Women's Health- Incontinence

Question 1

Brief Screen questions (3)

Answer 1

• Do you ever leak urine or feces?
• Do you ever wear a pad because of leaking urine?
• Do you have pain during intercourse?

Question 2

Full Screen: Stress Incontinence

Answer 2

• Do you leak urine when you cough, laugh or sneeze?
• Do you lose urine when you lift heavy objects such as baskets of wet clothes or furniture?
• Do you lose urine when you run, jump or exercise?

Question 3

Full Screen: Urge Incontinence

Answer 3

• Do you ever have such a uncomfortable strong need to urinate that you leak if you don’t reach the toilet, Do you sometimes leak with this strong urge?
• Do you develop an urgent need to urinate when you hear running water?
• Do you develop an urgent need to urinate when you are nervous, under stress or in a hurry?
• When you’re coming home can you usually make it to the door, but then you lose urine just as you put the key in the lock?
• Do you have an urge to urinate when your hands are in cold water?

Question 4

General Screening pelvic floor screening

Answer 4

• Do you find it necessary to wear a pad because of leakage?
• Does your bladder awaken you from sleep? How many times each night?
• How often do you leak urine or feces?
• How often do you inadvertently leak gas?

Question 5

Pelvic Organ Prolapse; Overactive PFMs, incoordination, obstruction or urinary retention

Answer 5

• Do you ever feel as though you are “sitting on a ball” or that there is something in the way when you’re sitting?
• Do you ever feel as though something is “falling out” of your perineal area?

Question 6

Symptoms of Obstruction

Answer 6

• Do you find it hard to begin urination?
• Do you have a slow urinary stream?
• Do you strain to pass urine?

Referral required

Question 7

Pelvic pain Questions

Answer 7

• Do you have pain during vaginal penetration, including intercourse, insertion of a tampon or vaginal examination?
• Do you have pelvic pain with sitting, wearing jeans or bike riding?

Needs specialist therapist (PT)

Question 8

What are two typical patient responses to urinary incontinence that may actually perpetuate or worsen the problem?

Answer 8

• Embarrassment and avoiding to talk with a healthcare provider about this problem that could also be associated with pelvic, perineal or genital pain. It makes it difficult to explain the reasons for activity limitations if pt do not disclose the location or the nature of pain. This perpetuates the problem and causes increased emotional stress.
• Disuse and decreased awareness of PFMs and abdominals lowers the chance of seeking help and trying to solve the problem (ex. Children brought up with the concept that genitalia is not to be touched or explored)

Question 9

Principles of strengthening to the PFM’s when designing a treatment for impaired PFM performance.

Answer 9

• Follow the principles of overflow (challenge the muscle at its fullest to improve strength) and specificity (exercise muscles correctly in isolation)
• Progress exercise from the appropriate level for each pt. If initially able to hold 3 sec. Progress to 3-4 sec hold, to max 8-12sec
• Twice as much rest as hold time is advised for a weak muscle; make sure they relax completely between contractions
• # of repetitions depends on how many the patient is able to perform before fatigue at evaluation
• Quick contractions (hold <2 sec), also progressed based on how many pt is able to perform at initial eval
• 3-4 sets/day up to 30-80 pelvic floor contractions per day
• Facilitation and overflow from the abdominals, adductors and gluteals should be encouraged for patients with 0-⅖ PFM strength, but at 3/5 pt. Should learn to isolate PFM and contract without the help of accessory muscles

Question 10

Sample Exercise prescription: strengthening of PFM

Answer 10

• Duration of endurance muscle contraction:5 sec
• Rest between endurance muscle contraction: 10 sec (double)
• Repetitions of endurance muscle contraction: 5X
• Repetitions of quick muscle contractions: 10X
• Sets/day: 4-6
• Position: gravity eliminated: supine or side-lying
• Accessory muscle use: not at this time

Question 11

Redundancy in anatomical and physiological mechanisms that help preserve continence. (12)

Answer 11

1. Perineal membrane -Compressor urethra, Urethrovaginal sphincter, Sphincter urethra
2. Supportive role of PFMs- resting tone
3. Neurologic innervation (S2 -S4 and pudendal nerve)
4. External and Internal Anal/Urethral Sphincter tone and reflexes- both autonomic and voluntary control of sphincters
5. Central Nervous System Integrity
6. Puborectalis- fecal continence- colorectal angle
7. Organ position relative to outlet position
8. Increased tone in response to increased IAP (intraabdominal pressure)
9. Proximal urethra is within the IAP pressure zone
10. Reflex inhibition of detrusor in response to PF contraction
11. Compliance/ relaxation of detrusor to allow filling
12. Spongy, viscoelastic urethral walls (related to estrogen levels)

Question 12

PFM Screening questions can also be categorized as

Answer 12

• Hyopactive
• Hyperactive

Question 13

Hypoactive screening questions

Answer 13

1. Do you leak urine when you cough, laugh or sneeze
2. Do you lose urine when you lift heavy objects such as baskets of wet clothes or furniture?
3. Do you lose urine when you run, jump or exercise?
4. Do you ever have such a uncomfortable strong need to urinate that you leak if you don’t reach the toilet? Do you sometimes leak with this strong urge?
5. Do you develop an urgent need to urinate when you hear running water?
6. Do you develop an urgent need to urinate when you are nervous, under stress or in a hurry?
7. When you’re coming home can you usually make it to the door, but then you lose urine just as you put the key in the lock?
8. Do you have an urge to urinate when your hands are in cold water?
9. Do you find it necessary to wear a pad because of leakage?
10. Does your bladder awaken you from sleep? How many times each night?
11. How often do you leak urine or feces?
12. How often do you inadvertently leak gas?
13. Do you ever feel as though you are “sitting on a ball” or that there is something in the way when you’re sitting?
14. Do you ever feel as though something is “falling out” of your perineal area?

Prolapse included in hypoactive

Urge incontinence is a nerve problem but the nerve problem affects the muscles

Question 14

Hyperactive screening questions

Answer 14

• Do you ever feel as though you are “sitting on a ball” or that there is something in the way when you’re sitting?
• Do you have pain during vaginal penetration, including intercourse, insertion of a tampon or vaginal examination?
• Do you have pelvic pain with sitting, wearing jeans or bike riding?

The prolapse questions also could pertain to this too bc sitting on the ball could be the muscles

Question 15

When to refer pts with incontinence issues?

Answer 15

• Signs of obstruction
• Doesn’t respond to behavioral or front line interventions

Question 16

What is the gold standard for pts with PFM issues?

Answer 16

Internal examination

PTs need dditional training to be able to do this

Question 17

How to perform an External Examination

Answer 17

External palpation- Pts do not have to take off their pants

• Patient in a side-lying position palpate up between ischial tuberosities as the patient contracts
• Should feel a lift up or lift away from your hand
• If you don’t feel anything, you could change your explanation around, move your hands (you may be in the wrong spot), pt may be too weak for you to feel a palpable contraction
• Pt may be performing a valsalva (common mistake)

Question 18

How to teach pt to perform a self assessment

Answer 18

• Have pt pt their hand on their pelvic floor
• Can do external or a digital self assessment
  
  • Duration, number of reps, slow, number of reps, fast
• Jumping Jack test
  
  • Do 5 jumping jacks, if no leakage, wait an hour and a half and do 5 more
  • Pt should be able to do 5-10 jumping jacks in 2-3 hours without leaking
  • Only for advanced patients

Question 19

Different ways to perform Biofeedback

Answer 19

• Pressure biofeedback- Insert into vagina and number registers
  
  • Good for home use and to monitor how exercises are going
  • Disadvantage when compared to electrical: gives a reading even if you are just bearing down (valsalva)
• EMG Biofeedback
  
  • Vaginal probe but has electrical sensors on it that pick up on the electrical sensory actions of the pelvic floor muscles
  • More likely to register very weak contractions which can be very important bc if they are that weak, often times patients can’t feel if anything is happening at all
• RUSI (ultrasound imaging)

Question 20

Typical responses- When patients begin to notice leakage (when it starts to be problematic)

Answer 20

• Decrease their fluid intake (worried about wetting themselves so they won’t drink much and can then eventually reset the bladder capacity)
  
  • Urine is really concentrated which can increases the urge to go (almost like a bladder irritant)
• Going to the bathroom all of the time
  
  • Trying to keep bladder empty
  • Not a good thing bc it also retrains the bladder to the small capacity so that the bladder forgets that it needs to hold urine

Question 21

Behavioral interventios for pts with PFM issues

B- CoP²ED²

Answer 21

• Biofeedback
• Coordintion training
• Pelvic floor exercises
• Postural training
• E-stim
• Decrease IAP
• Down training of overactive mucles

Question 22

What does Pelvic Floor Exercises include?

Answer 22

• Must include contraction and relaxation
  
  • Risk of pts going crazy with exercises and then leads into hyperactive down the road
• Cue to contract all PFM’s together
  
  • Doesn’t matter which layer you are contracting, just think about contracting the whole thing
• Don’t valsalva
  
  • With pelvic floor contraction or instead of pelvic floor contraction
• Overload
  
  • Progress so that it is always a challenge
  • If you aren’t challenging the muscles you will never get them stronger
• Use overflow only if necessary but wean
  
  • If pt has one muscle that’s weak, they may have trouble initiating a contraction so if you can find a muscle that’s strong that usually works with it, you may use it to start the contraction of the weak muscles
  • Adductors or gluteals (squeeze the ball and try to involve the pelvic floor in the same contraction)
  • May not want to do abdominals bc it increases IAP, this is bad for someone that is already weak
• Isolate then integrate
  
  • Integrate into functional activities
  • Functionally the pelvic floor works with abdominals, hips, etc.
• Exercise rx should be specific to patient’s abilities
  
  • If someone can only do 3 contractions, don’t make them do 10
  • The last 7 aren’t helping them, they can be frustrating and it can hurt them
    
    • They may start using other muscles, forming bad habits
    • Leaks may increase bc pt is fatiguing the muscles too much during exercises that when they need to hold their urine, they can’t

Question 23

Specific Rx for pelvic muscles should include:

Answer 23

• Duration: for endurance
  
  • Holding a contraction
• Rest: completely; 2:1 progressing to 1:1 (rest:contraction)
  
  • Important bc these are really little muscles
• Slow reps: 3-second contractions
• Fast reps: less than 2 second contractions
  
  • Quick Flicks
• Sets: 5-6 times per day, 30-80 total/day
• Position: inverted on wedge, to supine, to wedged the other way, to sitting, to standing, to function.
  
  • This will shift organs away from the pelvic floor and gravity will help muscle
    
    • Inversion is a gravity assisted position
• Accessory muscle use: only if no other way
  
  • Overflow
  • Use it if you have to

Beware of over fatigue bc it can increase symptoms

Question 24

Some poins about using E-stim (3)

Answer 24

• If someone is very weak, they may need stimulation to get the muscle contraction started
• Typically a specialist does this
• Painful

Question 25

Bladder Training: How to teach pts skills to retrain their voiding habits and fluid intake

Answer 25

Begin with baseline from bladder diary * Average voiding interval * Bladder irritants, fluid intake * Dilute with water * Pt drinks whatever they want but drink the same amount of water in between * Urge deferment * Try to wait 5 more minutes * Don’t tell pt to wait 3 hours (if pt voids every hour) * Pelvic floor contractions, keeps pts mind occupied (think of something else like counting backwards), breathing, relaxing, walk don’t run

Question 26

How to decrease IAP **(ALLS)**

Answer 26

* **A**ddress chronic cough * **L**ose weight * **L**axatives if they are constipated * **S**witch to cardio vs. weight lifiting

Question 27

Coordination training

Answer 27

“the knack”- squeeze before you sneeze Automatic for us, it’s a reflex

Question 28

What does the evidence say about behavioral interventions vs Surgery (3)

Answer 28

* Surgery success rate is high at first but then not so much bc of the boat thing * If you still have no pelvic floor to hold the boat up the repair will detiorate * Behavioral intervention will help the surgery last longer

Question 29

How to downtrain overactive muscles

Answer 29

Contract maximally then relax

Question 30

What is the biggest issue with training

Answer 30

Adherence (Apps, reminders, etc.)

Question 31

Urinary Incontinence: Is it really a big deal? basic facts

Answer 31

* Involves men and women * 10 million in America * Mostly women (13-25% of American women) * Exact number depends on how you define it

Question 32

Why does urinary incontinence cost so much?

Answer 32

* Costs 10.3 billion dollars annually * Medical visits (PT’s, OBGYN, urologists) * Purchase of supplies (diapers and pads) * Pads are much more common * Now more marketed towards people with incontenince not just periods * People try to hide it so they use more and more pads * Surgery * “Female surgery” * Medications * Usually a first line of defense especially with people with urge incontinence * Something you stay on forever and ever

Question 33

True / Flase- Urinary incontinence only affects older people

Answer 33

False it Doesn’t affect just older women * 1/3 of 450 female soldiers reported “problematic incontinence” * 31% of undergraduates, including varsity athletes, reported urinary incontinence

Question 34

True/False people witth incontinence and nocturia are more likely to suffer falls.

Answer 34

True they are 3 times more likely to fall * KAPOW! Hip fracture * Especially in the elderly with osteporosis

Question 35

How does incontinence problems spiral as far as activity and socialization?

Answer 35

* Start with little leaks and then gets worse * Turns into larger or more frequent leaks * Begins to drive where you will go? * How easy are the bathrooms to get to? * Tends to drive what you will drink or not drink * Scared of odor so you don’t go out * If you notice it happens when you exercise then you cut back on your exercise and it makes everything worse

Question 36

what % of women with UI could be helped with behavioral intervention?

Answer 36

* 80% of women -PT’s can help with this * Pts could use muscle background as well as modalities in contrast to medications and surgery

Question 37

Functional Incontinence

Answer 37

Mostly affect the transition phase * Loss of urine because of gait and locomotion impairment. * Long or difficult trip to the toilet with leaking on the way. * Incontinence is a secondary condition in pure functional incontinence. **Primary impairment:** gait and locomotion impairment and inability to get to the toilet quickly enough. **PT Treatment:** gait and locomotion and adjustment of the environment can improve function.

Question 38

Stress Incontinence- sometimes called urethral hypermobility

Answer 38

* Small urine leak with cough, sneeze, exercise * In stress incontinence, pt laughs, abdominal cavity pressure increases placing pressure on bladder. If urethral pressure is low the urethra is forced open slightly, a small amount of urine leaks out **Cause of SI-** similar to cause of underactive PFM Impaired body functions include: * Impaired PFM performance * Shortened endurance * Coordination impairments **Treatment** * PFM exercises * Vaginal weights * E-Stim

Question 39

Types of urinary incontinence

Answer 39

* Stress * Urge * Mixed * Functional * Overflow

Question 40

Urge Incontinence- sometimes called overactive bladder syndrome

Answer 40

* Largely about triggers * Moderate / large urine leaks with strong urge to urinate * The underlying cause of urge incontinence is often unclear and may include PNS and CNS nerve damage. * Linked to poor bladder habits (going frequently to the bathroom) and bladder irritants (coffee, nicotine, alcohol) * PFM weakness with impaired muscle performance and endurance impairment is often found in these pts. Primary tx for urge incontinence can include: * Bladder retraining * Avoiding bladder irritants, * PFE * Low frequency E-stim and * Medications

Question 41

Mixed Incontinence

Answer 41

* A combination of stress & urge incontinence symptoms and is thought to be a progression of incontinence symptoms over time. * Pts report leaking urine with increases in intra-abdominal pressure and with a strong urge to urinate. **Causes:** similar to the causes of underactive PFMs. * The PFMs are usually weak. **Treatment:** similar to urge incontinence- * Bladder incontinence * Avoiding bladder irritants * PFM exercises * E-stim * Vaginal weights, and in some cases medications.

Question 42

Overflow incontinence

Answer 42

* Results from failure to empty the bladder fully. * Small amounts of urine leaking constantly with cough and sneeze, straining to start urinating, feeling of incomplete emptying. **Obstruction is caused by:** * Tumor, * Scar tissue around the urethra * Enlarged prostate * Overactive PFM, or * other mechanical blockage * Decreased contractility of the bladder from a ***neurological deficit,*** such as peripheral nerve injury assoc. with radical pelvic surgery, cauda equina injury, or diabetes, also may contribute to overflow incontinence. * Pt impairments may include pain and altered tone from spasm of the PFMs. Mobility impairment may be caused by adhered scars. * Many cases involve neurologic incoordination of the PFMs or primary visceral dysfunction and require medical intervention. * A full medical evaluation is essential. Therapists should refer pts to the doctor if overflow incontinence is suspected. * PT treatment by pelvic floor specialists may include biofeedback, E-stim, myofascial release, PFEs and bladder training

Question 43

Cause of stress incontinence

Answer 43

similar to cause of underactive PFM: Impaired body functions include: * Impaired PFM performance * Shortened endurance * Coordination impairments

Question 44

Primary treatment of urge incontinence

Answer 44

* Bladder retraining * Avoiding bladder irritants * PFE * Low frequency E-stim and * Medications

Question 45

Treatment of stress incontinence

Answer 45

* PFM exercises * Vaginal weights * E-Stim

Question 46

Components of bladder fitness

Answer 46

* Go every 3-4hrs * Go 5-7X in 24hrs * Go for at least 8 secs (8 mississippi) * No JIC- Just in case * No straining * Sit on toilet * Drink enough water- 64 oz or 1/2 body weight in oz * Avoid constipation * Avoid bladder irritants * Go before and after sex * Abdominal strengtening exercises * Kegel's