Incontinence

Original Editor - Kirsten Ryan

Top Contributors - Kirsten Ryan, Nicole Hills, Wendy Walker, Laura Ritchie and Evan Thomas

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Introduction

Clinically Relevant Anatomy: Pelvic Floor

The pelvic floor is made up of the muscles, ligaments, and fascial structures that act together to support the pelvic organs and to provide compressive forces to the urethra during increased intra-abdominal pressure.

The pelvic floor muscles refer to the muscular layer of the pelvic floor. It includes the levator ani, striated urogenital sphincter, external anal sphincter, ischiocavernosus, and bulbospongiosus.[1]

The urethra, vagina, and rectum pass through the pelvic floor and are surrounded by the pelvic floor muscles. During increased intra-abdominal pressure, the pelvic floor muscles must contract to provide support. When the pelvic floor muscles contract the urethra, anus, and vagina close. The contraction is important in preventing involuntary loss of urine or rectal contents. The pelvic floor muscles must also relax in order to void.[1]


Image:Pelvic_floor.jpg [2]

Definitions

  • Urinary incontinence (symptom): Complaint of involuntary loss of urine.
  • Stress urinary incontinence: Complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing.
  • Urgency urinary incontinence: Complaint of involuntary loss of urine associated with urgency.
  • Mixed urinary incontinence: Complaint of involuntary loss of urine associated with urgency and also effort or physical exertion or on sneezing or coughing.
  • Urgency: Complaint of a sudden, compelling desire to pass urine which is difficult to defer.
  • Overactive bladder (OAB, Urgency) syndrome: Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.[3]

Etiology

Risk Factors

Epidemiology

Clinical Presentation

  • Urin Leaking
  • Urinary Frequency
  • Urinary Urgency
  • Nocturia
  • Prolapse

Diagnostic Procedures

A large portion of women with urinary stress incontinence can be diagnosed from clinical history alone. In a systematic review performed in 2006[4], little evidence was found to support the use of urinary diaries, and pad-tests although these measures are common diagnostic assessments used in physical therapy.[4]

Clinical history

Clinical history taking compared with multi-channel urodynamics was found to have 0.92 sensitivity and 0.56 specificity for the diagnosis of urinary stress incontinence based on the presence of stress incontinence symptoms.[4]

Pelvic Floor Muscle Function and Strength

Modified Oxford grading system:

  • 0 - no contraction
  • 1 - flicker
  • 2 - weak squeeze, no lift
  • 3 - fair squeeze, definite lift
  • 4 - good squeeze with lift
  • 5 - strong squeeze with a lift

Palpation

Palpation of the pelvic floor muscles per the vagina in females and per the rectum in male patients.[5]

PERFECT mnemonic assessment[5]:

P - power, may use the Modified Oxford grading scale
E - endurance, the time (in seconds) that a maximum contraction can be sustained
R - repetition, the number of repetitions of a maximum voluntary contraction
F - fast contractions, the number of fast (one second) maximum contractions
ECT - every contraction timed, reminds the therapist to continually overload the muscle activity for strengthening[5]

Pad Test

The 1 hour pad test was found to have 0.94 sensitivity and 0.44 specificity for diagnosing any leakage compared with multi-channel urodynamics.

The 48 hour pad-test was found to have 0.92 sensitivity and 0.72 specificity for the diagnosis of urinary stress incontinence.[4]

Urinary (Voiding) Diary

One study found a scale derived from a 7 day diary was 0.88 sensitive and 0.83 specific for the diagnosis of detrusor overactivity in women.[4] The National Institute for Diabetes and Digestive and Kidney Diseases provides clinicians with a easy to use Bladder Diary pdf that may be used in clinical practice[6].

Outcome Measures

Physical Therapy Management

Pelvic Floor Muscle Training (PFMT)

The pelvic floor muscles are known as the levator ani, made up of the pubococcygeus - puborectalis complex. Those muscles form a sling around the anorectal junction. They are made up of both Type I (slow-twitch) and Type II (fast-twitch) fibers. The majority are Type I (about 70%) which provide sustained support and are fatigue resistant. The remaining Type II fibers provide the quick compressive forces necessary to oppose leakage during increased abdominal pressure. A contraction of the pelvic floor muscles also causes a reflex inhibition of the detrusor muscle.[7]

Patient specific training is necessary to ensure a proper contraction of the pelvic floor muscle group. It is also essential to train both the fast and slow-twitch muscle fibers. Also, training must include instruction in volitional contractions before and during an activity that may cause incontinence, such as coughing, sneezing, and lifting.[5] Patients are typically recommended to perform the exercises four to five times daily.[8][5]

PFMT for the prevention of postpartum incontinence

PFMT for stress urinary incontinence

PFMT for urgency incontinence

Behavioral Therapy

The focus of behavioral therapy is on lifestyle changes such as fluid or diet management, weight control, and bowel regulation. Education about bladder irritants, like caffeine, is an important consideration. Also, discussing bowel habits to determine if constipation is an issue as it is important to educate the patient about avoiding straining.[9] Education and explanation about normal lower urinary tract function is also included. Patients should understand the role of the bladder and the pelvic floor muscles.[10]

Bladder Training

The information gathered from the bladder diary is used to guide decision making for bladder re-training, including a voiding schedule if necessary to increase the capacity of the bladder for people with frequency issues. Bladder training attempts to break the cycle by teaching patients to void on a schedule, rather than in response to urgency. Urge suppression techniques are taught, such as distraction and relaxation. It is also important to teach the patient to contract the pelvic floor to cause detrusor inhibition. A voluntary contraction of the pelvic floor muscles helps increase pressure in the urethra, inhibit detrusor contractions, and control urinary leakage.[9] [10]

Differential Diagnosis

Multi-channel urodynamics testing is the gold standard for making a condition-specific diagnosis. This testing is typically done in secondary care, not in primary care or physical therapy.[4]

Key Evidence

A systematic review published in the Annals of Internal Medicine in 2008[11] found good evidence that pelvic floor muscle training and bladder training resolved urinary incontinence in women. However, the effects of electrostimulation, medical devices, injectable bulking agents, and local estrogen therapy were inconsistent.[11]

Resources

Physiopedia's Clinical Guidelines: Pelvic Health Page

Websites

Presentations

http://www.youtube.com/watch?v=w08iCzxnQBUKegel or not.png
Pelvic Physiotherapy - to Kegel or Not?

This presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.

View the presentation

References

  1. Natural Childbirth. Childbirth and your pelvic floor. http://childbirth.amuchbetterway.com/childbirth-and-your-pelvic-floor/ (accessed 15 March 2011).
  2. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology 2003;61:37-49.
  3. 4.0 4.1 4.2 4.3 4.4 4.5 Martin JL, Williams KS, Sutton AJ, Abrams KR, Assassa RP. Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence. Neurourol Dynam 2006;25:674-683.
  4. 5.0 5.1 5.2 5.3 5.4 Laycock J. Pelvic muscle exercises: physiotherapy for the pelvic floor. Urologic Nursing 1994;14:136-40.
  5. The National Institute for Diabetes and Digestive and Kidney Diseases Bladder Diary. Available from: https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems/diagnosis. [last accessed 17/8/2018]
  6. Doughty DB. Promoting continence: simple strategies with major impact. Ostomy Wound Management 2003;49:46-52.
  7. Alewijnse D, Metsemakers JFM, Mesters I, van den Borne. Effectiveness of pelvic floor muscle exercise therapy supplemented with a health education program to promote long-term adherence among women with urinary incontinence. Neurology and Urodynamics 2003;22:284-295.
  8. 9.0 9.1 Burgio KL. Current perspectives on management of urgency using bladder and behavioral training. J Am Academy Nurse Pract 2004;16:4-7.
  9. 10.0 10.1 Payne CK. Behavioral therapy for overactive bladder. Urology 2000;55:3-6.
  10. 11.0 11.1 Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008;148:459-474.