Role of P.T. in Stress Urinary Incontinence PDF

Role of P.T. in Stress Urinary Incontinence By Prof. Dr. Asmaa Mahmoud Aly PT for Women’s Health  OBJECTIVES  To explore the various therapeutic modalities and exercise regimens utilized by physical therapists in the management and treatmen...

Role of P.T. in Stress Urinary Incontinence By Prof. Dr. Asmaa Mahmoud Aly PT for Women’s Health  OBJECTIVES  To explore the various therapeutic modalities and exercise regimens utilized by physical therapists in the management and treatment of stress urinary incontinence, including pelvic floor muscle training, biofeedback, electrical stimulation, and behavioral strategies.  To examine the evidence-based approaches employed by physical therapists for patient education and lifestyle modifications aimed at reducing the symptoms and impact of stress urinary incontinence on daily activities and quality of life.  To discuss the interdisciplinary collaboration between physical therapists, physicians, nurses, and other healthcare professionals in the comprehensive care of individuals with stress urinary incontinence  To assess the effectiveness and outcomes of physical therapy interventions for stress urinary incontinence through the review and analysis of relevant research studies, clinical trials, and outcome measures, with a focus on patient satisfaction, symptom improvement, and functional status Anatomy of the pelvic floor muscles Anatomy of Pelvic Floor Anatomy of Pelvic Floor Levator Ani Muscles Fig. 1Female pelvic floor muscles Function of Levator ani muscles Supportive: to the pelvic/abdominal organs, it elevates the pelvic floor, resisting increases in intra-abdominal pressure. Function of Levator ani muscles Sphincteric: Relaxes and contracts the urethral, vaginal and rectal openings. Function of Levator ani muscles Gutter like action: internal rotation of the head of the fetus in the 2nd stage of labor.  Definition of SUI It is involuntary leakage of urine, from the urethra and such leakage usually occurs on sudden rise of intra-abdominal pressure, as coughing, laughing, or any other physical activities in absence of detrusor muscle.  Strong and weak PFMS http://www.incontrolmedical.com/wp-content/uploads/2011/12/Content-Is_InTone_right_for_you1.jpg  Pathophysiology of SUI http://pcdsupport.org.uk/images/uploads/06_Stress_incontinencelarge.jpg  Etiology of SUI ❖Congenital: ▪ Congenital inherited defect of intrinsic vesical sphincter or muscular support of the bladder urethra. ▪ Spina bifida which affects the innervations of the sphincter mechanism. ❖Traumatic: weakness of the supporting structures as a result of the trauma of childbirth. ❖Hormonal: post menopausal atrophy and some times during pregnancy.  Factors that provoke or aggravate incontinence Excess body weight. Chronic cough. Smoking. Infection as well as inflammation of the urethra or the bladder. Caffeine intake. Drugs that has diuretic action.  Grades of SUI Grade I: Incontinence only with severe stress, such as coughing, sneezing, or jogging. Grade II: Incontinence only with moderate stress such as rapid movement or walking up and down stairs. Grade III: Incontinence only with mild stress such as standing, the patient is continent in the supine lying position. Symptoms of stress incontinence The main symptom of stress incontinence is leaking urine when you: Are physically active Cough or sneeze Exercise Stand from a sitting or lying down position Making the diagnosis  1.History The points to elicit are the main urinary symptoms affecting the patient. This will include UI associated with an increase in abdominal pressure (coughing, sneezing, physical activity), or incontinence with urgency, frequency and nocturia.  Enquiries should also be made regarding intake of caffeinated drinks, red wine and acidic or spicy food. If an acute onset of UI has occurred, a review of any new medications and a full neurological examination should be performed. Tests for diagnosis of SUI may include: Cystoscopy to look inside the bladder. Pad weight test: You exercise while wearing a sanitary pad. Then the pad is weighed to find out how much urine you lost. Voiding diary: You track your urinary habits, leakage and fluid intake. Pelvic or abdominal ultrasound. Post-void residual (PVR) to measure the amount of urine left after you urinate. Urinalysis to check for urinary tract infection. Urinary stress test: You stand with a full bladder and then cough. Urodynamic studies to measure pressure and urine flow. X-rays with contrast dye to look at your kidneys and bladder.  Genital prolapse  Definition: Descent of one or more of genital organs (uterus, vagina, bladder, urethra, rectum, Douglas pouch) through the fasciomuscular pelvic floor below their normal level. Types of prolapse  1-Anterior vaginal wall prolapse: a. Cystocele: It is a prolapse of the upper part of the anterior vaginal wall with the base of the bladder.  b. Urethrocele: It is a prolapse of the lower part of the anterior vaginal wall with urethra.  c. Cysto-urethrocele: It is a complete anterior vaginal wall prolapse II.Posterior vaginal wall prolapse:  - a. Rectocele: It is a prolapse of middle third of posterior vaginal wall with anterior wall of the rectum.  b. Enterocele: It is a hernia of Douglas pouch. It occurs if upper third of posterior vaginal wall descends lined by peritoneum of Douglas pouch and containing loops of intestine IIIVault prolapse:  It is a descent of vaginal vault or inversion of the vagina after hysterectomy III.Uterine prolapse  1-Utero-vaginal: The uterus descends firstly followed by vagina, usually occurs in virgins or nulliparous due to congenital weakness of the cervical ligaments.  2-Vagino-uterine: The vagina descends firstly followed by the uterus, usually results from obstetric trauma Degrees of uterine prolapse:  1st degree: The cervix descends below its normal level on straining but does not protrude from the vulva. N.B: the external os of the cervix is at the level of the ischial spine.  2nd degree: The cervix protruds from the vulva on straining.  3rd degree (complete procidentia): The whole of the uterus is completely prolapsed outside the vulva and the vaginal wall becomes completely inverted over it Treatment Treatment depends on how your symptoms affect your life.  There are 3 types of treatment for stress incontinence: Behavior changes and bladder training Physical Therapy treatment Surgery BEHAVIOR CHANGES Making these changes may help: Drink less fluid (if you drink more than normal amounts of fluid). Avoid drinking water before going to bed. Avoid jumping or running. Take fiber to avoid constipation, which can make urinary incontinence worse. Quit smoking. This can reduce coughing and bladder irritation. Smoking also increases your risk for bladder cancer. Avoid alcohol and caffeinated drinks such as coffee. They can make your bladder fill up quicker. Lose excess weight. Avoid foods and drinks that may irritate your bladder. These include spicy foods, carbonated drinks, and citrus.  If you have diabetes, keep your blood sugar under good control  Physical Therapy Treatment (A) (B) Prophylactic Electrotherapy Treatment (Interferential) (C) (D) Curative Palliative Treatment Treatment Aims of the PT treatment: 1) To establish awareness of the function of the pubococcygeus muscle and urethral sphincter. 2) To normalize the pelvic support and sphincter mechanism. 3) To strengthen the pubococcygeus muscle.  (A) Prophylactic Treatment Proper Ante- Proper Post- natal Care natal Care Proper Intra- natal Care 1. Proper ante-natal care (before delivery): The pelvic floor muscles should be both strong and elastic. 2. Proper intra-natal care (during delivery): Avoid etiological factors: 1) Avoid straining during the first stage of labor. 2) Avoid the application of forceps before full cervical dilatation. 3) Episiotomy should be done when indicated to avoid hidden perineal lacerations, and 4) Avoid fundal pressure to deliver the placenta. 3. Proper post-natal care (after delivery): 1) Accurate repair of perineal tears or episiotomies. 2) Avoid early getting up of bed and avoid bearing down in early weeks of peurperium. 3) Avoidance of occurrence of R.V.F. by postural treatment. 4) Encourage pelvic floor exercises. 5) Prevent puerperal constipation in order to avoid strong bearing down efforts. 6) Care of general health to prevent debility and bad general health.  PFMs exercises For 300 repetition/day 1st step (pupovaginalis): Contract as if you control the urethral orifice, concentrate in this action, hold and then relax. 2nd step (puporectalis): Contract as if you control the bowel action, concentrate in this action, hold and then relax. 3rd step (whole muscle): Contract as if you control the bowel action, urethral orifice, concentrate in this action, hold and then relax. Patient while performing PFME Preventive role of PFM training Theoretically, it is estimated that strengthening the PFM by specific training would have the potential to prevent SUI and pelvic organ prolapse. Strength training may increase the PFM volume and lift the levator plate to a more cranial level inside the pelvis. If the pelvic floor possesses certain amount of stiffness, it is likely that the muscles could counteract the increases in abdominal pressures that occur during physical exertion  (B) Interferential therapy (Medium frequency current) For sever weakness and lack of awareness http://www.electrotherapy.org/Images/ift%20vacuum%20electrodes.jpg Techniques of Interferential: 1) Bipolar Technique: Electrode placement: The posterior electrode placed under the ischial tuberosities and the anterior one is put on the perineum. Frequency: 10-40 Hz. Duration: 15-20 min. 3 sessions / week for 4 weeks. 2) Quadripolar Technique: Electrode placement: Four large vacuum electrodes will be used. Two placed on the abdomen above the inguinal ligament, 3 cm apart, and two placed on the inner side of the thigh below the inferior border of the femoral triangle. Frequency: 10-100Hz Duration: 15-20 min. 3 sessions / week for 4 weeks. Mechanism of action:  Interferential current stimulate the deep seated structures so that the patients’ cortical awareness increase, thus facilitating the ability of the patient to perform voluntary contraction of a very weak PFMs.  (C) Curative Treatment (I) PFMs (II) Resistive Re-Education Exercises 1) Muscle education for pubococcygeus ms. 2) Biofeedback (Kegel 1) An inflated cuffed perineometer & EMG catheter. biofeed back). 2) Vaginal cones. 3) Mid-stream urine flow (Stop test). 4) Cyriax method.  (I) PFMs Education  I- MUSCLE EDUCATION FOR PFMs Graduations of PFMs ex: Quick Flick: Tighten and relax the ms as quickly as possible 10-20 times then relax for a count of 10. Slow contraction: Tighten the ms as hard as you can for a count of 10-20, then relax for a count of 10. Sustained contraction: Tighten the ms halfway and hold for 60sec. Then relax for a count of 20. Levator ani muscle at rest and during contraction Frequency of pelvic floor exercises: Different studies have recommended different number of contractions ranging from 8 to 12 contractions three times a day to 20 contractions four times a day and up to as many as 200 contractions per day. To obtain increased muscle strength of PFMs, it is necessary to apply a method, named as the progression model. This method requires doing repetition from 8 to 12 times with maximum contractions at moderate velocity and 1 or 2 min breaks between sets. Moreover, number of initial trainings which were two to three times in a week should be increased to four to five times per week. Frequency of pelvic floor exercises: ▪ In PFMT, progression can be achieved by changing positions from gravity‐free to antigravity or through the introduction of cones into the exercise sessions. ▪ Voluntary PFMs contractions in response to specific situations; for example, prior to and during coughing, lifting an object or jumping. The recommended supervised PFMT by The International Consultation on Incontinence Committee for women with SUI is 8–12 weeks. Finally, if it is desired to obtain better outcomes according to progression model, velocity and coordination training (“The Knack”) should include the use of repetitive, voluntary PFMs contractions in response to specific situations; for example, prior to and during coughing, lifting an object or jumping.  II- BIOFEEDBACK KEGEL PERINEOMETER http://wholewoman.com/blog/images/2012/10/images-4.jpeg It provides the patient by powerful sensory and visual biofeedback, is able to measure intra vaginal pressure up to 100 mmHg so that changes in pelvic floor strength can be measured.  EMG Biofeedback It provides the patient by sensory, visual and auditory biofeedback. It is useful in both increasing the level of pubococcygeus ms activity and improving the ability to relax on volition. It consists of vaginal electrode, 3 surface electrodes, screen and ear phone.  III- Mid Stream urine flow (Stop test) 1st step: patients are instructed to stop the flow of the urine near the end of the micturation. 2nd step: patients are instructed to stop the flow of urine at the beginning of the micturation. 3rd step: patients are instructed to interrupt their urine flow during their micturation.  IV- Cyriax Method This method aims to strength: pubococcygeus, gluteal, anal, and abdominal muscles. The patient is asked to lie in crock-lying position, breath in deeply from her nose, and at the same time contract pubococcygeus, gluteal, anal and abdominal muscles, then she imagines that she draws all internal viscera up towards the diaphragm, then she will asked to relax and expire air from her mouth with a sigh. (II) Resistive Exercises for PFMs  I- An Inflated Cuffed Catheter By using a small quantity of KY gel, an inflated cuffed catheter is inserted into the vagina. Then the patient is instructed to tighten the pelvic floor ms to prevent withdrawal of the catheter by the therapist. Gentle traction is applied which stretch the PFM and provide a sensory biofeedback. The cuffed could be inflated with air or water, depending on the laxity of vagina.  II- Vaginal Cones Vaginal cones (weights) are easy to use, it provides patient with a strong feedback. So, women can be trained to contract PFM in order to retain cones of increasing weight in the vagina. Cones are available in set of 5, with weights varying from20-70gm Resistive pelvic floor exercises using Vaginal cones  (D) Palliative Treatment (Mechanical Devices) Vaginal http://candgmedicare.com/wp-content/uploads/2012/02/hodge-pessary.jpg Pessary It is worn during the specific stressful activity such as jogging, volley ball or tennis to eliminate the SUI by preventing urethral Hodge Smith Pessary hyper-mobility through supporting the proximal urethera.  Intra-urethral inserts (urethral plug) http://www.riversideonline.com/source/images/image_popup/w7_femsoft.jpg It act as a barrier to the loss of urine. It has significant side effects such as haematuria and bacterial cystitis.  Fem Assist device Full-size image (33 K) It fits over the external meatus rather than within the urethra. But because it held in place by suction, it may cause urethral prolapse. Magnetic stimulation (MS) Magnetic stimulation is a novel approach, coming up in recent years. To use of MS there must be special chair. An electric current is passed around a metal coil, generating an electromagnetic field. When the person exposed to this field, electric current is generated in tissues. The electromagnetic fields spread easily through tissues causing ES. It has an armed treatment chair for the patient to sit comfortably and a compact control unit. It contains a generator, control buttons, a monitoring screen and modem. The stimulation coil is situated underneath the treatment chair to ensure direct focus on PFMs. Equipment of magnetic stimulation.