Part 1: Urinary Incontinence

The International Continence Society (ICS) defines Urinary Incontinence as the involuntary loss of urine resulting in social or hygienic complications ^[1]. More specifically, Urinary Stress Incontinence (USI) is a disruptive condition in which subjects complain of leakage on moments of exertion such as sneezing, coughing or running ^[4]. The condition has been found to affect 15% of the ambulatory population, an indication of its clinical relevance ^[3]. A physiotherapist is often needed for the management of this condition as it essentially of a musculoskeletal nature. The aim of this blog is to provide information about the specific therapies for USI and also to provide you with a thorough understanding of the application of Interferential Therapy in this condition. Part 1 of this 4-part blog focuses on the prevalence, aetiology and management of USI.

USI is generally considered a gender specific condition, affecting 35% of women over the age of 60 ^[5], however it is also prevalent in the male population affecting 17% of men the same age ^[6].  The condition has been found to be more common in the elderly population affecting only 8.5% of women and 1.6% of men under the age of 65 ^[7]. Common Risk factors for the condition include: age, pregnancy, childbirth, cognitive and functional impairment and obesity ^[6]. Women who have four or more children have been found to be more susceptible to the condition ^[7]. Risks associated with a more clinical nature include stroke, dementia, bladder cancer, reduced mobility, diabetes, chronic cough and some medications. Specific to men is incontinence following the treatment of prostate diseases. 30% of men experienced periods of incontinence after they’d had a prostatectomy ^[6]. The aetiology of the condition commonly involves weakness of pelvic floor muscles (PFM), as they provide primary support for the bladder and preserve urinary continence by providing urethral closure pressure ^[4]. The figure below represents the PFM as a dotted red line, estimating the anatomical location of the muscles (Urinary incontinence, n.d.).

In a healthy person, contraction of the PFM blocks the flow of urine by compressing the pressure rise in the urethra ^[2]. For this reason, activation of the PFM is fundamental in the treatment and prevention of USI.

Various methods of activation are performed including: Kegel Exercises, Biofeedback, Vaginal Cones and Electrical Stimulation. Kegel exercises involve active control of the PFM, which may prove to be a challenge for some patients as it is usually a reflex activation requiring no conscious control. This is the main premise for using biofeedback as a treatment intervention, as it provides the patient with a greater proprioceptive input in order to target the correct muscle groups. Biofeedback, however, involves the insertion of an intravaginal probe and may be cause patient discomfort. Vaginal Cones are a system of free weights help in the vagina in order to isometrically train the pelvic floor. Adherence to this form of rehabilitation is its main disadvantage as although the system is technically non-invasive, patient comfort is compromised. The advantages of electrical stimulation are that it is non-invasive, has no known negative side effects and is relatively user-friendly.

References

1.     Abrams, P., Blaivas, J. G., Stanton S. L. & Anderson J. T. (1988). The standardization of terminology of lower urinary tract function. Scandinavian Journal of Urology and Nephrology, 114, 5-19.

2.     Berghmans, L. C. M., Hendriks, H. J. M., Bo, K., Hay-Smith, E. J., De Bies, R. A. & Van Waalwijk, E. S. C. (1998). Conservative treatment of stress urinary incontinence in women: A systemic review of randomized clinical trials. British Journal of Urology, 82, 181-191.

3.     Cutner, A. & Cardozo, L. (1990). Urinary Incontinence: Clinical Findings, Practitioner, 234, 1018.

4.     Demirturk, F., Akbayrak, T., Karakaya, I. C., Yuksel, I., Kirdi, N., Demirturk, F., Kaya, S., Ergen, A., Beksac, S. (2008). Interferential current versus biofeedback results in urinary stress incontinence. Swiss Medical Weekly, 138(21-22), 317-321.

5.     Fantl, J. A., Wyman, J. F. & McClish, D. K. (1991). Efficacy of bladder training in older women with urinary incontinence. Journal of the American Medical Association, 265, 609-13.

6.     Litwin, M. S. & Saigal, C. S. (2004). Urinary incontinence in men. Urologic Diseases In America, 107-137.

7.     Thomas, T. M., Plymat, K. R., Blannin, J. & Meade, T. W. (1980). Prevalence of urinary incontinence. British Medical Journal, 281, 1243-1245.

8.     Urinary incontinence [Image] (n.d.) Retrieved from http://www.ccmurology.com/images/disease/stress_incontinence.gif