Physiotherapy management of Urinary incontinence

1. Pelvic floor physiotherapy for urinary incontinence
Presented By:-
Dr. Tabassum (PT) ,Mpt obs & gynae rehabilitation
Assistant Professor
SP&AHS, Physio Deptt. SGRRU & SMIHDehradun

2. S
PHYSIOTHERAPY MANAGEMENT OF URINARY INCONTINENCE
1. CLINICAL
PRESENTATION
3. PHYSIOTHERAPY
MANAGEMENT OF URINARY
INCONTINENCE
2. PT ASSESSMENT
4.BEHAVIOURAL
THERAPY
5.DIET PLAN
6. DRUG THERAPY
7.MEDICAL DEVICES
8.SURGICAL TREATMENT

3. 1.CLINICAL PRESENTATION
Urine Leaking
Urinary Frequency
Urinary Urgency

4. Nocturia
Prolapse

5. 2.pT aSSESSMENT
Diagnostic Procedures
Clinical history diagnosis of urinary stress incontinence based on
the presence of stress incontinence symptoms.
Pelvic Floor MuscleFunction and Strength
Modified Oxford grading system:
0 - no contraction
1 - flicker
2 - weak squeeze, no lift
3 - fair squeeze, definite lift
4 - good squeeze with lift
5 - strong squeeze with a lift

6. Palpation
PERFECT mnemonic assessment
P - power, may use the Modified Oxford grading scale
E- endurance, the time (in seconds) that a maximum
contraction can be sustained
R- repetition, the number of repetitions of a maximum
voluntary contraction
F- fast contractions, the number of fast (one second)
maximum contractions
ECT - every contraction timed, reminds the therapist to
continually overload the muscle activity for strengthening

7. Evaluation Of Urinary Incontinence
Pad Test The test involves the patient wearing a pre-weighed pad,
-Next the patient drinks 500 ml of sodium-free liquid in < 15 minutes,
resting, after which he/she exercises for 30 minutes. --The exercise
would include-
Activities such as -
Walking,
Climbing up and down a flight of stairs,
Standing up from sitting,
Coughing vigorously
Running on the spot for 1 minute.
The pad is then re-weighed and the resulting measurement given in grams of urine
lost

8. URINARY (Voiding) Diary
The National Institute for Diabetes and Digestive and Kidney Diseases provides
clinicians with an easy to use Bladder Diary pdf that may be used in clinical
practice
Outcome Measures
Incontinence Quality of Life Instrument (I-QOL)
International Consultation on Incontinence Modular
Questionnaires (ICIQ)
Male Urogenital Distress Inventory (MUDI)
Male Urinary Symptom Impact Questionnaire (MUSIQ)
Patient Global Impression of Improvement (PGI-I)
Patient Global Impression of Severity (PGI-S)

9. Pelvic Floor Distress Inventory - 20 (PFDI - 20)
Pelvic Floor Impact Questionnaire - 7 (PFIQ - 7)
The International Consultation on Incontinence
Questionnaire of Female Lower Urinary Tract Symptoms
Questionnaire (ICIQ-FLUTS)
The Bristol Female Lower Urinary Tract Symptoms
Questionnaire
The International Consultation on Incontinence
Questionnaire of Urinary Incontinence Short Form (ICIQ-UI
SF)

10. 3. PHYSIOTHERAPY MANAGEMENT OF URINARYINCONTINENCE
Pelvic floor muscle stregthening exercises for weak pelvic floor muscle
1. PELVIC FLOOR MUSCLE TRAINING
2. PELVIC FLOOR MUSCLE EXERCISES & BLADDER TRAINING
OR PFM RETRAINING
3. PELVIC FLOOR MUSCLE STRENGTHENING

11. PELVIC FLOOR MUSCLE TRAINING

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PELVIC FLOOR MUSCLE TRAINING
A home-based pelvic floor muscle training and bladder training in women with
urinary incontinence showed that combined pelvic floor muscle training and
bladder training decreased the symptoms and improved the quality of life
To strengthen your pelvic floor muscles, squeeze the muscles up to 10 times
while standing, sitting or lying down.
Do not hold your breath or tighten stomach, bottom or thigh muscles at the
same time.
When you get used to doing pelvic floor exercises, you can try holding each
squeeze for one second

13. PELVIC FLOOR MUHHSCLE EXERCISES & BLADDER TRAINING
Urgency may lead to Urine leakage . Bladder
Training can help hold the urine longer &
overcome that gotta go sensation without
medicines & surgery.
Step 1- Get checked for bladder infection or other health issues that can cause these
symptoms.
Advice for
• keep a bladder Diary.
• Write down time when Urinate
• how much urinated as well as what & how much drink.

14. s g
Some of the following Strategies:
Practice PFME Squeeze as explained
above.
This will help to close off the Urethra
preventing Urine from leaking.
Continue to squeez untill the need to
fades.
Another Option is to quickly squeeze
and release the muscles,
distracting the bladder from squeezing .
 Cross legs or sit on a hard surface.
 Distract mind. count backwards
from 100, and ask for shift position.
 we’ll find that leaning forwards
helps to settle bladder.
Step 2- Review the diary & plan for best
approach to bladder training
Advice for
• keep a bladder Diary.
• Write down time when Urinate
• how much urinated as well as what & how
much drink.
Step 3 - We Make a trainig Schedule.Most
women start Urinating every 30-60 minutes
during the-whether or not feel the need to go.
If women get the urge to go before the
scheduled, they do not run to the bathroom.

15. Step 4- After 1-2 weeks , if women are not having leaking accidents , then increase the
time between bathroom trips by 30 mintues.
Step 5- Noticiable improvement will occur within a couple of weeks. However, the
bladder retraining period can take several months

16. PFMT for the prevention of postpartum incontinencePelvic floor muscle
training
(PFMT) performed during pregnancy helps to decrease the short-term risk of
urinary incontinence in women without prior incontinence.
A systematic review including randomized or quasi-randomized trials
on primiparous or multiparous pregnant or postpartum women found
that PFMT during pregnancy and after delivery can prevent and treat
urinary incontinence. The authors recommended a supervised training
protocol following strength-training principles, emphasizing close to
maximum contractions and lasting at least 8 weeks.
 PFMT for stress urinary incontinence
A new systematic review analyzing the efficacy of pelvic floor muscle training
(PFMT) in the treatment of UI and its effect on the improvement in muscle strength,
endurance, and urinary leakage among non-pregnant women suggests pelvic floor
muscle training

17. with education as the most effective treatment and recommends it as the
first line of treatment for improving urinary incontinence in non-pregnant
women. The review demonstrated that PFMT effectively reduced urinary
leakage and improved pelvic floor muscle contraction.
 PFMT for urgency incontinence
PFMT has been shown to improve or cure symptoms of urge urinary incontinence.[51]
In addition to PFMT, behavioural therapies and bladder training (described below) may
be beneficial in this population

18. • Previous studies have suggested that Pelvic Floor Muscle Exercise (PFME)
is effective and works as a first-line treatment approach for intervention in
the case of SUI. Pelvic floor muscle contracts in a cranial and forward
direction during and prior to physical exertion and high velocity movements
including coughing, sneezing, or laughing, thus preventing urine leakage The
pelvic floor plays a significant role in body's core. At the same time, it
contracts the deep abdominal and back muscles. As a result, these muscles
provide support, strength, and stability to the spine and internal organs
during the movements of the body. Strengthened or strong core muscles
provide support the pelvic organs and help to control against leakage. Thus,
it can reduce or eliminate UI. Strengthening of the core muscle can reduce
the UI, helping to control the leakage

19. • PFME in supine, sitting, kneeling, and standing positions, which follow by an
increase number of contractions and duration of holding.
• The exercise regimen of holding went from 4 seconds to 30–40 seconds. The
contractions will be increased up to 20 contractions as progression.
• CORE MUSCLE Strengthening
The patient will be instructed to work on the transverse abdominis muscle
(core muscle). They will be instructed to contract the pelvic floor as above and
keep the PFM relaxed.

21. PELVIC FLOOR MUSCLES STRENGTHENING EXERCISES
Bridge With Hip Rotations
Lie on back and
Position a small, inflatable exercise ball between knees
Loop a small resistance band/Thera band around the
outside of your knees. Place your feet on the floor,
with knees bent, and point feet straight ahead.
Ask for lift hips into a bridge position, then alternate
gently pressing knees in against the ball and out against the
resistance band.
Repeat the movement with toes pointed inward, then
outward.
 Repeat 10 times per variation. Squat With Pelvic-Floor Integration

22. Side Clamshell
Lie on side with your hips stacked and knees bent.
Stabilize themsleves with a hand on the floor in front
them.
Lift and contract your pelvic-floor muscles, and begin to lightly exhale.
Keeping feet together, open legs like a clamshell as far
as comfortably can.
If it’s difficult to do this without hips rolling back,
position yourself against a wall.
Pause for one or two seconds with knees open,
then return to the starting position and release the pelvic-
floor contraction.
 Repeat 10 times per side. Side Clamshell

23. Squat With Pelvic-Floor Integration
Stand with feet wider than hip-width apart, with toes
slightly angled out, arms at your sides, ribs over the pelvis,
and the pelvic floor relaxed.
Inhale through nose squat down as far as comfortably can,
allowing pelvic floor to stay relaxed and keeping belly soft.
Exhale through mouth return to standing,
contracting and “lifting” the pelvic floor.
Think about exhaling as if you are fogging up a mirror with
breath.
Repeat 10 times. Squat With Pelvic-Floor Integration

24. 4.BEHAVIOURALTHERAPY
 The focus of behavioral therapy is on lifestyle changes such as-
- Fluid or diet management,
-Weight control
-Bowel regulation.
-Education about bladder irritants, like caffeine, is an important consideration.
-Also, discussing bowel habits to determine if constipation is an issue as it is
important to educate the patient about avoiding straining.
-Education and explanation about normal lower urinary tract function is also
included.
-Patients should understand the role of the bladder and the pelvic floor
muscles.S

25. Bladder Training
The information gathered from the bladder diary is used to guide decision
making for bladder re-training, including a voiding schedule if necessary to
increase the capacity of the bladder for people with frequency issues.
Bladder training attempts to break the cycle by teaching patients to void on
a schedule, rather than in response to urgency.
Urge suppression techniques are taught, such as distraction and relaxation.
It is also important to teach the patient to contract the pelvic floor to cause
detrusor inhibition.
 A voluntary contraction of the pelvic floor muscles helps increase pressure
in the urethra, inhibit detrusor contractions, and control urinary leakage.

26. Double voiding, to help you learn to empty your bladder more completely
to avoid overflow incontinence. Double voiding means urinating, then
waiting a few minutes and trying again.
Scheduled toilet trips, to urinate every two to four hours rather than
waiting for the need to go.
Fluid and diet management, to regain control of your bladder. You may
need to cut back on or avoid alcohol, caffeine or acidic foods. Reducing
liquid consumption, losing weight or increasing physical activity also can
ease the problem.

27. Some foods may aggravate overactive bladder (OAB) symptoms, but specific
dietary changes, such as eating more fiber, may help reduce them.
OAB, certain foods and drinks can further irritate bladder or urinary tract.
This can cause an uptick in the following sympto
• frequent urge to urinate
• frequent urination
• bladder spasms
• urinary incontinence
• In general, drinking enough water supports your overall health. But if anyone
has OAB, more fluid intake typically means more trips to the bathroom. If those
fluids are carbonated, they may aggravate your symptoms even more.
5.DIET PLAN

28. Whether or not you follow a specific
diet, choose foods rich in vitamins,
such as non-acidic fruits and
vegetables.
Fruits that may support bladder
health include:
• Bananas
• Apples
• Grapes
• Coconut
• Watermelon
• Strawberries
• Slackberries
Vegetables that may support
bladder health include:
• Asparagus
• Broccoli
• Cucumbers
• Kale
• Carrots
• Celery
• Lettuce
• Peppers

29. Foods high in fiber can help
even constipation, which can put
additional pressure on your bladder.
Fiber-rich foods include:
• lentils
• beans
• raspberries
• artichoke
• barley
• bran
• oats
• almonds
Protein is also essential for your
overall health. Good sources of
protein include:
• fish
• chicken
• tofu
• eggs

30. Tomato products
According to the Cleveland Clinic,
tomatoes are an acidic food that can
potentially irritate your bladder and
worsen OAB symptoms. People who
are particularly sensitive should also
cut out tomato products, such as:
• Pasta
• Pizza sauce
• Ketchup
• Salsa
Coffee and tea
Chocolate
Citrus fruits to watch out for are:
• Oranges
• Limes
• Lemons
• Grapefruits
Foods to avoid in Over Active Bladder

31. Alcohol can irritate the bladder
and disrupt the signals to your
brain that make you aware of
bladder overflow.
• Beer
• Wine
• Liquor
 Carbonated beverages
• The fizz in carbonated beverages
can potentially aggravate OAB
symptoms. Be wary of drinks
such as:
• Soft drinks
• Soda water
• Energy drinks

32. Spicy foods
Sweeteners
Processed foods
Onions
Cranberries

33. 6.DRUGTHERAPY
• Anticholinergics. These medications can
calm an overactive bladder and may be
helpful for urge incontinence. Examples
include oxybutynin (Ditropan XL),
tolterodine (Detrol), darifenacin
(Enablex), fesoterodine (Toviaz),
solifenacin (Vesicare) and trospium
chloride.
• Mirabegron (Myrbetriq). Used to treat
urge incontinence, this medication
relaxes the bladder muscle and can
increase the amount of urine your bladder
can hold. It may also increase the amount
you are able to urinate at one time,
helping to empty your bladder more
completely.
• Alpha blockers. In men who have
urge incontinence or overflow
incontinence, these medications
relax bladder neck muscles and
muscle fibers in the prostate and
make it easier to empty the bladder.
Examples include tamsulosin
(Flomax), alfuzosin (Uroxatral),
silodosin (Rapaflo), and doxazosin
(Cardura).
• Topical estrogen. Applying low-dose,
topical estrogen in the form of a
vaginal cream, ring or patch may
help tone and rejuvenate tissues in
the urethra and vaginal areas.

34. 7.MEDICAL DEVICES
Internal vaginal devices are placed
inside the vagina to support the bladder
neck or compress the urethra and
thereby reduce or prevent leakage. Most
female devices currently available are
for women with stress urinary
incontinence (SUI) or mixed urinary
incontinence, and are designed to
prevent urinary leakage.
Devices designed to treat women with
incontinence include:
• Urethral insert, a small, tampon-like
disposable device inserted into the
urethra before a specific activity, such as
tennis, that can trigger incontinence. The
insert acts as a plug to prevent leakage
and is removed before urination.
• Pessary, a flexible silicone ring that you
insert into your vagina and wear all day.
The device is also used in women with
vaginal prolapse. The pessary helps
support the urethra, to prevent urine
leakage.

35. Interventional therapies in incontinence include
• Bulking material injections: A synthetic
material is injected into tissue surrounding
the urethra. The bulking material helps
keep the urethra closed and reduce urine
leakage. This procedure is for the
treatment of stress incontinence and is
generally less effective than more-
invasive treatments such as surgery. It
may need to be repeated more than once.
• OnabotulinumtoxinA (Botox): Injections
of Botox into the bladder muscle may
benefit people who have an overactive
bladder and urge incontinence. Botox is
generally prescribed to people only if
other treatments haven't been successful.
• Nerve stimulators. There are two
types of devices that use painless
electrical pulses to stimulate the
nerves involved in bladder control
(sacral nerves). One type is
implanted under your skin in your
buttock and connected to wires on
the lower back. The other type is a
removable plug that is inserted
into the vagina. Stimulating the
sacral nerves can control
overactive bladder and urge
incontinence if other therapies
haven't worked.

36. Sling procedures: Synthetic material (mesh) or strips of your body's tissue
are used to create a pelvic sling underneath your urethra and the area of
thickened muscle where the bladder connects to the urethra (bladder neck).
The sling helps keep the urethra closed, especially when you cough or
sneeze. This procedure is used to treat stress incontinence.
Bladder neck suspension: This procedure is designed to provide support to
your urethra and bladder neck — an area of thickened muscle where the
bladder connects to the urethra. It involves an abdominal incision, so it's
done during general or spinal anesthesia.
8.Surgical treatment

37. Prolapse surgery:In women who have pelvic organ prolapse and mixed
incontinence, surgery may include a combination of a sling procedure
and prolapse surgery. Repair of pelvic organ prolapse alone does not
routinely improve urinary incontinence symptoms.
Artificial urinary sphincter: A small, fluid-filled ring is implanted
around the bladder neck to keep the urinary sphincter shut until there's a
need to urinate. To urinate, you press a valve implanted under your skin
that causes the ring to deflate and allows urine from your bladder to
flow.

38. References
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primary care: a pragmatic controlled trial”.Brazilian Journal of Physical Therapy. Volume-
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https://doi.org/10.1016/j.bjpt.2019.01.007
2. Voices for PFD.,2016. “Pelvic Floor Muscle Exercises & Bladder
Training”.https://www.voicesforpfd.org/assets/2/6/Bladder_Training.pdf.
3. Physiopedia Urinary Incontinence,2017.https://www.physio-
pedia.com/Urinary_Incontinence
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40. • Medically reviewed by Natalie Butler, R.D., L.D. — Written by Ryan Wallace —
Updated on May 19, 2023. “11 Foods to Avoid if You Have Overactive Bladder
(OAB)”. Health Line https://www.healthline.com/health/11-foods-to-avoid-if-you-
have-oab
• Medically reviewed by Cynthia Taylor Chavoustie, MPAS, PA-C — Written by
Corey Whelan — Updated on October 2, 2023. “How to Create a Diet for Your
Overactive Bladder”. Health Line https://www.healthline.com/health/overactive-
bladder/overactive-bladder-diet#other-natural-remedies

41. THANK YOU
T H A N K Y O U