Conservative Incontinence treatments
Pelvic Floor Muscle Training (PFMT)
As the pelvic floor is a group of muscles, just like those you can see on your legs or arms, they are trainable! Supervised pelvic floor muscle training (also known as Kegels) are recommended for all women, regardless of age to treat urinary incontinence. This is because experts have studied women like you and know that it is the best treatment available. We also know that regularly checking in with your pelvic physiotherapist is going to be much more effective than going at it alone. It is also essential that you are assessed before starting your program to ensure you are performing both the relaxation and contraction phases properly and that they program is individualized. You may need to work on different aspects of the training to improve speed, endurance, coordination, or relaxation.
Just like PFMT, bladder training has the highest recommendation for the treatment of urinary incontinence in women. Bladder training is a program that combines patient education, a voiding schedule, and strategies to control urgency or leakage such as bladder calming, distraction, relaxation and pelvic floor muscle contraction. This treatment tends to be favoured by pelvic physiotherapists for the treatment of urge urinary incontinence, frequency, urgency, or mixed urinary incontinence. Understanding how the bladder and brain work together to process all the incoming information is the first step to regaining control of your bladder problem.
Lifestyle advice is another non-invasive treatment of urinary incontinence. This often targets all of the additional factors that are thought to contribute to urinary incontinence. Pelvic physiotherapists can help you with an exercise regime to reduce weight if you are overweight or obese, (as this can directly impact your urinary incontinence), help manage constipation and provide advice around optimal fluid intake.
Continence pessaries are a type of vaginal support pessary, a medical device that is inserted into the vagina to help support the bladder and urethra. These support pessaries can be prescribed by gynaecologists, some GP’s and pelvic physiotherapists with training in this area. They can be used during provocative activities such as running or exercise, or used every day for comfort. You do not need a referral to see a pelvic physiotherapist for a pessary, however regular review by your GP and/or your gynaecologist is important if you do choose this option.
Posterior Tibial Nerve Stimulation for Overactive Bladder
Transcutaneous Posterior Tibial Nerve Stimulation (TPTNS) is a treatment option for some women with urinary frequency, urgency and urge incontinence. A small battery operated device emits mild electrical impulses that travel to the skin via electrodes placed on the lower leg. The electrical impulses act on the posterior tibial nerve which can be accessed close to the ankle. Stimulating this nerve helps to influence the actions of the nerves that innervate the bladder because they share some of the same origins in the spinal cord, this is called ‘neuromodulation’. While the exact mechanism of TPTNS treatment is unknown, it has been found to be effective when used in combination with other interventions such as pelvic floor muscle training plus bladder training and it is less invasive and has less bothersome side effects than the drugs commonly used in treatment of these conditions making it a great option for some women.
Using Medication for Incontinence treatment
There are several medications available for the management of urinary incontinence, depending on your symptoms and the type of incontinence you have. Medication needs to be guided by and prescribed by your GP or specialist (Urologist, Gynaecologist, Pain Specialist).
In addition to bladder training, a class of drugs called anticholinergics are another first line treatment for incontinence that occurs with urgency. There are several drugs in this class that have shown to be effective, but the most widely used in Australia is Oxybutynin (Ditropan®). Urinary incontinence that occurs with urgency is often associated with involuntary spasms of the muscle of the bladder wall. These drugs block some of the signals to this muscle making the spasms less intense. Unfortunately, the drug can affect other receptors in the body and result in adverse effects such as dry mouth, dry eyes, confusion, constipation, blurred vision, somnolence and increased heart rate. This is why bladder training is often recommended first because it doesn’t have any side-effects.
Another drug that has been shown to be effective in treating overactive bladder is Mirabegron. Mirabegron (Betmiga®) is a Beta3 adrenergic receptor agonist. This means that it helps activate these receptors in the bladder wall, which results in relaxation of this muscle and improves the capacity of the bladder.
Again, there are some side effects including hypertension, headache, UTIs, nasopharyngitis, constipation and tachycardia.
In women with genitourinary symptoms of menopause (GSM) or vaginal atrophy, topical vaginal oestrogen may help improve urinary incontinence. As oestrogen levels decline after the menopause, the blood vessels, connective tissue, skin and muscle weaken, lose elasticity and this may contribute to leakage.
Surgery for continence
Surgery is usually considered for incontinence if pelvic floor muscle training has been unsuccessful. In addition, these procedures are usually only performed once your family is complete as a future pregnancy may compromise the surgery and reduce the effectiveness.
There are several types of continence surgeries available and your gynaecologist or urologist will be able to explain which surgery may be recommended in your individual situation.
Generally speaking, there are two main types of procedures that can be done:
- Midurethral sling procedures
- Burch procedure (colposuspension)
Mid urethral sling
Since the mid 90’s the most common continence surgery involves the placement of a permanent sling (tape) under the urethra. The sling works by supporting the urethra when you sneeze, cough or exercise so that urine doesn’t escape.
Colposuspension (also called Burch colposuspension) is an operation that is done through a lower abdominal incision, whereby sutures (stitches) are placed in the vagina on either side of the urethra (pipe through which the bladder empties) and connected to supportive ligaments to elevate the bladder neck and urethra.
There is strong evidence to support the role of physiotherapists with additional training in women’s and pelvic health to treat a number of conditions across all life stages – from more commonly known pelvic health issues affecting women such as incontinence and prolapse, to pelvic and sexual pain concerns and also for helping children and adolescents with bed wetting or other bladder/bowel control concerns.
We hope the information in this blog has been useful and should always be considered in conjunction with an individual assessment with your physiotherapist and/or other health care provider skilled in the area such as a GP or gynaecologist.
We would love to help you manage your concerns and get you back achieving your goals worry –free!