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Pelvic floor physiotherapy for urinary incontinence
PresentedBy:-
Dr. Tabassum(PT)
mpt obs & gynae rehabilitation
Assistant Professor
SP&AHS, Physio Deptt. SGRRU& SMIH
Dehradun
S
PHYSIOTHERAPY MANAGEMENT OF URINARY INCONTINENCE
1. CLINICAL PRESENTATION
3. PHYSIOTHERAPYMANAGEMENT OF
URINARYINCONTINENCE
2. PT ASSESSMENT
4.BEHAVIOURAL THERAPY
5.DIET PLAN
6. DRUGTHERAPY
7.MEDICAL DEVICES 8.SURGICALTREATMENT
1.CLINICAL PRESENTATION
Urine Leaking
Urinary Frequency
Urinary Urgency
Nocturia
Prolapse
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
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
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
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)
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)
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
PELVIC FLOOR MUSCLE TRAINING
s
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
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.
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.
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
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
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
• 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
• 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.
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
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
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
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
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.
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.
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
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
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
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
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
Spicy foods
Sweeteners
Processed foods
Onions
Cranberries
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.
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.
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.
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
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.
References
1. Camila Teixeira Vaz a b & Rosana Ferreira Sampaio a et al., 2019. “Effectiveness of
pelvic floor muscle training and bladder training for women with urinary incontinence in
primary care: a pragmatic controlled trial”.Brazilian Journal of Physical Therapy. Volume-
23.
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
4.Nipa SI, Sriboonreung T, Paungmali A, Phongnarisorn C. The Effects of Pelvic Floor
Muscle Exercise Combined with Core Stability Exercise on Women with Stress Urinary
Incontinence following the Treatment of Nonspecific Chronic Low Back Pain. Adv Urol.
2022 Sep 5;2022:2051374. doi: 10.1155/2022/2051374. PMID: 36105867; PMCID:
PMC9467742.
5. Wendy Watkins.,2020.”How to Strengthen Your Pelvic-Floor Muscles”| Experience
Life by life time
6.Aoki Y, Brown HW, Brubaker L, Cornu JN, Daly JO, Cartwright R. Urinary
incontinence in women. Nature reviews Disease primers. 2017 Jul 6;3(1):1-20.
7.McGuire EJ. Pathophysiology of stress urinary incontinence. Reviews in urology.
2004;6(Suppl 5):S11.
8.Lawrence JM, Lukacz ES, Liu IL, Nager CW, Luber KM. Pelvic floor disorders,
diabetes, and obesity in women: findings from the Kaiser Permanente Continence
Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct 1;30(10):2536-3541.
• 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
THANK YOU
T H A N K Y O U

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PT MANAGEMENT OF URINARY INCONTINENCE.pptx

  • 1. Pelvic floor physiotherapy for urinary incontinence PresentedBy:- Dr. Tabassum(PT) mpt obs & gynae rehabilitation Assistant Professor SP&AHS, Physio Deptt. SGRRU& SMIH Dehradun
  • 2. S PHYSIOTHERAPY MANAGEMENT OF URINARY INCONTINENCE 1. CLINICAL PRESENTATION 3. PHYSIOTHERAPYMANAGEMENT OF URINARYINCONTINENCE 2. PT ASSESSMENT 4.BEHAVIOURAL THERAPY 5.DIET PLAN 6. DRUGTHERAPY 7.MEDICAL DEVICES 8.SURGICALTREATMENT
  • 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
  • 12. s 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.
  • 20.
  • 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
  • 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 1. Camila Teixeira Vaz a b & Rosana Ferreira Sampaio a et al., 2019. “Effectiveness of pelvic floor muscle training and bladder training for women with urinary incontinence in primary care: a pragmatic controlled trial”.Brazilian Journal of Physical Therapy. Volume- 23. 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 4.Nipa SI, Sriboonreung T, Paungmali A, Phongnarisorn C. The Effects of Pelvic Floor Muscle Exercise Combined with Core Stability Exercise on Women with Stress Urinary Incontinence following the Treatment of Nonspecific Chronic Low Back Pain. Adv Urol. 2022 Sep 5;2022:2051374. doi: 10.1155/2022/2051374. PMID: 36105867; PMCID: PMC9467742.
  • 39. 5. Wendy Watkins.,2020.”How to Strengthen Your Pelvic-Floor Muscles”| Experience Life by life time 6.Aoki Y, Brown HW, Brubaker L, Cornu JN, Daly JO, Cartwright R. Urinary incontinence in women. Nature reviews Disease primers. 2017 Jul 6;3(1):1-20. 7.McGuire EJ. Pathophysiology of stress urinary incontinence. Reviews in urology. 2004;6(Suppl 5):S11. 8.Lawrence JM, Lukacz ES, Liu IL, Nager CW, Luber KM. Pelvic floor disorders, diabetes, and obesity in women: findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct 1;30(10):2536-3541.
  • 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