PT MANAGEMENT OF URINARY INCONTINENCE.pptx

PFME in supine, sitting, kneeling, and standing positions, which follow by an increase number of contractions and duration of holding.

The exercise regimen of holding went from 4 seconds to 30–40 seconds. The contractions will be increased up to 20 contractions as progression.
CORE MUSCLE Strengthening
The patient will be instructed to work on the transverse abdominis muscle (core muscle). They will be instructed to contract the pelvic floor as above and keep the PFM relaxed.

1. Pelvic floor physiotherapy for urinary incontinence Presented By:- Dr. Tabassum (PT) mpt obs & gynae rehabilitation Assistant Professor SP&AHS, Physio Deptt. SGRRU & SMIH Dehradun

2. S PHYSIOTHERAPY MANAGEMENT OF URINARY INCONTINENCE 1. CLINICAL PRESENTATION 3. PHYSIOTHERAPY MANAGEMENT OF URINARY INCONTINENCE 2. PT ASSESSMENT 4.BEHAVIOURAL THERAPY 5.DIET PLAN 6. DRUG THERAPY 7.MEDICAL DEVICES 8.SURGICAL TREATMENT

3. 1.CLINICAL PRESENTATION Urine Leaking sudden loss of urine secondary to increased intra abdominal pressure that is bothersome or affecting the patient’s quality of life. Physical activities precipitating SUI include laughing, sneezing, straining, coughing, or exercising Urinary Frequency Abnormally frequent urination (e.g., once every hour or two) Urinary Urgency a sudden, strong need to urinate. This causes a discomfort in your bladder. Urgent urination makes it difficult to delay using the toilet

4. Nocturia Frequent night time urination can have causes that aren't due to underlying disease. Examples include drinking too much liquid close to bed time, pregnancy or ageings Prolapse when 1 or more of the organs in the pelvis slip down from their normal position and bulge into the vagina. It can be the womb (uterus), bowel, bladder or top of the vagina.It is not life threatening, but it can cause pain and discomfort.

5. 2.pT aSSESSMENT Diagnostic Procedures Clinical histor y diagnosis of urinary stress incontinence based on the presence of stress incontinence symptoms. Pelvic Floor Muscle Function and Strength Modified Oxford grading system: 0 - no contraction 1 - flicker 2 - weak squeeze, no lift 3 - fair squeeze, definite lift 4 - good squeeze with lift 5 - strong squeeze with a lift

6. Palpation PERFECT mnemonic assessment P - power, may use the Modified Oxford grading scale E - endurance, the time (in seconds) that a maximum contraction can be sustained R - repetition, the number of repetitions of a maximum voluntary contraction F - fast contractions, the number of fast (one second) maximum contractions ECT - every contraction timed, reminds the therapist to continually overload the muscle activity for strengthening

7. Evaluation Of Urinary Incontinence Pad Test The test involves the patient wearing a pre-weighed pad, -Next the patient drinks 500 ml of sodium-free liquid in < 15 minutes, resting, after which he/she exercises for 30 minutes. --The exercise would include- Activities such as - Walking, Climbing up and down a flight of stairs, Standing up from sitting, Coughing vigorously Running on the spot for 1 minute. The pad is then re-weighed and the resulting measurement given in grams of urine lost

8. URINARY (Voiding) Diary The National Institute for Diabetes and Digestive and Kidney Diseases provides clinicians with an easy to use Bladder Diary pdf that may be used in clinical practice Outcome Measures Incontinence Quality of Life Instrument (I-QOL) International Consultation on Incontinence Modular Questionnaires (ICIQ) Male Urogenital Distress Inventory (MUDI) Male Urinary Symptom Impact Questionnaire (MUSIQ) Patient Global Impression of Improvement (PGI-I) Patient Global Impression of Severity (PGI-S)

9. P elvic Floor Distress Inventory - 20 (PFDI - 20) Pelvic Floor Impact Questionnaire - 7 (PFIQ - 7) The International Consultation on Incontinence Questionnaire of Female Lower Urinary Tract Symptoms Questionnaire (ICIQ-FLUTS) The Bristol Female Lower Urinary Tract Symptoms Questionnaire The International Consultation on Incontinence Questionnaire of Urinary Incontinence Short Form (ICIQ-UI SF)

10. 3. PHYSIOTHERAPY MANAGEMENT OF URINARY INCONTINENCE Pelvic floor muscle stregthening exercises for weak pelvic floor muscle 1. PELVIC FLOOR MUSCLE TRAINING 2. PELVIC FLOOR MUSCLE EXERCISES & BLADDER TRAINING OR PFM RETRAINING 3. PELVIC FLOOR MUSCLE STRENGTHENING     

11. PELVIC FLOOR MUSCLE TRAINING

12. s PELVIC FLOOR MUSCLE TRAINING A home-based pelvic floor muscle training and bladder training in women with urinary incontinence showed that combined pelvic floor muscle training and bladder training decreased the symptoms and improved the quality of life To strengthen your pelvic floor muscles, squeeze the muscles up to 10 times while standing, sitting or lying down. Do not hold your breath or tighten stomach, bottom or thigh muscles at the same time. When you get used to doing pelvic floor exercises, you can try holding each squeeze for one second

13.     PELVIC FLOOR MUHHSCLE EXERCISES & BLADDER TRAINING Urgency may lead to Urine leakage . Bladder Training can help hold the urine longer & overcome that gotta go sensation without medicines & surgery. Step 1- Get checked for bladder infection or other health issues that can cause these symptoms. Advice for keep a bladder Diary. Write down time when Urinate how much urinated as well as what & how much drink.

14. s g Some of the following Strategies: Practice PFME Squeeze as explained above. This will help to close off the Urethra preventing Urine from leaking. Continue to squeez untill the need to fades. Another Option is to quickly squeeze and release the muscles, distracting the bladder from squeezing . Cross legs or sit on a hard surface. Distract mind. count backwards from 100, and ask for shift position. we’ll find that leaning forwards helps to settle bladder. Step 2- Review the diary & plan for best approach to bladder training Advice for keep a bladder Diary. Write down time when Urinate how much urinated as well as what & how much drink. Step 3 - We Make a trainig Schedule.Most women start Urinating every 30-60 minutes during the-whether or not feel the need to go. If women get the urge to go before the scheduled, they do not run to the bathroom.

15. Step 4- After 1-2 weeks , if women are not having leaking accidents , then increase the time between bathroom trips by 30 mintues. Step 5- Noticiable improvement will occur within a couple of weeks. However, the bladder retraining period can take several months

16. PFMT for the prevention of postpartum incontinencePelvic floor muscle training (PFMT) performed during pregnancy helps to decrease the short-term risk of urinary incontinence in women without prior incontinence. A systematic review including randomized or quasi-randomized trials on primiparous or multiparous pregnant or postpartum women found that PFMT during pregnancy and after delivery can prevent and treat urinary incontinence. The authors recommended a supervised training protocol following strength-training principles, emphasizing close to maximum contractions and lasting at least 8 weeks. PFMT for stress urinary incontinence A new systematic review analyzing the efficacy of pelvic floor muscle training (PFMT) in the treatment of UI and its effect on the improvement in muscle strength, endurance, and urinary leakage among non-pregnant women suggests pelvic floor muscle training

17. with education as the most effective treatment and recommends it as the first line of treatment for improving urinary incontinence in non-pregnant women. The review demonstrated that PFMT effectively reduced urinary leakage and improved pelvic floor muscle contraction. PFMT for urgency incontinence PFMT has been shown to improve or cure symptoms of urge urinary incontinence.[51] In addition to PFMT, behavioural therapies and bladder training (described below) may be beneficial in this population

18. Previous studies have suggested that Pelvic Floor Muscle Exercise (PFME) is effective and works as a first-line treatment approach for intervention in the case of SUI. Pelvic floor muscle contracts in a cranial and forward direction during and prior to physical exertion and high velocity movements including coughing, sneezing, or laughing, thus preventing urine leakage The pelvic floor plays a significant role in body's core. At the same time, it contracts the deep abdominal and back muscles. As a result, these muscles provide support, strength, and stability to the spine and internal organs during the movements of the body. Strengthened or strong core muscles provide support the pelvic organs and help to control against leakage. Thus, it can reduce or eliminate UI. Strengthening of the core muscle can reduce the UI, helping to control the leakage

19. PFME in supine, sitting, kneeling, and standing positions, which follow by an increase number of contractions and duration of holding. The exercise regimen of holding went from 4 seconds to 30–40 seconds. The contractions will be increased up to 20 contractions as progression. CORE MUSCLE Strengthening The patient will be instructed to work on the transverse abdominis muscle (core muscle). They will be instructed to contract the pelvic floor as above and keep the PFM relaxed.

20. PELVIC FLOOR MUSCLES STRENGTHENING EXERCISES Bridge With Hip Rotations Lie on back and Position a small, inflatable exercise ball between knees Loop a small resistance band/Thera band around the outside of your knees. Place your feet on the floor, with knees bent, and point feet straight ahead. Ask for lift hips into a bridge position, then alternate gently pressing knees in against the ball and out against the resistance band. Repeat the movement with toes pointed inward, then outward. Repeat 10 times per variation. Squat With Pelvic-Floor Integration

21. Side Clamshell Lie on side with your hips stacked and knees bent. Stabilize themsleves with a hand on the floor in front them. Lift and contract your pelvic-floor muscles, and begin to lightly exhale. Keeping feet together, open legs like a clamshell as far as comfortably can. If it’s difficult to do this without hips rolling back, position yourself against a wall. Pause for one or two seconds with knees open, then return to the starting position and release the pelvic- floor contraction. Repeat 10 times per side. Side Clamshell

22. Squat With Pelvic-Floor Integration Stand with feet wider than hip-width apart, with toes slightly angled out, arms at your sides, ribs over the pelvis, and the pelvic floor relaxed. Inhale through nose squat down as far as comfortably can, allowing pelvic floor to stay relaxed and keeping belly soft. Exhale through mouth return to standing, contracting and “lifting” the pelvic floor. Think about exhaling as if you are fogging up a mirror with breath. Repeat 10 times. Squat With Pelvic-Floor Integration

23. 4.BEHAVIOURAL THERAPY The focus of behavioral therapy is on lifestyle changes such as- - Fluid or diet management, -Weight control -Bowel regulation. -Education about bladder irritants, like caffeine, is an important consideration. -Also, discussing bowel habits to determine if constipation is an issue as it is important to educate the patient about avoiding straining. -Education and explanation about normal lower urinary tract function is also included. -Patients should understand the role of the bladder and the pelvic floor muscles.S

24. Bladder Training The information gathered from the bladder diary is used to guide decision making for bladder re-training, including a voiding schedule if necessary to increase the capacity of the bladder for people with frequency issues. Bladder training attempts to break the cycle by teaching patients to void on a schedule, rather than in response to urgency. Urge suppression techniques are taught, such as distraction and relaxation. It is also important to teach the patient to contract the pelvic floor to cause detrusor inhibition. A voluntary contraction of the pelvic floor muscles helps increase pressure in the urethra, inhibit detrusor contractions, and control urinary leakage.

25. Double voiding , to help you learn to empty your bladder more completely to avoid overflow incontinence. Double voiding means urinating, then waiting a few minutes and trying again. Scheduled toilet trips , to urinate every two to four hours rather than waiting for the need to go. Fluid and diet management , to regain control of your bladder. You may need to cut back on or avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or increasing physical activity also can ease the problem.

26. Some foods may aggravate overactive bladder (OAB) symptoms, but specific dietary changes, such as eating more fiber, may help reduce them . OAB, certain foods and drinks can further irritat e bladder or urinary tract. This can cause an uptick in the following sympto frequent urge to urinate frequent urination bladder spasms urinary incontinence In general, drinking enough water supports your overall health. But if anyone has OAB, more fluid intake typically means more trips to the bathroom. If those fluids are carbonated, they may aggravate your symptoms even more. 5.DIET PLAN

27. Whether or not you follow a specific diet, choose foods rich in vitamins, such as non-acidic fruits and vegetables. Fruits that may support bladder health include : Bananas Apples Grapes Coconut Watermelon Strawberries Slackberries Vegetables that may support bladder health include: Asparagus Broccoli Cucumbers Kale Carrots Celery Lettuce Peppers

28. Foods high in fiber can help even constipation, which can put additional pressure on your bladder. Fiber-rich foods include: lentils beans raspberries artichoke barley bran oats almonds Protein is also essential for your overall health. Good sources of protein include: fish chicken tofu eggs

29. Tomato products According to the Cleveland Clinic, tomatoes are an acidic food that can potentially irritate your bladder and worsen OAB symptoms. People who are particularly sensitive should also cut out tomato products, such as: Pasta Pizza sauce Ketchup Salsa C offee and tea Chocolate Citrus fruits to watch out for are: Oranges Limes Lemons Grapefruits Foods to avoid in Over Active Bladder

30. Alcohol can irritate the bladder and disrupt the signals to your brain that make you aware of bladder overflow. Beer Wine Liquor Carbonated beverages The fizz in carbonated beverages can potentially aggravate OAB symptoms. Be wary of drinks such as: Soft drinks Soda water Energy drinks

31. Spicy foods Sweeteners Processed foods Onions Cranberries

32. 6. DRUG THERAPY Anticholinergics . These medications can calm an overactive bladder and may be helpful for urge incontinence. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium chloride. Mirabegron (Myrbetriq) . Used to treat urge incontinence, this medication relaxes the bladder muscle and can increase the amount of urine your bladder can hold. It may also increase the amount you are able to urinate at one time, helping to empty your bladder more completely. Alpha blockers . In men who have urge incontinence or overflow incontinence, these medications relax bladder neck muscles and muscle fibers in the prostate and make it easier to empty the bladder. Examples include tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), and doxazosin (Cardura). Topical estrogen . Applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas.

33. 7.MEDICAL DEVICES Internal vaginal devices are placed inside the vagina to support the bladder neck or compress the urethra and thereby reduce or prevent leakage. Most female devices currently available are for women with stress urinary incontinence (SUI) or mixed urinary incontinence, and are designed to prevent urinary leakage. Devices designed to treat women with incontinence include: Urethral insert , a small, tampon-like disposable device inserted into the urethra before a specific activity, such as tennis, that can trigger incontinence. The insert acts as a plug to prevent leakage and is removed before urination. Pessary, a flexible silicone ring that you insert into your vagina and wear all day. The device is also used in women with vaginal prolapse. The pessary helps support the urethra, to prevent urine leakage.

34. Interventional therapies in incontinence include Bulking material injections: A synthetic material is injected into tissue surrounding the urethra. The bulking material helps keep the urethra closed and reduce urine leakage. This procedure is for the treatment of stress incontinence and is generally less effective than more-invasive treatments such as surgery. It may need to be repeated more than once. OnabotulinumtoxinA (Botox): Injections of Botox into the bladder muscle may benefit people who have an overactive bladder and urge incontinence. Botox is generally prescribed to people only if other treatments haven't been successful. Nerve stimulators . There are two types of devices that use painless electrical pulses to stimulate the nerves involved in bladder control (sacral nerves). One type is implanted under your skin in your buttock and connected to wires on the lower back. The other type is a removable plug that is inserted into the vagina. Stimulating the sacral nerves can control overactive bladder and urge incontinence if other therapies haven't worked.

35. Sling procedures: Synthetic material (mesh) or strips of your body's tissue are used to create a pelvic sling underneath your urethra and the area of thickened muscle where the bladder connects to the urethra (bladder neck). The sling helps keep the urethra closed, especially when you cough or sneeze. This procedure is used to treat stress incontinence. Bladder neck suspension: This procedure is designed to provide support to your urethra and bladder neck — an area of thickened muscle where the bladder connects to the urethra. It involves an abdominal incision, so it's done during general or spinal anesthesia. 8 .Surgical treatment

36. Prolapse surgery: In women who have pelvic organ prolapse and mixed incontinence, surgery may include a combination of a sling procedure and prolapse surgery. Repair of pelvic organ prolapse alone does not routinely improve urinary incontinence symptoms. Artificial urinary sphincter: A small, fluid-filled ring is implanted around the bladder neck to keep the urinary sphincter shut until there's a need to urinate. To urinate, you press a valve implanted under your skin that causes the ring to deflate and allows urine from your bladder to flow.

37. References 1. Camila Teixeira Vaz a b & Rosana Ferreira Sampaio a et al., 2019. “Effectiveness of pelvic floor muscle training and bladder training for women with urinary incontinence in primary care: a pragmatic controlled trial”.Brazilian Journal of Physical Therapy. Volume-23. https://doi.org/10.1016/j.bjpt.2019.01.007 2. Voices for PFD.,2016. “Pelvic Floor Muscle Exercises & Bladder Training”.https://www.voicesforpfd.org/assets/2/6/Bladder_Training.pdf. 3. Physiopedia Urinary Incontinence,2017.https://www.physio-pedia.com/Urinary_Incontinence 4.Nipa SI, Sriboonreung T, Paungmali A, Phongnarisorn C. The Effects of Pelvic Floor Muscle Exercise Combined with Core Stability Exercise on Women with Stress Urinary Incontinence following the Treatment of Nonspecific Chronic Low Back Pain. Adv Urol. 2022 Sep 5;2022:2051374. doi: 10.1155/2022/2051374. PMID: 36105867; PMCID: PMC9467742.

38. 5. Wendy Watkins.,2020.”How to Strengthen Your Pelvic-Floor Muscles”| Experience Life by life time 6.Aoki Y, Brown HW, Brubaker L, Cornu JN, Daly JO, Cartwright R. Urinary incontinence in women. Nature reviews Disease primers. 2017 Jul 6;3(1):1-20. 7.McGuire EJ. Pathophysiology of stress urinary incontinence. Reviews in urology. 2004;6(Suppl 5):S11. 8.Lawrence JM, Lukacz ES, Liu IL, Nager CW, Luber KM. Pelvic floor disorders, diabetes, and obesity in women: findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct 1;30(10):2536-3541.

39. Medically reviewed by Natalie Butler, R.D., L.D. — Written by Ryan Wallace — Updated on May 19, 2023. “11 Foods to Avoid if You Have Overactive Bladder (OAB)”. Health Line https://www.healthline.com/health/11-foods-to-avoid-if-you-have-oab Medically reviewed by Cynthia Taylor Chavoustie, MPAS, PA-C — Written by Corey Whelan — Updated on October 2, 2023. “How to Create a Diet for Your Overactive Bladder”. Health Line https://www.healthline.com/health/overactive-bladder/overactive-bladder-diet#other-natural-remedies

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