D. James Ballard, PT, DPT, GCS The University of Utah, Dept. of Physical Therapy Training a Wayward Bladder
Agenda 1. Discuss urinary incontinence 2. Review pelvic floor and lower urinary tract functional anatomy 3. Review pelvic floor muscle training 4. Review action steps to improve bladder control!
What Is Urinary Incontinence (UI)? Involuntary leaking of the bladder
Urinary Incontinence Effects Effects quality of life: Contributes to inactivity Can lead to social isolation Risk factor for falling
Urinary Incontinence and Falls Increased the probability of falling by almost 6 times in a group of people with Parkinson s disease Could early diagnosis and treatment of UI decrease the risk of falling? (Balash 2005) 2016 Davis Phinney Foundation The Victory Summit Salt Lake City, UT February, 26, 2016
Costs of Overactive Bladder, Urgency Urinary Incontinence 2007 Estimated Total National Cost: $65.9 billion 2020 Projected Cost: $82.6 billion (Coyne, Wein, Nicholson, et al. 2014)
Urinary Bladder Function Storage (filling) phase: Bladder stores urine until it can be emptied voluntarily Disorders cause urinary incontinence Emptying phase: Bladder releases contents under voluntary control Disorders cause voiding difficulty
Parkinson s Disease and Bladder Dysfunction Basal Ganglia: Believed to have an inhibitory effect on spontaneous bladder contraction With cell loss in the substantia nigra, bladder overactivity develops
Urinary Incontinence Types Stress: Involuntary leakage on effort or exertion, or on sneezing or coughing Urgency: Involuntary leakage accompanied by or immediately preceded by urgency (Abrams P, et al. 2010) 2016 Davis Phinney Foundation The Victory Summit Salt Lake City, UT February, 26, 2016
Urgency Urinary Incontinence Amount of urine loss can be significant Most common type of UI in older adults Common in Parkinson s Cause not completely understood
Urgency Urinary Incontinence Common bladder triggers: Sudden exposure to cold temperature Sound of water running Coughing or laughing Key in door Coitus
Parkinson s Disease and Bladder Dysfunction Lower urinary tract symptoms (LUTS): Storage Symptoms Nocturia >60% Frequency 16 36% Urgency 33 54% Incontinence: females 28%, males 26% (Sakakibara et al. 2011)
Parkinson s Disease and Bladder Dysfunction Lower urinary tract symptoms (LUTS): Voiding Symptoms (compared to control group) Delayed urination 44% of men only Prolonged or weak stream 70% of men Straining 28% of women (Sakakibara et al. 2011)
Treatments Behavioral therapies Pelvic floor (Kegel) exercises Bladder training Electrical stimulation (Nygaard 2010)
Pelvic Floor Muscle Exercise Strengthens: Levator ani muscles Striated sphincters Perineal muscles
Action Step 1 Do pelvic floor (Kegel) exercises correctly and consistently Do them right! Do them right now!
Pelvic Floor Muscle Exercise Verbal Cues: Squeeze muscles at your anus as if you are trying to hold back gas or a bowel movement. Tighten the muscles you use to stop flow of urine Words & Phrases: Squeeze, tighten, hold, pull up and in.
Pelvic Floor Muscle Exercise Typical Instructions: Do 3 sets of 15 contractions per day Begin holding contractions for 2 secs Over several weeks, build up to holding contractions for 10 secs (Nygaard, 2010)
Pelvic Floor Muscle Exercise Cochrane Review (2010): The review provides support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress, urge, or mixed, urinary incontinence.
Pelvic Floor Muscle Exercise and Urgency Urinary Incontinence Men and women with idiopathic Parkinson s disease (N=20) Decreased weekly urinary incontinence episodes from 9 (4-11) to 1 (0-3) Quality of life scores improved (Vaughan, Juncos, Burgio, et al. 2011)
Pelvic Floor Muscle Exercise Limitations Effect of exercise is not immediate Must exercise consistently Many people do them wrong: Bump et al. (1991): 51% did exercises incorrectly after brief verbal instruction Bo et al. (1990): 30% did exercises incorrectly
Pelvic Floor Muscle Exercise and Stress Urinary Incontinence Theories of mechanisms: Conscious contraction before or during episodes of intra-abdominal pressure prevents pelvic floor descent ( Knack ) Consistent strength training builds stiffness of pelvic floor improving structural support (Bo K 2004)
Action Step 2 To prevent stress urinary incontinence (leaking with coughing, exertion and sneezing): Squeeze before you sneeze
Bladder Training Void according to the clock, not urge Aim is to increase bladder capacity by gradually increasing time between voids 15 to 30 min increases in interval Initial interval determined using information from bladder diary
Bladder Diary Your name: Date: Time Drinks Trips to the Bathroom Accidental Leaks Did you feel a strong urge to go? What were you doing at the time? What kind? How much? How many times? How much urine? (circle one) How much? (circle one) Circle one Sneezing, exercising having sex, lifting, etc. Sample Coffee 2 cups sm med lg sm med lg Yes No Running 6 7 a.m. Yes No 7 8 a.m. Yes No 8 9 a.m. Yes No (National Kidney and Urologic Diseases Information Clearinghouse)
Action Step 3 To suppress urinary urgency and decrease urine loss after urge to void: Freeze and squeeze Positive affirmations I am in control of my bladder. Diaphragmatic breathing
Urinary Incontinence: Common Myths Nothing can be done Normal part of aging Surgery is only treatment Voiding should not be postponed
Conclusions Urinary incontinence affects millions of Americans First choice of treatment should be the least invasive with the fewest potential adverse complications. (AHCPR Clinical Guideline)
Conclusions Behavioral treatment methods are effective in the treatment of most types of UI The greatest obstacle to progress is the belief that no progress is possible. - Sir Francis Bacon
Action Steps Review 1. Do pelvic floor exercises daily to improve control and strength of pelvic floor muscles 2. Squeeze before you sneeze for stress incontinence 3. Freeze and squeeze for urgency incontinence 4. Discuss challenges with doctor and healthcare team