W e s te r n Au s t ra l i a

Oncology
Menopause
Endometriosis
New Mothers

Pelvic Floor Physiotherapy for the

Management of Incontinence

Kealy France
Continence and Women’s Health Physiotherapist
 Overview
•  Role of a Continence and Women’s Health Physiotherapist
•  Function of the Pelvic Floor Muscles
•  Pelvic Floor Muscle Dysfunction
o Bladder and Bowel Symptoms

•  Risk Factors for Pelvic Floor Muscle Dysfunction

•  Urinary Incontinence
o Stress, Overactive Bladder Syndrome/Urgency Urinary Incontinence, Overflow Incontinence
o Pathophysiology, Function of Pelvic Floor Muscles, Physiotherapy Assessment and Management, Evidence

•  Anal Incontinence
o  Pathophysiology, Function of Pelvic Floor Muscles, Physiotherapy Assessment and Management, Evidence

•  Questions?
 Continence and Women’s Health
Physiotherapy
•  Post graduate qualification – Curtin University
•  Assessment and Treatment of Pelvic Floor, Bladder and
Bowels

•  Incontinence •  Bowel Dysfunction

o Urinary and Anal o Constipation
o Men, Women, Children o Defecation dysfunction
•  Pain •  Pelvic Organ Prolapse
o Pelvic Girdle •  Antenatal and Postnatal
o Dyspareunia o Exercise and pelvic floor muscle training
o Pain conditions – Chronic pelvic pain, vaginismus o Perineal treatment, caesarean scar treatment
•  Bladder Dysfunction o Breastfeeding – blocked ducts, mastitis, cracked nipples
o Urgency, frequency, nocturia o Musculoskeletal complaints – LBP, Pelvic girdle pain
o Poor voiding dynamics •  Men
o Incomplete emptying o Prostatectomy and BPH
o Reduced sensation/urge to void o Pre and post operative PFMT
 Function of the Pelvic Floor Muscles
•  Continence and evacuation
o Bladder
o Bowel

•  Support
o Pelvic Organs

•  Stability
o Lumbo-pelvic system

•  Control of Intra-abdominal Pressure

•  Sexual Function
o Arousal
o Performance
 Pelvic Floor Muscle Dysfunction
•  Bladder Symptoms
o Urinary Incontinence
o Bladder storage issues – frequency, nocturia, urgency, OAB syndrome
o Sensory – bladder sensations increased, decreased or absent
o Voiding difficulties – hesitancy, slow stream, dysuria, post micturition dribble
o Lower urinary tract infection – UTI, recurrent UTI and haematuria
o Prolapse

•  Bowel Symptoms
o Ano-rectal Incontinence
o Defecation difficulties/constipation
o Urgency
o Prolapse
o Pain
 Risk factors for Pelvic Floor Muscle
Dysfunction
•  Female •  Family History
o Pregnancy •  Ethnicity and race (environmental component)
o Childbirth •  Co-morbidities
o Menopause
•  Physical activity
o Gynaecological surgery
•  Caffeine use and carbonated drinks
•  Age
•  Smoking
•  Obesity
•  Chronic cough
•  Lower urinary tract symptoms
•  Chronic constipation and straining
•  Prostatectomy
•  Functional Impairment

(ICS 2013)
Types of Incontinence
 Stress Urinary Incontinence
Definition
•  Complaint of involuntary loss of urine on effort or physical exertion, or with sneezing and coughing.
•  Activity related incontinence.
•  Observation of involuntary leakage from the urethra synchronous with effort or physical exertion, or with sneezing and
coughing.

•  Most common type of urinary incontinence in women

o Accounts for 49-60% of UI in women < 55 years

(Haylen et al 2010 IUGA/ICS Terminology; ICS 2013)

 Stress Urinary Incontinence
Pathophysiology
Multiple theories:
•  Hammock Theory (DeLancey 1994)
•  Integral Theory (Petros and Ulmsten 1990)
•  Intrinsic Sphincter Deficiency (ICS 2013)
•  Urethral hypermobility (Enhorning 1961)

•  International Continence Society 2013 recommends that SUI likely a continuum between intrinsic sphincter deficiency
and hypermobility.

•  SUI is associated with:

o Striated muscle mass and function deterioration (Level 1 Evidence)
o Pudendal nerve dysfunction (Level 1 Evidence)
o Urethral mucosa and sub-mucosa vascularisation
o Intrinsic urethral smooth muscle dysfunction
o Urethral mobility issues (Level 2 Evidence)

(ICS 2013)
 Stress Urinary Incontinence
Risk Factors
•  Age
•  Pregnancy – parity
•  Childbirth
•  Menopause
•  BMI – high
•  Constipation
•  Coughing
•  Low back/Pelvic Pain
•  Gynaecological surgery
•  Heavy lifting/manual tasks

(ICS 2013)
 Stress Urinary Incontinence
Role of the Pelvic Floor Muscles
•  Activation of pelvic floor muscles (PFM) prior to and during increases in intra-abdominal pressure = urethral
compression = increased urethral pressure (DeLancey 1988).

•  Upward and anterior displacement of pelvic floor supports the urethral and bladder neck position (Thompson et al 2003, Bo 2001).

•  Pelvic floor muscle training (PFMT) improves the resting tone and shortens the levator ani (Doumullin et al 2007).

•  External urethral sphincter hypertrophy is achieved with PFMT (Madill et al 2011)

 Stress Urinary Incontinence
Pelvic Floor Muscle Dysfunction
•  Decreased PFM tone and maximal strength
•  Decreased endurance and speed of contraction
•  Altered neuro-motor control
o Decreased reflexive activation of PFM
o Decreased reflexive co-activation of TA
o Decreased cortical control
(Morin et al 2004; Verelst et al 2004; Barbic 2003, Devreese 2004)

Goals of Pelvic Floor Muscle Training

•  Strengthen PFM
•  Achieve hypertrophy of PFM and external urethral sphincter (increase resting tone and structural support)
•  Improve the timing and automatic recruitment
(Bo 2014; ICS 2013)
 Stress Urinary Incontinence
Physiotherapy Assessment
•  Identify causative/contributing factors
•  PFM function – VE +/- RTUS
•  Real time Ultrasound
o Elevation
o Relaxation
o Endurance
o Timing/fast
o Functional activation (sit-up, ASLR)
•  Vaginal Examination – PERFECT
o Tone, POP, fascial defect, specificity of contraction, timing
•  EMG/Peritone
 Stress Urinary Incontinence
Physiotherapy Management
•  Education
o PFM A&P, role of PFM in SUI, pathophysiology of SUI, identification of risk factors
•  Bowels
o Optimise stool consistency – Type 3-4 BSS, dietary and fluid modification, laxative or fibre supplements
o Eliminate straining – defecation dynamics, splinting
•  Exercise Modification
o Low impact ideally
o Pelvic floor friendly
•  Pelvic Floor Muscle Training (Level 1 Evidence, Grade A Recommendation) (ICS 2013)
o Increase strength, endurance, timing and co-activation of lower abdominals
o +/- Biofeedback (RTUS, EMG)
o ‘The Knack’ (Miller 2008)
•  Bladder neck support
o Tampon/contiform/pessary (Bo 2004)
 Stress Urinary Incontinence
Physiotherapy Management
•  Weight loss (Level 1 Evidence, Grade A Recommendation) (ICS 2013)
•  Topical vaginal oestrogen (Cody et al 2012)
•  Encouragement/support/motivation +++

Interdisciplinary Liaison
•  If no improvement (6-8 weeks) – Urologist/Urogynaecologist for opinion and management
•  Urodynamic studies for further investigation
•  Surgical options
 Stress Urinary Incontinence
Evidence

Supervised PFMT should be offered as a 1st line treatment for women with SUI (Grade A
Recommendation) (ICS 2013)

•  Health professional led PFMT programs are better than self-directed programs with more health professional contact
better than less (Grade A Recommendation)
•  Weight loss should be considered a first line treatment to reduce UI prevalence (Level 1 Evidence, Grade A
Recommendation)
•  PFMT is better than no treatment or placebo treatment for women with SUI (Level 1 Evidence)
•  PFMT is a better first line treatment than E-stim or vaginal cones (there is no benefit to adding BFB) (Level 2 Evidence)

(Moore, Dumoulin et al ICS 2013)

 Overactive Bladder Syndrome
Definitions
•  Overactive Bladder Syndrome (OAB)
o Symptom syndrome
o Presence of urgency, usually accompanied by frequency and nocturia +/- urge incontinence
o Absence of UTI or obvious pathology
o OAB wet versus OAB dry

•  Urgency
o Sudden compelling desire to pass urine, which is difficult to defer

•  Urgency Urinary Incontinence (UUI)

o Involuntary loss of urine associated with urgency OR detrusor overactivity

•  Detrusor Overactivity (DO)

o Diagnosed with urodynamic studies only

(Haylen et al 2010 IUGA/ICS Terminology)

 Overactive Bladder Syndrome
Pathophysiology

Peripheral Neurogenic
•  Urothelial Factors •  Suprapontine
o Chemical mediators o CVA, PD
•  Myogenic Factors •  Spinal Cord
o Detrusor denervation o SCI, MS
o Increased excitability
•  Inflammation Non-Neurogenic
•  Ischaemia •  Outflow Obstruction
•  Ageing, low oestrogen
Central •  Proximal urethra
•  Conscious sensation •  Behavioural
•  Volition •  PFM dysfunction
•  Emotional response •  Idiopathic

(ICS 2013)
 Overactive Bladder Syndrome
Clinical Presentation
•  Detrusor overactivity
•  Bladder oversensitivity (without detrusor overactivity)
o Early first sensation of filling
o Early normal desire to void
•  Poor detrusor compliance (small bladder capacity)
•  Irritative Symptoms
•  Third space offload - nocturia
•  Dysfunctional Voiding
o Post void residuals
o Bladder Outlet Obstruction
•  Behavioural
o Just in case voiding
o Excessive or low fluid intake
o Anxiety
Overactive Bladder Syndrome and Urgency
Urinary Incontinence
Role of the Pelvic Floor Muscles
•  Increase urethral pressure
•  Inhibit detrusor contraction
•  Guarding Reflex
o PFM and EUS automatically switch on while the bladder fills

(Burgio et al 1985; DeGroat 1997)

 Overactive Bladder Syndrome and Urgency
Urinary Incontinence
Pelvic Floor Muscle Dysfunction
•  PFM are significantly impaired in women with UUI
o EMG Assessment
o Reduced urethral closing pressure
o Reduced muscle activation (Gunnarsson & Mattiasson 1999)

•  PFM elevation and relaxation on real time ultrasound (RTUS) are difficult in women with OAB (Thompson 2005)
•  Accumulative effect of PFM dysfunction and other pathophysiology (Bo 2007)

Goals of Pelvic Floor Muscle Training

•  PFM contraction as an urge suppression strategy
•  Strengthening and hypertrophy to stabilise neurogenic activity
o Potential to resolve other factors underlying OAB/UUI that PFM dysfunction contributes to e.g. POP, urethral instability

(Bo 2014, ICS 2013)

 Overactive Bladder Syndrome and Urgency
Urinary Incontinence
Physiotherapy Assessment
•  MSU – clear infection (1st line management)
•  Post void residual (RTUS)
•  Bladder Diary (3DBC)
o Frequency: Day/Night
o Voided volumes: min, max, average
o Degree of urgency
o Intake: total volume 24hrs, type of fluids
o Input vs. Output
o Correlation to fluid intake
•  PFM Assessment (RTUS and VE)
o Muscle strength, tone, TP, urethral closure
o Activation patterns

(ICS 2013; Ghonieum et al 2008)

 Overactive Bladder Syndrome and Urgency
Urinary Incontinence
Physiotherapy Management
•  Education
•  Clear infection – urinalysis, MSU
o If infection treated – proof of cure 5-7 days following AB’s
•  PVR – determine cause
•  Check/treat bowel dysfunction
•  Behavioural modification – eliminate ‘JIC’ voids
•  Fluid modification/timing
•  Pelvic Floor Muscle Training (Grade A Recommendation) – Based on assessment findings (ICS 2013)
o Normalise tone/eliminate TP
o Increase strength and endurance
o Urethral closure/lift
o Correct activation technique (co-activation of lower abdominal wall)
o Motor control patterns – improve altered patterns (upper abdominal bracing)
 Overactive Bladder Syndrome and Urgency
Urinary Incontinence
Physiotherapy Management
•  Bladder Calming and Retraining (Grade A Recommendation) (ICS 2013)
–  STOP – relax and breathe
–  PFM contraction (correct technique)
–  Calming Strategies
o Distraction/Walking
o Perineal/clitoral pressure
o Toe curls/calf stretch
o Sacral rubbing/pressure
o Top lip pressure, ankle pressure point
•  Retraining
o Calm the urge
o Defer the urge and gradually increase deferment times
•  Neuromodulation/TENS (Grade C Recommendation)
o Must eliminate PVR prior
o 2/24 per day for 6-8 weeks
 Overactive Bladder Syndrome and Urgency
Urinary Incontinence
Physiotherapy Management
•  Weight loss (Grade A Recommendation)
•  Regular Exercise
•  Stress reduction and active relaxation techniques

Interdisciplinary Liaison
•  If no improvement referral to GP and Urologist for opinion and management
•  Further investigation
–  Cystoscopy
–  Urodynamics
•  Medications
 Overactive Bladder Syndrome, Urgency &
Mixed Urinary Incontinence
Evidence

PFMT should be offered as a 1st line treatment for women of all ages with UUI or MUI (Level 1
Evidence, Grade A Recommendation) (ICS 2013)

•  PFMT is better than no treatment or placebo and should be offered as a first line conservative treatment for women of
all ages with UUI or MUI (Level 1 Evidence, Grade A Recommendation)
•  Bladder training may be an effective treatment for women with UUI, SUI and MUI (Level 1 Evidence, Grade A
Recommendation)
•  PFMT and bladder training are effective first line conservative treatments of UUI or MUI (Grade B Recommendation)
•  Bladder training can be as effective as antimuscarinic drug therapy for women with detrusor overactivity or UUI (and
has less side effects) (Level 1 Evidence, Grade B Recommendation)
•  PFMT is better than Oxybutynin as a 1st line treatment (Grade B Recommendation)
(ICS 2013)
 Overflow Incontinence
Definition
When the bladder is unable to empty, it over fills/distends and small volume leakage occurs (ICS 2013).

Pathophysiology - Associated with voiding dysfunction

•  Outflow obstruction
o Bladder (detrusor underactivity, atonic detrusor, stones)
o Bladder neck (stricture, stone)
o Prostate (enlargement, cancer)
o Urethral (stricture, prolapse, TVT)
o Sphincter (dysynergic with detrusor, overactive PFM)
•  Neurogenic
o Detrusor dysynergia, atonic bladder
•  Medication
•  Co-morbidities
o DM
•  PVR common sign
 Overflow Incontinence
Physiotherapy Assessment
•  Urinalysis/MSU – clear infection
•  Pre void volume and post void residual (RTUS)
•  Bladder Diary (3DBC)
o Frequency: Day/Night
o Voided volumes: min, max, average
o Degree of urgency
o Intake: total volume 24hrs, type of fluids
o Input vs. Output
o Correlation to fluid intake
•  PFM Assessment (RTUS and VE)
o Muscle strength, tone, TP, urethral closure
o Activation patterns
 Overflow Incontinence

Physiotherapy Management
•  Urinalysis/MSU – clear infection
•  Determine underlying cause – obstructed, behavioural, neurological
•  Pre and Post void residual (RTUS)
•  Bladder Diary (3DBC) for education
•  Education
o Good bladder habits
o Appropriate fluids
o Timing of fluids, loading
•  Voiding Dynamics
o Positioning
o Relaxation (no straining)
o Timed voids
o Double voids
o Splinting
 Overflow Incontinence
Physiotherapy Management
•  Manage contributing factors
o UTI’s – AB’s, cranberry
•  Bowels – optimise stool, defecation dynamics
•  PFMT – based on assessment findings
o Impaired relaxation: PFM down training with breathing sequence, visual cues
o Normalise resting tone, decrease pain, manage TP’s
o  Achieve consistent/complete relaxation of PFM
o POP, underactive – Up training and strengthening
•  Relaxation strategies – diaphragmatic breathing sequence

Interdisciplinary Liaison
•  GP/Urologist/Urogynaecologist/Neurologist
•  Continence Nurse – Intermittent self catheterisation
•  Further Investigations
o Urodynamics – low compliance, little to no detrusor activity, detrusor leak point pressure
o Renal function
 Overflow Incontinence
Evidence for Dysfunctional Voiding

•  PFMT aimed at relaxation plus diaphragmatic breathing ex – positive effects in children with dysfunctional voiding
(Zivkovic et al 2010)

•  PFMT with biofeedback – improvements in men with chronic prostatitis at 10 weeks (He et al 2010)
•  PFMT improves effectiveness of double voids – in women with recurrent UTI and DV (poor quality study) (Minardi et al 2010)
 Bowels
Pelvic Floor Muscle Dysfunction

•  Ano-rectal Incontinence
•  Defecation difficulties/constipation
•  Urgency
•  Prolapse
•  Bleeding
•  Pain
 Anal Incontinence
Definition
•  Involuntary loss of flatus, liquid or solid stool that is a social or hygienic problem (ICS 2005)

Types
•  Passive
•  Urge
•  Stress
•  Smearing
 Anal Incontinence

Pathophysiology - Multifactorial Cause

CONTAINER   CONTROL  
(bowel)   (PFM  &  EAS)  
COMMANDER        
(brain)   -­‐  Ability  to   -­‐ Structure  
  process  in  
CONTENTS   4mely  manner   -­‐   Func4on  
-­‐   Cogni4on  
(faeces)   CONDUIT  
-­‐   Ability  to   (anorectum)  
 
access  toilet    
-­‐ Gut  Mo4lity   -­‐ Rectal  capacity/
-­‐   Stool  form   compliance/
-­‐   Medica4ons   sensi4vity  
-­‐   Anal  closure  
-­‐   Diet  
-­‐   Emo4ons  
 Faecal Incontinence
Potential Underlying Problems

1. Rectal hypersensitivity and PFM (PR/EAS) overactivity

•  Faecal urgency ! dysfunctional PFM ! anxiety+ ! gut motility++ ! urgency FI

2. Rectal hypersensitivity and PFM (PR/EAS) underactivity

•  Urgency ! dysfunctional PFM/weak ! FI ! anxiety++ ! urgency++

3. Rectal hyposensitivity and PFM (PR/EAS) overactivity

•  Constipation & FI present, usually hx of childhood constipation, no warning

4. Rectal hyposensitivity and PFM (PR/EAS) underactivity

•  Both sluggish, no warning, no protective ability of PFM
 Risk Factors for Anal Incontinence
•  Age o Vit D deficiency
•  Gender •  Smoking
•  Diabetes •  Physical Mobility
•  GI Disorders •  Radiation therapy
o Diarrhoea •  Rectal prolapse
o Rectal urgency •  Surgery
o Constipation/impaction o Anorectal
o IBS o Rectal
•  Neurological o Hysterectomy
o Dementia o Cholycystectomy
o Depression •  Obstetric Injuries
o SCI o Neurogenic trauma
o CVA o Mechanical trauma
•  Nutrition
o Obesity
 Anal Incontinence
Goals of Pelvic Floor Muscle Training
Prior to PFMT
•  Optimise stool consistency
•  Normalise urge
•  Normalise frequency and defecation

Pelvic Floor Muscle Training

•  Optimisation of ‘exit’
o Address/improve impairments of PFM, PR, EAS
o Proprioception
o Normalise rectal sensation
o Management of rectal capacity and compliance
 Anal Incontinence
Physiotherapy Assessment
•  Identification of modifiable factors – contributors to AI/FI •  EMG
o Resting tone
•  Stool assessment – BSS
o MVC
o Type 4 (consistency firm or pasty)
o Hold time
•  Bowel and diet diary
o Resistance to fatigue
•  Pelvic Floor Muscle Assessment – DRE o Quality of sustained contraction
o Resting tone/pressure
o Relaxation following contraction
o Squeeze pressure
o Estimated length of anal canal
o PERFECT
o Relaxation following contraction
o Proprioception
o Pain/discomfort
o Simulated defecation
 Anal Incontinence
Physiotherapy Management
•  Education – Bowel function and FI
•  Lifestyle modifications (Level 5 Evidence)
o Weight loss (no benefits without surgery)
o Environmental factors
o Medications (diarrhoea side effects)
•  Diet and fluid modification
o Fasting (eat at home when close to toilet)
o Avoid risky foods (vegetables, fruit, high fat foods (fried), caffeinated food/drinks, dairy, alcohol
o Identification of dietary intolerances (lactose, gluten, dairy, sorbitol/fructose, caffeine, alcohol, pre/pro/synbiotics (cause loose stools -
> FI)
•  Dietary fibre
o Insoluble fibre (possibly good for loose stools and associated FI)
o Soluble fibre supplements – psyllium husk (Level 1 Evidence, Grade B Recommendation) (ICS 2013)
•  Reduces FI of loose stools, liquid stool +/- rectal irrigation
(ICS 2013)
 Anal Incontinence
Physiotherapy Management
•  Defecation dynamics
•  Establishment of regular habit (QoL/social situations)
o Predictability to manage FI e.g. morning routine -> BO ->Imodium
•  Pelvic Floor Muscle Training (Level 2 Evidence)
o Strengthening then endurance
o Focus on posterior PFM
o Manometric biofeedback with experienced therapist (Level 1 Evidence)
•  Rectal Irrigation (Level 2 Evidence for reduction in FI)
o More effective for faecal soiling than loose stool FI
•  Medications
o Loperamide (Level 2 Evidence for mx of diarrhoea associated FI)
•  Recovery time in supine
o After BO to mx passive FI and smearing. Combine with PFMT
•  Skin Management and Containment
o Barrier creams, pads, plugs
(ICS 2013)
 Anal Incontinence
Physiotherapy Management Summary

Stress FI
Passive FI
•  Up-train PFM
•  Optimise stool consistency
•  Optimise stool consistency
•  Optimise PFM
•  The Knack
•  Eliminate/minimise PF challenging activities
•  Eliminate PF challenging activities/habits
•  Defecation dynamics and emptying strategies (may
include rectal irrigation) •  Defecation dynamics

Urge FI Smearing
•  Calm down gut motility to normalise frequency •  Optimise stool consistency (firm up)
•  Reduce urgency/rectal sensitivity (relaxation, rectal •  Up-train PFM
balloons, PFMT, BFB) •  Hygiene
•  Optimise stool consistency
•  Up-train PFM
 Anal Incontinence
Interdisciplinary Liaison
•  Clinical Psychologist - Stress/Anxiety Management
•  Continence Nurse – Rectal Irrigation
•  GP/Specialist for opinion and management
•  Further Investigations
o ARM
o EAUS
o Defecation Proctogram
o Neurophysiologic studies
 Anal Incontinence

Evidence

•  Manometric biofeedback by an experienced therapist is better than PFMT alone (Level 1 Evidence)
•  PFMT is recommended as an early intervention in the treatment of faecal incontinence (Level 2 Evidence, Grade B
Recommendation)
•  There is no added benefit to adding E-stim or fast contractions in PFMT (Level 2 Evidence)
(ICS 2013; Bliss et al 2013)
Questions?

THANK YOU