Stress incontinence - how can physio help?

Hi,

I had a 35 y/o lady present to me with a long history of stress incontinence (since age 10). She has two children aged 7 and 5. This lady has just started personal training at the gym and is becoming embarassed by her incontinence.

The patient is aware of pelvic floor exercises and states that she has been doing them "on and off" for many years now and they do not seem to be helping.

Are there any other options, other than continuing to encourage pelvic floor exercises in various different positions, that I can suggest to this lady?

Any suggestions would be much appreciated.
Thanks, Jackie

Hi!

With this kind of patient, I try to establish why she has stress incontience in the first place.
- How does her TrAb and Bladder look under U/S examination?
- Does she have a symmetric contraction of her TrAb and pelvic floor?
- Is she generating too much intra-abdominal pressure (IAP) via her muscular system (overactive obliques, rectus abdominus, intercostals, etc)?

I have found that some people have a pelvic floor that is essentially fine but they generate so much IAP that they push through their pelvic floor.

Perhaps she may have some scarring due to tearing or episiotomies from childbirth. This could lead to poor symmetry during pelvic floor contractions.

Perhaps she has a diastasis recti which stops that TrA, Lumbar multifidus and pelvic floor from doing their job.

Another thing may be that she thinks she is doing a pelvic floor contraction but is only doing her internal obliques or pubococcygeus and not the anterior pelvic floor. I have found this problem a lot with people who have been doing yoga and Pilates - the instructors don't seem to realise that core-activation is very subtle.

Sometimes a dysfunctional pelvis means that the core muscles aren't able to do their job effectively.

Does she have urinary urgency, loss of control or is it just stress incontinence?

I would start by look at her breathing, ensuring that her lateral basal expansion is correct and equal, that her tummy or chest is not moving more than the other.

Then I would look at her core activation and Active SLR to look for load transfer problems.

Let us know how she is going... :D

Hi Jackie,
Many women think they are doing pelvic floor exercises but then don't do them correctly, or do them inappropriately. She needs to be checked vaginally. Checking if she does TrA correctly is important, but it is possible to contract it and still be bulging the PF. She needs to learn to do the exercises well but also functionally.
To determine the type of incontinence she needs a comprehensive assessment. Many women with urge incontinence do PFX's without much success, but learning how to control the bladder does wonders.
If you don't have the experience to assess/treat this how about asking your local continence physio for a consultation? We don't bite!
Irma

Hi jackie, I agre with the earlier replies and emphasise that if you are not skilled in continence management, please do refer her to someone who is, there is a lot she will be able to do to help herself and yes people who do Pelvic floor exercises and they dont work, are usually doing the wrong action - pushing down not pulling up - or are doing too many or (more commonly ) far too few. also doing PF exs lying down is useless if the problem only occurs when she is doing exercises, the PF exercise programme needs to be tailored to the patient just like an exercise programme for any other muscle - graded resistance, increased reps, increased holding times etc.
Good luck, and if you havent done any WH & Continence stuff thus far, give it a go, its absolutely fascinating and consists of far more than just "the pelvic floor"!!

Thanks for the advice all!

This lady is due to have another appointment with me in two weeks time - I have been doing lots of reading and have a few tests (stop urine test, self vaginal test and Jumping Jack test as described in Hall and Brody (1999)) and suggestions for her.

I am working in regional Australia and there is no continence physio in our area (this lady also works in the local health system and is reluctant to go to certain health professionals due to knowing them outside of work and being embarassed by the situation). Is it appropriate to refer her to a gynecologist or any other health professional?

I believe this is an area which is lacking in my region and am interested in learning more about the topic, so if anyone can suggest text books and/or courses to attend to further my knowledge in the area it would be much appreciated!

Thanks again, Jackie

Hi Jackie,
There are several courses run in most states depending on where you live. What you are looking for is a basic pelvic floor course. Most capital cities run them often under the auspices of the APA continence and women's health SIG. Some are privately run such as ones at Royal Hosp for women in Sydney, Pauline Chiarelli in Newcastle.
If you are really keen Melbourne Uni offers a post Grad Cert. in Continence.
If you have a gynea that you know and who is willing to work with you ask him/her to show you how they assess the pelvic floor (they do it differenly but it's better than nothing) and ask how well she is moving it.
how far are you from a major centre? could/would she be willing to travel to a continence physio (and you with her) for an one off consultation. I know I occasionally get physios visiting here.
Irma

hello
mr. physio u have not mentioned any thing of modalities given for incontinence. if u have not started with either ES OR IFT better start with IFT every alternate days with frequency from 0 to 130 hz which will stimulate smooth muscles and striated with motor nerves and pain fibres also. if u have any querry u r free to ask

PLease be carefull with comments like that. There is not a lot of evidence for the use of IFT or ES and very little that actually looks at different protocols.
Why would you want to stimulate pain fibres in the pelvic floor?? Stimulating the bladder smooth muscles may cause a contraction of these: causing empyting. ES and IFT are good as an augmentation to learning how to conttract the PF but still requires a full assessment. The pelvic floor needs to be worked dynamically and in conjunction with the rest of the core muscles. Stims is not going to teach that.

Hi

I did womenshealth while on a rotation in the NHS(UK). I was thrown into the deep end as I did not really know enough about the subject of incontinence at the time. I used a little book by Pauline Chiarelli "Womens Waterworks, Curing Incontinence". This is a brilliant book for physio and patient alike. I used to give it to my patients to read.You can download it from the net. It gives the patient practical and realistic advice.

These patients can be challenging to treat because there is also a huge emosional and pchycological component involved in some of these patient. Incontinence can be very self limiting and demoralising without the proper support and treatment!

Good luck.
Annelize