Chronic Disease Management 3: Urinary Incontinence – Part 2

Alright, so I left you with a pretty serious cliffhanger on that last post. Here is the big ending! This is going to go pretty deep into the BASICS of management techniques for urinary incontinence. Like I keep saying, I’m not a pelvic floor therapist, but I do know enough about the basics that I can help you out and get you started. In Part 1 of this post, we discussed MANY of the lifestyle changes that need to happen to reduce or resolve urinary incontinence, but in this post, we are going to talk about the exercises! Remember, these posts are discussing management of urinary incontinence in all populations, but specifically in the presence of other chronic diseases. You can read much more about that in Part 1. Here is a little review…

I was speaking with a colleague of mine who also does a fair amount of chronic disease management and critical care work as a Physical Therapist. We were discussing heart failure management, the incidence of incontinence and urinary tract infection, and the effects these things have on our patients. We came up with this saying, “If you drink too much water, you’ll die. If you don’t drink enough water, you’ll die.” As morbid as that sounds, it’s all about finding the healthy balance.

In the case of heart failure, you’ll tend to find that less water is better (due to fluid limitations) but that patients still need to meet a minimum amount in order to function. Many of these patients ALSO develop urinary incontinence, either as a secondary effect of their heart failure medications and pathophysiology, or as a diagnosis due to many other possible causes. Finding their individual healthy balance can be really tough, but they definitely can’t do it alone. They need your education in the importance of water for the proper function of the cardiopulmonovasculorenourinary system. Ha!

Patients who have COPD also have a very high incidence of urinary incontinence which is thought to be linked to chronic coughing and structural changes in their chest which lead to changes in the length-tension relationship of the diaphragm and altered breathing patterns. If you read the post on Intra-Abdominal Pressure and Part 1 of Urinary Incontinence Management, you’ll understand that these relationships play a large role in pelvic floor function, bladder contractility, and incontinence management. Feel free to check out all the other linked posts to put that one together for yourself.

Pelvic Floor Strengthening and Managing Bladder Contractility

I’ll start off by just clearly stating a reminder here: NOT ALL PATIENTS NEED KEGELS. I know, we hear about Kegels all the time. They are huge part of incontinence management because stress incontinence or mixed incontinence which is at least partially stress incontinence is a large proportion of cases. If your patient is reporting symptoms of overflow incontinence, you may not want to use Kegels for management because they don’t need more tightening! I continue to not claim to be an expert, so when in doubt, consult your local pelvic floor therapist.

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Time for an Anatomy Lesson: Two Types of Kegels

The Quick Flick and the Long Hold are the two main types of Kegels exercises I use with my patients. I use them both and for different reasons, so I’ll take you through the specifics. Quick Flicks are also referred to as “knacks”, so you will see both terms used here. It’s important to remember that several different muscle fiber types exist in the muscles of the pelvic floor and all must be addressed to adequately increase strength. Anatomy lesson: We are talking about the levator ani muscle, which provides the “sling” support for the pelvic organs. This muscle, in addition to several smaller hip and pelvis muscles, makes up the pelvic floor. Coccygeous is the small band of muscle just posterior in this image, and also helps to support the pelvic organs.

The Levator Ani, which has three parts with different functions, is going to be the focus of the morphological information I provide. Going back to your basics, you have type 1 (slow-twitch) and type 2 (fast-twitch) fibers present in the muscles of the pelvic floor. These fiber types both decrease in number and size with age. Research shows us that more than 50% of women CANNOT voluntarily contract their pelvic floor muscles, and personal experience is that a far greater a number of men also cannot. People NEED to be trained.

The Tiny Pebble

Here goes my crazy. I get some serious looks for this one, but it WORKS!!! The way the levator ani contracts is similar to the diaphragm. When it contracts, it pulls upward in to the body. When you teach someone how to activate and contract this muscle, you need to ensure they are performing the correct motion. A very effective way to do this is to use the “Tiny Pebble” explanation. You ask your patient to pretend that there is a tiny pebble at the opening of their anus. To perform a pelvic floor contraction, they want to grab the tiny pebble with their anus and then attempt to pull it up inside. How long they do this for will be determined by the type of exercise you are asking them to do. Here is what I mean:

The Quick Flick: How-To and Why

Quick flicks are fast contractions of the pelvic floor. These address the type 2 muscle fibers. Increasing the presence and function of type 2 muscles fibers BY ITSELF can significantly reduce the presence and risk of stress incontinence.

You will ask your patient to grab the pebble 5 times in a row, and put it back down between each one. These should be somewhat fast but that will depend on your patient’s skill level.

Quick flicks, or knacks, are really useful for two things:

1. Performing a quick flick just prior to an increase in intra-abdominal pressure, like a cough or sneeze, can give the pelvic floor a bit more support to prevent leakage. This is the primary usage of knacks.
2. The other function of quick flicks is neurological. Say you are walking home and are about 5 minutes from your door. You know you have to go to the bathroom pretty bad because your bladder is sending you all kinds of signals telling you so. If you perform a few sets of quick flicks, you can silence those alarms temporarily until you can get home to use the bathroom, essentially preventing function incontinence.

That second one can be really useful for our patients who need to get up out of bed in the middle of the night to use the bathroom, but have a long walk, move slowly, or need to make several adjustments and preparations before going. You can just buy a little bit of time to reduce the rushing, make the trip safer, and reduce the fall risk.

The Long Holds: How-To and Why

Long Holds address type 1 muscle fibers (the slow-twitch fibers). Increasing the size and number of these muscle fibers can significantly improve pelvic organ support and be helpful for different types of overflow incontinence that may be due to organ prolapse. However, it can also be really useful for long-term strengthening programs and endurance training. Sometimes we are further than 5 minutes from home and still have to wait.

To instruct your patient in long holds, ask them to grab the tiny pebble, pull it up inside, and hold it there. I typically start with 5 second holds and build from there. I have them do one 5-second hold at a time.

The “why” of this one I feel like is pretty obvious but it’s basically endurance. You need to be able to support your pelvic organs all day and you need to control your urine flow all day. This may take some time to achieve and there are all different ways to go about this training. I like to have people in the hospital or at home perform their pelvic floor exercises every time a commercial comes on the TV. That gets a lot of sets and reps in!

The Bigger Picture

Planning out your sets and reps shouldn’t be any different than when you are training any other muscle group. If you are using the Oddvar-Holten curve to prescribe your sets and reps, and you want to focus on strengthening, you may want to do fewer reps per set than if you were working on endurance training with longer sets of more reps. You can’t really calculate a 1-Rep Max other than the weight of the internal organs, so using body weight is about the closest you’re going to get. Just a different way to apply the basics of what you already know, right?

But that’s not the whole thing. I talked a lot about intra-abdominal pressure regulation in relationship to the pelvic floor and my instruction in pelvic floor exercises is not complete without including instructions on how to properly BREATHE during these exercises. I will want you now, when your patients perform these, they will hold their breath, just like every other type of exercise we have patients do. They may also stick their tongue out or raise their shoulders or eyebrows with the muscle contractions. I typically end up doing the eyebrow thing, too, when I’m teaching it… It makes it a bit more entertaining. But you have to correct the breathing part! When you put it all together, your instructions to your patient go like this:

The counting out loud part of this is crucial. If they aren’t counting out loud, they are probably holding their breath. If they are counting out loud, you know they are breathing out! Like I mentioned earlier, you will inevitably get many people who hold their breath during these exercises. I like to remind them that these particular muscles are NOT breathing muscles. I know that is a bit simplistic, but it makes them laugh a bit and then I know they are breathing.

BONUS: Internal Exam NOT Required

When you are instructing patients in these techniques, research has shown that verbal instruction alone is more than sufficient to produce the ability to contract the pelvic floor musculature.

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Protecting the Pelvic Floor

You may work with a population of patients who are young, highly athletic, healthy, and deny any urinary incontinence or other pelvic floor issues. That is so great! But, let’s keep it that way, shall we? The BEST way to treat a chronic disease is to prevent it from happening in the first place! It is important to remember that the pelvic floor is a set of muscles, tissues, bones, and joints that need to be cared for, well used, and protected, just like any other body system. You need to take in to consideration patients who do high-impact activity and/or high-load lifting. Their intra-abdominal pressure regulation is CRUCIAL to protecting that pelvic floor. Read more about that in the post specific to intra-abdominal pressure. But pregnant women also need to know some tips on protecting their pelvic floor before, during, and after birth so that they can have minimal issues throughout. Obviously, there is a tiny-space occupying person that is GOING to cause some strain, so we have to work on how to manage that strain.

High Impact & High Load Athletes

High impact athletes, like runners, gymnasts, and cheerleaders, can find some pretty interesting ways to force their body to achieve the high level tasks the want to achieve. That doesn’t necessarily mean they are using their body the right way to achieve them. Runners may need help with regulating their breathing and maintaining the strength of their pelvic floor muscles to prevent leakage on the initial contact phase of their running gait. Gymnasts and cheerleaders may find that they can stabilize their body in many crazy ways, but can also be fully capable of stabilizing with your shoulder complexes or their glutes and still have minimal core activation. This combination CAN lead to reduced pelvic floor muscle activation and result in stress urinary incontinence. If that is the case, you may find you have to reprogram their trunk stability techniques to include pelvic floor and core.

Pregnancy, Labor, and Post-Partum

This section could be a whole other post, but, like I keep saying, I’m no expert here. What I can tell you is that pregnant women have to pee, a lot. It’s a function of a growing baby taking up space and physically placing pressure on the bladder and other organs within the intra-abdominal space. Not all women will experience incontinence with pregnancy, but many will. We can’t resolve that for the most part, but we can improve it. Lots of water and lots of bathroom breaks are crucial for incontinence management for pregnant women, but this isn’t always achievable due to work and life demands. So, do the best you can with the schedule.

Strengthening that pelvic floor and training knacks will not only help patients manage incontinence, but prepare them for birth. Think about a patient who needs a total knee replacement but has weak quads… You wouldn’t expect them to have a stellar rehab from that knee replacement unless they did some pre-habilitation first to increase quad strength and activation. The same goes for birth. Strengthening the pelvic floor prior to birth can shorten and ease the recovery afterward. Good pelvic floor activation and control can help post-partum women regain control of their incontinence before it becomes a bigger issue. Remember how we talked about the importance of length-tension relationships and breathing with pelvic floor functoin? In the case of cesarean section (C-section) managing intra-abdominal pressure and reducing the work of the pelvic floor can be crucial. Again, not an expert here, so get them to a pelvic floor therapist ASAP!

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Most of all, if you have incontinence, if your friend does, or your mom does, or your neighbor does, or your gym buddy does, tell them there is help that doesn’t involve surgery or medication. Tell them about pelvic floor PT. Network with the pelvic floor PT’s in your area. These PT’s are amazing! Give out their cards. Make it a normal thing to talk about. Your friends, family, and patients will thank you.

Do you have a favorite Pelvic Floor PT in your area? We can all use a bigger network! Give them a shout out in the comments!

References

Ayeleke, R. O., Hay-Smith, E. J., & Omar, M. I. (2015). Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women. The Cochrane database of systematic reviews, 2015(11), CD010551. https://doi.org/10.1002/14651858.CD010551.pub3

Bush, H. M., Pagorek, S., Kuperstein, J., Guo, J., Ballert, K. N., & Crofford, L. J. (2013). The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study. Journal of women’s health physical therapy, 37(1), 11–18. https://doi.org/10.1097/JWH.0b013e31828c1ab3

Carvalho, N., Fustinoni, S., Abolhassani, N. et al. Impact of urine and mixed incontinence on long-term care preference: a vignette-survey study of community-dwelling older adults. BMC Geriatr 20, 69 (2020). https://doi.org/10.1186/s12877-020-1439-x

Fitz, F. F., Paladini, L. M., Ferreira, L. A., Gimenez, M. M., Bortolini, M., & Castro, R. A. (2020). Ability to contract the pelvic floor muscles and association with muscle function in incontinent women. International urogynecology journal, 31(11), 2337–2344. https://doi.org/10.1007/s00192-020-04469-0

Koelbl, H., Strassegger, H., Riss, P. A., & Gruber, H. (1989). Morphologic and functional aspects of pelvic floor muscles in patients with pelvic relaxation and genuine stress incontinence. Obstetrics and gynecology, 74(5), 789–795.

Kuchel, G. A. and DuBeau, C. E. (2009). Urinary Incontinence in the Elderly in Geriatric Nephrology. American Society of Nephrology. Retrieved from https://www.asn-online.org/education/distancelearning/curricula/geriatrics/Chapter30.pdf

Mayo Clinic. (2020). Bladder Control: Lifestyle strategies ease problems. Retrieved from https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problem/art-20046597

Nuotio M, Tammela TL, Luukkaala T, Jylhä M. Predictors of institutionalization in an older population during a 13-year period: the effect of urge incontinence. J Gerontol A Biol Sci Med Sci. 2003 Aug;58(8):756-62. doi: 10.1093/gerona/58.8.m756. PMID: 12902536.

Simmering, J. E., Tang, F., Cavanaugh, J. E., Polgreen, L. A., & Polgreen, P. M. (2017). The Increase in Hospitalizations for Urinary Tract Infections and the Associated Costs in the United States, 1998-2011. Open forum infectious diseases, 4(1), ofw281. https://doi.org/10.1093/ofid/ofw281

Welk B, Baverstock R. Is there a link between back pain and urinary symptoms? Neurourol Urodyn. 2020 Feb;39(2):523-532. doi: 10.1002/nau.24269. Epub 2020 Jan 3. PMID: 31899561.

Zilberberg MD, Shorr AF. Secular trends in gram-negative resistance among urinary tract infection hospitalizations in the United States, 2000–2009. Infect Control Hosp Epidemiol 2013; 34: 940–6.

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