2. Physiotherapy Management Of Female Urinary Incontinence Dehghan FM,PT,PhD Associate Prof. Shaheed Beheshti Medical Unicersity

3. Lower Urinary Tract Dysfunction ( which PT is effective) Urinary Incontinence Stress, urge, or mixed incontinence Frequency urgency syndrome Spastic urethral sphincter syndrome Poor relaxation of urethral sphincter Pelvic pain syndrome

4. Dehghan FM,PT,Ph.D3

5. Electrotherapy Methods Biofeedback Therapy Electrical Stimulation (Neuromodulation/ Neurostimulation/PFE S) Electromagnetic Stimulation Therapy Pelvic Floor Muscle Training Knack Maneuver Kegel Exs. Lumbo-Pelvic Stabilization Exs.

6. Dehghan FM,PT,Ph.D5 Biofeedback Provides the patient with immediate auditory and/ or visual information about the physiological process q It's a therapy, where people are trained to improve their health by using signals from their own bodies q By watching the monitor and listening to the sound, the patient gets the feedback information and he can adjust his thinking and behavior *Sensory *Pressure(Man ometric/Perino metric) *EMG *Cystometric/U rodynamic *Ultrasonic Types of BF

7. Dehghan FM,PT,Ph.D6 “ Sensory BF ” ● V aginal Palpation ● Mirror ● Vaginal Cones

8. Sensory Biofeedback Vaginal Cones :PF Trainer &BF Pressure Biofeedback : Perinometer

9. Dehghan FM,PT,Ph.D8 Electromyographic Biofeedback EMG activity is actually the sum total of all of muscle cells "firing away!" Non- invasive, painless, skin surface sensors capable of detecting this electrical signal generated by any muscle of body provide amazingly accurate information about human behavior

10. B ladder transverse view at rest & PFM Contraction 9 Ultrasonic Biofeedback

11. Electrical stimulation ( Nerve &Muscle) Nerve Electrical stimulation works through a process called Neuromodulation This means that the therapy reconditions the nerves that control bladder function. Unwanted contractions of the bladder are inhibited and normal function is restored.

12. Nerve Stimulation for Bladder Inhibition A feedback system is present in micturition process Detrusor instability may be caused by ineffective inhibition by sphincter Intravaginal or pudendal nerve stimulation of sufficient intensity causes a complete bladder relaxation The higher intensity the more efficient bladder is inhibited via spinal reflex mechanism

13. Transcutaneus Electrical Nerve Stimulation (TENS) Transcutaneus electrical Nerve Stimulation of acupuncture points may be used to inhibit detrusor activity Surface electrodes are placed bilaterally over both tibial nerves or both common proneal nerves. (5cm over the medial malleous). Parameters: Intensity:5-8 v Frequency:2-10Hz Pulse width:5-20msec

14. Transcutaneous sacral dermatome: - sacral, suprapubic, common peroneal, posterior tibial nerves Mechanism of action: Large skin afferents inhibit/facilitate spontaneous reflex activity within the dermatome Posterior Tibial N. stimulation The negative electrode placed behind the internal malleolus and the positive one at 10 cm above.

15. Intra Vaginal/PF Stimulation refers to ES of Pudendal N. Low frequency (20 Hz) appliy on genuine SUI Trans/Intra vaginal ES is effective in urge UI,First line treatment for pure urge incontinence Women with mixed UI who does not wish to undergo PME or surgery

16. Pelvic Floor Muscle Stimulation Induces a reflex contraction of striated para- and periurethral muscles and a simultaneous reflex inhibition of detrusor contraction A sacral reflex arc and peripheral innervation must be intact No effect can be expected in complete lower motor neuron lesions Successful PFM stimulation was reported in 50- 92 % women with incontinence. Patients without previous incontinence surgery have the best result. Urodynamic parameters change little after functional ES for SUI. Patients with SUI may have a better PFM contractility after ES that results in increased urethral resistance during stress

17. Protocol for Electrostimulation Kegel exercises should be followed after discontinuing FES to keep pelvic floor muscles in optimal condition Treatment combined with estrogen is recommended. In menopause women Mechanical vaginal mucosal irritation may occur in atrophic vaginitis Th ere were two main types of electrostimulator, both of which used vaginal/anal probes. Long-term stimulation threshold,(20–50 Hz) was delivered below the sensory. Devices were to be used for 6 to 8 hours/day for at least 3 months before assessment of outcome. Maximal stimulation (10–20 Hz) used a high-intensity stimulus for no more than 20-30 minutes daily and no less than twice weekly. The stimulator was used at least 10 to 20 times before evaluation of the effect.

18. Contraindication of ES Heart pacemakers Pregnancy women Urethral obstruction and overflow incontinence Complete peripheral denervation Urinary tract infection Uterine prolapse or high grade cystocele Low compliance and cooperation of patient

19. Dehghan FM,PT,Ph.D18 Extracorporeal Magnetic Innervations (ExMI)

20. Pelvic Floor Muscle Training Dehghan FM,PT,Ph.D19 Strong evidences to suggest that for women with stress, urge and mixed incontinence PFMT is better than no treatment Reasons why PFMT should be an Effective Measure 1-Strengthening PFM ’ S->better support for the urethra under “ stress ” 2- Morphological changes occurring after strength training 3-Trained muscles might be less prone to injury or? Easier to return after damage 4-Previously trained muscle has a greater strength reserve

21. Five Steps for PFM Training in PFD 1-Knack Maneuver (Ashton –Miller 1998,2008) Teaching women to tighten their PFM in preparation for a known leakage provoking event (Hidden self-care Mechanism) 2- Pelvic floor strengthening:kegel Exe. Teaching Women to set aside time to contract the PFM as a repetitive exe. For strength development &enhancement of reflex responses.3-Lumbo-Pelvic Stabilization Exs. PFM Contraction during ADL/4-Functional Training 5-Correction of biomechanical/structural deformities 20

22. Samples of Some Kegel Exe. Once you have found the correct muscles, and know what it feels like when you tense them, you should do the following exercises. Tense the muscles so you feel a lifting sensation. Hold this lift for as long as you can up to 10 seconds. Don't hold your breath whilst doing this. Relax. You should have a definite feeling of letting go. Wait 10-20 seconds then repeat the ?lift?. You should aim to lift then relax 12 times. Do 5-10 short fast lifts. You should try to spend 5-10 minutes each day on this exercise routine. 21

23. Dehghan FM,PT,Ph.D 22 Samples of PFM Exercises ( 2)Semi-Reclined (3) Sitting Position (5)Standing (1)Lying Position (4)Kneeling on all fours

24. Lumbo –Pelvic Stabilization Exs. The pelvic floor muscles are programmed to work with the innermost abdominal muscle, Transverse Abdominis (TrA) as both are part of the core stability mechanism. 23

25. Abdominal Hollowing * Lie on your back with your knees bent. *Keep your spine in neutral position, neither arched up nor flattened against the floor. *Inhale deeply and relax your stomach. Dehghan FM,PT,Ph.D24

26. Thanks for your Attention