Using Physiotherapy to Manage Urinary Incontinence in Women

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1 Using Physiotherapy to Manage Urinary Incontinence in Women Bladder control problems are common, and affect people of all ages, genders and backgrounds. These problems are referred to as urinary incontinence (UI), meaning an involuntary loss of urine. Some incontinence facts in Australia include: - 1 in 3 women who has given birth to a child will experience bladder control issues - 1 in 5 children wet the bed occasionally - 1 in 100 adults never achieve bladder control during sleep - 1 in 20 adults have bladder and bower control problems

2 The most common type is called Stress Incontinence, which is the loss of urine on physical exertion, such as when playing sports, or coughing and sneezing. This is caused by the urethra (opening of the bladder) not being closed tight enough during physical activities, causing leakage. In people without UI, the urethra should remain closed even when intra-abdominal pressure is increased during physical exertions. The other type of urinary incontinence is known as Urge Incontinence, where the person experiences a sudden, compelling, and difficult-to-defer urge to pass urine. One of the causes for this type of UI is over-activity and spasms of the bladder muscles. When the bladder muscles contract, pressure increases, leading to possibility of leakage. UI can be a cause for tremendous distress, causing personal and hygiene problems. It can limit social, employment, and leisure opportunities. It is a sensitive health issue that can occur in both women and men, although prevalence in women is much higher. Symptoms of Urinary Incontinence People with bladder control problems may experience: - leaking urine with coughs, sneezes or exercise - leaking urine on the way to the toilet - passing urine frequently - rushing to the toilet (urgency) - getting more than 2 times per night to pass urine - wetting the bed when asleep - always feeling their bladder is not completely empty - having poor urine flow - needing to strain to empty the bladder - frequently having urinary tract infections (UTIs)

3 What Is The Cause? Urinary incontinence can be temporary or persistent. Certain drinks, foods or medications can temporarily stimulate your bladder and increase your volume or urine. Examples are: - caffine - alcohol - tea and coffee - heart and blood pressure medications - Artificial sweeteners Alternatively, incontinence can be due to physical changes, including: - Pregnancy and childbirth - Menopause - Hysterectomy - Enlarged prostate - Aging of bladder control muscles - Tumours - Neurological disorders Physiotherapy Management Options for Stress Incontinence Physiotherapy treatment is safe, non-invasive and can be very effective. It is often the first line of treatment before other options such as surgery are considered. Pelvic Floor Muscle Training Strengthening your pelvic floor muscles will help enormously in regaining bladder control by supporting the muscles around the urethra, thereby stopping urine leakage. Your physiotherapist will work through a training program similar to the one below: Step 1: Ensure correct contraction of pelvic floor muscles Your physiotherapist will first make sure you are able to identify and contract the pelvic floor muscles correctly. This is important as 50% of women perform this exercise incorrectly when they were first given verbal instruction initially.

4 One verbal cue your physiotherapist might use is Imagine you are trying to stop the flow of urine midstream. You should feel a tightening of the inside around the vagina and anus. But you shouldn t move your legs, or tighten your bottom muscles. Step 2: Increase strength and endurance of pelvic floor muscles The next step in the program would be to increase the strength, tone and endurance of those pelvic floor muscles so they are strong enough to be used in everyday activities. Your physiotherapist will gradually progress your individualized program to increase the frequency, duration and intensity of your pelvic floor muscle training. Adequate intensity is necessary to promote muscular changes. According to the American College of Sports Medicine Strength training should be designed such that performing one set of 8 to 12 reps takes the muscle to the point of volitional fatigue. A sample initial prescription might be 3 secs x 8 reps x 2 sets. Step 3: Learning to use the strengthened pelvic floor muscles in functional activities The final step is to learn to coordinate and contract the pelvic floor muscles just prior to and during activities that increase your intra-abdominal pressure, such as coughing or sneezing, as this will prevent urine leakage. Evidence has shown that performing the contraction before a cough can reduce urine leakage from 73% to 98%! Your physiotherapist may instruct If you need to cough, you should squeeze your pelvic floor muscles just before you cough, and continue to hold that squeeze until after the cough. Symptom Management Devices Contraction of pelvic muscles is very useful for situations such as coughing, sneezing and moving from sitting to standing, etc. But for sporting activities and times when you need to be out and about, you may consider incontinence devices that can be inserted to provide support to the urethra. They may be prescribed by your doctor or physiotherapist, and may include: - Continence Dish - Hodge Pessary or Tampons - Contiform - Vaginal Sponge Physiotherapy Management Options for Urge Incontinence Treatments for urge incontinence will still include pelvic floor muscle training as mentioned above. Electrical stimulation may also be used to reduce bladder overactivity.

5 In addition, your physiotherapist is able to prescribe strategies to manage over-activity within the bladder itself. They may include: Lifestyle Changes - Keep body weight within healthy limits. By doing so, the weight of the abdominal contents pressing against the pelvic floor is lessened and prevents the pelvic floor from weakening further. - Seek early treatment for prolonged cough, and stop smoking preferably. - Fluid management Cut back on alcohol and caffeine which are natural diuretics that increase the urge to urinate. Reduce excessive liquid consumption, while increasing physical activity will also help the condition. Behavioural Techniques Your doctor may recommend the following techniques to manage your condition: - Bladder training the aim is the delay urination briefly whenever you get the urge to go. To start off, you may aim to hold off for 10 mins before you visit the toilet. Gradually, you want to lengthen the time between toilet trips so you only go every 2 to 4 hours. - Double voiding this helps you to empty the bladder more completely in urination. Whenever you finish urinating, wait a few mins, and then try one more time to empty the bladder. - Scheduled toilet trips to proactively schedule in trips to visit the toilet every 2 to 4 hours, rather than waiting for the urge to come before you go. Do not rush to the toilet During periods of high bladder muscle activity and urge to use the bathroom, rushing to the toilet at this time will further increase pressure and chance of leakage due to all the movements. Also, the increased anxiety brought on by rushing will likely exacerbate your urge.

6 Instead, whenever the person feels the urge to urinate, waiting for a brief period (eg 30 secs) can often turn the initial urge to a more manageable one, and then calmly walk to the toilet. 3 strategies can be used to temporarily suppress the urge to urinate: 1) Sitting on edge of chair or table this puts pressure on some of the nerves around the genital areas, which can inhibit over-activity of the bladder muscles 2) Pelvic Floor contraction Contraction of pelvic floor muscles also has the effect of reducing spasms of bladder muscles, therefore reducing the urge to urinate. 3) Staying calm and perform relaxed breathing this increases frontal lobe activation in your brain, and can inhibit bladder contractions. Urinary Incontinence need not be debilitating when it s effectively managed. Make good use of the above strategies, and talk to your physiotherapist or doctor for further advice. When the stress of incontinence is gone, life takes its place (adapted from Panadol)