Urinary incontinence: role of the physiotherapist

A personalised pelvic floor programme can help improve urinary control,

urgency frequency and help build bladder capacity, writes Grainne Walsh

URINARY INCONTINENCE (UI) IS defined as a “complaint of involuntary loss of urine.” The key is to establish what is deemed normal function. What is not normal and should be

addressed includes:

• Leaking urine at any stage (cough, sneezing. laughing, giggling, with urge)

• Emptying the bladder more frequently than every 3-4 hours

• Going to the bathroom several times a night to urinate

• Pain in the bladder

• Mapping the daily routine around urinary symptoms

• Feeling as if the bladder does not fully empty

• Pelvic pain

• Limiting food/drink because of bladder symptoms

• Pain with sex- penetrative, oral, masturbation or avoiding sexual activity due to urinary symptoms.

Pelvic floor physiotherapy

A pelvic health physiotherapist is trained to assist in the management of bowel, bladder and sexual function conditions in both women and men. They provide services including:

• Anatomy and education of bladder, bowel, and sexual function systems

• Breath work/relaxation/awareness techniques

• Lifestyle education

• Bladder/bowel management

• Device education

• Sexual education

• Tissue and neural mobilisation

• Myofascial release

• Acupuncture/dry needling

• Pelvic floor activation/release exercises

• Personalised and patient-specific programmes

• Referrals to relevant doctors, eg. occupational therapists, psychologist and any support networks that are helpful

• Education on medications.

Pelvic health physiotherapists may use many different tools to help educate during their consultations. This includes anatomy models, diagrams, video links, bio-feedback, electrical stimulus, lubrication advice, dilators, bladder diaries, education sheets, pessaries, anal balloons.

Muscle training programmes

Twenty-six per cent of women and 41.4% of men suffer from urinary incontinence/lower urinary tract symptoms. NICE guidance for lower urinary tract symptoms (LUTS) and urinary incontinence and pelvic organ prolapse guidance states that for urinary symptoms, physiotherapy and conservative measures are front-line treatments.2,3 Clinically and through research it is noted that supervision of rehabilitation programmes yield the most success for patients recovering from the transient side effects of prostate surgery.4 Patients should be offered supervised pelvic floor muscle training for at least three months for treatment of stress urinary incontinence or mixed urinary incontinence.

Pelvic floor muscle training programmes should comprise at least eight contractions performed three times per day. It is not recommended to use pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training and it is advised to continue an exercise programme if pelvic floor muscle training is beneficial. Electrical stimulation is also not recommended as routine treatment and it is not suitable to use in the diagnosis of overactive bladder. Electrical stimulations, and electronic or biofeedback devices for pelvic floor training should only be used under the assessment and supervision of a pelvic health physiotherapist to assess suitability and necessity.

Differences between female and male pelvic exercises

Contrary to belief, it’s not all about weakness. It really comes down to function. Through a thorough pelvic health exam it is established what functional needs are required to be addressed to assist the patient. The question always is how do we get organs (bowel, bladder, uterus/prostate) and the musculature to work to the best benefit for the patient. When we look at the pelvic floor, women and men have the same muscle groups. These sit like a hammock of support, beginning behind the pubic bone and warp in a circle shape around the rectum. The role of the pelvic floor is to control bowel, bladder and sexual function.

However, when training the pelvic floor, gender differences need to be considered. In women we train the pelvic floor from the posterior aspect. The patient gently tightens the back passage as if trying to stop passing wind. The stomach muscles or buttocks should not be contracted, as these are not pelvic floor muscles. Women should feel a gentle lift from the back passage forward into the vagina.

This approach promotes the best support of the uterus, bladder and bowel (all have potential for descent due to risk of prolapse) which will improved functional support of all urinary control in these areas. Also, the female urethra is short, at approximately 4.8-5.1 cm, with a short exit from the bladder to outside the body.

The male urethra, in comparison, is approximately 20cm long, and the bladder is positioned to the anterior aspect of the pelvis. When we train the pelvic floor in men for urinary problems, we tighten and shorten the penis. The stomach or buttock muscles are not tightened and the anus is not squeezed. Visualisation is a turtle’s head returning into its shell. Men should feel a tightening in the base of the shaft where the penis is attached into the body and a gently tightening in the testicles.

A personalised pelvic floor programme can help improve urinary control, urgency frequency, help build bladder capacity to assist in bladder training, improve flow and emptying of the bladder, reduce or resolve nocturia, as well as improve confidence in symptoms due to having more awareness and control.

Behavioural therapies and lifestyle adjustments can show great results. Bladder training with lifestyle advice, when done with bladder diaries and education, can really improve bladder function. It can reduce urinary symptoms such as overactivity, nocturia, urgency and frequency. This needs to be completed for at least six weeks while under the review of a physiotherapist to help assess whether the addition of medication may help advance progress.

Lifestyle tips

• Correct fluid intake =1.5-2L. (easy to take in a pint each meal = 1.5L per day)

• Voiding in waking hours normal every 3-4 hours

• Void before bed and first thing in the morning

• Not normal to void at night

• Do not empty your bladder ‘just in case’

• Remove caffeine (tea, coffee, green tea)

• Citrus fruits, tomatoes and spicy food can bother the bladder

• Fizzy drinks, fizzy water irritate the bladder

• Alcohol is an irritant to the bladder.

For some, when bladder training and medication is not successful, the addition of TTNS (transcutaneous tibial nervous stimulation) has proven to be successful. The patient uses this at home rather than the traditional PTNS (posterior tibial nerve stimulation) where they have to attend a clinic. This promotes autonomy and independence and control of treatment for the patient, rather than depending on the clinic or practitioner.

Toilet position is key

Women should not hover over the toilet, but take a seat. Otherwise this can increase the risk of prolapse or exacerbates existing prolapse and means the bladder does not empty fully.

Men should pee standing up – sitting can kink the pipe! Remember the water tank is stored in the roof of the house, not the basement. You need gravity to assist the lengthy drainage of the urethra.

For women who feel they don’t fully empty or dribble when they are done, it is encouraged to double void.

For men it is always encouraged after urination to employ the post-void dribble technique to reduce any residual fluid that may drip out.

UI deteriorates sexual function in women. Prevalence of female sexual dysfunction has been shown to be 38.2%, with 19.6% for male sexual dysfunction.

It is important that we rule out constipation in this population and make them aware that three times a day to three times per week is within a normal range for bowel function.

Each defecation should have a feeling of satisfaction on emptying. If not, this would be a good area to investigate further, perhaps working on bowel plans and defecation techniques. These can be taught by pelvic health physiotherapists.

Constipation and LUTS

It has been suggested that constipation could increase the risk of LUTS in women. This is because the urinary and bowel tracts are interrelated structures and their common embryology, overlapping innervation, and anatomical proximity could mean that dysfunction in the bowel may affect the balder.

Constipation is common and is estimated to affect 12-32% of middle-aged women. The National Institute of Health and Care Excellence guidelines state that constipation and LUTS

often co-occur and recommend screening for constipation in women while assessing and treating LUTS.

Among those younger than 50 years of age, chronic constipation was 9.2% in men and 18.3% in women; however in those older than 70 years it was 20.6% in men vs 25.0% in

women respectively.

It is generally agreed that multidisciplinary support is essential in the management of patients with urinary incontinence. Clinical nurse specialists, advanced nurse practitioners, urology, urogynecology, gynaecology, pelvic health physiotherapists etc.all have a management role in this condition.

Clinical Review: Urinary incontinence: role of the physiotherapist

Grainne Walsh is a clinical specialist physiotherapist in pelvic health at the Mater Private Hospital, Dublin