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Pelvic floor muscle retraining for incontinence

Jeanette Haslam
MPhil GradDipPhys MCSP SRP
Independent Clinical Specialist in Continence and Women's Health
Senior Visiting Fellow
University of East London
T:01434 382504
E:jeanette@thehaslams.net

Both men and women may suffer from incontinence, although women of childbearing years are the ones that are most often surprised by being affected by the condition. Any lack of bladder or bowel control can cause great distress. However, it has been shown that only 25% of women with urinary incontinence have consulted a doctor about it.(1) Pelvic floor muscle re-education is the basis of many treatments and is the main concern of this article.

Prevalence
Incontinence remains a subject that is not considered to be a part of everyday polite conversation despite the fact that there is a high prevalence in the general population. A recent prevalence study conforming to the definitions and standards recommended by the International Continence Society (ICS) concluded that millions of women in Europe have urinary incontinence.(1,2) The questionnaire revealed a UK prevalence of female urinary incontinence of 42%, in comparison with 23% in Spain, 44% in France and 41% in Germany. All healthcare provision planners should consider the implications for care of such numbers of people. Faecal incontinence is widely accepted as affecting 2-5% of the general population.(3)

Department of Health advice
So what is being done? The Department of Health document Good Practice in Continence Services raised the hopes of professionals in continence care that at last something would be done.(4) The advisory document outlined the need for integrated continence services so that anyone with a continence problem was assessed and treated by a seamless service. However, the National Service Framework for older people was mandatory for integrated continence services throughout England by April 2004.(5) Unfortunately, this policy has not been translated into action in many Primary Care Organisations.(6) Meanwhile, specialist continence physiotherapists and nurses strive to provide an evidence-based service to the best of their abilities, to fulfil the needs of clinical governance while alleviating the distress, discomfort and possible humiliation that can accompany incontinence.

Assessment
All those presenting with incontinence problems need a thorough assessment.(7) A private treatment room is essential to allow detailed history taking and physical examination. Due to the sensitive nature of the problem, the interviewer must be empathetic and able to ask questions and receive answers without any sign of embarrassment or discomfort. Practical issues such as providing a first-line screening by a dipstick sensitive to both leucocytes and nitrites to eliminate bacteriuria is essential - especially if a person presents with symptoms of frequency and urgency. Appropriate action can then be taken before commencing any other treatment.
To gain informed consent to physical examination and treatment there must be a full and adequate description to the person of what the examination involves. This must include a full verbal description and use of models and diagrams. Phrases such as "lift and squeeze as though trying to stop yourself passing urine and wind"; "imagine that you are trying to squeeze your vagina as though having intercourse"; "imagine your pelvic floor is a lift in which you close the doors and then lift up to floor one, floor 2, floor 3" may be used.
The physical assessment should include an abdominal, perineal and vaginal/anorectal assessment as appropriate. The whole aim is one of discovering as much information as possible both verbally and physically to determine a patient-centred appropriate treatment regimen for the individual.
If there is any suspicious neurological symptom discovered, a full neurological assessment should be carried out and appropriate referral made if necessary.

Pelvic floor muscle exercises
Pelvic floor muscle exercises (PFMEs) are the mainstay of treatment in the majority of patients. It has been shown that verbal and written instructions alone are insufficient to determine that an adequate PFME is taking place, therefore a physical assessment is essential.(8,9)
Palpation of the pelvic floor muscle (PFM) both establishes that an appropriate PFM contraction is taking place and is used to determine an appropriate exercise regimen. This is done by assessing the PFM for its strength, power, endurance and fatigability.(10) This will include grading the muscle according to the modified Oxford grade, assessing the length of good PFM contractions and the number of times that they can be repeated, as well as the number of short, fast contractions.(11) This way an exercise programme can be determined that is specific for the individual.
After a careful PFM assessment the next most important factor to success is sufficient motivation to encourage compliance with the advice given. The primary problem is one of ensuring that the PFMEs are performed correctly and adequately. To this end, the proposed exercise regimen must fit in with the individual's lifestyle. It is pointless to advise a frequency of exercise that is impossible in a person's life. It is much better to practise three sessions of PFMEs with maximum concentration and effort than many more done in a hurried, nonchallenging fashion.
PFMEs should also be functional in that they are practised in a variety of positions, and so that the person practices "the knack".(12) This means that they always contract their PFM before any activity that increases intra-abdominal pressure, such as coughing, laughing, sneezing or shouting. Usually the aim is for an increasing ability over a period of time to being able to hold a 10-second contraction and be able to repeat it 10 times, followed by 10 short, fast PFM contractions.
In recent years there have been many studies done on the efficacy of using the transversus abdominis to encourage and coactivate the PFM. However, these studies have small numbers in them of mainly continent women. In a recent review of how PFMEs work, it was concluded that at this time there is little to support the use of transversus abdominis for indirect training of the PFM.(13)
 
Other methods of re-educating the PFM
If a person is unable to contract their PFM it will be necessary to initiate a contraction via other means. Neuromuscular stimulation can teach a person the feel of an appropriate PFM contraction, and by joining in with such a stimulated contraction they can regain the ability to use their PFM for themselves.
Those people suffering with an overactive bladder may also have neuromuscular stimulation to assist in normalising regular reflex activity.(14) It is essential that practitioners have knowledge of the correct parameters to be used when using stimulation.
Different forms of biofeedback may also be used to assist in re-educating the PFM. This can be as simple as self- examination or the use of a pelvic floor educator, cones, manometry or electromyography.(15) All of these methods may be useful; the skilled professional ensures that the appropriate modality is used.

Conclusions
It is essential that any health professional assessing and treating people with incontinence problems has a sound knowledge base and appropriate training in both examination and therapeutic techniques. Those involved in the assessment and treatment of people with continence- related problems are in a privileged position in that they are often told facts that the person has never vocalised before. The person with the courage to ask for help deserves to receive the best evidence-based therapy that is available from well-trained professionals.

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References

  1. Hunskaar S, Lose G, Sykes D, Voss S. The prevalence of urinary ­incontinence in women in four European countries. BJU Int 2004;93:324-30.
  2. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of the lower urinary tract function. Neurourol Urodyn 2002;21:167-78.
  3. Kenefick N. The epidemiology of faecal incontinence. In: Norton C, Chelvanayagam S, editors. Bowel ­continence nursing. Beaconsfield: Beaconsfield Publishers; 2004. p. 14-22.
  4. Department of Health. Good Practice in Continence Services. London: DH; 2000.
  5. Department of Health. National Service Framework for older people. 2001. Available from: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/Publications...
  6. Thomas S. Is policy translated into action? London: Continence Foundation; 2003.
  7. Laycock J. Patient assessment. In: Laycock J, Haslam J, editors. Therapeutic management of ­incontinence and pelvic pain. London: Springer; 2002. p. 85-9.
  8. Bø K, Larsen S, Oseid S, Kvarstein B, Hagen R, Jorgenson J. Knowledge about and ability to correct pelvic floor muscle exercises in women with urinary stress incontinence. Neurourol Urodyn 1988;7:261-2.
  9. Bump RC, Hurt WG,Fantl JA, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol 1991;165:322-7.
  10. Haslam J. Pelvic floor muscle ­exercise in the treatment of urinary incontinence. In: Laycock J, Haslam J, editors. Therapeutic management of incontinence and pelvic pain. London: Springer; 2002. p. 63-6.
  11. Laycock J. Patient assessment. In: Laycock J, Haslam J, editors. Therapeutic management of ­incontinence and pelvic pain. London: Springer; 2002. p. 45-54.
  12. Miller J, Ashton-Miller J, DeLancey J. A pelvic muscle ­pre-contraction can reduce cough related urine loss in selected women with mild SUI. J Am Geriatr Soc 1998;46:870-4.
  13. Bo K. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Int Urogynecol J Pelvic Floor Dysfunct 2004;15:76-84.
  14. Laycock J, Vodusek DB. Electrical stimulation. In: Laycock J, Haslam J, editors. Therapeutic management of incontinence and pelvic pain. London: Springer; 2002. p. 85-9.
  15. Haslam J. Biofeedback for pelvic floor muscle dysfunction. Urol News 2002;6:16-7.

Resources
Association for Continence Advice
www.aca.uk.com
Continence Foundation
www.continence-foundation.org.uk
International Continence Society
www.icsoffice.org
Incontact
www.incontact.org

Further reading
MacLean AB, Cardozo L. Incontinence in women. London: RCOG Press; 2002
Pemberton JH, Swash M, Henry MM. The pelvic floor: its function and disorders. London:Harcourt; 2002