Stress Incontinence

Guided by: Dr. Dayanand Kiran Vice Principal

Presented by: Ankita Dubey

Introduction
The term CONTINENCE is used to describe the normal ability of the person to store urine and faeces temporarily, with conscious control over time and place of micturition and defaecation.

INCONTINENCE
It has been defined as involuntary or inappropriate passing of urine faeces or both that has an impact on social functioning or hygiene (DoH 2000) Types of incontinence: 1. Temporary 2. Permanent

Prevalence
1. Urinary incontinence > faeceal incontinence
2. Female >male ratio is 3:1 3. Percentage of problem increases with age (evidences) 4% - 15-20yrs 10% - 35-44yrs 12%- 55-64yrs 16%-75-84yrs

Types of Incontinence
Urodynamic stress incontinence:
The phrase stress incontinence may be used to denote A symptom: Patient complains of involuntary loss of urine with increased intra abdominal pressure. A sign: An involuntary spurt, dribble or droplet of urine is noted when the person is asked to jump at one place. A condition: In which there is loss of urine when in absence of detrusor contraction, the intravesical pressure exceeds the maximum urethral pressure. In this the urethral closure mechanism is incompetent with associated bladder neck hyper mobility.

Genuine stress incontinence:

GSI is involuntary loss of urine occurring in absence of detrusor contraction, when interstitial pressure exceeds maximum urethral pressure. Urgency & Increased frequency Atrophy of muscles Vicious Cycle Decreased challenge to muscles Repeated voiding

Causes of GSI
Urological Obsteretical Hormonal

Medical
Aging Pharmacological Psychological Life style and environmental

Other Types of Incontinence

Extra urethral incontinence:

Loss of urine through channels other than urethra that is through fistulae.

Detrusor over activity incontinence:

Patient with such problem present with urge incontinence, which is involuntary leakage of urine accompanied by or immediately preceded by urgency. Causes: Local pathologies, Neurogenic detrusor over activity.

Nocturnal Enuresis: Over Flow Incontinence:

It is incontinence associated with distended bladder when chronic urine retention present leading to rise in bladder pressure leading to dribbling of urine until pressure in urethra and bladder equates. Causes: diabetic neuropathy, spinal shock, cauda eqina syndrome.

Giggle Incontinence:
Found in girls around age of puberty it is cause by detrusor over activity induced by laughter.

Functional incontinence:
Loss of urine resulting from deficit in ability to perform toileting function secondary to physical or mental limitation.

Assessment Methods
Objective test :
1 History of Patients condition & detail of present state.

2 Pad test
3 Frequency and volume charting 4 Visual analog scale

5 Manual strength grading

6 Perineometery 7 Biofeedback 8 Paper towel test 9 Quality of life and symptoms questionnaires

Urodynamic radiological and electromyographical assessment

Cystometery Urethral pressure profilometery

Uroflowmetery
Distal urethral electric conductance

Electrophysiological test
EMG

Management
1. Rehabilitative Therapy

2. Pharmacological Therapy
3. Surgical Therapy

Rehabilitative Therapy

Role of Pelvic Floor Muscles

To support pelvic organs

Integral to increase intra abdominal pressure Maintain anorectal angle

Rectal supports during defecation

Urethral closures Bladder inhibition

Spine unloading
Pelvic spinal stability

Pelvic Floor Anatomy

Histological overview
Types of muscle fiber in Levator ani muscles: TYPE1 i.e. Large diameter slow twitch fiber( highly fatigue resistance) TYPE2 i.e. fast twitch striated muscles fiber (highly fatigable but able to generate great power)

Exercise physiology
Slow twitch fiber are to be recruited for postural, visceral support. so while exercise these fibers are to be recruited first by forceful contraction of muscles to increase strength and for hypertrophy. Fast twitch fiber is required for urethral closure and these are recruited by repetitive contraction to increase endurance.

Pelvic floor muscle exercise

Muscles awareness

Abdominal contraction Tactile stimulation Self digital examination. Vaginal weight Foleys catheter. Neuromuscular stimulation.

Muscles reeducation

Visualization. Language. Starting position: In patient with extreme weakness and proprioception deficit it is gravity assisted position that is hips higher than heart such as supported bridge. Instruction: try and stop voiding urine by pressing the leg together and contracting the buttocks. Change of starting position: supine, side lying, quadruped, sitting, standing.

Protocol
Criteria for Strength training

8-10 maximum contraction sustained for 5-6 second. It is done 3-4 times a day for 3-4 days a week.

Criteria for Endurance Training

In supine & maintain normal spine / pelvic floor lifted & hold as long as possible. Rest 5-7 second. Repeat above hold & rest 3 times (A set of 4). Rest 1-2 min. Repeat set as 4. Continues working in set of 4 for 10 to 20 min. preferably in morning. Increased length of each hold on endurance improves even up to 20-30 sec.

Kegels Exercises

Aim: To strengthen the pelvic floor muscles. Types of exercise: 1. First exercise consist of squeezing PC muscles for 3sec than relax for 3sec and squeeze again. At first do 10-3sec squeeze any time of day. 2. In second the objective is to squeeze muscles release it and than squeeze it again and than release as soon as possible. the exercise is called as Flutter Exercise. 3. Exercise consist of imagining that there is tampon at opening to vagina and that you are sucking it up into vagina.some women can actually suck water in there vagina and spurt it out again. 4. Exercise consist of bearing down while bowel movement but emphasis more on vagina than anal. Bearing down should be maintained for 3sec.

Free exercises of pelvic floor

Crook lying (with Pelvis lifted); brace Buttocks, press knees together, and pull up between legs.

Leg lift lying (Heels supported and Legs crossed); Hip raising and adduction with Pelvic Floor contraction.
Side lying (Legs bent); Leg stretching and adduction with Pelvic Floor contraction.

Inclined long sitting (Ankles crossed); brace Buttocks, press knees together and contract Pelvic Floor.
Standing Legs crossed; Heel raising with Pelvic Floor contraction. Resisted Exercise for the Adductors of the hip, particularly those which also use the Hip Extensors are used, e.g. crook lying, Knee closing (with Pelvis lifting) and outdrawing (with Pelvis lowering).

Pelvexiser

Phenix Electro Stimulator

Biofeedback

It can be used for treatment as well as assessment. Types of biofeedback instruments are:Manometery:- Manometric device used with a vaginal pressure probe & it gives biofeedback by means of manometer visual display. Computerized Manometeric Equipments:- In this patient supported in lying position and a deflated vaginal probe is introduced in to vagina to a predetermined depth & than using a blank screen patient is asked to perform VPFMC & result is visualized. Perineometer:- Kegel describe a pneumatic device to measure pressure within the vagina and to motivate the patient to practice PFM exercise. A compressible air filled rubber sensor inserted into vagina and is attached to manometer. A woman contract her muscles several times and note the highest reading on dial and length of time for which she could hold the contraction. Hand held devices:- Manometer hand held devices are meant for home use and are costly.

Electromyography
Computerized EMG equipment is used to pick up bioelectric activity of pelvic muscles and show it on screen. In this a vaginal electrode (periform) is used to record activity in lying standing and jumping.

Electric stimulation

If no VPFMC is present than this is beneficial to produce contraction. Electric stimulation of 250micro seconds and frequency of 30 to 40 Hz is used. If VPFMC is present than stimulation of pulse duration 500 micro seconds and frequency of 5to 10 Hz is given. The objective here is to inhibit destructor activity and normalize reflex activity.

Interferential therapy

In this medium frequency current of either 2 kHz or 4 kHz is used. It is usually meant for giving electric stimulation to pelvic muscles so as to increase the reflex activity in destructor.

Vaginal cones

These are form of weights which are used for increasing strength and endurance. Basic idea of cone usage is that there is increase reflex activity of PFM to support and retain the cone against gravity and to counteract downward slippage. Weight of cone varies from 10 to 100 gm. Selection of cone lightest cone is inserted into vagina with patient in half lying position; cone is inserted such that pointed string is facing downwards. The patient is than asked to stand and walk. If the patient can retain for 1min the patient can be progressed to next heavy cone. Heaviest cone retain for 1min is chosen for exercise. Session: cone inserted two times in a day and patient is asked to walk for about 15 min.

Step free vaginal weights

Bladder Retraining

Bladder Retraining/ drill are 1st described by Jeffocate & Francis & Ka bladder discipline. It is used in frequency, urgency with out leakage & urge incontinence patients. Main aim -to correct faulty habit -Control urgency -Prolong voiding periods -Decreasing incontinence episodes -Built up patients confidence Deferment technique used are -Repeated max. PFM contact. -Perennial presence (Sitting on rolled towel) -Standing on Tip of Toes. -Distraction such as TV/Music, games etc.

Timed Voiding:Where patient unable to go to toilet independently in such cases nurse will make patient sit on commode 2 hourly whether the patient has desire to void/not.

Bladder control tips

1 Do not severely reduce fluids intake to avoid going to

toilet.
2 Drink only moderate volume of fluid. 3 Empty the bladder before going to sleep. 4 Always empty bladder completely. 5 Reduce caffeine intake.

6 Modify drinking habit.

7 Drink bladder friendly fluids.

Urinary incontinence with increased intra abdominal pressure

Functional Training

In all effort activities like sneeze, cough, push, drag, nose blow pelvic support is required. This support is alternatively achieved by abdominal bracing exercises.

Bracing exercises are used for;

1 Quick and sustain rise of IAP. 2 It is recruited to counter downward impact on pelvic floor. 3 To maintain normal lumber curve. Command given is make your waist wide and hold

Technique of sneeze; improper sneeze can lead to excessive downward stress on pubococcygeus muscles. In learning to sneeze patient hold with a fixed diaphragm as the id sound is made and than change to choo when diaphragm forcibly expels the air. Abdominal in drawing for coughing and lifting; a proper abdominopelvic pattern can be used for bracing. Command is to draw abdomen towards lower back and hold

Pharmacological Management

a- adrenergic stimulants. Estrogen. Serotonin. Norepinephrine.

Surgical management
Colposuspension Tension free vaginal type ( TVT )

Preoperative assessment and management

ASSESSMENT: Checklist - Preexisting medical condition- respiratory problem, mobility problem, backache, diabetes, constipation. - Smoking - Proposed surgery and indication - Continence status - Previous surgery or physiotherapy for the condition - Any other relevant information, MANAGEMENT: - Respiratory management - Smoking Cessation - Circulatory management - Bed mobility - Pelvic floor muscles exercises - Abdominal muscles exercise - Posture and back care.

Post operative management

- Increasing the intensity of above mentioned exercises - Early ambulation .

Prevention of problem

Pelvic floor muscles exercise with hip adductors and extensors exercise to maintain good strength and endurance.
Adequate fiber and fluid intake.

Abdominal and Pelvic Floor pattern during strenuous activity

Avoid straining at defecation

Voiding only when necessary & not just in case

Few P.F. exercise on regular basis