Pelvic floor therapy for incontinence

Deborah C. Escalante

Pelvic floor physical therapy can give women with urinary incontinence the skills they need to regain bladder control. It works by improving the strength and function of the muscles that support the bladder, urethra and other pelvic organs.

The pelvic floor muscles, called the levator ani, stretch from the pubic bone to the tailbone, creating the “floor” of the pelvis. The urethra, vagina and rectum pass through small openings in this muscle group. The levator ani helps maintain pressure within the urethra, preventing urine leakage.

Aging, childbirth, surgery or certain medical conditions can damage or weaken the levator ani. Strengthening these muscles can lessen the contractions associated with overactive bladder and help keep the bladder, uterus and rectum in their proper positions.

At the UCSF Center for Urogynecology and Women’s Pelvic Health, pelvic physical therapy is provided by physical therapists who specialize in urinary incontinence and pelvic organ prolapse. We work with each patient to develop a personalized program that meets her needs and goals. The components of an individual program may include pelvic muscle exercises (commonly called Kegels), biofeedback or electrical stimulation of muscles.

If you’re interested in pelvic floor physical therapy, please talk to your doctor about a referral.

What Is Urinary Incontinence?

Urinary incontinence is any undesired leakage of urine. A person with the condition also may have trouble starting the urine stream or holding urine. Urinary incontinence involves the muscles of the pelvic floor. These muscles attach to the bottom of the pelvic bones. They run from front to back and create the base of your core (torso, between the pelvic floor and diaphragm). They form a hammock structure that lifts and supports the internal organs. The pelvic floor muscles also:

  • Control the sphincter muscles (ringlike muscles that open and close certain body openings).
  • Support the low back.
  • Stabilize the pelvic bones.
  • Help with sexual function.

Women may be more likely than men to have urinary incontinence. However, men may underreport the condition.

Different types of urinary incontinence include stress, urge, mixed, and functional incontinence, as well as urinary frequency.

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Stress Incontinence

The pelvic floor muscles and urogenital diaphragm (fibrous and muscle structures below the diaphragm) surround the urethra (the tube through which urine leaves the body). They help keep it closed when pressure is placed on the bladder. Stress incontinence occurs when these structures are weak or fail to support the urethra. Leakage happens when movement or physical activity puts excess pressure on the bladder. It can occur with:

  • Laughing, sneezing, or coughing.
  • Physical activity or exercise such as running.
  • Activities such as lifting.

Women with stress incontinence often have pelvic floor muscle dysfunction due to:

  • Pregnancy and childbirth, which put stress or pressure on the bladder or cause trauma to the pelvic floor muscles.
  • Episiotomy (a procedure often used to ease childbirth).
  • Perineal injury or tearing during childbirth.
  • Injury or trauma, such as a pelvic fracture.
  • Inflammation, such as cystitis.
  • Surgery in the vagina or rectum.
  • Lack of exercise or a lifestyle that involves too much sitting.

Urge Incontinence

This is a sudden, strong need to pass urine. People with this type of incontinence often experience a leak before reaching the bathroom. A strong coordinated contraction of the pelvic floor muscles helps decrease the urge to urinate. It also helps to keep the urethra closed. People with urge incontinence may lack this control due to pelvic floor weakness or tightness. Or they may experience spasms that contribute to bladder contractions. Conditions such as anxiety may increase the urge to empty the bladder.

Urge incontinence also can be learned. This is also known as “just-in-case” voiding. For example, someone who always urinates upon arriving home can begin to associate this with a need to go. Over time, they may feel this urge on the way home. This high-urgency feeling may lead to incontinence.

Caffeine and sugar, acidic foods, and smoking can irritate the bladder. These can lead to inflammation or cause the bladder muscle (detrusor) to contract more. This contraction can contribute to incontinence.

Mixed Incontinence

Some people experience both stress and urge incontinence.

Functional Incontinence

Leakage not directly related to the bladder or pelvic floor muscles is called functional incontinence. This type of incontinence results from problems other than weak pelvic floor muscles or bladder control. It happens when external factors, such as using a walker or crutches that slow movement, prevent a person from reaching the toilet in time. Even without a strong urge to urinate, people may leak urine on the way to the bathroom. The causes of functional incontinence include:

  • Joint pain or muscle weakness (including low core, pelvic, or hip pain) that makes it hard to move.
  • Confusion, dementia, or delirium.
  • Depression or anger.
  • Slow movement or mobility (such as when using a walker).
  • Barriers or obstacles that block easy access to a bathroom (such as rugs or furniture).
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Urinary Frequency

A person with an overactive bladder feels the need to empty it often during the day. They also may get up more than once at night to urinate. It may be caused by infection or other conditions that affect the urinary tract (kidneys, bladder, and the tubes or ducts through which urine flows). Being sensitive to certain foods or drinks also can contribute to urinary frequency.

Physical Therapy for Incontinence, Prolapse and the Pelvic Floor

Pelvic floor physical therapy at a glance

  • The pelvic floor is the group of muscles stretching from a woman’s tailbone (back) to pubic bone (front) that serve as a physical support to local organs.
  • Over time, weakness of the pelvic floor muscle can adversely affect urination, bowel function and sexual intercourse.
  • Pelvic floor physical therapy offers a series of nonsurgical interventions.
  • Physical therapists help women to retrain their pelvic floor muscles through outpatient sessions to improve function and strength, typically within six to eight weeks.

Benefits of pelvic floor physical therapy

This pelvic floor acts as a support structure to the bladder, uterus, rectum and urethra, which aids bladder retention. The ability to relax and contract the pelvic floor allows for healthy function of the bladder and bowels.

The pelvic floor can become weak or damaged resulting in a pelvic floor disorder, such as pelvic organ prolapse, urinary or fecal incontinence, and other storage and evacuation problems. When this occurs, pelvic floor therapy can help to “rewire” the brain and muscles to control the coordination of key muscle groups.

Every patient undergoing pelvic floor physical therapy will have a specialized program built around the level and frequency of rehabilitation needed.

Physical therapy treatments for incontinence, prolapse and the pelvic floor

We offer multiple types of treatment options for someone who is suffering from a pelvic floor disorder. When the physicians at CU Urogynecology feel that physical therapy would be the ideal treatment option, they will refer the patient to the physical therapy department. The physical therapists will find the best type of therapy for each patient depending on the condition, her medical history and the desired outcome.

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Learn about the primary treatment options offered at the UCHealth physical therapy offices below.

Pelvic floor exercises

Physical therapists teach patients how to properly do Kegels and other exercises to contract and relax pelvic floor muscles. They will also teach breathing and timing techniques to make the exercises the patient is learning more effective. The goal of these exercises is to stretch tight muscles, strengthen weak muscles and improve flexibility.

Manual therapy

A physical therapist may use soft tissue mobilization techniques to help with muscle tightness, function and posture of the pelvic floor. Our physical therapists may also show patients how to use a vaginal dilator during this time. A vaginal dilator is a tube-shaped device that can help women learn to relax their pelvic muscles to allow for easier penetration or help women who have been treated for gynecologic cancers.

Bladder training

A physical therapist can help patients learn how to extend the time between voiding. This can be done through scheduling times to use the bathroom and managing the overwhelming urges to urinate.

Biofeedback therapy

Biofeedback therapy involves placing a sensor near the pelvic floor muscles, which transmits the amount of force the woman is exerting to a computer. The computer displays the results on a monitor so the patient can immediately see whether she is using the correct muscles. Once she gets a sense of how to properly do the exercises, she can continue doing them without biofeedback therapy.

Electrical stimulation

At CU Urogynecology we work with the physical therapists to provide our patients with percutaneous tibial nerve stimulation (PTNS) as the main external electrical stimulation device. This low voltage electrical current is sent up from the ankle to the pelvic floor via the tibial nerve.

Learn more about PTNS

Physical therapy follow-up

  • Following the initial evaluation, the therapist will put together an exercise program and schedule follow-up appointments to assess muscle coordination, strength and overall function.
  • Patients typically will experience improvement in pelvic floor function 3-4 weeks following strength training.

Where to receive physical therapy treatment for the pelvic floor

If a patient needs to be seen by a physical therapist, the providers at CU Urogynecology work with her to find the closest location to receive treatment. We have 12 locations all over the Denver metro area for easy access, no matter what part of town a woman lives in.

We also offer physical therapy services in our Anschutz office. This can be a great option for before or after appointments with our providers.

Contact us to request an appointment with one of our urogynecologists to learn if this nonsurgical therapy is an option to treat a pelvic floor disorder.

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