Incontinence and Physiotherapy

1. Incontinence and Physiotherapy Debbie Bernstein September 2010

2. Objectives Better understanding of the role of Physiotherapy in Incontinence Know the groups of patients that will benefit from physiotherapy

3. Introduction Based at North Manchester General Hospital since 1999 Specialised in Womens� Health in 2004 SLA set up with Manchester PCT in 2006, clinics based in Harpurhey and Newton Heath. 9.5 hrs per fortnight based in primary care facilities Physio Clinic to commence in Burnage � Sept 2010 Private work

4. Referrals into physio Secondary care Received from Consultant Gynaecologists, Midwives, GPs, Physios, Urologists and Bowel Specialists. Primary care Ref received from primary care clinicians, if pelvic floor oxford scale 0-1, and after verbal consultation. Manchester GP (out of area if selected service through choose and book) Secondary care Consultants

5. Inclusion/Exclusion criteria Service includes care for females with pelvic floor dysfunction and urinary incontinence, bladder or bowel problems or urology and gynaecology conditions Exclusion � haematuria, female pateints with significant prolapse, recurrent UTIs (more than 2 in 6 months) Clients who are housebound, who have chronic conditions and are unsuitable for treatment will be referred to district nursing service for home assessment.

6. Type / Incidence Stress Urge Mixed Faecal Incontinence Reflex Overflow Can affect anyone at any age Overall 1in 4 women and 1 in 10 men suffer from urinary incontinence UI substantially increases risk of admission to nursing home (Thom et al, 1997) 1 in 5 of the mobile, actively, elderly population is wet - disastrously wet so that their quality of life is affected. 40-50% of the elderly in nursing/residential homes have incontinence

7. Symptoms Leaking Frequency Urgency Nocturia Dysuria Dysparuenia PMD Prolapse

8. Assessment Subjective/Objective Frequency/ Volume chart Urinalysis QOL assessment VE/Informed consent

9. Aims of Treatment Improve pelvic floor muscle strength and prevent further damage Education around workings of bladder � what is normal? Correcting poor habitual habits Management of problem Always Patient specific

10. Audience Participation Pelvic floor anatomy � which of these is NOT one of the superficial pelvic floor muscles Pubococygeous Ischiocavernosus Superficial transverse perineal Urethrovaginalis

11. Treatment Pelvic Floor PFME � The knack Vaginal cones Biofeedback Electrical stimulation Oestrogen based vaginal creams Weight loss Lifting Advise Smoking Cessation Avoiding straining bowels Ensure correct medication for chest complaint

12. Pelvic floor exercises Tailored to individual patients Includes fast and slow twitch muscle fibres Performed until muscle fatigues, several times a day Practised for 15-20 weeks Continued on a maintenance program Exercised in functional problems

13. Biofeedback Defined as registration of a physiological activity by audio or visual means Used to increase motivation and adherence Digital palpation Pelvic floor educator Electromyography � NeuroTrac Simplex

14. Cone therapy Cone of suitable weight and size introduced into vagina above pelvic floor Feeling of losing the cone produces a contraction of the pelvic floor in an attempt to retain it. Can help in motivating some pts as they see a steady improvement in weight held

15. Neuromuscular electrical stimulation Training the pelvic floor and external urethral sphincter by producing a series of electrically induced contractions, to improve strength and function. Re � education tool for patients who cannot perform a voluntary contraction Treatment for women who demonstrate a grade 0,1 (or possibly 2) and would otherwise be unable to re-educate their pelvic floor muscles Once grade 3 voluntary contraction achieved stim may be discontinued and physiotherapy continued with pelvic floor exercises.

16. Neuromuscular Electrical Stimulation-continued Should be active assisted Daily/twice daily (home treatment) 5 mins initially increased to 20 mins Contraindications � pacemaker, inflammation/infection vulva/vagina, recent/ current haemorrhage /haematoma, compromised circulation, atrophic vaginitis, pregnancy, presence of abnormal or malignant cells in pelvic or abdominal area.

17. Bladder Training Training/diaries. Average Bladder capacity 400 � 500mls, voids 4-8 x day Fluid Correction 1.5 -2 litres, avoid irritants Avoiding post micturition dribble Advise re cystitis/water infections Mobility issues/commodes/clothing

18. Management Hygiene/pads Psychosexual counselling Devices eg contrele activgard Discussions around medication & surgery

19. Elderly � Audience Participation Which of these is NOT a cause of Transient Incontinence ? UTI Diabetes Acute illness Faecal impaction

20. Bowels - Treatment Diet Correction Correct defecation Posture Anal sphincter Exercises Medications Holding on problem Habits Biofeedback Electrical stimulation Referral on

21. Evidence Clinical Guidelines for physiotherapy Management of females aged 16-65 with SUI (CSP 2001) Clinical Guidelines on Urinary Incontinence (NICE 2006) Supervised PFMT of at least 3 month duration Guideline on Management of Faecal Incontinence � mentions referral to specialist continence service for people who continue to have episodes of FI after initial management. Treatments offered may include PFMT, biofeedback and elec stim NHS Institute for innovation & Improvement (2009) stated that there was a medium quality body of evidence to support continence physiotherapy, although scope of intervention varied widely.

22. THANK YOU FOR LISTENING ANY QUESTIONS