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Incontinence: physiotherapy treatment can help.

Gill Brook
MCSP SRP
Physiotherapy
Coordinator
Surgery and Women's Health
Bradford Royal Infirmary
Chairman
Association of Chartered Physiotherapists in Women's Health
Treasurer
International Organisation of Physical Therapists in Women's Health

All nurses know that incontinence is not a rare problem, and many are involved in the promotion of continence and management of incontinence. Urinary leakage in the general population may affect as many as 20%, with figures much higher for those in residential care, nursing homes and hospitals. Faecal incontinence is less common, but may still affect 3-5% of people over 65 in the community and more in institutions.(1)

The Royal College of Physicians advises that, when appropriate and available, conservative methods of treatment should be tried before more invasive measures such as surgery are considered.(1)

Why physiotherapy?
Physiotherapy students receive extensive training in anatomy and physiology. Once qualified, they work at junior and senior levels in all areas of physiotherapy, and some choose continence or women's health as their specialty.
 
Such therapists work in many, though not all, parts of the UK. Many will have undertaken a lengthy post-registration course in either continence or women's health, and some will have done both. They are, therefore, well prepared for a role in the promotion of continence and treatment of incontinence.

Types of incontinence
There are numerous types of incontinence, but those most commonly treated by the physiotherapist are:

  • Stress urinary incontinence - this is the most common type of urinary incontinence. It is typified by loss of urine during activities such as coughs, sneezes and exercise. Leakage occurs because the pressure on the bladder is greater than the pressure keeping the urethra closed, so urine escapes.
  • Urge urinary incontinence - patients usually complain of urinary frequency, urgency and urge incontinence. It may be that the bladder is overactive and is contracting at inappropriate times, causing a loss of urine.
  • Mixed incontinence - it is not uncommon for patients to have symptoms of both stress and urge.
  • Faecal incontinence - continence physiotherapists also treat patients who leak faeces or flatus, or who have staining of their underwear. This may occur passively or with the urge to defecate.

Referral and assessment
In most cases, a patient will be referred to the physiotherapist by a GP, gynaecologist, urologist or colorectal surgeon.

A comprehensive assessment is undertaken, often lasting an hour. This will include current symptoms and medical history. If the patient consents, a vaginal or anal examination will be done, to look and feel for abnormality and to assess the pelvic floor (and anal sphincters, if appropriate).
 
Physiotherapists strongly recommend this internal examination as, without looking and feeling, it is very difficult to assess pelvic floor function. One study suggested that, when given verbal instruction on how to perform a pelvic floor contraction, up to 25% of women will do it incorrectly.(2) A vaginal assessment would reveal this and allow the therapist to advise the patient on the correct action.

Urinalysis and bladder scan may also be undertaken, and patients are asked to complete a bladder diary to assess bladder function.

Treatment and advice
Following assessment and examination, the physiotherapist will discuss their findings with the patient, and agree on realistic goals and an action plan. Progress can be gradual, so patients should be told that they may not be discharged for some months.

The resources available to the physiotherapist are variable, but treatment may include pelvic floor exercises, biofeedback, weighted vaginal cones and electrical stimulation.

Based on the assessment findings, the patient will be given a full explanation and advised appropriately. This could include how much to drink per day, and what to drink. Also, advice on ways to defer micturition will be given if urinary frequency is a problem.

Pelvic floor exercises
Studies have shown that pelvic floor exercises reduce the symptoms of stress urinary incontinence,(3) as a stronger pelvic floor may improve support for the bladder and increases the closure pressure of the urethra during coughs, sneezes and exercise.
 
Any programme should include exercises for both fast- and slow-twitch muscle fibres (ie, fast hard squeezes and slower, gradual squeezes that can be held for up to 10 seconds. Women with urinary incontinence have also been shown to decrease leakage by squeezing their pelvic floor muscles before coughs and sneezes.(4)

Biofeedback
If available, many physiotherapists use biofeedback to give the patient a means of seeing (or hearing) what their muscles are doing during a pelvic floor contraction. The equipment used can be anything from a simple vaginal probe that responds to pressure and gives a numerical reading, to a sophisticated, computerised system that can show and record pressure or electromyographical (EMG) activity in the pelvic floor. At least one paper has suggested that biofeedback and exercises can be more effective than exercises alone.(5)

Cones
Weighted vaginal cones might also help strengthen the pelvic floor. The patient would probably have to purchase a set herself, as most are not suitable for sterilisation. A cone of suitable weight and size is placed high in the vagina, and the woman contracts her pelvic floor to prevent it from falling out. Cones have also been shown to help activate the muscles in women when a contraction could not be felt during examination.(6) Most manufacturers offer cones of different weight, or hollow cones to which weights can be added as the patient's muscles get stronger.

Electrical stimulation
The physiotherapist can use some form of neuromuscular electrical stimulation in the treatment of urinary or faecal incontinence. This may be done in the physiotherapy department, and home units are also available. The latter allow the patient more regular (possibly daily) treatment.

Stimulation is usually delivered via a vaginal (urinary incontinence in women) or anal (faecal incontinence or urinary incontinence in men) electrode. Different electrical frequencies have been shown to have different effects - 35Hz is often used for stress incontinence as it has been shown to strengthen muscle.(7) It might also help the patient "get the hang of" pelvic floor contractions, after which the exercises alone might be preferred.(8)

For patients with urgency, urge incontinence and urinary frequency, 5-10Hz can be used, as this may reduce symptoms, probably by acting on the highly complex bladder reflexes.(9)

Stimulation (via an anal electrode) plus exercises was shown in one study to be more effective than exercises alone in the treatment of faecal incontinence.(10)

Conclusion
Continence physiotherapists can offer a variety of conservative measures to reduce or cure both urinary and faecal incontinence. They may work privately or for the NHS. The physiotherapy department of any hospital will be able to tell you if they offer such a service.

References

  1. Royal College of Physicians. Incontinence: Causes, management and provision of services: A report by the Royal College of Physicians. London: RCP; 1995.
  2. Bump RC, Hurt GH, Fantl JA, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol 1991;165:322-9.
  3. Berghmans L, Hendriks H, Hay-Smith E, deBie R, van Waalwijk van Doorn E. Conservative management of stress urinary incontinence in women: a systematic review of randomised controlled studies. Br J Urol 1998;82(2):181-91.
  4. Miller J, Ashton-Miller J, DeLancey JOL. The Knack: use of precisely-timed pelvic muscle contraction can reduce leakage in SUI. Neurourol Urodyn 1996;15:392-3.
  5. DeKruif YP, van Wegen E. Pelvic muscle exercise therapy with ­myofeedback for women with stress urinary incontinence: a meta-analysis. Physiotherapy 1996;82:107-13.
  6. Deindl FM, Schussler B, Vodusek DB, Hesse U. Neurophysiologic effect of vaginal cone application in ­continent and urinary stress ­incontinent women. Int Urogynecol J 1995;6:204-8.
  7. Low J, Reed A. Electrical ­stimulation of nerve and muscle. In: Electrotherapy Explained. Oxford: Butterworth Heinemann; 2000: 53-141.
  8. Benton LA, Baker LL, Bowman BR, Waters RL. Functional Electrical Stimulation. California: Rancho Los Amigos Rehabilitation Centre; 1981.
  9. Fall M, Lindström S. Electrical ­stimulation. A physiological approach to the treatment of urinary ­incontinence. Urol Clin North Am 1991;18(2):393-407.
  10. Fynes MM, Marshall K, Cassidy M, Behan M, Walsh D, O'Connell PR, O'Herlihy C. A prospective, ­randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal ­incontinence after obstetric trauma. Dis Colon Rectum 1999;42:753-61.

Resource
Association of Chartered Physiotherapists in Women's Health (ACPWH) can help you find a continence physiotherapist.
Write to: Membership Secretary ACPWH
c/o Chartered Society of Physiotherapy
14 Bedford Row London WC1R 4ED
E:enquiries@womensphysio.com
W:www.womensphysio.com