Physiotherapy approaches for urgency and urge incontinence Liz Childs Pelvic Health Physiotherapist

 Assessment - subjective - objective (including bladder diary) - clinical reasoning – functional requirements of patient  Education - normal anatomy/function - mechanism of their problem - treatment options  Goal Setting  Treatment Physiotherapy management urgency and UI - overview

 Reduce urgency  Prolong voiding intervals  Increase bladder capacity  Reduce incontinence  Restore patient confidence in controlling bladder Treatment aims

 Bladder training  Pelvic floor muscle training  Electrical stimulation  TENS  Lifestyle interventions Physiotherapy treatment approaches

3 components: 1. Scheduled voiding regime  Set frequency of voiding  Don’t void until next scheduled time  Gradually extend inter-void intervals 2. Urge control strategies  Distraction – eg alphabet backwards  Relaxation  PFM exercises - to inhibit bladder contraction  Perineal pressure  Toe standing Bladder training - protocols

3. Monitoring  Monitor adherence (Patient diary, self monitoring, ph check)  Provide motivation / encouragement  Evaluate progress  Determine adjustments to void interval Bladder training protocols cont..

Theories: (ICI 2009) 1.Improved cortical inhibition over involuntary detrusor contractions 2.Improved cortical facilitation over urethral closure during bladder filling 3.Increased knowledge of circumstances of incontinence  behavioural changes 4.Increased reserve capacity of bladder Bladder training – mechanism of action

 Few studies  BT vs no treatment or vs control  Fewer episodes incontinence  Less frequency, urgency, nocturia  Helpful short term, need more studies to determine long term benefit (Cochrane review RCTs) Bladder training – Evidence

ICI (2009) :  Not clear what most appropriate protocol is  Recommend:  assign voiding interval based on baseline voiding frequency eg 1 hr (30 mins or less if required)  Increase mins / week – dependent on tolerance, feelings of control and confidence  BT is an appropriate first line conservative therapy for women with UUI (Grade A) Bladder training – clinical recommendations

 PFM exercises 1.During urgency episode, hold until urge passes 2.Regular strengthening exercises: long term aim  inhibit onset of urgency  No consensus on optimal protocols (few studies)  Frequency of exercises  Number reps, how long to hold  Internal assessment required – 50% women given verbal or written instruction were found to be performing PFM ex’s incorrectly (Bo et al, 1988; Hesse et al, 1991) Pelvic floor muscle training – protocols

 Increased activity / tension PFM: influences afferent input to CNS  inhibitory effect on voiding  Improved urethral closure  Inhibition micturition reflex  Urge inhibition Pelvic floor muscle training – mechanism

 PFM dysfunction found in women with urge / UI  Significant difference in degree of muscle activation of continent women (age, parity equivalent) (Bo, 2007)  Problems with studies  No internal assessment of PFM activity  BT included in studies  Short time frames – need 3-6 months for muscle hypertrophy Pelvic floor muscle training – evidence

ICI (2009):  Supervised PFM training should be offered as first line conservative therapy for women with urinary incontinence (stress, urge, mixed)  Research relatively new…basic research shows  possible to learn to inhibit detrusor with PFM contraction  PFM contraction & hold can stop urge to void Pelvic floor muscle training – clinical recommendations

 Vaginal (or anal) probe  Daily use – home or clinic  UK parameters (Teresa Cook, 2006)  Frequency 5-20 Hz  Pulse duration 0.5 – 1.0 m/sec  5-20 mins / day Electrical stimulation – regime

 Not many studies  Many combinations of current type, waveform, frequency, intensity, electrode placement, probes etc  problem with research -poorly reported methodology -hard to recommend optimum regime / protocols  Some evidence ES better than placebo (Bergmans et al, 2001) Electrical stimulation – evidence

ICI (2009):  Few studies, but single trials suggest a protocol of 9 weeks, 1-2x day, may be better than no treatment  Further research required Electrical stimulation – clinical recommendations

 Pads over sacrum – sacral nerve roots  Theories: 1.Sacral nerve root stimulation activates external urethral sphincter  reflex then inhibits detrusor activity 2.Increased levels of cerebrospinal endorphins may help with detrusor inhibition TENS

 Studies have shown improvement in Frequency Urgency Nocturia Urge incontinence (Walsh et al, 1999; Hasan et al, 1996; Soomroet et al, 2001) TENS - evidence

 Weight loss  Increased risk urgency associated with obesity (Ailing et al, 2000; Dallosso et al 2003)  Caffeine intake  Reduce to max 100mg/day  significant reduction in urgency & frequency, but not UUI (Bryant et al, 2002)  Some evidence decreased caffeine combined with BT is effective in reducing urgency Lifestyle interventions

 Smoking - unclear  Prevalence of UUI higher in smokers than non-smokers (Tampakondis et al, 1995)  Other studies – no association  No studies addressed effects of cessation Lifestyle interventions cont…

 Value of physiotherapy  Non invasive  Simple, cheap  Improved QOL  Few unpleasant side effects  No surgery for urgency / UI  Drugs may not be an option for some  Can be useful combined with medication Value of physiotherapy

 Different options available for physiotherapy treatment of urge / urge incontinence  Most studies involve combinations of treatments  Physiotherapy shown to help improve urgency and urge incontinence  More studies required Conclusion