Involuntary loss of bladder control or incontinence affects men and women, young and old. Industry experts estimate that more than 25 million adults in the United States have urinary incontinence.
Mixed incontinence is a combination of two types of the condition: stress and urge incontinence. Stress incontinence is the involuntary loss of urine when the intra-abdominal pressure is raised such as with coughing, laughing, and sneezing or with exertion and exercise. Urge incontinence is the involuntary loss of urine preceded by a strong desire to void with little warning.
Besides leaking urine, patients with mixed incontinence may experience urgency, higher than normal frequency, the need to void during hours of sleep or painful urination. Patients might experience musculoskeletal pain (lumbar, pelvis or coccyx), postural dysfunctions, abnormal breathing patterns, generalized weakness and/or bowel problems.
"Both types of incontinence are identified by collecting a history of the problem, asking specific questions about the behavior of the symptoms, assessing the strength and resting tone of the pelvic floor musculature, and assessing related symptoms like lumbosacral pain," shared Sallie Cowgill, PT, clinical supervisor, Olympic Physical Therapy in Bellevue, WA.
"Treatment by a physical therapist can help manage, if not alleviate, the symptoms of urinary incontinence," said J'Anna Post, PT, OCS, owner of Olympic Physical Therapy. "Physical therapists are the ideal providers to treat this condition because of their skill in assessing and treating musculoskeletal conditions, especially those involving the spine and lumbopelvic region. Their expertise in manual therapy, therapeutic exercise, sEMG Biofeedback, motor control and training in behavioral instruction makes them well suited."
Identify and Treat
Although stress and urge incontinence share the symptom of involuntary urine loss, careful consideration of symptoms, bladder habits and voiding frequency will guide the PT as to which type of incontinence is present. Combined with a physical examination of the pelvic floor musculature, the PT is able to identify the appropriate treatment for the correct diagnosis.
Post believes that the key to treatment success lies in the patient's self-motivation and participation. "The more diligent a patient is in sticking to the daily routine of exercise, the more effective the exercises are in relieving the symptoms of incontinence," she said.
The initial evaluation includes a thorough subjective history and medical screening which begins with the primary complaint or onset of the incontinence. "Specific details about the frequency of incontinence and of urination, the degree of leakage and during which activities, the ability to start and stop a urine flow, and the volume and type of liquid intake in a day, are recorded," said Cowgill. "A daily bladder diary is an important component used to objectively obtain information on these issues."
Medical screening includes a review of the patient's obstetrics/gynecology care; surgeries; previous back pain or injury; medical problems that affect breathing; or any related illness such as MS, spinal cord injury, CVA, cardiovascular disease and diabetes that might affect the condition.
The PT conducts a physical exam of the perineum and pelvic floor including reflexes, sensation, and muscle strength and pain. The PT conducts an sEMG biofeedback evaluation to assess the pelvic floor muscle performance during rest and 2- and 10-second contractions. The therapist also performs a musculoskeletal screen of the abdominal wall, trunk and lumbopelvic region and evaluation of breathing patterns, posture and alignment. During the first visit, a treatment plan is established and the importance of the patient's role in the program is emphasized, according to Post.
Sallie Cowgill, PT, uses biofeedback for pelvic floor training at Olympic Physical Therapy in Bellevue, WA.
Cowgill recently treated a 40-year-old female patient with a history of incontinence that began after her first child was born four years ago. Forceps were used during her delivery and 30 stitches were required. She did not receive physical therapy treatment for this initial complaint. Following the birth of her second child two years ago, the patient had onset of urgent urination and interrupted sleep due to coccyx and lumbar pain. The patient exhibited a worsening of the initial stress incontinence during activities such as laughing and coughing. She had an ovarian cyst removed four years ago but otherwise, her medical history was non-contributory.
The PT customarily obtains information about medical conditions that might affect the patient's symptoms such as previous history of back pain or injury, neurological, diabetes, cardiovascular, constipation, surgical history of the spine and/or pelvic region, obstetric, gynecological and urologic history and medications.
The patient was given a thorough pelvic exam floor exam and was screened for musculoskeletal breathing dysfunction. The PT also performed sEMG baseline testing.
When working with this type of patient, the PT takes a detailed subjective history of the patient's current complaints, onset and progression of symptoms with specific details on bladder symptoms, leakage, number of pads used, activities that cause leakage, frequency of urination, symptoms of urgency, fluid intake and bladder irritants. "This information allows the therapist to understand the extent of the patient's problems and how the symptoms are affecting the patient's life," Post explained.
This particular patient was experiencing leakage of a few drops of urine several times a day. The episodes occurred in sitting, standing or lying down and she consistently had loss of urine when sneezing, coughing or laughing heavily. The patient was urinating four times per day, and waking with urgency two to three times per night. She did not experience difficulty initiating a urine stream but was unable to delay or stop a urine stream once it started. She drank three to four glasses of liquid per day, mostly tea, coffee and juice.
This patient was treated seven times in the clinic. During the first visit, she was instructed in pathomechanics, pelvic floor anatomy and normal continence. Her initial baseline sEMG biofeedback of pelvic floor musculature recorded elevated value at rest, below normal contraction strength and erratic sustained contraction. She held her breath while performing a Kegel contraction. The musculoskeletal assessment revealed postural dysfunction as the cause of the lumbosacral pain.
Cowgill progressed treatment of the pelvic floor with strengthening and relaxation exercises, diaphragmatic brething, urge supression strategies, counter strain for spinal dysfunction and pain, core exercises and a home exercise program. Cowgill used sEMG training of pelvic floor muscle isolation and control. Subsequent bladder diary entries revealed low intake of liquids, frequent leakage throughout the day, and infrequent pattern of involuntary voiding.
At the time of discharge, the patient had relief of urgency symptoms, was sleeping through the night; had no incontinence of urine with sneezing, coughing and laughing; and had resolved lumbar pain relating to pelvic floor dysfunction. She was drinking normal amounts of liquid throughout the day and urinating on a normal frequency.
She was able to perform a pelvic floor contraction with normal breathing. The sEMG recorded normal values at rest, normal contraction strength, and ability to sustain a steady contraction for 10 seconds.The patient was discharged to an independent home program. She elected to continue advancing her fitness level and functional capacity with a strength and conditioning specialist at Athletic Engineering, a division of Olympic Physical Therapy.
Kegels are an important component of the treatment plan and have been shown to be effective in reducing the symptoms of incontinence. "It is vital for patients to identify and correctly perform Kegel exercises with coordinated diaphragmatic breathing," Post explained.
Kegels are practiced first in the supine position, but are quickly incorporated into daily functional activities, such as driving, sitting at the computer, or standing in the grocery line. The therapists advise patients to perform a Kegel before doing activities that cause leakage such as laughing, coughing and jumping. Cowgill believes that assessing appropriate relaxation of the pelvic floor musculature after each contraction is equally important, however, kegel exercises are only part of the program.
Once the patient is able to isolate the correct pelvic floor muscles, the PTs progress the patient with exercises to enhance pelvic floor control. These exercises include core strengthening bringing in the transverse abdominus, coordination with trunk and other pelvic muscles, lumbopelvic stabilization, diaphragmatic breathing exercises and functional closed chain activities. A variety of positions are used, working toward functional activities and those in which leakage used to occur.
The modalities used to treat the urinary incontinent population train and strengthen the pelvic floor. The PTs use SEMG biofeedback to help the patient identify and isolate the pelvic floor musculature. Internal electrical muscle stimulation is an option for recruiting weak pelvic floor musculature. If patients have associated pain, such as lumbosacral pain, the PTs use interferential current, heat/ice.
Behavioral modification includes examination of activities or behaviors that may contribute to incontinence. Patients are provided with tips on lifestyle changes that make the bladder less irritable, avoiding foods and beverages which are bladder irritants, such carbonated beverages, alcohol and citrus fruits, and to ensure the patient is consuming the proper amount of fluids.
Bladder retraining includes completion of a bladder diary and establishing a voiding schedule that can retrain the bladder to prolong the time between urinating to normal intervals, Post told ADVANCE.
Education is Necessary
"Properly educating patients about incontinence is a primary factor in providing successful treatment," said Cowgill.
The clinic's PTs use skeletal models and pictures to teach pelvic floor and spinal anatomy, normal bladder function and the role of the pelvic floor muscles and incontinence. "We help patients understand what things could disrupt the normal control of continence and how posture, breathing and trunk control impacts continence," said Post. "We use appropriate educational videos, books and patient resources on urinary incontinence."
The educational component includes tips on lifestyle changes that improve normal bladder and pelvic floor function. The therapist explains what the patient can expect from treatment including the frequency and duration of visits, and understanding the importance of committing to the program.
"Education is important to the success of our treatment program," Post said. "Our patients have a genuine understanding of the program because most of our education occurs one on one with our patients versus just using videos or other methods."
Rebecca Mayer is senior regional editor of ADVANCE and can be reached at firstname.lastname@example.org