Physiotherapy Management Of Female Urinary

IncontinenceDehghan FM,PT,PhD

Associate Prof.Shaheed Beheshti Medical

Unicersity

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

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PT Approaches

For FUI

Lifestyle

Biofeedback

Behavioral Therapy

Electrical Stimulation

Neo-Control

PFMT

Electrotherapy Methods

• Biofeedback Therapy• Electrical Stimulation(Neuromodulation/

Neurostimulation/PFES)• Electromagnetic

Stimulation Therapy

Pelvic Floor Muscle Training

• Knack Maneuver• Kegel Exs.• Lumbo-Pelvic

Stabilization Exs.

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Biofeedback Biofeedback

• Provides the patient with immediate auditory and/ or visual information about the physiological process

It's a therapy, where people are trained to improve their health by using signals from their own bodies

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(Manometric/Perinometric) *EMG*Cystometric/Urodynamic *Ultrasonic

Types of BF

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“Sensory BF”●

• Vaginal Palpation● Mirror● Vaginal Cones

Sensory BiofeedbackVaginal Cones :PF Trainer &BF

Pressure Biofeedback:

Perinometer

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Electromyographic BiofeedbackEMG 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

Bladder transverseview at rest &

PFM Contraction

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Ultrasonic Biofeedback

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.

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

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

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.

stimulationThe negative electrodeplaced behind the internal malleolus and the positiveone at 10 cm above.

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

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

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

There were two main types of electrostimulator, both ofwhich 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

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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

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Extracorporeal Magnetic Innervations (ExMI)

Pelvic Floor Muscle Training

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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

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 Training5-Correction of biomechanical/structuraldeformities

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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.

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Samples of PFM Exercises(2)Semi-Reclined

(3) Sitting Position (5)Standing

(1)Lying Position

(4)Kneeling on all fours

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.

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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.

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Thanks for your Attention