Stress Urinary Incontinence
Today, we’re talking about how Stress Urinary Incontinence (SUI) is treated. Before we jump in, let’s quickly review SUI. SUI is the involuntary loss of urine due to an increase in intraabdominal pressure. If you need more of a review, check out this post.
Bladder losing urine due to pressure/stress
How is it treated?
As mentioned in our last chat, there are multiple potential reasons for your SUI. Seeing a pelvic floor specialist will help you to determine the underlying cause of your SUI, as well as a plan of care specific to your needs. Each cause is treated differently, which it is so important to be evaluated by a specialist, rather than blindly following advice found online. I often see patients with SUI who tell me they are going to tell all of their friends with similar issues what their homework is so that their friends can do it, too. While I absolutely love that this is a topic more and more folks are feeling comfortable sharing with their friends, the research in this area consistently reports that the best way to improve is to follow a personalized plan of care. Following your friend’s plan of care, or sharing your own with someone else, could do more harm than good.
SUI related to pelvic floor weakness:
The pelvic floor should be able to aide in continence by providing increased pressure to the urethra during the “lift” portion of a pelvic floor contraction. This pelvic floor contraction, including the squeeze and lift components, should reflexively occur during times of increased intraabdominal pressure. Often times, this reflexive motion of the pelvic floor is not present, or the pelvic muscles are too weak to lift against the increased pressure, and this results in the pelvic floor dropping, instead of lifting, during times of increased intraabdominal pressure. This dropping of the pelvic floor means the urethra does not get any extra support and can result in SUI. The therapist should be able to determine whether this dropping of the pelvic floor is due to the lack of reflexive pelvic floor contraction, or due to true weakness. If the pelvic floor muscles are truly weak, the treatment involves strengthening of the pelvic floor and surrounding hip musculature.
The first step, is learning how to perform a kegel. And by the way, that's pronounced “Kay-gul” not “Kee-gul”—little pet peeve of mine, so let’s vow to get it right for my own sanity. Studies show that, while it may seem natural, many people are unable to perform a kegel correctly (1). A pelvic floor specialist will help guide you toward correct kegel performance, also known as a correct pelvic floor muscle contraction. Once you are able to correctly contract the pelvic floor muscles, you will work on increasing strength, endurance, and power, just as you would with any other muscle you are trying to strengthen.
Your therapist will also teach you how to use the muscles during functional activities, so that you are able to perform the contraction when it actually matters. Your therapist might have you utilize electromyographic biofeedback (EMG BF), real-time ultrasound imaging (RUSI), vaginal weights/cones, core and hip strengthening, and breathing techniques. Most importantly, an individualized plan should be created and followed. Note that muscles take 6-12 weeks to strengthen (2). The same is true for the muscles of the pelvic floor. If your symptoms fail to improve quickly, give them a bit more time. The keys to improving SUI when weakness is the culprit are time and consistency.
There are also external options that can help with SUI. These include objects that provide a source of pressure to the urethra in order to aide in continence. A more long-term solution is a pessary. Usually, the pessary used for SUI is a ring with a knob on one side. The knob sits against the urethra providing pressure and the openness of the ring allows for activities including penetrative intercourse. The pessary can be left in for longer periods of time (days to weeks) and removed to clean. A second, shorter-term solution is the use of a poise impressa. This device is inserted into the vagina similarly to a tampon, but it does not absorb fluids, as a tampon does. Instead, it provides a supportive, firm surface to press against the urethra. This could be an option to use during exercise or during activities that typically cause SUI. The downside is that these are only single-use devices and boxes do not come cheap. They do come in different sizes so they can be more easily customized.
Finally, for pelvic floor muscles that are very weak (and I’m talking about when they can barely turn on at all), there is the option to use a TENS unit (transcutaneous electric nerve stimulation). For this type of treatment, you will utilize an intra-vaginal electrode, aka the electrode delivering the electric current is inserted into your vagina—it’s not as uncomfortable as it sounds, but it’s also probably not on your list of most favorite things. The electrical stimulation is turned up on the machine and you would use this for 30-60 min at a time most days of the week. You should start to see some improved strength (or more so, improved awareness) of the pelvic floor muscles in a couple of weeks.
TENS Unit with standard electrodes
SUI related to pelvic floor tension:
Let’s say your pelvic floor is “tight.” What do we mean by this? When we use the word “tight” to describe a muscle, we are implying that the muscle is stuck in a shortened position. To better visualize this, let’s talk about a muscle you’re probably more familiar with: the biceps. Imagine yourself doing bicep curls. When your elbows are straight and the weights are closer to your hips, your bicep muscle is lengthened. When you bend your elbows and curl the weight up toward your shoulders, your biceps shorten.
For the pelvic floor, the muscles are lengthened during urination or defecation—they move downward and stretch to remove tension on the pelvic organs and allow for normal evacuation. As you recall from above, the pelvic floor muscles also shorten regularly, one example of which is during periods of increased intraabdominal pressure. The shortened state of the pelvic floor occurs when the muscles are lifted and contracted. A “tight” pelvic floor occurs when the muscles of the pelvic floor remained in this shortened or seemingly contracted position. This can occur for many reasons, including chronic pelvic pain. The important thing to note is that, while it may seem counterintuitive that constantly lifted pelvic floor muscles could do anything but help compress the urethra and therefore aide in continence, a tight muscle is not a functional muscle.
To understand why, let’s return to our example of the biceps. Imagine you’re walking by a table with a glass of water and you decide to pick up the glass of water to have a sip. In order to do this, you will need to straighten your elbow to some extent, grab the water glass, and bend your elbow to bring the glass toward your lips. Now imagine your bicep is stuck in a shortened position: your elbow is bent and your hand is near your shoulder. It’s going to be difficult to pick up that glass of water without lengthening the muscle, and even though your hand is near the position it will need to be when you drink the water, without the lengthening of the biceps, you can’t even grab the water glass to begin with.
A muscle needs to be able to lengthen and shorten in order to reach its full potential as a muscle. The pelvic floor muscles can’t aid in avoiding incontinence just by staying in a shortened position—they need to be able to lengthen in order to reach full potential during the contraction. All of this is to say that if your pelvic floor can’t lengthen, it also most likely can’t do its essential job of contracting and shortening during times of increased intraabdominal pressure and therefore it is no help in reducing incontinence.
In order to improve SUI related to a tight pelvic floor, your therapist might run you through methods of improving the lengthening of your pelvic floor. This could include stretching, working on bearing down, improving the relationship between your breathing and pelvic floor activity, and other activities. It will also include resolving whatever issue first caused the tightness of the pelvic floor. For example, if your pelvic floor is tight due to chronic pelvic pain and regular clenching, then you will also work on reducing pelvic pain, so that you are able to relax the muscles of the pelvic floor. This relaxation may also include surface electromyographic biofeedback (sEMG), real time ultrasound imaging, or tactile forms of biofeedback.
SUI related to pelvic floor dyscoordination:
As described above, the pelvic floor needs to lift during times of increased intraabdominal pressure in order to help compress the urethra and avoid incontinence. If the pelvic muscles are not strong enough to lift against the pressure, they may be too weak. However, what if you have good pelvic floor strength, good pelvic floor muscle range of motion, including lift and lengthening, but you still have urinary incontinence? In this case, you might be having a difficult time coordinating the pelvic floor muscles to act when you need them. I touched on this briefly in the SUI related to weakness category, but if the pelvic muscles are strong, but are not able to reflexively lift during times of increased intraabdominal pressure, you may have discoordination. This could be something you’ve suffered from all your life, or it could develop with years of improper pelvic floor activation, unawareness, or a physical trauma, such as giving birth.
If this is you, fear not! You already have the tools you need, including strength, to achieve urinary continence. During your physical therapy plan of care for pelvic floor dyscoordination, you will work on learning how and when to activate your pelvic floor muscles when you need them most. Your therapist will likely start with the basics and then work with you toward the specific activities in which you notice incontinence in order to practice pelvic floor activation during such activities. Your plan of care might also include, you guessed it, sEMG, as it is a way for you to gain a visual cue if you feel disconnected from your pelvic floor. Once you start to retrain this reflexive pelvic floor activation, it will become easier over time.
Other treatments:
It is worth mentioning that, while I’ve gone over a bunch of physical therapy treatment options for SUI, there are other treatment options outside of the scope of a physical therapy practice. One gaping hole I’ve left out is surgery. We’ll chat about this in the future, when we have a bit more time to dig in, but for now just remember that even if surgery seems like the best option, most surgeons will want you to at least try pelvic floor PT prior to jumping straight into the more invasive route. Also, physical therapy outcomes for SUI are very good, and not too different than outcomes after surgery, so while it might take some patience, it is possible to reach a positive and satisfying result (3). Finally, many patients have fantastic surgical outcomes, but some experience an onset of new and different symptoms. Make sure you are taking all of this into consideration when thinking about your treatment options.
I hope this clears up some of your questions regarding SUI and incontinence in general. If you’re suffering from any kind of incontinence please, please, please let this be your sign to seek treatment. You are worth it!
Chat soon and XOXO,
Your Pelvic Bestie
References:
1. Welles Henderson J, Wang S, Egger MJ, Masters M, Nygaard I. Can women correctly contract their pelvic floor muscles without formal instruction? Female Pelvic Med Reconstr Surg. 2013 Jan-Feb; 19(1): 8-12 http://doi.org/10.1097/SPV.0b013e31827ab9d0
2. Kubo, Keitaro1; Ikebukuro, Toshihiro2; Yata, Hideaki3; Tsunoda, Naoya2; Kanehisa, Hiroaki1. Time Course of Changes in Muscle and Tendon Properties During Strength Training and Detraining. Journal of Strength and Conditioning Research 24(2):p 322-331, February 2010. | DOI: 10.1519/JSC.0b013e3181c865e2
3. Labrie J, Berghmans BL, Fischer K, Milani AL, van der Wijk I, Smalbraak DJ, Vollebregt A, Schellart RP, Graziosi GC, van der Ploeg JM, Brouns JF, Tiersma ES, Groenendijk AG, Scholten P, Mol BW, Blokhuis EE, Adriaanse AH, Schram A, Roovers JP, Lagro-Janssen AL, van der Vaart CH. Surgery versus physiotherapy for stress urinary incontinence. N Engl J Med. 2013 Sep 19;369(12):1124-33. doi: 10.1056/NEJMoa1210627. PMID: 24047061.
*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.
