Urinary incontinence is the involuntary leakage of urine from the bladder.
Urinary incontinence is more common than many people realise, affecting over 5 million Australians (approximately 1 in 4 people). It is estimated that 80% of the people who experience urinary incontinence are women and whilst this condition can occur at any age it becomes more frequent as we get older. Urinary incontinence can also become more prevalent during and after pregnancy, as well as with certain surgeries.
Physiotherapists, particularly those trained in pelvic and/or women’s health, play a key role in both the prevention and treatment of urinary incontinence using evidence-based rehabilitation strategies.
Signs and Symptoms
Urinary incontinence can vary in presentation. Common signs and symptoms include:
- Involuntary leakage of urine during physical activities such as coughing, laughing, sneezing, lifting, or exercising.
- Urgency, or a sudden, intense urge to urinate followed by leakage.
- Frequent urination (more than 8 times per day).
- Nocturia, or waking more than once per night to urinate.
- Incomplete bladder emptying or dribbling.
- Leakage without awareness, often seen in neurological conditions.
These symptoms can be occasional or frequent, mild or severe, and may have a significant impact on quality of life, including mental health and social participation.
Types and Contributing Factors
There are various types of urinary incontinence; the cause can differ dependent on type of incontinence experienced. The below list outlines both the type and cause:
1. Stress Incontinence:
Occurs when there is increased pressure on the bladder due to activities like coughing, sneezing, or lifting. It can be caused by…
- Weak pelvic floor muscles
- Pregnancy and childbirth
- Menopause (due to decreased oestrogen levels)
- Pelvic or prostate surgery
2. Urge Incontinence:
Characterised by a sudden urge to urinate followed by leakage of urine. It can be caused by…
- Overactive bladder (OAB)
- Neurological disorders such as Parkinson’s disease or multiple sclerosis
- Bladder irritation (e.g. from infections or certain foods/drinks)
3. Mixed Incontinence:
As the name suggests this type of incontinence involves elements of both stress and urge incontinence and hence the aforementioned causes often overlap.
4. Overflow Incontinence:
Occurs when the bladder doesn’t empty properly, leading to dribbling. Causes may include…
- Enlarged prostate
- Nerve damage
- Medications
The above list is not exhaustive of the causes/contributing factors of urinary incontinence. It is also important to consider that certain lifestyle habits or behaviours can impact the likely hood of developing urinary incontinence including smoking, obesity and poor toileting habits.
Assessment of Urinary Incontinence
There is a myriad of tests that can be performed to assess different elements of urinary incontinence, including but not limited to severity, pelvic floor strength and quality of life impact. Assessment will likely commence with a detailed history which can help guide further assessment and treatment.
Urinary diaries can also be a useful addition to assessment. Your physiotherapist may ask you to record a urinary diary to gain further insight into the pattern of voiding; allowing for better understanding of the type of urinary incontinence being experienced. Studies suggest tracking incontinent episodes over seven days allows for a stable and reliable measurement.
Physical examination is also a key part of the assessment of urinary incontinence and may involve both external and internal examination. This is an important component of assessment as it allows for your clinician to determine pelvic organ prolapse, contraction and the nature of tissues in the pelvic floor region.
It can also be useful to assess the strength of the pelvic floor using the Modified Oxford Scale which quantifies strength as below:
0: No contraction
1: Flicker
2: Weak contraction though no lift
3: Moderate contraction with lift
4: Good contraction with lift
5: Strong contraction with lift
Prognosis
With appropriate treatment, urinary incontinence can often be significantly improved or even resolved. Prognosis depends on:
- Type and severity of incontinence
- Duration of symptoms
- Underlying medical or neurological conditions
- Adherence to physiotherapy and lifestyle modifications
Most individuals see notable improvement with treatment/rehabilitation programs lasting at least 8-12 weeks.
Treatment
Treatment is tailored to the type and cause of incontinence, and physiotherapists play a key role in conservative management. Surgery is rarely the first option and is usually reserved for persistent or severe cases.
1. Pelvic Floor Muscle Training (PFMT)
This is the first-line treatment for most types of urinary incontinence and involves targeted exercises to strengthen the muscles supporting the bladder, urethra, and pelvic organs.
It helps to improve muscle tone helps prevent leakage during stress and improves bladder control. Other tools such as biofeedback and electrical stimulation can also be used to improve awareness and activation of pelvic floor muscles.
There is a great research base regarding PFMT with one study finding that women who engage with this treatment are 8 times more likely to report cure of symptoms than those who do not receive this treatment.
2. Bladder Retraining
Mainly used for urge and mixed incontinence and involves teaching patients to delay urination gradually, timed voiding schedules to build bladder capacity and strategies to suppress urge sensations (e.g. deep breathing, distraction techniques.
The research into this technique is still developing although some studies suggest it may be more effective than anti-cholinergic medication, particularly when paired with PFMT.
3. Lifestyle Modifications and Behavioural Techniques
Physiotherapists provide education and support to implement key lifestyle changes and positive habits. It involves the regulation of fluid intake, avoiding bladder irritants such as caffeine and alcohol, and promoting healthy toileting habits, among other techniques.
This is a broad topic of discussion with various sub-categories of intervention relevant under this umbrella. That being said one study stated that behavioural techniques are an effective, low cost adjunct to other modalities of treatment for urinary incontinence.
Conclusion
The above list is the tip of the iceberg in regards to treatment for urinary incontinence. Your physiotherapist will tailor treatment to your needs based on your clinical presentation. They may also use modalities such as electrical stimulation or liaise with additional health professionals to be able to maximise your treatment.