Urinary Incontinence

There are five types of Urinary Incontinence

Stress Urinary Incontinence
Over Active Bladder, Urgency with or without Urge Incontinence
Mixed Urinary Incontinence
Overflow Incontinence
Functional Incontinence

Bladder management problems have a major impact on women's quality of life, work, social and sexual activities.
It is important to remember that you are not alone if you have incontinence issues.

4.8 million Australians suffer from incontinence
65% of women and 30% of men sitting in a GP waiting room have some form of incontinence
70% of people with urinary leakage do not seek advice and treatment for their problem
1 in 3 Australian women suffer from urinary incontinence

43% of subjects with incontinence and prolapse depressed their pelvic floor on ultrasound when instructed to lift (straining strategy) (Continence Foundation of Australia)

There are three types of Urinary Incontinence that we treat at Innovative Physio/Pilates

Stress Urinary Incontinence
Over Active Bladder, Urgency and or Urge Incontinence
Mixed Urinary Incontinence

New ICS (International Continence Society) Publication - The Unspoken Impact of Urinary Incontinence amongst Women

14 August 2014 by Sophie Mangham http://www.ics.org/news/316

YouTube video of Gill Smith, Innovative Physio, Women’s Health Physiotherapist and Luisa , mother of 2 and client of Innovative Physio discussing the importance of pelvic floor health and awareness.

https://www.youtube.com/watch?v=pDRvYQQMRMA

Stress Urinary Incontinence (SUI)

Stress Urinary Incontinence (SUI) is defined as involuntary loss of urine on effort or physical exertion or on sneezing or coughing. (ICS International Continence Society 2013)
The International Continence Society is a registered charity with a global health focus which strives to improve the quality of life for people affected by urinary, bowel and pelvic floor disorders by advancing basic and clinical science through education, research, and advocacy.
SUI is the most common form of incontinence for which women seek medical attention.
SUI occurs where the abdominal pressure exceeds the bladder pressure and urine can escape

Who is at risk?

Pregnant and postnatal women
Women who have ever had a baby
Menopausal and post menopausal women
Women post gynaecological surgery
Elite athletes
Women involved in excessive strength based fitness regimes
Adolescent girls involved in high levels of activity eg competitive gymnastics, dance, ballet and trampolining.

This risk is higher if they have;

History of back pain
Experienced injury to their pelvic area
Sedentary jobs causing weakness of the deep stabilising muscles
Constipation and strain regularly to empty bowels
A chronic cough or sneeze (e.g. due to smoking, asthma or hay fever)
Overweight
Done regular heavy lifting (eg at the gym or as part of their job or lifting children)

SUI can be the direct result of pregnancy and vaginal delivery. Pelvic floor muscles, fascial connective tissue and nerves can be overstretched through pregnancy and vaginal delivery resulting in a less functioning support of the pelvic organs, which includes the bladder.
The Good news is that in 2010 the Cochrane Collaboration (which puts all relevant studies together) published a review, Pelvic floor muscle training vs. no treatment, or inactive control treatments for urinary Incontinence in women, which analysed the effectiveness of pelvic floor strengthening in stress and urge incontinence.
The conclusion of this analysis was the strongest level of evidence available, which is Level 1/Grade A evidence that pelvic floor strengthening should be offered as the first line of treatment for Stress Urinary Incontinence.
In Britain the National Institute of Health recommends that all women with SUI considering surgery should undertake pelvic floor strengthening education from a Pelvic Floor Post Graduate trained Physiotherapist. Those clients who are unable to effectively strengthen their pelvic floor muscles to significantly reduce the symptoms of SUI are then considered for surgery.

How do we treat Stress Urinary Incontinence?

Management strategies may include

real-time ultrasound biofeedback to teach optimal motor control of the pelvic floor muscles
teaching pelvic floor muscle contraction and strengthening correctly via vaginal examination
pelvic floor strength exercise program
education on how to maximise the function of the pelvic floor muscles in everyday life by connecting to the abdominal cylinder muscles commonly referred to as ‘The Core.’
teaching the correct timing of the PFM to stop leakage with a cough or sneeze referred to as ‘ The Knack’
clinical pilates program to help bridge the gap between pelvic floor exercises and day to day function
discussion of lifestyle change to help best manage the problem
looking how diet and fluid intake may influence their problem
management strategies for constipation as this can contribute to SUI
optimal defecation dynamics

Pelvic disorders plague female triathletes

Women who compete in triathlons are at increased risk of pelvic floor disorders, including incontinence, according to a study presented at a July meeting of the American Urogynecologic Society and International Urogynecological Association.
The Findings are the result of a nationwide web-based survey of 311 female triathletes aged 18 and over conducted by Dr Johnny Yi from Chicago’s Loyola University Health System. The research revealed that 37 percent of the female triathletes experienced stress urinary incontinence, while 16 percent experienced urgency incontinence. 5 percent experienced pelvic organ prolapse and 37 percent experienced anal incontinence. 18 percent of respondents had pelvic girdle pain, with higher levels for those with stress urinary urgency incontinence, and anal incontinence. Dr Yi said “doctors should be aware of how common these conditions are in this group of athletes and treat patients appropriately to avoid long-term health consequences.

This article was originally published in http://www.continence.org.au/data/files/Bridge_2014/Bridge_spring_2014_web.pdf

Prevalence study of stress urinary incontinence in women who perform high-impact exercises.

Celina Fozzatti C , Riccetto C, Herrmann V, Brancalion MF, Raimondi M, Nascif CH, Marques LR, Palma PP. Int Urogynecol J 2012; 23: 1687-1691.
We at Innovative Physio Pilates encourage you to read this fascinating article of how performing high impact exercise can be a risk factor equal to pregnancy and childbirth in developing stress urinary incontinence (SUI). Misguided heavy exercise can damage the pelvic floor due to excessive increases in intra abdominal pressure leading to unwanted SUI. Our team at Innovative Physio are passionate about teaching women the importance of the functional anatomy and whole body biomechanics to maximise pelvic floor awareness and optimal recruitment whilst exercising, encouraging appropriate exercise regimes.
We promote pelvic floor safe exercise.

http://www.canadiancontinence.ca/EN/research-studies/prevelence-of-sui-in-women-who-perform-high-impact-exercises.php

Urge Incontinence (Overactive Bladder)

New ICS Publication - The Unspoken Impact of Urinary Incontinence amongst Women.
14 August 2014 by Sophie Mangham
http://www.ics.org/news/316

Overactive bladder (OAB), Urgency with or without Urge Incontinence.

Overactive bladder (OAB) is a syndrome characterized by symptoms of urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia (increased night time urination). The term OAB can only be used if there is no proven infection or other obvious pathology.

OAB affects about 12% of both men and women. The incidence increases with
advancing age and affects between 70-80% of people by the age of 80. More women than men exhibit incontinence, but, overall, 33% of patients have OAB with urgency incontinence (“OAB wet”), while 66% have OAB without urgency incontinence (“OAB dry”). OAB is a bothersome condition that negatively affects quality of life and can lead to social isolation.

OAB also has significant psychological and financial consequences, and may be associated
with increased morbidity and mortality in the elderly.

Symptoms

Urgency is the sudden, compelling desire to pass urine which is difficult to defer
Urgency urinary incontinence is the complaint of involuntary leakage of urine that is accompanied by or immediately preceded by urgency.
Frequency denotes voiding too often during waking hours. In clinical trials, this has generally been defined as urinating more than 8 times in a 24 hour period. The new ICS definition does not specify a particular figure, as an increase in the day time frequency is a subjective matter that can be confirmed by a bladder diary.
Nocturia refers to the patient waking due to the need to void.
Detrusor overactivity (DO) is a diagnosis made after urodynamics, clinical studies of bladder function. Such testing demonstrates involuntary detrusor contractions during bladder filling. While OAB is a clinical diagnosis, DO occurring spontaneously or by provocation, is a urodynamic diagnosis that may or may not be associated with OAB.
The majority of people with OAB are thought to have detrusor overactivity (DO): 69% of
men and 44% of women with urgency but no incontinence have DO, while 90% of men
and 58% of women with urge urinary incontinence have DO.

(ICS International Continence Society 2013)

The International Continence Society is a registered charity with a global health focus which strives to improve the quality of life for people affected by urinary, bowel and pelvic floor disorders by advancing basic and clinical science through education, research, and advocacy.
The Good news is that in 2010 the Cochrane Collaboration (which puts all relevant studies together) published a review, Pelvic Floor Muscle Training vs. No Treatment, or inactive Control Treatments for Urinary Incontinence in Women, which analysed the effectiveness of pelvic floor strengthening in stress and urge incontinence.
The conclusion of this analysis was the strongest level of evidence available, which is Level 1/Grade A evidence that pelvic floor strengthening should be offered as the first line of treatment for Urge Incontinence.

How do we treat Overactive Bladder (OAB?)

complete a bladder diary over 3 days
recommend urinalysis (dipstick) to rule out infection. This should be done at your local GP.
real-time ultrasound biofeedback to teach optimal motor control of the pelvic floor muscles
teaching pelvic floor muscle contraction and strengthening correctly via vaginal examination
pelvic floor strength exercise program
education on how to maximise the function of the pelvic floor muscles in everyday life by connecting to the abdominal cylinder muscles commonly referred to as ‘The Core.’
clinical pilates program to help bridge the gap between pelvic floor exercises and day to day function
discussion of lifestyle change to help best manage the problem
looking how diet and fluid intake may influence their problem (reducing the amount of caffeinated drinks)
bladder training (cognitive behavioural therapy)
relaxation of pelvic floor muscles
optimal defecation dynamics

Bladder Training

The aim of bladder training is to restore the normal function of your bladder.
When you do bladder training you are aiming at:

successfully suppress an unwanted bladder urge
decrease the number of times you are going to the toilet
increase the amount of urine you pass each time around 300mls
Hold on for longer or put off emptying your bladder.

The normal bladder can hold between 600-800 mls. It is usual to empty the bladder around 6 times per day. It is normal to make it to the toilet without rushing, or to be able to put off emptying the bladder if it is not convenient for you.

You have the ability to make your brain the boss of your bladder.
Generally it will take 4-6 physiotherapy sessions to cover all of the above. Sessions will vary from a 60 minute appointment to a 30 minute appointment.
It is a fantastic feeling to suppress a bothersome bladder urge whilst putting the key in the front door and calmly do a lap of the house before deciding whether or not the bladder needs emptying.

Mixed Urinary Incontinence

Mixed Incontinence:

Refers to the presence of both stress and urge incontinence. For example, someone has the combination of stress incontinence (leaking with coughing, sneezing, exercise, etc.) and urge incontinence (leaking enroute to the toilet, or leaking when putting the key in the front door), this is known as mixed urinary incontinence. Often, a woman may first experience one kind of leaking, and finds that the other begins to occur later.
The continence team at Innovative Physio/Pilates will treat Urgency and Urge Incontinence in the following manner

Screen client for Urinary Tract Infection (UTI) as this condition can cause bladder urgency and urge incontinence. A visit to the GP to get a midstream urine test ruling out any infection or treating as appropriate.
Bladder diary to record the frequency and volume of urinating during the day and night
Accident diary to record any episodes of incontinence
Record fluid and caffeine intake to assure within normal levels
Real time ultrasound screening of Pelvic Floor Muscle contraction checking for the correct motor control pattern
Vaginal examination to asses strength of the pelvic floor muscle
Prescribe a Pelvic Floor muscle strengthening program that is unique to the client
Bladder retrain to achieve urge suppression and make your brain the boss of your bladder
Functional application of the Pelvic Floor Muscles – bringing the pelvic floor muscles into function