Swapneela Jacob
Physiotherapist, Women’s Health Department
Masterskill Physiotherapy And Rehabilitation Centre

Incontinence is the involuntary leakage of urine when intra abdominal pressure rises in a woman whenever she laughs, sneezes, coughs, exercises or lifts heavy weights. It is a silent epidemic that is bothersome and debilitating, preventing women from enjoying many activities and daily work. It makes them feel embarrassed and low, causing emotional stress and affecting the quality of life.

WHO has estimated that about 10% of all women suffer from this socially-crippling condition. Studies show that Malaysia has the second highest number of women suffering from stress incontinence following childbirth (post-natal). This figure is likely to be higher, as women don’t tend to report this condition, partly because they are too embarrassed to talk about it and partly because they think nothing can be done for it.

Incontinence happens due to hyper mobility of bladder neck and proximal urethra, which results in the failure of transmission of intra abdominal pressure of laughing, coughing and sneezing to the proximal urethra, preventing the maintenance of urethral closure and thus causing urine leaks. The urine leaks are usually just a few drops that wet the underpants, thus women with this condition have to wear sanitary pads and panty liners all the time. Also, the odor of urine makes them feel shy, so friends and family members are reluctant to spend time with them.

Stress incontinence is experienced:
During PREGNANCY: Pelvic floor muscles are over-loaded with increased weight of the baby, uterus, amniotic sac and the amniotic fluid, thus weakening the muscles.
 
During CHILDBIRTH: The stretching, stress and tension of the pelvic floor muscles after pushing the baby out makes them weak, slack and atonic. If the pudendal nerve is injured during long labour or with forceps delivery, stress incontinence tends to happen later in life.
 
In HYSTERECTOMY: The uterus along with surrounding muscles are removed. The bladder
loses its support, thus even slight pressure can cause urine leakage.
 
During MENOPAUSE: Hormonal change, estrogen withdrawal and ageing render the muscles weak and atonic. 40% of all menopausal women suffer from stress incontinence.
 
OBESITY: Increases your risk of experiencing stress incontinence because the accumulation of excess weight in the abdominal area adds pressure to your bladder and causes urine leakage. Losing weight can decrease severity of incontinence.
 
Women suffering from chronic CONSTIPATION usually suffer from incontinence due to the severe stress they pose on their pelvic floor muscles when straining for bowel movement.
 
Chronic SMOKERS usually suffer from chronic cough, ultimately leading to incontinence.
 
DIABETES and certain medications like Hypertensive drugs also cause other types of incontinence such as urge incontinence and overflow incontinence.
 
Women suffering from UTERINE PROLAPSE are likely to suffer from incontinence due to bladder weakness.

 
Strengthen the pelvic floor muscles
Many women don’t know that help is available and they suffer in silence thinking that this is a usual part of ageing. In this context, physiotherapy is the first line of treatment for stress incontinence .For a long time stress incontinence was treated surgically without going through physiotherapy. However, the outcome of surgery have not always been positive, with success rates as low as 50% - 60%, with the potential risk of complications.

This leads to the recommendation that physiotherapy be tried first, which carries no risk and is an easy and approachable method of treatment.

Physiotherapy treatment consists of:

1. ELECTROTHERAPY — Interferential currents, pelvic floor muscles stimulation, Biofeedback
2. EXERCISETHERAPY — Pelvic floor muscles rehabilitation, Kegel’s exercises, vaginal weights and cones

Understanding how to contract the pelvic floor muscles correctly is essential for successful outcome. Expert guidance by a trained women’s health physiotherapist is needed to teach women the correct way to exercise the pelvic floor muscles, as it is very important to teach the women where exactly these muscles are located.

The main aim of all physiotherapy treatment is rehabilitation of pelvic floor muscles. This includes:

• Pelvic floor exercises
• Intermittent Electrical Stimulation of pelvic floor muscles and muscle tissue
• Exercises — Perineometer
• Pelvic floor muscles strengthening using vaginal weights and cones.

All such treatment aims at increasing the resting tension, recruitment speed and contractile fore of the pelvic floor muscles’ voluntary sphincter component. Research shows that about 80% of patients who choose a physiotherapy exercise regime guided by a physiotherapist and educational materials for about 3 months or longer can find relief from pure stress incontinence.

 
Getting started
A thorough physiotherapy assessment of the patient is done prior to starting the treatment program. This consists of proper history taking, pad test and evaluating the pelvic floor muscles’ strength with a digital examination.

Electrical stimulation of the pelvic floor muscles using therapeutic currents like IFT- interferential currents and muscle stimulator can help to strengthen the muscles. Low grade electric current is applied to patients with use of a tampon-shaped vaginal or anal electrodes. Treatment is given every day, consisting of 20 mins session of rectangular impulse, with a pulse duration of 1 ms frequency and 20 Hz intensity 35 ma.

For chronic cases, stimulation is given daily for about 3 months. Biofeedback is a treatment that utilizes computerized devices to help the patient gain awareness of pelvic floor muscle contractions. You need to go to the physiotherapy clinic daily for treatment.

Pelvic floor exercises are also known as Kegel’s exercises. They are very important and should be done by all incontinence patients. The most important point about these exercises is that they can be done anytime, anywhere, such as while standing, lying, watching TV, cooking etc. Some examples of how these exercises can be done are:

1. Imagine that you are outdoors and you need to go washroom urgently, but there is no washroom nearby. So what will you do?? You will try to hold or tighten your urinary passage so that your urine does not leak out. As soon as you find the washroom, you relax or release your urinary muscles. This is the exercise!!!
   Contract and relax your pelvic floor muscles about 200 times a day, but be sure to contract the ‘right’ muscles. Here are some examples:
   • Tighten your pelvic muscles as if to stop passing wind or to stop motion
   • Stop yourself from urinating
   • Stopping urine midstream
   • Contracting your pelvic floor muscles during sexual intercourse — squeeze, hold, release
2. Imagine that the pelvic floor is like a lift going up. Make your pelvic muscles go up, then slowly bring them down.
3. Bladder training: Urinating every 2 hours, whether you feel like it or not.
4. Pelvic floor muscles training can also be done with perineometer exercises.
5. Vaginal cones and weights can be inserted into the women’s vagina to strengthen the pelvic floor muscles.

 
The advantages of physiotherapy:

• The pelvic floor muscles are strengthened, conditioned and toned
• You can do the exercises on your own once you have mastered the technique
• Childbirth becomes easier
• Prevents uterine prolapse in the future
• Social life becomes more enjoyable. You can laugh and cough without worrying!
• Self-confidence increases

To have a “LEAK FREE” life and to make your life easier and happier, you should practice the pelvic floor exercises. Incontinence is a challenge for society as it is a grave problem, but increasing awareness about treatment options can help a woman find freedom in control. Pelvic floor training will help women with all types of incontinence, especially those who exercise for 3 months or more.