Physiotherapy approaches for urgency and urge

incontinence

Liz ChildsPelvic Health Physiotherapist

Assessment - subjective - objective (including bladder

diary) - clinical reasoning – functional

requirements of patient Education - normal anatomy/function

- mechanism of their problem - treatment options

Goal Setting Treatment

Physiotherapy managementurgency and UI - overview

Reduce urgency Prolong voiding intervals Increase bladder capacity Reduce incontinence Restore patient confidence in controlling

bladder

Treatment aims

Bladder training Pelvic floor muscle training Electrical stimulation TENS Lifestyle interventions

Physiotherapy treatment approaches

3 components:1. Scheduled voiding regime

Set frequency of voiding Don’t void until next scheduled time Gradually extend inter-void intervals

2. Urge control strategies Distraction – eg alphabet backwards Relaxation PFM exercises - to inhibit bladder contraction Perineal pressure Toe standing

Bladder training - protocols

3. Monitoring Monitor adherence

(Patient diary, self monitoring, ph check) Provide motivation / encouragement Evaluate progress Determine adjustments to void interval

Bladder training protocols cont..

Theories: (ICI 2009)1.Improved cortical inhibition over involuntary detrusor contractions2.Improved cortical facilitation over urethral closure during bladder filling3.Increased knowledge of circumstances of incontinence behavioural changes4.Increased reserve capacity of bladder

Bladder training – mechanism of action

Few studies BT vs no treatment or vs control

Fewer episodes incontinence Less frequency, urgency, nocturia

Helpful short term, need more studies to determine long term benefit

(Cochrane review RCTs)

Bladder training –Evidence

ICI (2009) :Not clear what most appropriate protocol isRecommend:

assign voiding interval based on baseline voiding frequency eg 1 hr (30 mins or less if required)

Increase 15-30 mins / week – dependent on tolerance, feelings of control and confidence

BT is an appropriate first line conservative therapy for women with UUI (Grade A)

Bladder training –clinical recommendations

PFM exercises1. During urgency episode, hold until urge passes2. Regular strengthening exercises: long term aim

inhibit onset of urgency No consensus on optimal protocols (few studies)

Frequency of exercises Number reps, how long to hold

Internal assessment required – 50% women given verbal or written instruction were found to be performing PFM ex’s incorrectly (Bo et al, 1988; Hesse et al, 1991)

Pelvic floor muscle training –protocols

Increased activity / tension PFM: influences afferent input to CNS inhibitory effect on voiding Improved urethral closure Inhibition micturition reflex Urge inhibition

Pelvic floor muscle training –mechanism

PFM dysfunction found in women with urge / UI Significant difference in degree of muscle

activation of continent women (age, parity equivalent)(Bo, 2007)

Problems with studies No internal assessment of PFM activity BT included in studies Short time frames – need 3-6 months for muscle

hypertrophy

Pelvic floor muscle training –evidence

ICI (2009):Supervised PFM training should be offered as first line conservative therapy for women with urinary incontinence (stress, urge, mixed)Research relatively new…basic research shows

possible to learn to inhibit detrusor with PFM contraction

PFM contraction & hold can stop urge to void

Pelvic floor muscle training –clinical recommendations

Vaginal (or anal) probe Daily use – home or clinic UK parameters (Teresa Cook, 2006)

Frequency 5-20 Hz Pulse duration 0.5 – 1.0 m/sec 5-20 mins / day

Electrical stimulation – regime

Not many studies Many combinations of current type, waveform,

frequency, intensity, electrode placement, probes etc

problem with research -poorly reported methodology-hard to recommend optimum regime / protocols

Some evidence ES better than placebo (Bergmans et al, 2001)

Electrical stimulation –evidence

ICI (2009):Few studies, but single trials suggest a protocol of 9 weeks, 1-2x day, may be better than no treatmentFurther research required

Electrical stimulation –clinical recommendations

Pads over sacrum – sacral nerve roots Theories: 1.Sacral nerve root stimulation activates

external urethral sphincter reflex then inhibits detrusor activity

2.Increased levels of cerebrospinal endorphins may help with detrusor inhibition

TENS

Studies have shown improvement in • Frequency• Urgency• Nocturia• Urge incontinence

(Walsh et al, 1999; Hasan et al, 1996; Soomroet et al, 2001)

TENS -evidence

Weight loss Increased risk urgency associated with obesity (Ailing et al, 2000; Dallosso et al 2003)

Caffeine intake Reduce to max 100mg/day significant reduction

in urgency & frequency, but not UUI (Bryant et al, 2002) Some evidence decreased caffeine combined with

BT is effective in reducing urgency

Lifestyle interventions

Smoking - unclear Prevalence of UUI higher in smokers than non-

smokers (Tampakondis et al, 1995) Other studies – no association No studies addressed effects of cessation

Lifestyle interventions cont…

Value of physiotherapy Non invasive Simple, cheap Improved QOL Few unpleasant side effects No surgery for urgency / UI Drugs may not be an option for some Can be useful combined with medication

Value of physiotherapy

Different options available for physiotherapy treatment of urge / urge incontinence

Most studies involve combinations of treatments

Physiotherapy shown to help improve urgency and urge incontinence

More studies required

Conclusion