Physical Therapy for Stress Urinary Incontinence

Physical Therapy Treatment of Stress Urinary Incontinence

• Aims of treatment:
• Inform patients about factors that may provoke or aggravate incontinence
• Establish awareness of and function of pubococcygeus muscle and urethral sphincter
• Normalize pelvic support and sphincter mechanism
• Strengthen pubococcygeus muscle

Treatment of Stress Urinary Incontinence

• Divided into three categories: Prophylaxis, Actual Treatment, and Surgical Treatment
• Prophylaxis: prevent parturition (most common traumatic cause) by proper intra-natal and post-natal care
• Proper intra-natal care:
  • Keep bladder empty during 1st stage of labor
  • Proper management of 2nd stage of labor by firm support of perineum
  • Avoid using forceps and ventose before full cervical dilatation
  • At crowning, ask the mother to stop bearing down during contractions and start to pant
  • Proper timing of episiotomy if needed
• Proper post-natal care:
  • Repair any perineal tear or lacerations within 24 hours
  • Strengthening exercises to strengthen pubococcygeus muscle
  • Avoidance of bladder infection by washing vulva and perineum

Curative Treatment

• Physical therapy treatment divided into two phases:
• Muscle re-education of pubococcygeus muscle:
  • Graduations of PCM exercises
  • Biofeedback
  • Cyriax method
• Resistive pelvic floor exercises:
  • Inflated cuffed catheter and vaginal cones
• Muscle re-education of pubococcygeus muscle:
• Urethral closure pressure must be higher than intra-vesical pressure
• Strengthening of pelvic floor muscles (PFMs) is key to treatment
• Re-education and strengthening of PFMs can be achieved by:
  • Graduations of pubococcygeus muscle exercise
  • Quick flicks and slow contractions

Post-operative Physiotherapy

• Chief objective: recover as early as possible without complications
• After recovery from anesthesia:
• First day:
  • Deep breathing exercise
  • Supported cough and huff
  • Circulatory exercise
  • Static abdominal exercise
  • Pelvic rocking exercises
  • Pelvic floor exercise (once urethral catheter is removed)
• Second day:
  • All the exercises above
  • Early ambulation
  • Further progression of exercises

Bladder Drill

• Aim: restore bladder capacity to near normal levels
• Involves timed voiding (interval between voids is gradually increased)
• Patient should increase time interval and try to suppress strong urge before void interval is relapsed
• Bladder training takes 3 or more months

Fecal Incontinence

• Definition: uncontrolled passage of feces or gas over at least 1 month
• Causes:
• Muscle damage
• Nerve damage
• Constipation
• Hemorrhoids
• Surgery
• Rectal prolapse
• Rectocele
• Grades:
• Using Park's scale:
  • Grade I: normal continence
  • Grade II: continent for solid and liquid stools but not flatus
  • Grade III: continent for solid stools only
  • Grade IV: complete incontinence

Assessment of Fecal Incontinence

• Detailed history:
• Incontinent symptoms
• Medical and surgical history
• Medications and quality of life
• Anorectal manometry:
• Evaluating anal resting pressure (normally around 30-40 mm Hg)
• Anal squeeze pressure around 150% of resting pressure
• The volume that should fill the rectum to indicate 1st sensation is 25-35 ml
• Maximum tolerance for stretch is 200-300 ml

Treatment of Fecal Incontinence

• Dietary consideration:
• Inform patients about factors that contribute to bowel disturbances and loose stool consistency
• Fiber supplementation:
  • Fibers increase stool bulk when fermented
  • Fiber with high water content allows gel formation which normalizes stool consistency
• Behavioral modification:
• Weight reduction
• Cessation of smoking
• Avoid straining during bowel movement
• Pharmacological treatment:
• Loperamide to reduce diarrhea and increase internal sphincter tone
• Oral laxatives and glycerol suppositories to treat constipation
• Pelvic floor exercise:
• In the form of quick flicks, sustained sphincter contraction, and submaximal sustained contractions (Kegel exercises)
• Core stability training:
  • Strengthening the abdominal muscles, pelvic floor muscles, and diaphragm
• Biofeedback therapy:
• 1st approach: strength and endurance of anal sphincter using biofeedback apparatus
• 2nd approach: using biofeedback in combination with rectal balloon
• Electrical stimulation:
• To enhance strength and endurance of muscles of external anal sphincter
• Using low frequency or medium frequency current stimulation
• Radiofrequency energy to the anal canal:
• Increases collagen deposition and tissue remodeling
• Mechanical inserts (Temporary):
• Anal inserts:
  • Prevents uncontrolled loss of solid stool
• Procon incontinence device:
  • Treatment of severe fecal incontinence (FI) who are unfit for surgery or previous surgical treatments have failed