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Incontinence: an expert physiotherapists perspective

Jeanette Haslam
MPhil GradDipPhys  MCSP SRP
Chartered Physiotherapist acting as a Clinical Specialist in Continence and Women's Health
Chairman
Association for Continence Advice (UK)

Urinary incontinence has been defined as "the involuntary loss of urine which is objectively demonstrable and a social or hygienic problem",(1) and faecal incontinence as "the involuntary or inappropriate passing of liquid or solid stool".(2) Either may cause distress, discomfort and humiliation.
A report by the Department of Health states that each health authority needs to ensure that there is a routinely available integrated continence service covering prevention, assessment, treatment and specialist care.(3) Proactive questioning will ensure that early intervention is undertaken. The people questioned should include:

  • Women during the childbearing years.
  • Pre- and postgynaecological surgery.
  • Pre- and postprostatectomy surgery.
  • Peri- and postmenopausal women.
  • The elderly.
  • The disabled.

The symptoms may include stress urinary incontinence, faecal incontinence, frequency or urgency.

Assessment
Incontinence symptoms need to be carefully assessed by an adequately-trained health professional before instigation of treatment. Assessment should include a full history of the problem, and details of the present symptoms and how they are affecting the patient's life. It should also include questions regarding environmental, mobility or manual-dexterity problems. An initial dipstick leucocyte and nitrite test for bacteriuria should be performed and an MSU (midstream urine test) sent as appropriate. The patient should be examined abdominally for any palpable mass or signs of urinary retention. A perineal examination should be performed to assess any signs of prolapse, excoriation and ability to voluntarily contract the pelvic floor musculature; a rectal examination may also be necessary. The patient's desire and likely motivation and compliance with conservative treatment should also be determined.
The aim should be one of promoting continence and conservative treatment rather than automatically resorting to containment aids.

General advice
It must never be assumed that patients have knowledge of what is considered "healthy living".

Pelvic floor muscle exercises
Informed consent and the option to bring a person of choice with them should be given before any pelvic floor muscle (PFM) assessment.(4) Palpation of the PFM can determine contractility, strength, power, endurance and fatigability. A patient-specific exercise regimen is necessary to consider the needs of both slow and fast muscle fibre.
It has been shown that appropriate PFM exercises can result in improvement in the range of 65-75%.(5) In order to expect these results, there must be involvement of a well-trained clinician with experience in PFM re-education programmes.
A progression may involve the use of weighted vaginal cones, usually available as a series of 20-60g weights. These are unsuitable for use by some women, such as those with a significant degree of prolapse, any vaginal infection or during pregnancy. Before advising on the use of cones it must also be confirmed that the woman is happy to insert a vaginal device into herself, as a recent study found that only 21% of women were happy to insert a continence device into their vagina.(6) A continence physiotherapist or nurse will be able to give appropriate advice.

Bladder training
Completion of a frequency-volume chart will determine whether or not the patient will benefit from a bladder training programme. The patient will need to be highly motivated and physically and mentally able. The programme aims to gradually increase the time between voids by using a variety of strategies, taking into consideration individual need and level of ability.
Bladder training is likely to succeed if the person is guided, monitored and motivated. It is counter-productive to produce instructions and expect a patient to carry them out alone.

Biofeedback
Biofeedback involves sensory information being given to a patient in order to assist them in achieving an activity. There are many different ways of giving PFM biofeedback:

  • An appropriately-trained person palpating the PFM.
  • The patient being taught self-digital examination (it is often easier to use a thumb than a finger for such self-examination).
  • The use of vaginal cones as previously discussed.
  • The use of visual and auditory equipment (there are sophisticated clinic-based equipment and small home biofeedback units available).

Neuromuscular electrical stimulation (NMES)
Some people are unable to initiate a voluntary PFM contraction and need help from NMES to provide sensory input. By using appropriate stimulation parameters, rehabilitation becomes possible.
Stimulation using different parameters can also be used to treat detrusor overactivity and faecal incontinence. Individuals need to be advised and treated by a health professional trained in the use of NMES to maximise the potential for success.
 
Clean intermittent self-catheterisation (CISC)
CISC has been shown for many years to be a safe and effective way of managing a patient incapable of fully emptying their bladder. It is associated with lower rates of urinary tract infection (UTI) and causes fewer complications to the upper urinary tract and renal function than when using indwelling catheters. Patients need to be taught the technique fully by a skilled healthcare professional who can support, encourage and motivate the patient in its use.
 
Provision of pads
It may be necessary to manage an incontinence problem by giving advice and providing appropriate containment aids. Currently there is a great variation in the provision of the type, quantity and quality of continence supplies. Available supplies should be provided only after an adequate assessment and management plan has been formulated. The patient should be regularly reviewed to ensure that they receive appropriate supplies.

Medication
It may be desirable to consider anticholinergic medication for the treatment of the unstable bladder alongside bladder training. Antidiuretic hormone medication may be considered appropriate for the treatment of nocturnal enuresis. Correct advice should be given to patients regarding the use of diuretics, and consideration should be given to the effects of polypharmacy.

Devices
At any one time there are several occlusive devices on the market to assist in the management of urinary incontinence. They often suffer from a lack of published research and, as such, should be treated with caution. However, they may be appropriate for self-purchase by some women after a careful assessment.

Summary
Incontinence is a very real problem for many people. Most cases can be conservatively managed in the community. There are skilled specialist nurses and physiotherapists who can provide such a service, so that only those with more complex problems need be referred to specialist centres. Audit of care will ensure that effective management continues to take place.

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References

  1. Abrams P, Blaivas JG, Stanton SL, Anderson JT (International Continence Society Committee on Standardisation of Terminology). The standardisation of terminology of lower urinary tract function. Scand J Urol Nephrol 1988;144:5-19.
  2. Royal College of Physicians. Incontinence: causes, management and provision of services (a report). London: Royal College of Physicians; 1995.
  3. Department of Health. Good practice in continence services. Leeds: NHS Executive; 2000 (www.doh.gov.uk/continenceservices.htm)
  4. Royal College of Obstetricians and Gynaecologists. Intimate examinations: report of a working party. London: RCOG Press; 1997.
  5. Wilson PD, Bo K, Bourcier A, et al. Conservative management in women. In: Abrams P, Khoury S, Wien A, editors. Incontinence: 1st International Consultation on Incontinence 1998. United Kingdom: Health Publications;1999. p. 579-636.
  6. Prashar S, Simons A, Bryant C, Dowell C, Moore KH. Attitudes to vaginal/urethral touching and device placement in women with urinary incontinence. Int Urogynecol J 2000;11:4-8.

Resources
Association for Continence Advice
T:020 8692 4680
W:www.aca.uk.com

International Continence Society (UK)
E:RamsayINR@aol.com

The Continence Foundation
T:020 7404 6875
W:www.continence-foundation.org.uk

Incontact
T:020 7717 1225

Five-year forecast

  • High-quality audited continence therapy available at PCG and PCT level
  • Evidence from randomised control trial to show a definitive muscle re-education programme
  • Patterned neuromuscular electrical stimulators
  • Medication more specific to the bladder with less unpleasant side-effects

Further reading
Button R, Roe B, Webb C, et al. Continence promotion and management by the primary health care team. London: Whurr Publishers; 1998.

Doughty DB. Urinary and fecal incontinence. London: Mosby; 2000.