Urinary Incontinence: The Undiscussed Topic

“Do you sprint to the bathroom as soon as you get the key in the door? Do you leak just a little every time you exercise or sneeze?” These are questions you should ask all your female patients. If they answered yes to either one of these questions, then they may be one of the millions of women who suffer from urinary incontinence. Urinary incontinence is the involuntary loss of urine associated with physical exertion, such as a sneeze, or associated with a trigger such as the sound of running water. That’s right, leaking even just a little still counts as incontinence.

One in every four women will experience some degree of incontinence during their adult life. Sadly, many of these women don’t discuss this problem with a healthcare provider until it’s been going on for years. In fact, many women believe that leaking just a little with activity is perfectly normal and that wearing pads or undergarments is just an inevitable part of aging. After all, celebrities are doing commercials for these things. It must be normal. Wrong! Using pads or undergarments may be a billion dollar industry, but it is definitely not something that women should just expect or accept.

There are two primary types of incontinence: Urge and Stress. Urge incontinence is the involuntary loss of large amounts of urine which is often associated with a trigger such as running water or simply returning home from an errand. Urge incontinence often results in urinary frequency: going to the bathroom more often than necessary to avoid leakage. We call this, peeing “just in case.” The problem is that over time, your bladder can actually shrink, and going to the bathroom every hour can become your new norm. That’s way too much time spent sitting on a toilet! Urge incontinence is often treated with bladder retraining which involves urge suppression techniques and gradually increasing the time between trips to the bathroom.

Stress incontinence is the involuntary loss of small amounts of urine which results from increased intra-abdominal pressure. This increase in pressure is the result of regular functions such as sneezing or laughing, but it can also come from improper technique with activities such as lifting or getting out of the bed. If your pelvic floor isn’t strong enough to support your bladder, then the increased pressure wins, and urine is allowed to leak out. Stress incontinence is typically treated with pelvic floor and abdominal strengthening exercises. It’s important for your patients to know if they are squeezing the right muscles and if they are working them the right way. One quick way to do a self-check is to perform a Stop Test. For this test, you simply tell the patient to start to urinate and then attempt to stop the flow. If she can stop it completely, then you know she’s on the right track and may just need some exercise education. If your patients attempt to stop results in only a slowing of their urine stream or no change at all, then she will likely need to see her doctor or a pelvic health physical therapist. Sometimes the pelvic floor muscles are just too weak to work on their own and they need a little extra assistance. This is where things like electrical stimulation, biofeedback and manual intervention come into play. It is important to explain to your patient that a Stop Test should only be done occasionally to assess her strength at home. It is not to be used as an exercise.

Many women don’t have just stress or just urge incontinence. Typically it’s more a combination of the two, so the most effective interventions include bladder retraining and pelvic floor strengthening. Pelvic floor strengthening exercises are often referred to as Kegel exercises. It’s important to understand that if your patient is doing these correctly, no one should know. In other words, a proper Kegel involves isolating the muscles inside the vagina and rectum. When these muscles are tightened, there shouldn’t be any visible movement. If your patient’s Kegel involves squeezing her thighs together or raising her eyebrows, then she probably is not getting it right. Try sitting in a chair and imagine lifting a small object with just your vagina. Nothing else should be moving. Now try holding that position for ten seconds. Relax and repeat. It may feel like an eternity, but your pelvic floor needs to work a whole lot longer than that. Now try lifting that object for just two seconds and then relaxing. Repeat that process ten times in a row. These are two of the most basic Kegel exercises. Once your patient has mastered these, you can have her kick it up a notch by adding pelvic floor exercises to her current exercise program. Generally speaking, you want to tighten your pelvic floor every time there’s an exertion during exercise, just like breathing. Train your patients to exhale and squeeze their pelvic floor at the same time. For example, if you’re teaching a squat then she would tighten on the way up. If you’re doing a seated row, have your patient squeeze when pulling her shoulders back. By doing this, you will make your patient’s pelvic floor exercises more functional and more challenging.

There are also a number of exercises that can be done to isolate the pelvic floor in different positions. Using a large exercise ball, have your patient lie on her back on the floor with one or both feet on the ball. She should then slowly pull the ball towards her and then slowly push it away. As she pushes the ball away, cue her to tighten her pelvic floor. (See Figure 1.) This is considered a gravity eliminated exercise, so it should be fairly easy. To challenge her muscles a little more, have her sit on the exercise ball and do a pelvic tilt. The pelvic floor should be relaxed during the anterior tilt and then tightened during the posterior tilt. The gentle stretch to the perineum which is elicited during the anterior tilt will help to facilitate a better contraction. The contact with the ball also helps provide sensory feedback so that your patient can feel themselves pull away from the ball. (See Figure 2.) You can then progress your patient to standing exercises such as a squat with the ball behind her back. As she moves down into the squat position, her pelvic floor should be relatively relaxed. This motion will again elicit a stretch so that she can better squeeze the pelvic floor as she returns to standing. (See Figure 3.) If your patient is a little more advanced, try cueing her to also contract her transverse abdominus at the same time as her pelvic floor. This will really maximize the contraction.

Sometimes, no matter how hard you try, your patient may still not be able to isolate her pelvic floor muscles. If you and your patient just can’t tell what’s going on down there, have her talk to her doctor. They may need to rule-out other medical reasons which may be causing incontinence such as prolapse or neurological issues. Or they may refer her to a pelvic health PT who can determine if electrical stimulation or biofeedback are needed to jump-start the pelvic floor. Either way, remind your patient she is not alone in this battle. She is one of millions. But her case is not hopeless, and help may be just around the corner.