INCONTINENCE Continence and Pelvic Floor Rehabilitation Dr Irmina Nahon PhD Pelvic Floor Physiotherapist www.nahonpfed.com.au Defined as the accidental and inappropriate passage of urine or faeces (ICI 2013) Various studies have put the incidence of incontinence in women as between 8.5% and 43% Women over 50 have the highest incidence in all studies Incontinence leads to Social isolation Depression and low self-esteem Unwillingness to exercise Marital problems 2 Dr. Irmina Nahon, PhD. TYPES OF INCONTINENCE Stress Mixed Urgency & Overactive bladder Functional Overflow Faecal Increased intra-abdominal pressure overcomes the urethral or anal closure mechanism and allows the passage of a small amount of urine or faeces Caused by Dysfunctional pelvic floor muscles and poor ligamentous support for the bladder neck and anal sphincter 3 Dr. Irmina Nahon, PhD. 4 Dr. Irmina Nahon, PhD. CONTRIBUTORY FACTORS Childbirth < 3 children Heavy babies Very quick, or very long 2nd stages. Forceps or ventouse deliveries Chronic constipation Chronic respiratory disease Prolonged heavy lifting or unwise exercise regimes Low back pain especially with neural compromise IS EXACERBATED BY Being overweight and unfit Smoking Low oestrogen levels Patient reports: When I cough or sneeze or laugh or run, I leak a little bit 5 Dr. Irmina Nahon, PhD. 6 Dr. Irmina Nahon, PhD. 1
Identify and address contributing factors Consider HRT or topical Oestrogen if indicated Assess pelvic floor muscles & refer to physiotherapist for strengthening as first line management Consider surgery to elevate bladder neck if severely incontinent or if conservative management fails PLEASE REMEMBER: 75% of mild to moderate stress incontinence can be cured with correct pelvic floor muscle training (Neumann 2005) URGE INCONTINENCE In the presence of an overpowering need to void, the voiding mechanism overcomes central inhibition and forces the untimely emptying of bowel or bladder Patient reports: When I need to go, I really need to go and sometimes I don t get there in time. 7 Dr. Irmina Nahon, PhD. 8 Dr. Irmina Nahon, PhD. URGE INCONTINENCE OVERACTIVE BLADDER Lower urinary tract infection or inflammation Inadequate or excessive fluid intake Intake contains a high percentage of Caffeine Tannin Alcohol Stress Bad habits going just in case Small bladder capacity Symptom complex that includes urinary urgency, with or without urge incontinence, accompanied by urinary frequency and nocturia (ICS 2012) The symptoms can occur in the absence of pathologic or metabolic factors that would explain them. Urodynamic studies may be needed for differential diagnosis The ICS endorsement of the term OAB recognizes that patients with this symptom syndrome are almost always treated by nonsurgical means on an empirical basis, ie, without a urodynamic confirmation of the presumed diagnosis, detrusor overactivity. (Abrams 2002) 9 Dr. Irmina Nahon, PhD. 10 Dr. Irmina Nahon, PhD. URGE INCONTINENCE & OAB Test for & treat infection or inflammation Ask for a 3 day bladder dairy Consider stress level management Assess hormone status Refer to continence advisor to commence bladder training programme Refer to physiotherapist if pelvic floor muscles are weak Anti-cholinergic medication has proved helpful DETRUSOR INSTABILITY A sudden and spontaneous contraction of the detrusor muscle causing complete emptying of the bladder Diagnosed on urodynamics Bladder training Anti-cholinergic medication have proved helpful Trials of TENS using low frequencies have had mixed results E-stims found to be very successfully in carefully selected severe cases 11 Dr. Irmina Nahon, PhD. 12 Dr. Irmina Nahon, PhD. 2
FUNCTIONAL INCONTINENCE FUNCTIONAL INCONTINENCE The patient is either physically incapable of Reaching the toilet in time, Or cannot perceive the need to void. Disabling illness or frailty Inconvenient toilet facilities Medication Poor balance or dizziness Lack of cognitive awareness of bladder control Referral to a continence advisor who will advise on: Appropriate clothing Appropriate signage Toilet timing routine Use of continence pads and protective devices 13 Dr. Irmina Nahon, PhD. 14 Dr. Irmina Nahon, PhD. OVERFLOW INCONTINENCE An involuntary dribbling of urine usually associated with an over-distended bladder and a defective sensory nerve supply Fluid chart may show large intake and very large voids >800mls /MANAGEMENT Timed voiding program Reduction in fluid intake Double voiding to reduce residual volumes. Clean intermittent self catheterization PHYSIOTHERAPY PELVIC FLOOR MUSCLE TRAINING Should be first line of treatment Can be done before expensive testing is done AIMS Identify the muscles Contraction without co-contraction of accessory muscles Functional pelvic floor exercises Development of lifetime habits 15 Dr. Irmina Nahon, PhD. 16 Dr. Irmina Nahon, PhD. PELVIC FLOOR MUSCLE TRAINING Need to be taught in a practical way Need to be assessed with a vaginal examination (Bø 2005) Practical and functional exercises (Bø 1995) Women can t learn from a brochure 1 in 3 push down rather than pull up need physical confirmation of correctness (Chiarelli 2003) Descent of pelvic organs towards the introitus associated with vaginal wall & pelvic ligament weakness (Jelovsek 2007) NB. The pelvic floor muscles may be strong 17 Dr. Irmina Nahon, PhD. 18 Dr. Irmina Nahon, PhD. 3
Stretched pelvic fascia and ligaments following very fast or very long 2nd stages. Many large babies Patients with cervix on view at delivery are at higher risk of future prolapse. Constipation and chronic cough Heavy lifting Chronic low back pain associated with weak transverse abdominal muscles Strengthen lower abdominal and pelvic floor muscles if necessary (Harvey 2003) Address constipation and respiratory disease Modify lifestyle These measures will not cure vaginal wall prolapse but may prevent further descent AND will give surgery a better long-term outcome. 19 Dr. Irmina Nahon, PhD. 20 Dr. Irmina Nahon, PhD. Pelvic pain Chronic or recurrent pelvic pain that apparently has a gynaecological origin but for which no definitive or cause is found (Engeler 2013) Many different forms and names: vulvodynia, vaginismus, dyspareunia, chronic pelvic pain, painful bladder syndrome, idiopathic interstitial cystitis,... Majorly life altering! Treatment for pelvic pain Hypertonic pelvic floor muscles Treat symptomatically Trigger points, myofacial release, relaxation therapy, down training, lifestyle intervention, exercise (Rosenbaum 2007) Injection therapy, botox. 21 Dr. Irmina Nahon, PhD. 22 Dr. Irmina Nahon, PhD. POINTS TO REMEMBER Your questions will elicit the answers you want Continence information will not be volunteered Mild to moderate urinary incontinence can be treated very successfully conservatively. Lifestyle changes include good bladder and bowel habits Pelvic floor muscle training can cure incontinence if weak muscles are the problem Surgery should not be considered unless symptoms severe and/or conservative management has failed Where to refer Pelvic Floor Physiotherapists check if they do intimate examinations Continence Clinic (ACT Health Community Health) Continence Foundation of Australia website http://www.continence.org.au/ National Continence Helpline 1800 33 00 66 23 Dr. Irmina Nahon, PhD. 4
Thank you for your attention Any questions? www.nahonpfed.com.au 5