Physical Therapy for Stress Urinary Incontinence

Role of Physical Therapy in Stress Urinary Incontinence

• Stress urinary incontinence (SUI) is involuntary leakage of urine due to sudden increases in intra-abdominal pressure (e.g., coughing, sneezing, exercise). It occurs in the absence of detrusor muscle activity.
• Physical therapists use various modalities to manage SUI, including pelvic floor muscle training (PFMT), biofeedback, electrical stimulation, and behavioral strategies.
• Therapists provide patient education on lifestyle modifications to reduce SUI symptoms and improve quality of life.
• Interdisciplinary collaboration is crucial for comprehensive SUI care, involving physical therapists, physicians, nurses, and other healthcare professionals.
• The effectiveness of physical therapy interventions is assessed through research studies, clinical trials, and outcome measures focusing on patient satisfaction, symptom improvement, and functional status.

Anatomy of Pelvic Floor Muscles

• Diagrams and descriptions of the puborectalis, pubococcygeus, and coccygeus muscles are presented.
• These muscles are crucial for pelvic floor support and continence.

Anatomy of the Pelvic Floor

• Diagrams illustrate the pelvic floor, depicting the pelvic bones, bladder, uterus, vagina, urethra, rectum, and coccyx.
• The pelvic floor muscles are shown as supporting structures within this region.

Anatomy of Levator Ani Muscles

• Diagrams portray the pelvic floor muscles' structure, identifying parts of the levator ani group like the puborectalis, pubococcygeus, and iliococcygeus.
• These muscles are crucial for pelvic floor support.

Function of Levator Ani Muscles

• The levator ani muscles support the pelvic/abdominal organs by elevating the pelvic floor and resisting increases in intra-abdominal pressure.
• These muscles act as sphincters, relaxing and contracting to control urethral, vaginal, and rectal openings.
• In the birthing process, the muscles assist with the internal rotation of the fetal head during the second stage of labor.

Definition of Stress Urinary Incontinence (SUI)

• SUI is characterized by involuntary leakage of urine that usually happens with a sudden rise in intra-abdominal pressure, such as coughing, laughing, or physical activity.
• This leakage occurs in the absence of bladder contractions intended to expel urine.

Strong and Weak Pelvic Floor Muscles

• Diagrams illustrate the differences between strong and weak pelvic floor muscles' effect on the bladder neck and urethral sphincter.
• Weak muscles are associated with SUI.

Pathophysiology of SUI

• SUI occurs if the pelvic floor muscles weaken. The pelvic floor "sags" allowing the bladder neck to prolapse through a weakening pelvic floor.
• A lack of contraction of the pelvic floor during increases in intra-abdominal pressure results in the urethra failing to tighten, allowing urine to leak.
• The diagrams illustrate this process.

Etiology of SUI

• Congenital SUI may be inherited, relating to defects in intrinsic vesical sphincter or in muscular support in the bladder & urethra.
• Underlying conditions like spina bifida can affect the sphincter mechanism.

Traumatic and Hormonal Causes of SUI

• Traumatic SUI occurs due to childbirth trauma weakening pelvic supporting structures.
• Hormonal changes, such as post-menopausal atrophy, or pregnancy-related changes, might contribute to SUI.

Factors Aggravating Incontinence

• Excessive body weight, chronic cough, smoking, and bladder/urethral infections can trigger or worsen incontinence.
• Caffeine and diuretic medications also aggravate symptoms.

Grades of SUI

• Grade I involves leakage only during strenuous activities like coughing & sneezing.
• Grade II relates to leakage from moderate stress, like walking stairs.
• Grade III only causes leakage from mild stress with normal function in the supine position.

Symptoms of Stress Urinary Incontinence

• The primary symptom is involuntary urine leakage during physical activity, coughing, sneezing, or changing positions from sitting or lying down

Making the Diagnosis of SUI

• Thorough patient history regarding urinary symptoms, including frequency and nocturia, is essential.
• Factors like fluid intake, food items (spicy, acidic), and recent medication use are also considered.
• A full neurological examination might be necessary in cases of acute onset.

Tests for Diagnosing SUI

• Physical exam tests include cystoscopy (bladder examination), pad weight test (assessing urine loss during activity), and voiding diaries (tracking urine leakage & intake).
• Pelvic and abdominal ultrasounds, post-void residual (PVR) testing (final urine volume), urinalysis, urinary stress tests (stand with full bladder and cough), and urodynamic studies (pressure & flow) are also used.
• X-rays with contrast are also used to view the kidneys and bladder.

Genital Prolapse

• Genital prolapse involves the descent of one or more genital organs, such as the uterus, vagina, bladder, urethra, rectum, and Douglas pouch, below their normal position through the pelvic floor.

Types of Prolapse

• Anterior Vaginal Wall Prolapse: This includes:

  • Cystocele: Prolapse of the upper part of the anterior vaginal wall, which involves bladder tissue.
  • Urethrocele: Prolapse of the lower part of the anterior vaginal wall, involving the urethra.
  • Cysto-urethrocele: This is a combined prolapse of the anterior vaginal wall, involving both the bladder and urethra.

• Posterior Vaginal Wall Prolapse: This includes:

  • Rectocele: Prolapse of the middle portion of the posterior vaginal wall, often involving the rectum.
  • Enterocele: This is a hernia of the Douglas pouch, where tissue containing loops of intestine protrudes into the posterior wall.

• Vault Prolapse: A descent or inversion of the vaginal vault (top portion of the vagina) after a hysterectomy

• Uterine Prolapse: Descending uterus, sometimes followed by the vagina due to either congenital weakness of the cervical ligaments (in nulliparous women) or obstetric trauma.

Degrees of Uterine Prolapse

• 1st degree: Descent of the cervix, but it doesn't extend outside the vagina.
• 2nd degree: Cervix protrudes into the vagina.
• 3rd degree: The entire uterus descends outside the vagina, a complete procidentia.

Treatment of SUI

• Three types of treatment exist for SUI:
  • Behavior changes and bladder training: These include modifying fluid intake, avoiding strenuous activities, preventing constipation, and managing weight. Avoiding caffeine and spicy/acidic food can also help.
  • Physical therapy: This involves PFMT, biofeedback, electrical therapies, exercises and may use resistance devices (e.g., vaginal cones, pelvic floor exercises etc).
  • Surgery: This is often a last resort, involving procedures to strengthen pelvic floor support or correct prolapses structurally.

PFMs Exercises

• Graduations of exercises for PFMs include:
• Quick Flicks: Rapid contractions/relaxations (10-20 times); hold & relax for 10 seconds.
• Slow contractions: Tighten & hold muscles as hard as possible (10-20 times); hold & relax for 10 seconds.
• Sustained contractions: Tighten & hold muscles halfway (60 seconds); relax for 20 seconds

Frequency of Pelvic Floor Exercises

• Different studies recommend varying numbers of PFMs contractions (8-12-200 max).
• A method called "progression model" can achieve this. It involves repetitions, controlled speed, and short breaks.
• Initial sessions might be 2-3 times a week that get increased to 4-5 times per week

Biofeedback

• Biofeedback provides sensory and visual cues to help patients understand pelvic floor muscle activity.
• Kegel perineometers are a common example; this measures intra-vaginal pressure during contraction and relaxation of the pelvic floor.
• Other methods (e.g. EMG) use electrodes to provide sensory feedback.

Mid-Stream Urine Flow (Stop test)

• A technique involves interrupting and stopping the flow of urine during urination at set points in the process (beginning or end).

Cyriax Method

• A physical therapy technique focuses on strengthening pelvic floor, gluteal, anal, and abdominal muscles using breathing and visualization.
• Patients lie in a specific position and contract these muscles as they breathe in, visualizing the viscera rising toward the diaphragm, before relaxing and exhaling.

Resistive Exercises Using Vaginal Cones

• Vaginal cones, increasing in weight, are used as resistance for PFMs exercises.
• The patient contracts the PFMs to maintain the cone in place.

Palliative Treatments for SUI (Mechanical Devices)

• Vaginal Pessaries: Worn to address SUI from activities such as excessive exercise, and hypermobility that cause urethral issues.
• Intra-urethral inserts (urethral plugs): Acting as a barrier to help retain urine by fitting over the external urethral opening; however, such treatment has possible side effects like hematuria or bacterial cystitis.
• Fem Assist devices: A different device that fits over the external urethral meatus for support; risk of prolapse because of suction action is present.

Magnetic Stimulation

• Magnetic stimulation (MS) is a relatively new approach using a special chair that generates magnetic fields.
• The magnetic fields stimulate (and increase awareness of the function/contraction of) underlying tissues. It is often used to increase awareness of pelvic floor muscle activity.

This quiz examines key concepts in physical therapy relating to stress urinary incontinence. It covers definitions, therapeutic modalities, and the importance of collaboration among healthcare professionals. Test your knowledge on pelvic floor muscles and treatment strategies for managing this condition.