- Urge urinary incontinence (inability to control the strong desire to void)
- Stress urinary incontinence (loss of urine during effort or exertion)
- Mixed urinary incontinence (combination of urge and stress).
Approximately 20 million people in the United States are affected by urinary incontinence per year.
Women with urinary incontinence who receive physical therapy report a better quality of life and decreased urinary leakage.
Women with urinary incontinence have increased tone of the pelvic floor muscles and significantly decreased pelvic floor strength.
Pelvic floor muscle therapy and exercises are an effective treatment approach for urinary incontinence. Physical therapy teaches patients to identify the muscles, contract and relax them, and thus strengthen them. This is turn results in decreased incidence of urinary incontinence.
Stress Urinary Incontinence:
Stress urinary incontinence is the involuntary leakage of urine on effort or exertion during activities of daily living. During effort or exertion, the intra-abdominal pressure increases, and the uretheral sphincter is unable to maintain a high pressure to overcome the pressure exerted on the bladder, along with incordination of the pelvic floor muscles.
It is highly prevalent in 15% to 40% of community-dwelling women. SUI has been associated with a poor quality of life.
In stress urinary incontinence there is a loss of structural support to the bladder or bladder neck which occurs occurs due to damage to the pelvic floor muscles, endopelvic fascia, and/or the pudendal nerve. SUI is associated with increased tone of pelvic floor muscles (PFM), weakness, and incoordination of PFM.
Childbirth is a risk factor for SUI. SUI following child birth is a very common cause of maternal morbidity. There is a high prevalence of postpartum SUI with vaginal delivery as compared to delivery by caesarean section. In a study by Runa B et al, they reported the overall incidence of SUI after normal vaginal delivery was 27.1%.
During childbirth, the integrity of the pelvic muscles and sphincters can be affected. There might be a perineal tear which will directly affect the pelvic muscles and result in their weakness. Or damage to the pudendal nerve which innervates the external urethral sphincter.
The pelvic muscles and sphincters attach into the perineal body. During childbirth, a perineal tear, will affect the integrity of the pelvic muscles and sphincters which will directly result in their weakness. There can also be stretching or tearing of the pelvic floor muscles. During vaginal delivery, there may also be damage to the pudendal nerve which innervates the external urethral sphincter.
Frequently, pelvic floor disorders coexist as they share the same pathophsyiologic mechanisms and risk factors. Pelvic symptoms that may co-exist with SUI are pelvic organ prolapse, dyspareunia, constipation, hip pain, low back pain. Women with urinary incontinence have a 7 fold higher risk of dyspareunia.
Women with urinary incontinence show a higher degree of depression and anxiety, limiting their physical and social activities in fear of urinary incontinence.
During physical therapy, it is important to address both the stress urinary incontinence and other pelvic disorders when forming a treatment plan.
Since pelvic disorders have common etiologies and risk factors, physical therapy treatment of SUI should improve the symptoms of the others.
Pelvic floor muscle training is the recommended treatment of choice for women with SUI.
In patients with SUI, PFPT improves the contraction strength of the PFM which increases intraurethral pressure during contraction, therby preventing urinary leakage.
Physical therapy outcomes for SUI are influenced by the number of visits. It has been documented in literature that the maximal effect of strength training occurs after 5 months of training. Patients who receive physical therapy for a longer duration (6 months) achieve better treatment outcomes.
Pelvic muscle strengthening is an effective first-line intervention for women with SUI. Pelvic floor muscle training strengthens the support of the pelvic organs and improves the closure of the urethral sphincter. The aim of PFM training is to teach women to contract the PFM before and during exertion, including coughing and sneezing. All the exercises taught in the clinic translate into a home exercise program.
Knorst and colleagues did a study of 30 women with SUI to test the efficacy of exercise intervention on pelvic floor muscles and urinary incontinence. The study demonstrated an increase in the PFM function and 90% of the women reported being satisfied and continent with physical therapy.
Physical therapy interventions for SUI includes exercises for the pelvic muscles which can improve urtehral closure and pelvic organ prolapse.
Barriers to therapy may include not having time to do the exercises or forgetting to do them.
Strengthening with coordination of the core muscles is the main focus of PFM exercise. The core muscles include the diaphragm, abdominals, quadratus lumborum, multifidus, hip muscles, and the pelvic floor muscles.
Along with strengthening, flexibility exercises (including stretches) for the hip and lumbo-pelvic muscles aid in re-training the core muscles. Relaxation techniques, which include diaphragmatic breathing also assist in decreasing pelvic muscle tone.
Women with SUI may have trigger points in pelvic floor and hip rotator muscles including the levator ani, piriformis and obturator internus muscles.
Manual therapy techniques used include myofascial release, trigger point release, muscle energy techniques, and visceral manipulation. Other manual therapy techniques used include manual facilitation for abdominal contraction, soft tissue mobilization, connective tissue manipulation, and joint mobilization at the sacrum, innominate, lumbar spine, coccyx, and pubic symphysis.