report.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
2
Version française
2.1
Introduction
Certains troubles urinaires du bas appareil (TUBA) restent inexpliqués après un bilan urodynamique. Ceci amène à la prise en compte d’une étiologie fonctionnelle. Une prise en charge globale associant rééducation périnéale et thérapie cognitive et comportementale (TCC) peut alors être proposée avant d’envisager des investigations invasives.
Dans notre pratique, cette approche s’adresse principalement à des patientes se plaignant d’une pollakiurie importante et d’urgenturie associée ou non à des fuites urinaires.
Nous présentons notre expérience concernant trois cas de femmes souffrant de ce syndrome avec différents degrés de sévérité.
2.2
Patientes
2.2.1
Cas #1
Femme de 66 ans présentant une pollakiurie diurne et nocturne avec des fuites importantes par urgenturie. Le bilan urodynamique était proche de la normale exception faite d’un retard à l’apparition du premier besoin (190 mL).
2.2.2
Cas # 2
Femme de 62 ans présentant une pollakiurie diurne et nocturne. Pendant la cystomanométrie une progression rapide du besoin a été observée; la capacité vésicale fonctionnelle était normale. La patiente rapportait peu de fuites mictionnelles.
2.2.3
Cas # 3
Femme de 43 ans présentant une pollakiurie diurne et des fuites importantes. Le bilan urodynamique était normal.
2.3
Méthodes
En première intention, 10 séances de 45 minutes étaient proposées à chaque patiente. L’intervalle des séances était d’une semaine pour les 8 premières, les 2 dernières étant espacées de 2 à 3 semaines. Si nécessaire, des sessions de rappel visant à stabiliser les résultats étaient réalisées.
L’objectif principal du traitement consistait à gérer l’urgenturie. Dans cette optique, un programme approprié incluant des stratégies d’adaptation à l’urgence était proposé.
Les principes généraux étaient : la donnée d’informations générales, la mise en évidence de comportements inappropriés, la modification du comportement mictionnel (augmentation de l’intervalle entre mictions, augmentation du nombre de mictions à besoin normal (B2)), la reformulation, la mise en application à domicile des principes enseignés en situation réelle, et la résolution de problèmes du quotidien.
Les « outils » utilisés pendant les séances étaient la relaxation, la travail musculaire qualitatif du périnée (perception, stabilité et durée de la contraction) et la respiration abdominale.
Les techniques apprises étaient dans un premier temps répétées pluri-quotidiennement (entraînement), puis mises en application en situation réelle. Chaque patiente remplissait un catalogue mictionnel journalier ; la programmation d’ingestion des liquides était établie conjointement avec le physiothérapeute.
Les évaluations ont été effectuées au cours de la séance initiale et de la dernière séance en utilisant l’échelle visuelle analogique de gêne (EVA) et le score MHU mesurant le handicap urinaire (items : urgenturie, fréquence mictionnelle, dysurie et incontinence urinaire à l’effort).
Toutes les séances ont été réalisées sous le contrôle du même physiothérapeute.
2.4
Résultats
Le nombre de séances proposées (initialement 10) a pu être réduit à 7 (cas #3), ou augmenté fortement (à 20 : cas #1) en fonction de la réponse au traitement ( Tableau 1 ).
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