Growing evidence supports that physical functional limitations can be a cause and consequence of urinary incontinence (UI) in aging adults.[1, 2] We have previously shown among older women without baseline UI, that with aging and onset of UI symptoms, there was greater risk of concomitant development of physical function impairments (PFI).[3]  Urinary incontinence and physical function impairment (PFI) are inter-related geriatric conditions that result, in part, from skeletal muscle dysfunction with aging. Given the crux of non-surgical treatment of UI combines pelvic floor muscle (PFM) training with behavioral management strategies. We hypothesized that the concomitant presence of UI and physical function impairment may impair the efficacy of pelvic floor muscle training.

The objective of this study was to examine the impact of PFI on PFM training for the treatment of UI in older women. We conducted a prospective cohort study of 61 community-dwelling women, older than 70 years, with at least moderate UI symptoms. UI severity was determined at baseline using the Questionnaire for Urinary Incontinence Diagnosis (QUID). Moderate UI was defined as having subscale score for stress ≥4, urge score ≥ 6, and/or total QUID score ≥ 10.  Physical function was determined using the Short Physical Performance Battery (SPPB) with PFI defined as SPPB score ≤9; a SPPB score >9 represented normal physical function. A 3-day bladder diary established daily UI frequency collected at baseline, 6, and 12 weeks. The Urinary Distress Inventory (UDI-6) was used to measure bother from UI symptoms at baseline, 6 and 12 weeks. Baseline PFM function was assessed objectively using the Peritron® perineometer and the P.E.R.F.E.C.T scheme to determine PFM strength, endurance, and efficiency. This schema was applied to create an individualized PFM training prescription. The 12-week PFM training prescription included 3-sets of daily PFM exercises, rapid contractions, and urgency and stress suppression strategies as appropriate. Behavioral therapy included fluid and bowel management as appropriate. Our primary outcome was the change in UI episodes from baseline to 6 weeks based on the presence of PFI at baseline. Secondarily, we examined the change in bother from UI episodes, change in strength of pelvic floor muscles, and the global impression of improvement at 6 weeks.  Clinical characteristics were compared based on the presence of PFI using descriptive statistics.  Inferential statistics were applied using the Student’s t-test was for continuous variables and Fisher’s Exact Test was for categorical variables for the primary and secondary outcomes. We had 80% power to detect differences at a p=value of 0.05 with 30 women in each group.

Based on presence of PFI at baseline, 33 women had SBBP≤9 and 37 had normal physical performance at week 6. The mean age was 76.9 ± 5.4 years. There were no differences in mean age or ethnicity between groups at baseline. Women with SPPB ≤ 9 had higher BMI, 33.6±14.5 kg/m2 vs 27.4±5.8 kg/m2 than in women with SPPB > 9, p=0.032.  At baseline, women with PFI had significantly more UI episodes [4.6±2.9 episodes/day] compared to women with normal physical function [2.7±2.1 UI episodes/day], p=0.006. Bother from UI symptoms was similar at baseline, p=0.42. (Table 1) Objective PFM strength was significantly weaker at baseline in women with PFI, [18.7±13.2 cm H20 compared to 29.3±16.0 cm H20 in women without PFI], p=0.005.  After 6 weeks of PFM training and behavioral therapy, incontinent women with PFI experienced a non-significant but greater decrease in UI episodes [-1.3±2.0 UI episodes/day] compared to women without PFI [-0.5±1.8], p=0.12. However, when asked about UI symptom bother after 6 weeks of PFM training, women with PFI had significantly lower changes in UDI-6 total scores from baseline [-0.5±3. 6] compared to women with normal physical function [-3.3±5.5], p=0.02. Further, 93% of women with normal physical function reported being better or much better after 6 weeks of PFM training and behavioral therapy compared to 69% of women with PFI, p=0.03. Overall, satisfaction was low between both groups with 55-61% of women being not at all or somewhat satisfied. (Table 1)

Older women with moderate-to-severe UI symptoms and physical function impairment may experience a modest improvement in UI episodes/day after PFT training and behavioral therapy.  However, the modest decrease in UI episodes/day did not result in improvements in bother or distress from their UI episodes.  Further, incontinent women with PFI had low overall satisfaction and lower global impression of improvement after 6 weeks of PFM training and behavioral therapy compared to their peers with normal physical function.  Current non-surgical approaches to treating UI in older women with physical function impairment may not significantly impact on symptom bother and severity.  Advancements in non-surgical treatments are needed to more significantly impact on UI severity and to improve treatment satisfaction for older incontinent women.

Older women with moderate-to-severe UI symptoms and physical function impairment may experience a modest improvement in UI episodes/day after PFT training and behavioral therapy.  However, the modest decrease in UI episodes/day did not result in improvements in bother or distress from their UI episodes.  Further, incontinent women with PFI had low overall satisfaction and lower global impression of improvement after 6 weeks of PFM training and behavioral therapy compared to their peers with normal physical function.  Current non-surgical approaches to treating UI in older women with physical function impairment may not significantly impact on symptom bother and severity.  Advancements in non-surgical treatments are needed to more significantly impact on UI severity and to improve treatment satisfaction for older incontinent women.

Tinetti, M.E., et al., Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA, 1995. 273(17): p. 1348-53.
Erekson, E.A., et al., Functional disability and compromised mobility among older women with urinary incontinence. Female Pelvic Med Reconstr Surg, 2015. 21(3): p. 170-5.
Parker-Autry, C., et al., Characterizing the Functional Decline of Older Women With Incident Urinary Incontinence. Obstet Gynecol, 2017. 130(5): p. 1025-1032.