Physical Therapy Guide to Incontinence
Urinary incontinence is any undesired leakage of urine that can occur during the day or night. According to the National Institute of Diabetes and Digestive and Kidney Diseases, more than 13 million people in the United States have urinary incontinence. Physical therapists design specialized treatment programs to help people with urinary incontinence gain control over their symptoms, and reduce the need for medication and possibly surgery.
Urinary incontinence is any undesired leakage of urine. People with the condition may have trouble starting the urine stream or holding urine. Urinary incontinence involves the muscles of the pelvic floor. These muscles attach to the bottom of the pelvic bones and run front to back, forming a hammock structure that lifts to support the internal organs and controls the sphincter muscles. The pelvic-floor muscles also help support the low back, stabilize the pelvic bones, and help with sexual function. Women may be more likely than men to have urinary incontinence; however, the condition in men may be underreported.
There are different types of urinary incontinence, including:
Stress incontinence. This occurs when there is increased intra-abdominal pressure and the pelvic-floor muscles do not have the control to maintain continence. Those with stress incontinence leak urine during a physical activity, such as playing a sport, or simply laughing or sneezing.
Urge incontinence. People with urge incontinence can experience a sudden, strong need to pass urine, and leak before reaching the bathroom.
Mixed incontinence. Some people experience both stress and urge incontinence.
Functional incontinence. Even without an intense urge to urinate, people with functional incontinence may leak urine on the way to the bathroom.
Urinary frequency. Some people feel the need to empty the bladder frequently throughout the day and more than once during the night.
The pelvic-floor muscles surround the urethra, and help to keep it closed during times when pressure is placed on the bladder. Therefore, stress incontinence can result from a weakness and/or lack of support in the pelvic-floor muscles. It can happen with laughing, sneezing, or coughing, or with exercise or activities such as lifting. Women with stress incontinence often have pelvic-floor muscle dysfunction as a result of:
Pregnancy and childbirth, which can put stress or pressure on the bladder and possibly cause trauma to the pelvic-floor muscles
Episiotomy (a surgical procedure sometimes used to ease childbirth)
Injury or trauma, such as a pelvic fracture
Inflammation, such as cystitis
Surgery in the vagina or rectum
Lack of exercise, or a sedentary lifestyle
A strong and coordinated contraction of the pelvic-floor muscles helps to decrease the urgency to urinate and helps keep the urethra closed. Patients with urge incontinence may lack this control due to pelvic-floor weakness or tightness, or may experience spasms that contribute to uncontrolled bladder contractions. Urge incontinence may also be increased by nervous conditions, such as anxiety.
Urge incontinence can also be a learned behavior. For example, if someone always goes to the bathroom when arriving home from work, they can begin to associate getting home from work with going to the bathroom. After some time, that person can begin to feel the urge to go to the bathroom on the way home. This high-urgency feeling may lead to urinary incontinence.
Foods, such as caffeine and sugar, acidic foods, and smoking can irritate the pelvic floor. The irritation can cause inflammation and/or make the bladder lining contract more, contributing to urge incontinence.
The causes of functional incontinence are not related directly to the bladder or pelvic-floor muscles, and include:
Joint pain or muscle weakness (ie, low back, core, pelvis, hips) that make movement difficult
Confusion, dementia, or delirium
Psychological problems such as depression or anger
The use of devices such as a walker, which slow movement
Environmental barriers, such as obstacles (rugs, furniture) that block easy access to a bathroom
A person with an “overactive bladder” feels the need to empty it frequently throughout the day, and has to get up more than once during the night to urinate. Sensitivities to certain foods or beverages can cause urinary frequency.
Your physical therapist will perform a thorough examination to identify the causes of your urinary incontinence, and will ask you to describe your symptoms and your daily experiences. They may assess the muscles of your pelvis, hip, and low back, as well as the coordination, strength, and flexibility of the muscles of your pelvic floor.
Your physical therapist also may refer you to a physician for additional tests, such as urodynamic testing, diagnostic ultrasound, or magnetic resonance imaging (MRI) to show any pelvic-floor muscle problems, to ensure an accurate diagnosis.
Based on the evaluation results, your physical therapist will create an individualized treatment program to improve your pelvic-floor muscle function. Your physical therapist can help you:
Gain control over your symptoms
Reduce the need for pads and special undergarments, incontinence medications, and possibly surgery
Treatments to Improve Pelvic-Floor Muscle Function
Your physical therapist will teach you how to "find" (sense the movement of) your pelvic-floor muscles by tensing and releasing them. The physical therapist will design an exercise program based on your condition to help you improve your pelvic-floor muscle function so you can better control your bladder.
Your treatments may include:
Kegel exercises. The Kegel exercise is performed by squeezing the sphincter muscles or imagining that you are trying to stop the flow of urine.
Biofeedback. Depending on your symptoms and level of comfort, your physical therapist may gently employ electrodes to measure your pelvic-floor muscle activity. The biofeedback obtained can help make you more aware of the correct way to use your pelvic-floor muscles.
Muscle strengthening exercises. Your physical therapist will teach you specific exercises to stretch and strengthen other important muscles that help support proper bladder function.
Electrical stimulation. Your physical therapist may apply gentle electrical stimulation to help improve your awareness of your muscle function.
Once individuals are performing pelvic-floor muscle contractions daily and correctly, they can begin to incorporate the exercises into their activities of daily living. Developing healthy bladder habits, such as regular and timed bathroom visits, and avoiding potential bladder irritants such as caffeine, can be helpful lifestyle changes for people with urinary incontinence.
Your physical therapist can provide information about:
Diet and nutrition, to help you avoid food and drinks that may irritate the bladder
Changing the behaviors that make your symptoms worse
Techniques to decrease urinary urge and frequency, such as muscle strengthening or stretching
Maintaining a healthy bathroom schedule
Maintaining bowel regularity
Drinking healthy fluids regularly to maintain hydration
Maintaining a regular exercise regimen or active lifestyle
Michelle is a 36-year-old elementary school teacher, and the mother of 2 children, aged 4 and 6 months. Since her return to work after the birth of her youngest child, Michelle has had a difficult time controlling her urge to urinate, and sometimes leaks urine before she reaches the bathroom. Just this week, when performing jumping jacks in her Saturday exercise class, Michelle is surprised to feel urine leakage. She calls her physical therapist.
Michelle’s physical therapist reviews her medical history, including the details of her deliveries, daily bathroom habits, and fluid intake. She performs an orthopedic screening of the muscles of Michelle’s abdomen and pelvis, as well as an assessment of the function of her pelvic-floor muscles. She diagnoses Michelle as having mixed incontinence. She explains the role of the pelvic-floor muscles in helping to prevent urine leakage, and designs a specialized treatment program for her.
Over the following weeks, Michelle’s physical therapist teaches her exercises to strengthen her pelvic-floor muscles, and explains how to appropriately use them during exercise to prevent leakage. She also instructs Michelle in how to use her pelvic floor to help control urinary urges. She designs a home-exercise program for Michelle, and teaches her tools, such as developing a regular bathroom schedule, to incorporate into her everyday life.
Eight weeks later, Michelle is able to perform in her exercise classes without urine leakage, is using her strategies to control her urge to urinate, and is living the life of a happy, busy mother of 2!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
Women’s health or pelvic-floor therapy is a specialty area; women or men with urinary incontinence may want to consider seeing:
A physical therapist who is experienced in treating women's health problems, pelvic-floor dysfunction, and urinary incontinence.
A physical therapist who completed a residency or fellowship in women's health physical therapy or who has obtained the women’s health clinical specialization. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
Get recommendations from family and friends or from other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with urinary incontinence.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence about treatment of urinary incontinence. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Quartly E, Hallam T, Kilbreath S, Refshauge K. Strength and endurance of the pelvic floor muscles in continent women: an observational study. Physiotherapy. 2010;96:311–316. Article Summary on PubMed
Borello-France D, Burgio KL, Goode PS, et al. Adherence to behavioral interventions for urge incontinence when combined with drug therapy adherence rates, barriers, and predictors. Phys Ther. 2010;90:1493–1505. Free Article
Borello-France DF, Downey PA, Zyczynski HM, Rause CR. Continence and quality-of-life outcomes 6 months following an intensive pelvic-floor muscle exercise program for female stress urinary incontinence: a randomized trial comparing low-and high-frequency maintenance exercise. Phys Ther. 2008;88:1545–1553. Free Article
Burgio KL, Goode PS, Urban DA, et al. Preoperative biofeedback assisted behavioral training to decrease post-prostatectomy incontinence: a randomized, controlled trial. J Urol. 2006;175:196–201. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
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