April 2001

Intervention for Incontinence

By Holly Lookabaugh-Deur, MHS, PT, GCS

Properly trained physical therapists are the natural choice for assessing and treating urinary incontinence.

Urinary incontinence is a highly prevalent, yet rare priority on the “impairments treatable with physical therapy” list used during a typical evaluation. Although undergraduate and graduate physical therapy educational programs dedicate very little time to the topic (less than 2 hours per the Commission on Acceditation in Physical Therapy Education) continuing education opportunities for health care professionals are gaining momentum on this important topic. Commonly misunderstood as a normal phase of aging, urinary incontinence is a condition with quite amazing clinical responses to physical therapy intervention. According to the National Association for Continence (NAFC), more than 13 million Americans suffer, often silently, from urinary incontinence (UI).1 While 85% of those with UI are women, men are not exempt from the effects of social isolation often caused by untreated incontinence. Koyama et al are convinced that nearly 82% of UI sufferers do not consult their physician about the problem.2 Furthermore, many elderly individuals are extremely reluctant to undergo any procedure or examination that would require revealing or manually examining the genitalia.3 Although the frequency of occurrence of UI varies between the noninstitutionalized (30%)4 and the institutionalized elderly (60%)5, the economic and social consequences of this disorder are equally compelling. UI may lead to abnormal skin and wound issues, reduced daily mobility for fear of being too far from toileting facilities, declining strength and balance, and an increased incidence of falls.6 As clinicians, we often steer away from unfamiliar clinical areas, particularly if the examination and treatment are somewhat mysterious or vary from the typical PT intervention. In our growing profession of advanced clinical specialists and limited practice settings, UI may seem like the perfect diagnosis to refer to another. Yet our profession now mandates that therapists wear many different hats for our patients—advocating for comprehensive management of the many interacting impairments we see and they feel. In today’s managed health care system, we may be “it” for the home health visit or the outpatient checkup, and to ignore obvious problems with ready solutions is unprofessional and irresponsible at best.

Necessary Background
Many of the advanced continuing education courses now available are thoroughly presented, beginning with the anatomy and function of pelvic floor, and progressing to detailed treatment considerations for a variety of obstetric/gynecologic disorders. To a physical therapist just beginning to understand the basics of UI, professional confidence builds from simple problem solving, perhaps without ever performing the higher level examinations and even touching the patient. The impact of bladder health education can be life-changing, and good habits can be taught and reinforced in any setting.

Therapists need a comprehensive background in the following areas before attempting to assess and treat urinary incontinence:

1. Anatomy and function of normal micturition.
2. Medications that aggravate and/or cause urinary incontinence.
3. Anatomy and function of the pelvic floor.
4. Methods of grading pelvic floor strength.
5. Understanding the differences between the signs and symptoms/assessment and treatment approaches of: urge, stress, mixed, overflow, and functional incontinence.
6. Healthy bladder habits.
7. Interpretation of a 3-7 day bladder diary and recommendations for change.
8. Therapeutic exercise prescription and instruction methods for pelvic floor strengthening and trunk and abdominal stabilization.
9. Methods of effective electrical stimulation and biofeedback to facilitate muscle strengthening.
10. Behavioral management techniques—bladder retraining and prompted voiding strategies.
11. Adapted toileting equipment and technique, bladder management supplies.

The list of basic clinical skills can be further enhanced with specialty training in other aspects of gynecological care. Therapists are involved in treatment of painful pelvic conditions, prevention of invasive procedures related to pelvic organ prolapse and pessary placement, and management of fecal incontinence.

Intervening the PT Way
Using the example of stress incontinence, intervention begins with a thorough understanding of the condition. Characterized by uncontrolled urination or slight leakage when there is a change in intra-abdominal pressure, stress urinary incontinence (SUI) is the most prevalent type of UI condition. SUI typically occurs during coughing, sneezing, heavy lifting, and other sudden movements of the trunk. It commonly occurs after childbirth when the trauma of delivery causes a stretching of the pelvic floor or damage to the pudendal nerve, or it may result from an improperly positioned urethra or weak pelvic floor. The disorder can occur at any age, but it is most commonly seen in individuals over 40. UI risk groups include postsurgical patients who experience pelvic or intra-abdominal trauma, such as with cesarean sections, transurethral resections of the prostate, and hysterectomies. Hip replacements affect the obturator internus, which supports the bowel and bladder. As therapists, we are well versed in total hip arthroplasty recovery programs, but may omit valuable discussion about temporary incontinence and ignore opportunities to reinforce simple pelvic floor exercises in our protocols. Postfall trauma victims and even postmenopausal hormonal changes affect the ability to maintain urinary continence.

Put it in writing
Assessment begins with patient completion of a detailed bladder diary for at least 3 days.7 The diary includes the time of day, amount of void, timing of medications, activities, fluid intake, and any other comments regarding urges, difficulty, or frequencies of urination. This overview of current bladder habits becomes the springboard for education: removal of bladder irritants, increasing episodes between voids by 15-minute increments until able to fill and hold the bladder for 2-4 hours, increasing intake of water and fluids, and the initiation of progressive therapeutic exercise for a weakened pelvic floor. These educational concepts, if properly instructed, reinforced, and progressed, can often alleviate or even eliminate the condition. If unsuccessful with exercise efforts with a proven weak pelvic floor, biofeedback and electrical stimulation of this skeletal muscle group may be effective. The ultimate goal is to teach principles to last a lifetime, encouraging self-management with professional clinical guidance whenever possible.
Education is but one tool utilized to treat basic urinary incontinence, and while it is beyond the scope of this article to discuss more advanced clinical skills, many physical therapy mentors can be found in the network of experts within the Women’s Health Section of the American Physical Therapy Association (APTA). Professional journals are an essential source of detailed studies supporting a variety of approaches for complex urinary incontinence conditions. More products are available to assist the physical therapist in treating these delicate conditions, and suppliers are often willing to share their growing area of expertise as well. Similarly, urologists are excellent resources for therapists to learn more about diagnostic tools such as cystograms. As the search for marketing niches continues, development of assessment and treatment skills related to urinary incontinence conditions may be a valuable addition to any therapeutic practice. Therapists who advocate for coverage of physical therapy services and the Women’s Health Section of APTA have successfully proven the efficacy of conservative care relating to this prevalent condition. The Health Care Financing Association reported an expansion of coverage of physical therapy services in a recent Fact Sheet published October 6, 2000. Electrical stimulation and biofeedback are covered services for urge and stress incontinence if a trial of pelvic exercise fails. This new Medicare benefit directly resulted from the research findings and efforts of dedicated therapists who believed in the value of their services and care.
Many resources suitable for novice and experienced therapists alike are available on the topic of urinary incontinence. NAFC is invaluable for the production of public education materials (PO Box 8310, Spartanburg, SC 29305-8310; (864) 579-7900; www.nafc.org). Certainly our first priority is to reach the many individuals who suffer from various forms of incontinence and promote using evidenced-based practice to treat it. Appropriate referrals from other interdisciplinary team members will grow in number as the proven results of our care become well known as acceptable alternatives for surgical intervention.

Holly Lookabaugh-Deur, MHS, PT, GCS, is currently the owner and president of Generation Care, Muskegon, Mich, a private geriatric practice, and Generation Care Country Homes, an adult foster care/assisted living center.

References 1. Public information brochure. Spartanburg, SC: National Association for Continence.
2. Koyama W, Koyanagi A, Mihar S, et al. Prevalence and conditions of urinary incontinence among the elderly. Methods In Med. 1998;37:151-5.
3. Prashar S, Simons A, Bryant C, et al. Attitudes to vaginal/urethral touching and device placement in women with urinary incontinence. Int Urogynecol J. 2000;11:4-8.
4. Jeter K, Faller N, Norton C. Nursing for Continence. Philadelphia:WB Saunders; 1990.
5. Fulz NH, Herzog A. Epidemiology of urinary symptoms in the geriatric population. Urol Clin North Am. 1996:23:1-10.
6. Robinson JP. Managing urinary incontinence in the nursing home: residents’ perspectives. J Adv Nurs. 2000;31:68-77.
7. Nygard I, Holcomb R. Reproducibility of the seven day voiding diary in women with stress urinary incontinence. Int Urogynecol J. 2000;11:1-15.

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