Liz Childs - Physiotherpapy Approach to Urgency and Urge

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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
Reduce urgency
Prolong voiding intervals
Increase bladder capacity
Reduce incontinence
Restore patient confidence in controlling bladder
Physiotherapy treatment approaches
Bladder training
Pelvic floor muscle training
Electrical stimulation
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
Distraction – eg alphabet backwards
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
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 –
 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
 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 –
 PFM exercises
During urgency episode, hold until urge passes
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 –
 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 –
 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
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
 PFM contraction & hold can stop urge to void
Electrical stimulation –
 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 –
 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
 Pads over sacrum – sacral nerve roots
 Theories:
1. Sacral nerve root stimulation activates external
urethral sphincter  reflex then inhibits detrusor
2. Increased levels of cerebrospinal endorphins may
help with detrusor inhibition
TENS evidence
 Studies have shown improvement in
Urge incontinence
(Walsh et al, 1999; Hasan et al, 1996; Soomroet et al,
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
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
 Different options available for physiotherapy treatment of
urge / urge incontinence
 Most studies involve combinations of treatments
 Physiotherapy shown to help improve urgency and urge
 More studies required