Women (and men) may experience bladder dysfunctions for a variety of reasons. The first place to start is with your physician who may diagnose the possible reasons why you might be experiencing the problem.
Treatments include a combination of medical, surgical, pharmacological and physical therapy interventions. Patients should be their own best advocates to explore the many treatment options available to them.
Most commonly, patients are referred to physical therapy for urinary leakage, urinary urgency/frequency or incomplete voiding. The pelvic floor muscles are generally weak and/or tense.
Understanding the pelvic floor
The pelvic floor is the area between the pubic bone in the front and the tail bone at the back. It is richly meshed with several small muscles, nerves, and other soft tissues. These structures form a sling that supports the abdominal and pelvic organs primarily the bladder, uterus and bowel. These muscles also encircle the openings of the bladder (urethra) bowel (rectum) and uterus (vagina) – they provide closure when appropriate and relax when we need to empty our bowels or bladder. When the muscles are weak, they cannot provide closure (you have leakage) or when they are too tense you might have incomplete voiding and/or sexual pain or constipation.
The pelvic floor muscles are made of 30% power fibers and 70% endurance fibers and both fibers are needed for the muscle to do its job.
The power fibers are activated to close the openings during a cough or sneeze so that no leakage occurs – these fibers are strong and fast (like a sprinter) but do not hold a contraction very long (up to 3 seconds).
The endurance fibers provide support for the organs (bladder, uterus and bowel) and are active even in sleep. These fibers minimize possibility of prolapse / falling out of the pelvic organs and help hold up the “bottom” during everyday activities. These fibers are not as powerful as the “power” fibers but resemble marathoners in that they can keep going for a longer period of time.
In addition the lower abdominal muscles provide frontal support to the pelvic organs. These muscles together form the core. These muscles are the primary target for physical therapy treatment.
In the case of bladder problems, treatment is primarily directed towards strengthening these muscles to provide support from the bottom (pelvic floor muscles) and the front (lower belly muscles) and to help these 2 groups of muscles to work together in a coordinated manner.
You may have heard of “kegel” exercise or you may have practiced these exercises. These are exercises that ask you to contract or squeeze the muscles around the urethra or rectum. Studies have shown that 40% of women are doing these exercises incorrectly based on verbal instruction alone. Patients (especially if you have weak muscles) use the buttock and/or inner thigh muscles. We strongly recommend at least one visit to physical therapy to ensure that you are doing your exercises correctly.
To understand the role of physical therapy in the treatment of bladder dysfunctions, it may be easier to first understand how the pelvic floor muscles are related to various bladder problems.
Stress incontinence: The involuntary loss of urine with physical exertion including cough, sneeze, getting up from a chair, exercise.
The power fibers in the pelvic floor muscle are weak and unable to withstand the pressure from a cough, sneeze, jump etc.
Urge incontinence: The loss of urine that occurs with a strong desire to urinate and the patient is unable to make it to the bathroom in time. The bladder contracts and the patient cannot delay the signal to make it to the bathroom in time.
The endurance fibers in the pelvic floor muscles, if activated in a timely manner, may help to ease bladder contractions and allow you to reach the bathroom in time. We also teach you "determent" techniques to help lessen the urgency and make it to the bathroom in time.
Mixed incontinence: A combination of both stress and urge.
Incomplete voiding: Patients are not able to empty their bladder completely. A small amount of urine remaining in the bladder after voiding is normal but a “high post void residual” indicates that the bladder is not emptying as fully as it should. This could be for several reasons. However, if your physician is referring you to physical therapy for incomplete voiding, he/she suspects that the muscles of the pelvic floor are not relaxing completely when you are urinating to allow the bladder to empty completely.
Sometimes, patients develop this problem from years of crouching or “hovering” i.e. not sitting fully on the toilet seat to empty usually for fear of germs or soiled toilet seats from other users. The problem with this is that the pelvic floor muscles are unable to fully relax (in fact the muscles are misfiring) and the bladder is not able to empty completely.
Physical therapy is directed towards re-educating the pelvic floor muscles to relax as the bladder contracts. Optimum toileting positions are discussed. Biofeedback and manual therapy is helpful.
Going to the bathroom too often is disruptive to daily activities and sometimes to sleep patterns. Patients are taught “deferment”/bladder retraining techniques to be able to delay the signal to urinate and move towards more normal voiding intervals. These include strengthening the pelvic floor muscles, patient education on other deferment techniques.
Electrical stimulation is also helpful to lessen bladder irritability.
Physical therapy treatment includes one or more of the following:
Assessment / Evaluation
The assessment is detailed and primarily directed towards determining the degree of weakness and in coordination of the pelvic floor and lower abdominal muscles.
We do ask you a detailed history of your symptoms and toileting habits, your fluid intake, some dietary questions and exercise history.
- Manually applied quick stretch to the muscles will jump start a weak muscle
- Correct misalignments of the joints in the pelvis and/or spine: tail bone, sacroiliac (joint mobilization). These misalignments may be perpetuating or contributing to inefficient muscle effort
- Gentle movements to mobilize stiff or tense bladder ligaments and related structures
Pelvic floor biofeedback or surface EMG
Biofeedback involves the insertion of a small probe into the vagina or rectum that “records” muscle activity and translates these signals onto a computer screen so that patients can “see” their muscle contraction, tension and relaxation. The ability to view muscle activity helps patients to see the results of their efforts as muscles strengthen or relax.
Electrical stimulation: For muscle re-education or to relax the bladder
Electrical stimulation at certain frequencies may be applied directly into the vagina or rectum to enhance muscle action. The stimulation recruits muscle fibers to contract at the same time that you are also making the effort to contract. At lower frequencies, electrical stimulation calms the bladder and lessens symptoms of urgency. Patients are given resources on how to order “home units” if necessary.
Exercise: To ensure accuracy and specificity
All muscles should have the ability to contract, relax, stretch and act in coordination with other muscles. Physical therapy is directed towards helping your pelvic floor muscles achieve all these functions and then learn to use these muscles in daily life (while lifting, cough, sneezing etc.) Depending on the strength and endurance of the pelvic floor and lower abdominal muscles, a tailored exercise program is designed to challenge the power and/or endurance fibers. Hints and tips help to minimize the use of the buttocks and inner thigh muscles. The number of repetitions, the position in which you do the exercises how often and how many and how to coordinate with the lower abdominal muscles – all make a difference to the effectiveness of the exercise.
Exercises are made more challenging as you progress.
The therapist will suggest modifications to your daily activities to minimize leakage and how to use your pelvic floor muscles throughout the day – as you lift, cough, exercise and go about your everyday activities.
How often and for how long will I need to come to therapy?
You can expect to attend therapy 2-3 times per month for 3 months depending on the complexity of your symptoms. For patients traveling long distances, other accommodations are suggested.
You will need a prescription from your physician and physical therapy services are reimbursed by most insurance companies.
Physical therapists are health care professionals who assess and manage patients who have medical problems or other health related conditions that limit their ability to move and perform their daily activities comfortably. Your physical therapist will take a detailed health history, examine you and develop a personal plan of care.
Treatment techniques are used to improve daily quality of life, strengthen and tone appropriate muscles and if needed, reduce pain, restore function, and prevent disability. Your Physical therapists will work with you to enhance health by developing fitness- and wellness-oriented programs for healthier and more active lifestyles tailored your ability.
It is important that you know your options for medical treatment and be an advocate for pelvic health.
For more information or to schedule an appointment call 713-799-6193.