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BackTable / OBGYN / Article
Female Urinary Incontinence Treatment: Physical Therapy, Weight Management & Intravaginal Device Options
Faith Taylor • Updated Jan 12, 2025 • 34 hits
Pelvic floor physical therapy is the cornerstone of urinary incontinence treatment. However, a number of devices are now available that either assist with physical therapy or provide some manner of symptom relief, leading patients and practitioners alike to question the role and suitability of different urinary incontinence treatment options.
Drawing on her expertise as a urogynecologist, Dr. Sarah Boyles explains how tailored interventions—including physical therapy, weight management, and purpose-built devices—can optimize outcomes and improve the quality of life for women living with urinary incontinence. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable OBGYN Brief
• Pelvic floor physical therapy is the primary treatment for urinary incontinence, with techniques tailored to each type. Patient engagement and access to a skilled pelvic floor therapist are essential for success.
• Stress incontinence can be treated through up-training, focusing on strengthening pelvic floor muscles and optimizing contraction timing
• Urgency incontinence treatment includes urge suppression strategies, where pelvic floor contractions help counteract bladder activity and control symptoms.
• Weight management plays a supportive role in improving incontinence symptoms, but clinicians must integrate it carefully to avoid reinforcing body image concerns.
• Intravaginal devices, such as Leva, K-Goal, Flight, and Perifit integrate feedback mechanisms that provide biofeedback and coaching, offering an alternative to pelvic floor physical therapy, particularly when therapist access is limited.
• Urethral seals, like the Finesse patch, provide targeted relief for situational incontinence, making them ideal for events or activities but not suitable for daily use due to ongoing cost.
• Pessaries designed for urinary incontinence offer long-term support. Devices like the Impressa and Uresta provide practical, self-fitting solutions, though fitting assistance may be required for optimal results.
Table of Contents
(1) Tailored Treatment Strategies for Urinary Incontinence: Pelvic Floor Physical Therapy & Weight Loss
(2) Intravaginal Devices for Pelvic Floor Therapy
(3) Devices for Urinary Incontinence Symptom Relief
Tailored Treatment Strategies for Urinary Incontinence: Pelvic Floor Physical Therapy & Weight Loss
Pelvic floor physical therapy is a primary treatment intervention for urinary incontinence, with techniques tailored to each type. Stress incontinence is addressed through up-training, focusing on strengthening pelvic floor muscles and optimizing contraction timing. Urgency incontinence, on the other hand, involves down-training to relax the bladder and pelvic floor, complemented by bladder retraining strategies to lengthen voiding intervals. Urge suppression techniques further enhance symptom control by leveraging pelvic floor contractions to counteract bladder activity. Patient engagement and access to skilled pelvic floor therapists are critical for success, as adherence to exercises often determines outcomes.
Weight management has proven to be a supportive treatment measure, with modest weight loss shown to improve urinary incontinence symptoms. However, Dr. Sara Boyles cautions clinicians to contextualize its role within a comprehensive treatment plan to avoid reinforcing body image concerns. These targeted approaches underscore the importance of individualized care in addressing urinary incontinence effectively.
[Dr. Suzette Sutherland]
We've talked a lot about the diagnosis of urinary incontinence in women, how to differentiate different types of incontinence. Now let's move into the treatment algorithms. We really made the point too, that it really depends on what type of incontinence that the woman has that will determine the type of treatment that will be appropriate for them. One woman's incontinence isn't another woman's incontinence. One woman's treatment that might prove successful for her isn't the same for the next woman. Let's move now into talking about those types of treatments. Can you give us an overview of the different types of treatments that we have available today?
[Dr. Sarah Boyles]
I completely agree with you. The first step is figuring out the diagnosis and then starting down the treatment algorithm. For both stress and urgency urinary incontinence, the initial recommendation is behavioral treatment and physical therapy, and education but what is done in those sessions is quite different. Sending someone to pelvic floor physical therapy or having them do muscle strengthening on their own will resolve stress urinary incontinence in about 60% of women.
It's an important point. It's important to start there. Sometimes you really need to get patient buy-in. Physical therapy only works if the patient is engaged in that. It's important to know your local resources and your local pelvic floor physical therapist. For stress incontinence, they're really focusing on strengthening the pelvic floor. They're focusing on breathing. Then it's not quite enough to have a strong pelvic floor. You also have to engage those muscles at the correct time. It becomes very educational.
I think it's important for all women, but there are definitely different things that the pelvic floor physical therapist will recommend for women who are very athletic or using their bodies in more extreme fashions, or even helping patients modify their workout routine so that they're doing exercises in a way that doesn't induce leakage. With urgency incontinence, it's important to have a strong pelvic floor as well.
They're also focusing on techniques like urge suppression, where contracting the pelvic floor will get the bladder to relax. That can dramatically impact women and help women with their urgency incontinence. They're focusing on bladder irritants. They also frequently will do bladder retraining, where they're lengthening the interval of time between voids, which can help with frequency and urgency and just reset the system.
[Dr. Suzette Sutherland]
When we look at pelvic floor physical therapy, we know that that's the only type of therapy for the most part that really can effectively work for both stress incontinence and urgency urinary incontinence. As you mentioned, you're doing different things at those physical therapy sessions, depending on which problem you're trying to target. I've heard the physical therapists themselves use the terms up training and down training.
Up training for I'm strengthening just to get stronger so I don't leak when I cough or sneeze. Down training to get the bladder, pelvic floor muscles, everything to quiet down for that urgency frequency issue. I think those terms are helpful for patients to understand when you say up training, I'm strengthening. Down training, I'm trying to learn to relax and control that bladder and pelvic floor.
[Dr. Sarah Boyles]
Some people will do some of this training in their clinic. Review urge suppression, make sure that the patient is contracting their muscles correctly. That all depends on how your clinic is set up and how much time you have. Sometimes that can be very time-intensive. I think if someone can do a pelvic floor contraction on their own, they don't have to go to pelvic floor physical therapy. They can do it on their own.
You also have to be very mindful of the additional benefits that pelvic floor physical therapy gives because definitely, there's a lot of coaching that happens there. There's a lot of accountability and someone is much more likely to stick to those exercises for the needed timeframe because you have to do those exercise for a minimum of six weeks to see improvement and sometimes up to three months. It really keeps people honest and keeps people doing it. Some people can do it on their own, but most of us need a guide.
…
[Dr. Suzette Sutherland]
Aside from doing exercises for strengthening for stress incontinence, if that's not sufficient, sometimes the problem is too far gone, and it might make them better, but it's not going to really solve the problem 100%. Take us down the algorithm. What are the next things that we can offer?
[Dr. Sarah Boyles]
I think one of the other important things to talk to people about is weight loss because we know that with weight gain, incontinence gets worse, and vice versa with weight loss, incontinence gets better. That with conservative management is always an important thing to bring up to someone so that they realize that. Sometimes when you talk to a patient, they'll say, "Oh, yes, that makes a lot of sense. I just gained 15 pounds, and my incontinence has clearly gotten worse." They may start focusing there.
[Dr. Suzette Sutherland]
Although we do see that it's reported in our literature improvements that happen just with 10, 20-pound weight loss, I do also try to make the point to women that it's not the only issue. To say if I would only lose 10 pounds, my problem would be solved. I think sometimes, women fall into this body image trap. I certainly see bone-thin women that have a lot of incontinence. So I say that to patients so they understand it's a piece of the puzzle. Things would improve if you are that much overweight and you lose some weight. If someone's just five pounds vacillating one way or another, that's not going to be the answer for them.
[Dr. Sarah Boyles]
t's true. You have to be careful not to play into people's demons. Usually, what I talk to people about that someone says, "Oh, I've gained 15 pounds. My incontinence is so much worse." Then I'll say, "If you lost the weight, then you'll be the way you were a year ago before you gained that weight. It's not going to totally go away. The weight loss might bring you back. You're right, it is one tool. It's not everything. Also, for weight loss, people need to be more active. If someone has stress incontinence, and you want them to exercise more so they can lose weight, and it makes the problem worse, that can be difficult for somebody to do.
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Intravaginal Devices for Pelvic Floor Therapy
Intravaginal devices offer an additional treatment option to pelvic floor strengthening but require proper usage and patient engagement to be effective. Dr. Sarah Boyles emphasizes that many peri-trainers rely solely on pressure detection, risking misinterpretation of a Valsalva maneuver as a proper contraction. Devices like the Leva stand out for their ability to distinguish muscle movement from pressure changes, providing accurate biofeedback and coaching. These features are critical for patients who lack access to pelvic floor physical therapists.
Other tools, such as K-Goal, Flight, and Perifit, also integrate feedback mechanisms and progressive exercise programs, with some incorporating gamified elements to enhance user motivation. Cost is highlighted as a key consideration, with affordable devices meeting essential criteria often being sufficient. These devices aim to educate users on correct technique, promoting active rather than passive engagement in pelvic floor strengthening, which is essential for long-term success.
[Dr. Suzette Sutherland]
We know that just handing them a handout on Kegels and say go home and do these is not effective. They will come back at their next follow-up appointment if they come back, six to eight weeks and they won't have done them effectively for sure if they've done them at all. We know that's not effective for all kinds of physical therapy. What do you think about some of the intravaginal devices or the devices that help people do the Kegels? What do you use in your practice and do you think that they're really helpful? At what point in the patient's education are they helpful?
[Dr. Sarah Boyles]
I think it all depends on the patient. If someone can do an effective Kegel contraction, then I think those devices will work if that person is committed to putting something in the vagina and doing those exercises regularly. Some people will do that and some people won't do that. There isn't as much accountability. You're more likely to do the exercises if you're checking in with someone regularly. There isn't as much coaching. I think all of those, softer points become really important.
For somebody who is very committed to doing those exercises and very motivated, I think that it is an additional tool, but it definitely doesn't work for everybody. The issue with a lot of the peri-trainers is that the majority of them cannot distinguish between a contraction and a Valsalva. They measure pressure. Someone could be Valsalving and thinking that their strength is increasing, and in reality, they're not doing anything. That's one of the reasons it's really important to make sure that they contract correctly. I really like the Leva device, L-E-V-A. The reason for that is that that device actually detects muscle movement. It can distinguish between a Valsalva and a contraction.
[Dr. Suzette Sutherland]:
It gives good, adequate biofeedback so to speak, and giving it accurately. That's really important.
[Dr. Sarah Boyles]
There are some people who don't have access to a pelvic floor physical therapist. There definitely are not enough pelvic floor therapists in all parts of the country. I think that device really gives a lot of benefit and it also has some coaching associated with it, too. Some of the other peri-trainers do as well. I think that coaching and having someone you can reach out to and talk to is really helpful for a lot of women.
[Dr. Suzette Sutherland]
That device is not available over the counter, though. It's available by prescription only. That differentiates it a little bit, too.
[Dr. Sarah Boyles]
There are many of these that are available. If a woman goes online, and I get asked this all the time, I think the thing that you really want to look for as the consumer is something that not only will because some electrical stimulation to cause contraction of the muscle, but also give you appropriate to feedback right to your point. Certainly, something that requires a prescription or a conversation with a physician, it's going to be validated as well.
Our physical therapists, they like the one called K-Goal. There's another one, Flight, that's out there. It uses a little bit different oscillation movements to try and improve the muscle strength. All of these also have a feedback mechanism, which is really important as is teaching the woman how to do it correctly. It's not just doing it passively for the woman. The woman is learning how to do the appropriate exercises. Some of them have different exercises and will change the exercises over time.
They become more difficult over time. The Perifit is the one that is most like a game. They call it a Flappy Birds game. Some people really like that. I think the other thing to be mindful of is cost. If someone is looking online and one is much cheaper than the other, and it fits these criteria, I would say pick the cheaper one.
Devices for Urinary Incontinence Symptom Relief
When selecting a urinary incontinence treatment device, factors such as cost, comfort, and effectiveness play a role in determining the best option for each patient. Urethral seals, like the Finesse patch, offer a cost-effective solution for women experiencing incontinence in specific situations. These disposable devices provide temporary relief, making them ideal for events or activities where leaks are a concern, but they are not suited for daily use due to their ongoing cost. Accessible over the counter, they are particularly useful for women who need targeted, situational support.
In contrast, pessaries, particularly those designed for incontinence, provide more sustained management of stress incontinence. Devices like the Impressa, available over the counter, offer a convenient trial option for women, while the Uresta allows for self-fitting, making it a practical and effective solution for many. Pessaries are ideal for women who require ongoing support, whether during specific activities like running or throughout the day. While the fitting process can be time-consuming and may require professional assistance, once correctly fitted, pessaries can provide long-term relief. The choice between these devices ultimately depends on the patient’s lifestyle, preferences, and the level of incontinence they experience.
[Dr. Suzette Sutherland]
Let's look into their other devices that are easy devices people can recommend that women try. There are some urethral seals that are available, there are certainly a vaginal pessary. Let's chat a little bit more about that. I don't have much experience myself with the urethral seals. What can you say about those?
[Dr. Sarah Boyles]
The urethral seal is exactly what it sounds like. It's a little patch that you put on the urethra and it stops small amounts of incontinence. You have to take it out to void. It's not reusable, it's disposable. I think it can help for someone who leaks a small amount in a specific situation. It's not something that you would use daily in an ongoing fashion just because of cost, I think. I think if you're leaking just at a specific time, it can be very helpful.
[Dr. Suzette Sutherland]
Is a prescription required?
[Dr. Sarah Boyles]
No, it's over the counter. The brand that I've seen with that is called Finesse. It's funny when people come to talk to you about incontinence because sometimes they're worried about a specific situation, "I'm going to a wedding, I'm doing this thing and I really don't want to leak at this particular point in time." I think for that type of situation, it's very helpful.
[Dr. Suzette Sutherland]
Sounds like it's good for situational things, right?
[Dr. Sarah Boyles]
Correct.
[Dr. Suzette Sutherland]
Traditionally, the other thing we use in the vagina, not in the urethra, would be pessaries, a vaginal pessary that has a little extra bumper that sits under the urethra. There are other pessary-like things over the counter too, as well as with prescription. Tell us about those.
[Dr. Sarah Boyles]
Pessaries can be used for prolapse, but there are specific pessaries that are used for incontinence as well. They will improve stress incontinence and only stress incontinence in about 60% of women. I really like pessaries. I think pessaries are a great tool. I think for women who leak on a run, putting in a pessary before they run is a brilliant idea and super helpful. You can wear a pessary all day long. It depends on the pessary. If you have a medical-grade pessary, incontinence pessary, you can wear it all day long, or you could just wear it during specific activities.
I think from the practitioner's side, pessaries are a little bit intimidating, because you have to have the patient come in, you have to do a pessary fitting. If you're not doing a lot of pessary fittings in the office, it may take you a long time. I just saw a patient yesterday who had this experience with her OB-GYN, where she really wanted a pessary, and that provider's poo-pooed it, and she didn't get a pessary. I'm sure that's just because they may not have had pessaries in the office, or the fitting can take a little bit of time.
[Dr. Suzette Sutherland]
Just didn't have time, right? I'm a big fan of having a specialized provider, whether it's a nurse practitioner or a PA who does your pessary fittings for you as the MD, or you have a separate time set aside, the patient comes in for the pessary fitting. I talk to patients about, there's an art to fitting pessaries, and if someone just shoves a pessary in and sends you home with them, and then you spit it out the first time you go to the bathroom, no wonder, it wasn't really fit to you. That happens to people because of lack of time, and so I agree completely.
[Dr. Sarah Boyles]
That's a real issue, and that's what we do in the office too, my nurse practitioners do the pessary fittings. There are also pessaries that are available over the counter. The Impressa is a pessary that's available over the counter. I would tell you, you can give someone that information, they can just go and get it. They're a little bit difficult to find in the store these days. I think it's easier to find them online and they can try the Impressa. Sometimes, if I am strapped for time or if there's something difficult in the schedule, I'll send someone out and say, "Why don't you try the Impressa and see if it works for you.
If it does work for you, then we will get a more permanent pessary for you." Because the Impressa is disposable. It comes in a couple of different sizes.
[Dr. Suzette Sutherland]
To clarify, it's for people who know what a pessary looks like, the traditional pessary anyways. The Impressa really is a fancy tampon, and it comes in different sizes, you were about to say there. It's much like a tampon, but does the same supportive action as a pessary does, but not quite as much as a well-fit pessary, probably.
[Dr. Sarah Boyles]
The insertion looks like a tampon, so it's all compressed. Then once you take out that applicator device, it explodes, it's almost like a tube.
[Dr. Suzette Sutherland]
Can we say expands, so women don't get scared about it exploding in their vagina?
[Dr. Sarah Boyles]
That's a fair point. The other thing I would say about the Impressa is usually when I have patients place an Impressa, I have them lubricate it because sometimes the material that it's made of can be a little bit irritating to people. I usually have them lubricate it before they place it.
There's the Impressa, which is available over the counter. There's a lot of development in this space. There's always new products coming to market. The other one that I use frequently is the Uresta. The Uresta was developed by a Canadian urogynecologist. It's over the counter in Canada. It's available by prescription in the United States, although it is going to be available over the counter soon in the United States, I think this summer, 2024 at some point in time.
The Uresta does not require a fitting appointment in the office. There are five sizes. Patients are given three sizes and they try them on their own. I've had pretty good results with the Uresta. The only thing that I would tell you about the Uresta, it looks like a plug and it's pretty firm when you feel it. When I recommend this to patients or when I prescribe it to patients, I always have to warn them that it looks like it would be really uncomfortable. It is not uncomfortable, so just go ahead and try it because when you look at it is not inviting. As long as it's effective.
Then you can always have someone come in and do a traditional pessary fitting. The Uresta can be worn all day long. The Impressa I think can be worn for six to eight hours. Then the Uresta, you should replace after a year. All incontinence pessaries that we fit in the office, you can wear for several years at a time.
Podcast Contributors
Dr. Sarah Boyles
Dr. Sarah Boyle is a urogynecologic surgeon at the Oregon Clinic in Portland, Oregon.
Dr. Suzette Sutherland
Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2024, August 6). Ep. 61 – Evaluating Female Urinary Incontinence: Essential Steps for the Generalist [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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