Transcript Liz Childs - Physiotherpapy Approach to Urgency and Urge

Physiotherapy approaches for
urgency and urge incontinence
Liz Childs
Pelvic Health Physiotherapist
Physiotherapy management
urgency and UI - overview
 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
Treatment aims
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Reduce urgency
Prolong voiding intervals
Increase bladder capacity
Reduce incontinence
Restore patient confidence in controlling bladder
Physiotherapy treatment approaches
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Bladder training
Pelvic floor muscle training
Electrical stimulation
TENS
Lifestyle interventions
Bladder training - protocols
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
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Distraction – eg alphabet backwards
Relaxation
PFM exercises - to inhibit bladder contraction
Perineal pressure
Toe standing
Bladder training protocols cont..
3. Monitoring
 Monitor adherence
(Patient diary, self monitoring, ph check)
 Provide motivation / encouragement
 Evaluate progress
 Determine adjustments to void interval
Bladder training –
mechanism of action
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 –
Evidence
 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 –
clinical recommendations
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 15-30 mins / week – dependent on tolerance,
feelings of control and confidence
BT is an appropriate first line conservative therapy for
women with UUI (Grade A)
Pelvic floor muscle training –
protocols
 PFM exercises
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During urgency episode, hold until urge passes
Regular strengthening exercises: long term aim  inhibit
onset of urgency
 No consensus on optimal protocols (few studies)
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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 –
mechanism
 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 –
evidence
 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 –
clinical recommendations
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
Electrical stimulation –
regime
 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 –
evidence
 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 –
clinical recommendations
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
TENS
 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 evidence
 Studies have shown improvement in
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Frequency
Urgency
Nocturia
Urge incontinence
(Walsh et al, 1999; Hasan et al, 1996; Soomroet et al,
2001)
Lifestyle interventions
 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 cont…
 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
Value of physiotherapy
 Value of physiotherapy
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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
Conclusion
 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