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July 2004


One Less Worry

By Holly Lookabaugh-Deur, PT, CWS, GSC, ABD


Holly Lookabaugh-Deur, PT, CWS, GSC, ABD (left), works with a client.
Women experience many physiological and psychological changes after childbirth, with one primary comment heard over and over again in the physical therapy clinic: “I just want to feel ‘normal’ again.” This article focuses on one aspect of the postpartum period that women are often not well prepared for by their physician or prenatal research: urinary incontinence.

Defined as a loss of complete control of one’s bladder, urinary incontinence (UI) occurs for several different reasons. It is not a “normal” part of aging, or something that all women must struggle with after childbirth. UI can be the result of many years of physiological changes, but with competent assessment and comprehensive education and care, the condition can be resolved quickly, with a strong likelihood that it may not be a problem again.

Although there are several types of UI, the three most common types affecting women after childbirth include stress UI, urge UI, and mixed UI ( a combination of stress and urge types).

To understand the UI type and potential solutions, one must have a working knowledge of the mechanism of normal micturition. The bladder has a “fill point” that normally causes a reflexive contraction (the “urge”) of the detrusor (bladder muscle) with a concurrent relaxation of the sphincter between the bladder and the urethra, as well as the external sphincter at the opening of the urethra to the exterior of the body. The pubococcygeal muscle (pelvic floor muscle group) also plays an important role in keeping the urethra closed until urination is voluntary. Stress UI occurs when the pelvic floor is weak and/or there is poor ligament support around the exiting urethra outlet and a variety of other potential physical causes surrounding the urethra. Symptoms of urine leakage occur usually during physical stress on these structures, such as during coughing, sneezing, lifting, or moving from sitting to standing.

Urge UI occurs when the detrusor contracts, usually more frequently than normal (every 3 to 4 hours), and urine leaks out without control. There are many reasons for urge UI, such as a neurological condition like multiple sclerosis, but more often, urge UI is caused by a bladder infection, bladder irritability, or simply poor dietary and bladder habits. Anxiety can play a significant role in urge UI.

Mixed UI is the most common type of UI in women, and it is simply a combination of both urge and stress UI types.

POSTPARTUM CHANGES
With a quick review of postpartum physiological changes, it becomes understandable that the new mother is likely to encounter challenges with normal urination, at least initially. The hormonal changes are complex, and extreme changes in production after childbirth to restore nonpregnant levels of hormones omplex, and extreme changes in production after childbirth to restore nonpregnant levels of hormones and/or lactation include fluctuations in all of the following: follicle-stimulating hormone, luteinizing hormone, prolactin, oxytocin, estrogen, progesterone, human chorionic gonadotropin, human placental lactogen, relaxin, corticotropin-releasing hormone (CRH), thyroxine, and parathyroid hormone.1 Hormone fluctuations can affect the ability of the urethra to close tightly and cause other irritation to the detrusor itself.

Postpartum ligament instability primarily occurs because of the direct impact of some of the hormones listed above. Widening of the total pelvic diameter during delivery of greater than 10 mm is suggested in the literature as the threshold for pathological consequences to the stability of the sacroiliac joints.1 Urinary incontinence during sit to stand transitions is closely associated with sacroiliac dysfunction and/or pubis symphysis dysfunction.2

Advice to Clients for Healthy Bladder Habits

•

7-9 trips to the bathroom per day maximum. Go to the bathroom no more than every 3-4 hours.

•

Avoid going to the bathroom "just in case", such as before leaving work, etc., if it means you will exceed the number of trips per day.

•

Your bladder should empty for at least 8 seconds, or it was "too soon" to go.

•

Sit on the toilet with your feet supported to allow your pelvic floor to relax. Do not strain to urinate faster or empty your bladder.

•

Drink water! Two thirds of what you drink during the day should be water.

•

Avoid bladder irritants if you struggle with excessive urges: chocolate, caffeine, spicy foods, aspartame, sharp cheese, tea, carbonated beverages, citrus fruits and juices, tomatoes, vinegar, plums, strawberries, lemon juice, onions, alcohol, tobacco, pinapple.

•

Avoid episodes of constipation; this can worsen incontinence. Use a stool softener as needed.

•

Strengthen your abdominal and pelvic floor muscles.

•

If you have the urge to "go", but it is too soon, stop moving, sit or stand still, contract your pelvic floor four to six times, breathe deeply, and relax until the urge passes. Suppress the urge if it is less than 2 hours since you last went to the bathroom.

Table 1. Healthy bladder habits.

Both conditions respond very well to manual therapy and specific mobilization techniques. Muscle function following delivery is initially impaired due to the severe strain and stress on the important abdominal muscle groups, often for up to 8 weeks after vaginal delivery.3 The pelvic floor stress of carrying the fetus and excess weight certainly impacts its ability to contract fully initially after birth, but equally important is the likely trauma to the pelvic floor during the delivery itself. The literature supports the incidence of postpartum dysfunction of the pelvic floor muscle groups with evidence of decreased intravaginal and intra-anal pressure generation studies. It is estimated that 21% of women who have uncomplicated vaginal deliveries and 34% of those with instrument-assisted vaginal deliveries complain of urinary incontinence.4 According to a study by Groutz et al, the major obstetric risk factors for changes in postpartum incontinence are: prolonged first and second stages of labor, operative vaginal delivery, and use of episiotomy.5

Physical changes that impact postpartum incontinence are a significant increase in bladder neck mobility, a decrease in functional urethral length, and/or a decrease in intravaginal pressures. Women who have forceps-assisted deliveries have been shown to have a significantly lower bladder neck position at rest, which places additional pressure on the urethral sphincter, requiring greater closing pressure to maintain continence. Other studies show that the pudendal nerve undergoes changes following delivery, often without return to prepartum values for up to 3 months after delivery.6 Pelvic floor dysfunction, caused by any of the physiological changes listed above, usually impacts continence for up to 6 months following delivery.

Summarizing the physical changes after childbirth, the ability to fully control one’s bladder is impacted by complex hormonal fluxes, pelvic floor dysfunction, and ligament instability affecting multiple supportive structures. The effects of estrogen and CRH withdrawal can contribute to the risk of mental health disorders such as depression. When combined with the caregiving stresses of impaired sleep patterns, irregular meals and eating patterns, and lactation and new fluid requirements, urge UI symptoms begin to surface with frequent urination attempts, which affects the bladder by essentially “teaching” the bladder to empty at a lower fill point; this causes more frequent bladder spasms without the physical ability to close the urethra sphincters. The new mother may become overwhelmed with frustration at having a new worry—whether she can make it to the bathroom in time.

TREATMENT METHODS
The physical therapist can help all of these symptoms in quick order. After evaluating a 3-day diary of food intake, liquids, and urination patterns, including amount, urge, and other physical activities, the therapist must also perform a physical assessment. Even if the PT has not received education beyond entry level on pelvic examination, sacroiliac function and pubic symphysis integrity and alignment should be a standard part of postpartum UI assessment.

Once these are “cleared,” the therapist has a better understanding of which components of the postpartum physiological changes are causing the onset of UI. At the very least, education of the client regarding healthy bladder habits, including proper pelvic floor exercises, should be initiated.

Treatment for urge and stress UI types should occur simultaneously, addressing frequency, diet, nutrition, and pelvic floor strength issues. Pelvic floor dysfunction can be addressed in a multitude of ways:

  • Home exercises, including appropriately performed Kegel exercises and pelvic bracing, progressing to functional tasks during these exercises. Both short and long hold (up to 10 seconds) contractions should be used in the prescription to address fast and slow twitch muscle fibers.
  • Pelvic floor exercise programs are often poorly defined and described to clients, with common pitfalls of overexercising with too rapid contractions and fatigue of the pelvic floor, or not advancing the program to allow for real strengthening. Vaginal weights can be self-administered and progressed during upright exercise during functional tasks.
  • Home exercise units: surface EMG or simple pressure gauge probes can supplement home exercise programs.
  • Surface and vaginal probe EMG can be used to analyze contraction patterns, and teach clients in a biofeedback manner how to utilize the “right” muscle groups.
  • Electrical stimulation, delivered by electrode to the pelvic floor externally or via vaginal probe internally, can stimulate and retrain a traumatized pelvic floor.

As physical therapists, we have many tools to facilitate a rapid return to full continence following childbirth. Women who undergo cesarean delivery often have the same UI issues from the physiological changes listed previously. Unfortunately, many women believe that UI is a normal part of recovery and do not address the issue with their physician or a physical therapist. Some of the instability and post-traumatic pelvic floor issues can manifest themselves months and years later with fibrous/scarring changes and dysfunctional problems that become more complicated to treat. Early education and intervention is the best advice, and even one visit to a health care professional can make a significant difference. Most women are not familiar with healthy bladder habits, so education can be life-impacting for many years to come (see Table 1).

The physical therapist can play a vital role in the quick recovery of a new mother, giving her sound advice, reassurance—and one less worry.

Holly Lookabaugh-Deur, PT, CWS, GSC, ABD, is owner and president of Generation Care, Muskegon, Mich, and Generation Care Country Homes, an adult foster care/assisted living center.

REFERENCES
  1. Abraham K. Physiological changes postpartum: a review of literature to guide physical therapist practice. Journal of the Section on Women’s Health. 2003;27:2.
  2. Snow RE, Neubert AG. Peripartum pubic symphysis separation: a case series and review of the literature. Obstet Gynecol Surv. 1997;52:438-443.
  3. Fleming N, Newton ER, Roberts J. Changes in postpartum perineal muscle function in women with and without episiotomies. J Midwifery Womens Health. 2003;48:53-59.
  4. Hayat SK, Thorp JM Jr, Kuller JA, Brown BD, Semelka RC. Magnetic resonance imaging of the pelvic floor in the postpartum patient. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7:321-324.
  5. Groutz A, Fait G, Lessing JB, et al. Incidence and obstetric risk factors of postpartum anal incontinence. Scand J Gastroenterol. 1999;34:315-318.
  6. Tetzschner T, Sorensen M, Lose G, Christiansen J. Pudendal nerve function during pregnancy and after delivery. Int Urogynecol J Pelvic Floor Dysfunct. 1997;8:66-68.

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