Incontinence is a prevalent health condition that is rarely discussed as people living with the condition are often embarrassed to discuss it with their healthcare providers. Incontinence includes the more common, urinary incontinence (UI) and the less common, fecal incontinence (FI); over-active bladder (OAB) refers to that frequent need for voiding without leakage. Many incontinent people will have both urinary incontinence and fecal incontinence, with or without urinary leakage.
The continence care community generally agrees that the prevalence of incontinence in Canada is about the same as in the United States—about 10% of the population. That means that approximately 3.5 million Canadians experience some form of incontinence. Individual research estimates for the prevalence of incontinence in Canada range from 2% to 50% of the population, depending upon the study, the research method, and the questions posed. For example, asking the question “are you incontinent” will garner a dramatically lower rate of positive responses that the question “do you suffer from occasional leakage of urine?” There tends to be a greater prevalence of incontinence amongst women than men; it is believed that this difference is related to female childbearing and other consequences specific to women.
What is Pelvic Health Physiotherapy?
The pelvis is a large bony structure located between the trunk and the legs. It is formed by the sacrum and the coccyx in the back, by a pair of bony hip bones on each side, and by cartilage called the pubic symphysis in the front. The pelvis is lined with a group of muscles (pelvic floor) that silently support the pelvic organs as well as assist in bowel, bladder, and sexual function. It also contains a large network of connective tissue—a web like suspension structure, that acts in dynamic function to support. Pelvic Health Rehabilitation is used to describe a number of conditions affecting the pelvic floor musculature. While specialized physicians (gynecologists and urologists) look at the health of the organs in this area, physiotherapists assess through internal exams and treat these conditions.
Urinary Incontinence (Stress, Urge, Overflow, Functional Mixed)
Urinary incontinence is the unwanted loss of urine at the wrong time or the wrong place. It can be just a few drops, enough to run down your legs, or enough to wet the floor. There are many myths surrounding urinary incontinence—such as it is an inevitable part of aging or to be expected after childbirth. However, urinary incontinence can affect anyone of any age or of either sex.
Fecal Incontinence: This is loss of bowel control, resulting in a loss of gas, liquid, or solid stool. It can affect men and women of any age.
Muscle weakness/damage to the rings which circle the anus (sphincter muscle) along with the pelvic floor muscle weakness may develop. Causes can consist of many factors such as significant tearing to the rectum after childbirth, forceps use, surgery, or recurrent straining.
Pelvic organ prolapse is a common condition, particularly affecting older women. Prolapse means “to fall”. This occurs when structures designed to keep organs in place weaken and stretch.
The prolapse can be mild, moderate, or severe and include symptoms of pressure incontinence, pain/discomfort, and emptying bowels. It can include organs such as bladder, bowel, and uterus.
Some women are at risk of pelvic floor problems during pregnancy and childbirth more than others.
- Multiple births and large babies.
- Instrumental births.
- Long second stage of labour (over 1 hour)
- Significant perineal tearing.
During pregnancy, the effects of the hormones released to allow your body to accommodate baby’s growth places pressure on the pelvic floor.
Train your muscles throughout your pregnancy and return to “SAFE” exercise programs after delivery, especially if you have common signs of a pelvic floor problem.
Good floor muscle tone assists to maintain bladder and bowel control and reduce the risk of developing a prolapse (fall of an organ).
Onset of menopause comes with so many changes involving the hormonal imbalances. Just like the rest of your body, the muscles in the pelvic floor can weaken. Contributing factors can include:
- Weight gain
- Less bladder elasticity
- Chronic conditions such as diabetes/asthma.
- Gynaecological surgery
- Anal tearing during childbirth.
This is another time in our lives to do pelvic floor muscle exercises.
The Pelvic Floor – How it Functions
The pelvic floor muscles form the base of muscles that work with the deep abdominal (stomach) and back muscle and the diaphragm (breathing) to support the spine and control the pressure inside the abdomen.
During exercise, the external pressure in the abdomen changes—it will increase when lifting weight and return to normal when the weight is put down. The muscles work in a co-ordinated effort and the pelvic floor lifts. In the ideal situation, this regulation of pressure happens automatically.
If any of these muscles (known as the core) are weakened or damaged when the external pressure increases (as in exercise) there is potential to overload the pelvic floor muscles, even in day-to-day activities.
Pelvic floor muscles also need to relax as well as hold and lift. It is common for individuals to brace these core muscles constantly in belief they are supporting their spine. Constant bracing can lead to tight and stiff structure, leading to many problems such as urgency, leakage, and pelvic pain.
For Men, Too! Pelvic Floor Health
Pelvic floor muscle exercises have long been considered only important for women. Studies have found that pelvic floor muscle exercises can help treat incontinence, bladder control, and sexual dysfunction.
Along with lifestyle changes (diet, alcohol intake, smoking) there is strong evidence that pelvic floor exercises are important for men who undergo a radical prostatectomy. These can hasten recovery from the surgery and are now being recommended before and after surgery in regaining control of bladder function.
Pelvic floor muscles can assist with conditions such as: Stress Urinary Incontinence, Overactive Bladder, and Postvoid Dribbling. This is due to increasing the strength of the external sphincter within the muscles and coordination of the reflexes that help maintain continence.
Correct technique is very important when doing your pelvic floor exercises. You should feel a “lift and a squeeze” inside your pelvis, but keeping the area above the bellybutton relaxed and the buttocks relaxed along with practicing relaxed breathing.
What to Expect
Physiotherapy is carried out in a private treatment room, providing a confidential environment. It begins with specific questions, your medical and surgical history, pregnancies and births, your diet, and lifestyle. A physical exam will then follow, which may include looking at your posture, abdominal muscles, and an internal examination.
Once the examination is complete, a discussion follows explaining the findings and exploring treatment options. This is a good opportunity for you to ask questions and gain a better understanding of what treatment approach will be implemented.
Based on the assessment findings, your physiotherapist will develop an individualized treatment program as many of the conditions in this area are multifactorial. This is then implemented into a comprehensive treatment approach—a return to a better function.
These treatment measures address:
- Training the pelvic floor muscles (exercise prescription).
- Education on healthy bowel and bladder habits.
- Diet considerations.
- Pain and stress management approaches.
- Manual therapy approach to create balance in other structures around the pelvis.
- Improved pelvic floor muscle awareness/sensation through modalities such as electrical stimulation and biofeedback.
Persistent Pelvic Pain
Persistent pelvic pain is often due to musculoskeletal disorders which may go unrecognized during a traditional pelvic examination of the cervix, of the uterus, and the adnexa done by gynecologists. Pelvic floor musculoskeletal disorders are common in women and often go unrecognized during the evaluation of pelvic pain syndromes. Pelvic pain is relatively common among women, and many of the medical resources and surgical interventions have not been successful. Unfortunately, some of these patients have a diagnosis that is not surgically correctable or have a multifactorial etiology for their pain. The pelvic floor musculature is therefore well recognized as a potential cause for ongoing pelvic pain but unfortunately the criteria for diagnosing musculoskeletal pain has not been well established or validated.
Several mechanisms of injury that may lead to spasm of the pelvic floor (pelvic floor hypertonus) include, but are not limited to, traumatic vaginal delivery, pelvic surgery, positions such as prolonged driving, or occupations that require prolonged sitting, gait disturbances, traumatic injury to the back or pelvis, and sexual abuse. Malalignment of the pelvis—especially in joints of the pelvis due to trauma, poor posture, pelvic floor deconditioning, muscular asymmetry. Excessive athletics also may contribute to muscular dysfunction of the pelvis.
Pain begins in an acute phase and is characterized by inflammation and the immune responses; however, may perpetuate with further spasm, inflammation, neurotransmitter release, and central nervous system desensitization. In many situations, adequate time has lapsed to heal structures but persistent pain and dysfunction continues. Pelvic floor pain can also arise in response to other ongoing, longstanding pain syndromes such as endometriosis, irritable bowel disease, vulvodynia, and interstitial cystitis.