Physiotherapy Intervention in Stress Urinary incontinence A review article

INTRODUCTION

Stress Urinary incontinence is defined as a loss of bladder control varying from a slight loss of urine after sneezing, coughing, or laughing, to complete in ability to control urination. It is also known involuntary urination or uncontrolled leakage of urine. It is common and distressing problem which may have a large impact on quality of life. It has identified as an important issue in geriatric care. The term enuresis is often used to refer the urine in incontinence primarily in children known as Nocturnal enuresis (Bed wetting). Pelvic surgery, pregnancy, childbirth and menopause are major risk factors. Urinary Incontinence if a often a result of underlying medical condition but is under reported to medicinal practioners. By the international incontinence society urinary incontinence is defined as involuntary loss of urine which is objectively a demonstrable, social and hygienic problem. There are three main types of urinary incontinence: 1. Stress urinary incontinence 2. Urge incontinence 3. Mixed incontinence Stress urinary incontinence is the state of leakage of urine from the bladder due to increase pressure on it experienced while taking any exertion such as laughing, coughing, sneezing, or lifting a baby. It capture both males and female but commonest among females, while urged incontinence is the complain of involuntary leakage accompanied by urgency. Women with stress urinary incontinence have sigficantly poorer quality life than there continent counter parts. It has been noticed 25-50 percent of female suffering from stress in incontinence urinary experiences coital dysfunction. It is the condition leaves the female with psychological morbidity particularly depression near about 25 % female take time off work because of stress incontinence. Over several years it has been the matter of research that female suffering from stress urinary incontinence have lack of confidence to face social gesture and remains conscious about their hygiene and health. The condition has been shown to affect areas such as relationship, work, travelling, sports, and other interest of physical hobbies. Published literature on bladder problems and their management previously focus on objective assessment of bladder function, noticeably urodynamic parameters which were used as probability for the amount of sufferer of stress urinary incontinence experience and determine the level of treatments with their different outcome majors. However, it is important to know about the feeling of women and how stress urine incontinence affects her life and those around her. The aim of this article literature to review the current literature on physiotherapy intervention in stress urine incontinence and different measure taken by physiotherapist to manage the lifestyle as well as female health. Cause of stress urine incontinence may be so many but the physiological effects occurs due to the weakness of pelvic floor. Due to this embarrassing condition female is unable to continue her normal activities of daily life, leading low self Physiotherapist have become involved in the clinical management of stress incontinence as the presumptive underlying impairements (decreased pelvic floor muscle strength or endurance awareness of bladder). Consequently there is a growing need to understand how physiotherapy interventions impact the stress urinary symptoms and impairments by increasing functional abilities of a female. This review article is designed to expose physiotherapist to a physiotherapy assessment of SUI and treatment possibly preventive role to play against SUI. Reviewing a series of categories including the anatomy of the pelvic floor and mechanism, pathophysiology and treatment of physiotherapy for SUI. Bladder Anatomy and Physiology: Anatomy and Physiology of the bladder are complex and various types of urinary incontinences are directly dependent on anatomy and physiology of bladder as well as associated structure. Anatomical structure of female pelvic floor involved the wirings in the bladder including detrusor muscle, internal and external sphincters, neck of bladder and proximal urethra and associated structures. Reduced activation of the sympathetic nervous system result in relaxation of detrusor muscle and closer of sphincters and filling of the bladder. When the volume of urine in the bladder reaches to 300 to 500ml the sensation of passing the urine relayed through spinal cord to the higher centers. Voluntary voiding (micturiton) involved the parasympathetic nervous system and the voluntary somatic nervous system. Getting information from these systems results of contraction of detrusor muscle and corresponding somatic nervous activity leading to relaxation of sphincters. Pathophysiology: Both the factors including genito urinary and non genito urinary may contribute to urinary incontinence in elders. Age related function changes in urinary tract may be the patho factor or detrusor over activity leaves to impaired bladder contractibility which decreases uretheral closer which leaves atrophy of urethal muscles and consider to be main contributing factor for stress urinary incontinence. Causes of stress urinary incontinence are as follows: 1. Mutiple vaginal deliveries 2. Complex vaginal deliveries 3. High infant birth weight 4. History of hysterectomy 5. Transition to menopause 6. Smoking 7. High body mass index 8. Constipation 9. Alzheimers disease 10. Cerebero vascular lesions 11. Diabetes 12. Hypertension incontinence which is termed as reversible cause of UI which oftenly described by DIAPPERS which means D for delirium, I for infection, A for aftrophy, P for pharmacological, E for endocrinal, R for restricted mobility, S for stool impaction (data adapted from references) .

Patients with urinary incontinence should be fully diagnosed and evaluated without loop holes, not only the patients own complaints are necessary to hear but thorow evaluation of vital signs and amount of micturition should be noted to sketch the investigation and plan of treatment accordingly. Formulating and accurate diagnosis may require the participation of clinicians, trained urologist, wide range of symptoms list depending on types and severity of urinary incontinence. Following should be evaluated 1. SUI (Stress urinary incontinence): Amount of leakage 2. Leakage related to external stimuli (coughing, sneezing) 3. Difficulty in initiating the urine stream 4. Sense of incomplete urination PAD test is the Key out come to measure the amount of leakage of urine, which is perform by the patient and subjected to fulfill the given task by the physiotherapist in various situation. Bladder diary is important to maintain for providing the diagnosis as well as the reevaluation after treatment. Bladder diary includes the female episodes of voiding, with following questions before executing the physiotherapy management. A. Average number of voids-? B. Average number of accidental episodes-? C. How many times she changes her inner lining? D. Maximum volume voided 300ml or more E. Minimum volume voided less than 50ml F. Night time micturition Along with bladder diary patient body mass index should also be assesed by making patient comfortable prior to the examination and the procedure should briefly explained again. Physiotherapist should follow the infection control A. Any abnormal tenderness or bloating B. Any perineal abnormalities C. Any irritation or redness in the vaginal area D. Any episiotomy done before E. Any perineal descent Final diagnosis of urinary incontinence should be established on the basis of objective examination findings, in which bladder diary proves to be very effective in useful. Diagnosis should also check the amount of leakage on lifting the child because it increases the intra abdominal pressure. It is important to note the vaginal examination and testing of muscle strength will help to form the line of treatment. A brief explanation of the present status should be given to the patient and physiotherapist should inform about the importance of physiotherapy in urinary incontinence along with the way of treatment as the part of informed consent.

Importance of correct diagnosis cannot be over emphasized but complete review of person‘s personal history including uro dynamic assessment is required which involves flow rates, residual urine, bladder pressure. Necessity of assessment falls for planning and interventional setting prior to the physiotherapy settings.

1. To improve first line chief complain. 2. To increase muscle strengths. 3. To maintain hygiene 4. To maintain diet and regulate digestion 5. To improve patient confidence to face social encounters 6. To improve metabolism 7. To improve obesity if present Physiotherapy treatment for females suffering from SUI includes pelvic floor physiotherapy, life style changes, behavioural therapy and medication. Pelvic floor physiotherapy is the important form of conservative treatment for SUI and termed as PFM which is done specifically for the contraction of LA (Levator Ani) muscle. The premise of this intervention urine control during time of exertion. Its seems valuable that LA muscle contraction could increase the strength of functioning muscle as well as complete bedding of bladder. Since the LA muscle consist of both slow and fast muscle fibre specific strength training increases the muscle tone and endurance. Kegel exercises are the important pelvic floor exercises taught to the patient verbally or by manual palpation. The effectiveness of Kegel exercises in the patient SUI depends on both frequency and intensity prescribed by the physiotherapist. It is advisable to perform 15 repetitions of 2-5 contraction in exercises regime for 3 sets per day for at least 8-9 weeks. For example in women with little to moderate stress urine continence has been associated with reduction in continence. The pelvic floor regime was also accompanied by ―KNACK principle. It is counter brecing technique which is taught by the clinicians to prevent the leakage during the increase abdominal pressure, the patient is taught to contract the pelvic floor muscle just before to physical stress such as sneezing coughing. According to Cochrane review of pelvic floor muscle exercises reveals greater improvement in those womens who receives our supervised kegal program for atleast for 3 to 4 months. It is also visible that physiotherapy treatment and management is effective when these exercises are based on physiological principles, because physiotherapy exercises improves endurance and muscle strength both. It is important to mention that in adjuncts to consideration that intensity and frequency of PFME program should be followed with the correct positioning of the patient. Borello France compared the effect of PFME progression that included practice in upright position that is sitting and standing. The main principle of physiotherapy intervention used in stress urine incontinence can be summarized as follows: 1. Pelvic floor muscle awareness should be taught to the patient. 2. Pelvic floor muscle strength and exercise in functional position should be taught. 3. Information about Knack principle should be given patient. 4. PFME should be individualized according to the grade of SUI. 5. KEGAL exercises are performed until the muscle fatigues, for atleast several times a day. 6. Pelvic floor muscle training is important while teaching uretheral closure which is an adequate support provided by the endopelvic facia and the

All though both stress and urge urinary incontinence can be treated with conservative management of physiotherapy their remains of profound stigma along with the feeling and social in acceptance and humiliation related to SUI. The main draw back of SUI is recreational withdrawal and root from fear anxiety along with low self confidence and unpleasurable Life impact of stress urinary continence has on daily life can differ greatly depending on the etiology and severity on the condition and individual to individual coping strategy. Consequences Of Stress Urinary Continence If Remain Untreated Numerous factors and medical condition can increased the rates of complications. For example obesity can be associated with stress urinary continence and is an important to control weight before starting physiotherapy treatment and if not treated properly stress urinary continence will lead to flooding of urine. Heart congestion can occur with increase abdominal pressure because of chronic stress urinary incontinence that is why it is necessary to treat SUI in its primary stages. Diabetes is having poly urea as it symptoms and stress urinary incontinence can be causing factor of reduction of water content in the body. Urinary tract infection may arise due to stress urinary incontinence and lead to hygiene problem because it may be a favourable atmosphere for the growth of bacteria. Nutritional deficiency may occur due to the loss of fluid results in fatigue and cramps. Embarrassing social behavior can be another consequence for untreated SUI because passive in sufficiency on dryness and hygiene may lead to low self esteem. Relationship Problem Due To Stress Urinary Incontenence Relationship of couples can be significantly affected by urinary continence. Nilshon et.al 2 showed that 38% of women and 32% of men reported that female partners in continence problem impacted negatively on their relationship. Further 20% women and 17% of men reported reduced intimacy, affection and physical proximity. Patient reveals that ―I became nervous and cannot actually relax, I am anxious about smelling bad and urine leakage when we are closely intimated. This shows that suffering from stress urinary incontinence may have an even higher cost in psychological terms than most of us can imagine.

Behavior training is important treatment that teaches patients how to use the pelvic floor muscle to inhibit detrusor contraction. Behavioural training is meant to teach the patient how to use anal spincters and muscle contraction (anal muscle and pelvic floor muscle) to prevent the leakage of urine. Fluid Consumption Training: Doctor should recommend the amount and timings of fluid intakes by the patient during the day time and night. However one should not limit what you drink so you become dehydrated. Patient should be taught strictly to avoid caffeinated and alcoholic beverage as it is believe that in some people dietary irritant affects bladder function. Healthy Life Style Changes Patient should quit smoking, alcoholism and should lose excess of body weight for controlling the stress urinary incontinence and causative factors for the leaking of urine which is coughing and sneezing one should prevent chronic cough for progression of treatment in stress urinary incontinence.

From these observation we review that plan for physiotherapy care should be individualized for each patient and should include optimum physiotherapy intervention. As outlined in table 1 these interventions include modalities to decrease pain, pelvic floor muscle exercise in detail with or without biofeed back will improve muscle strength as well as coordination between them. Physiotherapy includes PAD test which is the main outcome measure to weigh the PAD while female carries it in various activities. This test is having utmost importance though witch females her self diagnosed her underlying disease. Physiotherapy itself is a means of treatment for getting adjusted with various elements without any side effect .every patent cannot undergo surgeries but entertain physiotherapy session for better management of SUI in a very low cost. Physiotherapy deals with SUI in three phases that is preventive ,curative and rehabilitative that is why it is considered to be very effective in the reversible of SUI that is DIAPPERS.Thus patient is subjected to perform kegal set of exercises at home as a measure of home programme. Physiotherapist have explained the patent to be aware of hygiene and diet management.

Normally women with stress urinary incontinence receives physiotherapy treatment once a week for the period of 4 to 8 weeks and follow the home treatment program along with various instruction for improving lifestyle and behaviour programs. But regular regime of physiotherapy instructor and valuable assessment of pelvic floor muscle strength should be consider in follow up. Thus physiotherapy when accompanied smoking, child delivery, and chronic pelvic pain make affect the ability of the patient to perform pelvic floor muscles exercise correctly.

ACKNOWLEDGEMENT

Special thanks to my inspiration Mr Vipin Dwivedi(Husband)and my little daughter Aaradhya without whom it was not possible to accomplish the task. I would like to forward my deepest thanks to Dr.Namrata Srivastava & Dr.Kalpana Jain for their guidance, technical advice and support in completing this paper

It is advisible to use stabilization exercises to improve strength of core muscle along with lumbar stabilizing exercises and education to the patient for recommendation for using bladder and bowel training, fluid management and diet method for leading comfortable social encounters.

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Astt.Prof. Career College