If you leak when you cough, sneeze or laugh; frequently get a strong urge to use the bathroom, but have difficulty making it on time; or leak urine when you run or jump, seeking help from a women's health physical therapist should be in your future.
Being unable to control your bladder can cause physical and emotional discomfort. Involuntary urinary leakage or urinary incontinence (UI) affects a substantial portion of people -- most of them are women. Various forms include urinary frequency, urinary urgency and urinary leakage when you sneeze or cough. While it is most often considered something that affects older women, incontinence can be an issue for young healthy women who routinely carry or push and pull heavy loads.
Another problem experienced by many people is constipation, a common complaint that affects up to 30 percent of the United States population and when severe, can seriously impair quality of life. Poor diet, intestinal problems, certain medications and diseases such as hypothyroidism or diabetes mellitus may cause constipation. It was these issues that Doctor of Physical Therapy DeVonnia Bonimy-Lee addressed at the recent Doctors Hospital Distinguished Lecture Series as she explained how pelvic floor physical therapy offers a non-invasive, non-surgical and effective treatment option for both incontinence and constipation. And difficulty with UI and constipation, in most instances, are intimate issues most people don't feel comfortable talking about with their physician.
According to Dr. Bonimy-Lee, only 40 percent of people seek medical help for issues that can be managed with physical therapy and which have been addressed as early as the 1970s by Australian physio-therapist Elizabeth Noble who created the initial contact by creating exercises for patients in their childbearing years. Noble bridged the gap between the gynecological demographic and physiotherapy. Since then the demographics have been expanded to include issues for males as well as females -- pelvic floor dysfunction, pre-natal, postpartum, musculoskeletal pain, in addition to osteoporosis issues, or prevention as well as breast cancer rehabilitation and lymphedema management, -- a wide spectrum as it pertains to women's health physiotherapy for the pelvic floor region.
Today there are about 2,700 physiotherapists in the United States alone and 276 qualified women's health certified clinical specialists. Dr. Bonimy-Lee is the sole certified overseas specialist.
"We have the information, we have the education and now we can create the dialogue," said Dr. Bonimy-Lee of UI and incontinence and physical therapy.
"The pelvic floor is a group of muscles that act like a sling or hammock that supports the areas of the viscera within the abdominal cavity -- the bladder, the uterus, the bowel and everything that allows people to create opportunities for evacuation and storage. It's an area of muscles that are rarely talked about," according to the doctor.
The three functions of the pelvic floor are sphincteric (aiding in bowel and bladder control); supportive (provide support to the pelvic organs and abdominal viscera); and sexual (changes in muscle tension affect sexual function).
"When the bladder starts to fill up, the sphincter muscles start to close. As the bladder empties the urine, the sphincter opens up. Some people describe this relationship as an older married couple that starts to talk and one listens... because whenever you have the filling of the bladder, you really want the pelvic floor to be contracted and completely closed. Without that sort of very basic communication, you can have real dysfunction, and that dysfunction can be the result of weakness, the result of neurological injury, the result of metabolic changes, could be the result of your medication, but this is the most basic function of when it comes to urinary continence -- being able to maintain that storage function," said the doctor of physical therapy.
The muscles of the pelvic floor have a top triangle and a bottom triangle, all of which play an integral role in a person's storage and evacuation. Like any other muscle, the doctor said the pelvic floor has innervation -- nerves that tell the muscles what to do -- and every section of those muscles has different nerves that affect those muscles.
"Like any other muscle, if you have nerve dysfunction or if you have a nerve impairment, it's going to affect the muscle and you will have similar nerve issues as it relates to dysfunction -- numbness, tingling, pain, weakness," she said.
As it pertains to the pelvic floor, there is also fast twitch and slow twitch fibers. Slow twitch fibers are the muscles that help a person to maintain and store, until they find a bathroom; the fast twitch fibers create a powerful burst of movement, when a person coughs, laughs or sneezes and gets that strong, quick contraction. Dr. Bonimy-Lee said the pelvic floor is made up mostly of the slow twitch fibers, but that people also have a mix of fast and slow twitch to allow for your everyday activities.
Types of pelvic floor dysfunction
Types of pelvic floor dysfunction can be categorized in four sections -- supportive, hypertonus incoordination and visceral dysfunction. In supportive, a person may have loss of muscle, loss of nerve function, ligament injury or fascial integrity of the pelvic floor, that can result in issues with incontinence or prolapse or musculoskeletal dysfunction.
Hypertonus dysfunction is when a person has a lot of muscle tightness that creates pain as a result. Stress, diet, irritants to the bladder, whether general activity or genetic, can create issues that then can create pain -- dyspareunia, vaginismus (when women have difficulty with entry or gynecological examinations) with, levator ani spasm (which can create a lot of pain within the pelvic walls) and anismus (which is difficulty with bowel movement because there is so much tension that they're not able to relax to have a proper evacuation or bowel movement).
Incoordination, the merger between the pelvic floor muscles and abdominal muscles is that change in communication, when a person does not have that filling and then emptying of the bladder. Instead, they may be staccato, which is when the bladder half fills halfway and feel the urge to go much sooner; or they may not have proper closure, and the bladder doesn't fill anyway; or they may have leakage as the result of that inability to communicate.
Visceral dysfunction is about understanding what happens when a person has something going on, and it causes a dysfunction in the pelvic floor in that area, such as irritable bowel syndrome, or constant issues with interstitial cystitis, when the bladder is constantly irritated. In these situations, the pelvic floor does not know what to do because it's constantly having to work one way or the other. It never gets proper time to relax or contract, and as a result it becomes confused, resulting in visceral dysfunction that creates either pelvic floor weakness or pelvic floor hypertendency.
Common types of referral diagnoses
According to Dr. Bonimy-Lee, common referral diagnoses of patients with various types of pelvic floor dysfunction include urinary incontinence, pelvic organ prolapse, vaginal pain syndromes, coccydynia, colorectal pain or spasm or functional and idiopathic constipation (constipation that is not necessarily related to a blockage) and then proctitis (this follows cervical or rectal cancer treatment, when a person has had radiation treatment to the area which creates an irritation to the lining of the rectum, and the person has constant rectal pain as a result).
"Urinary incontinence really is about this involuntary loss or urine that's so severe it interferes with your social life or hygienic function. Functional constipation is where you're having two or more of these symptoms -- you may be straining more than one-quarter of the time, hard stools more than one-quarter of the time, incomplete evacuation, manual evacuation, or less than three bowel movements per week," she said.
"Now everyone has their own version of what is regular for them, but this is a seven-days issue and if you notice in seven days that you're having fewer bowel movements, this is a sign that maybe you're in that category of being constipated," she said.
According to United States statistics, UI specifically affects between 13 million and 17 million adults. Dr. Bonimy-Lee says it's not a normal part of aging.
"I don't want people to think because they're old they have to get [adult diapers]. That's not really normal. As you get older, you should just be exercising more. Like any other muscle of your body, you can strengthen your pelvic floor. You can promote general mobility. You can promote very good healthy lifestyle. You can have a healthy lifestyle that allows for wellness," she said.
Quality of life
The negative impact on UI is strong, as it affects quality of life and everyday interactions with people changes as a result. At certain point, the doctor said some people refuse to leave their homes as they are ashamed to go out. It's also a billion dollar industry with $16 billion spent a year in the U.S. on incontinence-related care, and estimates of up to $32 billion for the annual cost of urinary incontinence related care, according to the doctor.
In the young female adult population, between 20 to 30 percent are affected by urinary incontinence; in the middle aged set, 30 to 40 percent; and 30 to 50 percent in elderly females. But only 40 percent of the incontinent feel confident enough to bring it up with their physician; the other 60 percent never talk about it.
"They are embarrassed; angry, don't know what to do or how to get help; they have depression associated with being this person they're not familiar with anymore. They're socially isolated because of decreased participation in social activity, decreased participation in general activity and decreased self-esteem," said Dr. Bonimy-Lee.
"The impact on physical well-being also comes into play because now you have increased risks of falls because they're rushing to the bathroom; urine can leak on floor causing falls, skin irritation and infection from always having a moist area."
Urinary incontinence types include stress (caused by coughing, laughing, sneezing, jumping, hopping); urge (involuntary loss of urine associated with an abrupt and strong desire to void, which is more common in males); mixed (combination of stress and urge); overflow (involuntary loss of urine as a result of incomplete bladder emptying); and functional (involuntary loss of urine associated with inability to get to a toilet because of physical, cognitive or environmental barriers).
Incontinence demographics
While incontinence may be experienced by people of all ages, the doctor said that exercising females have a higher incidence of UI engaging in higher impact sports; and that soldiers carrying heavy loads on their back daily puts them at risk for UI. She also said it could also be developed as a result of prostatectomy (men), pre-and-post-menopausal women, and childbirth and children.
Causes of constipation are common (lack of physical activity, dehydration, laxative abuse, over-active bladder medication, calcium and iron supplements, pain medication, antihistamines), neurologic (Multiple sclerosis, Parkinson's disease, stroke, spinal cord injury, and intestinal dysfunction) and Metabolic (diabetes and hypothyroidism).
In physical therapy practice art internal examination of the pelvic floor is consistent with physical therapy practice. It complies with national physical therapy policies requiring the tests and measurements of neuromuscular function as an aid to the evaluation and treatment of a specific medical condition.
The role of physical therapy in UI treatment is to teach patients how to correctly contract and strengthen pelvic floor muscles. Treatment also aims to retrain behavioral habits that can exacerbate UI symptoms and teach patients how to functionally use the pelvic floor muscles during activities of daily living which include going to the bathroom, standing up, walking, and playing.
During the physical therapy evaluation the doctor asks lots of questions. Some questions patients would have to answer include how many times a day they use the restroom to urinate and for a bowel movement; how many pads they use a day, and what type of pads they use; when does UI occur and how many times per day or week. They're also asked about the severity of UI on your life. The objective of the physical therapy evaluation is also about understanding a person's functional mobility and what they can do in that moment.
The examination is involves both external and an internal components.
Physical therapy interventions
Physical therapy interventions include instruction in Kegel exercises, therapeutic exercise, electrical stimulation if needed, behavioral modifications, vaginal weights and functional mobility training.
Patients are encouraged to note that bladder irritants can include coffee, tea, soda, spicy foods, alcoholic beverages, citrus fruits and juices, tomatoes and vinegar and that the therapist my suggest substitutions that include low acid fruits such as pears, apricots and watermelon, coffee substitutions and non-citrus herbal teas.
Education in proper fluid intake of six to eight-ounce glasses per day is also important in the intervention. Dr. Bonimy-Lee said inadequate fluid intake contributes to constipation, which worsens urinary incontinence. And that the elderly are at risk for dehydration because of health problems as well as physical and mental disabilities that cause them to require assistance with eating and drinking.
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