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Urinary and Fecal Incontinence, have you ever heard of such a crappy thing?!

The interior of bladder.
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Urinary incontinence is very prevalent in our society affecting both men and women of all ages.  It does not just affect women who are older or who have given birth, nor is it a “normal” part of aging.   Burgio (1991) and Dionko (1986) found that 31% of women 42-50 years of age are affected and 38% of women over 60 years of age, and less than 50% of women consulted their MD about it.  Risk factors include more than 3 births, birth weight greater than 8 pounds, increased intra abdominal pressure such as repeated coughing, asthma and smoking.   A study in 2007 by Eliasson revealed that of 200 women who presented to Physical Therapy for complaints of low back pain, 78% also had urinary incontinence.  Symptoms may occur 20 years after an injury.

Urinary incontinence can be called urge, stress or mixed.  Urge urinary incontinence is when you have a sudden urge to go that cannot be delayed.  This may be triggered by hearing running water, seeing a toilet, or getting to your front door with the keys to the house in your hand.  Stress incontinence is the type we hear about in the movies as though it were a “normal” part of life as in “Don’t make me laugh so hard or I’ll pee my pants.”  Stress incontinence occurs with impact such as running, jumping, coughing, or sneezing as it causes stress to the muscles of the pelvic floor.  Mixed incontinence is the most common and involves both stress and urge incontinence.

So how much do you really know about normal bladder function?  The bladder normally holds 2 cups or urine, but we get the urge to void when the bladder is half full.  BUT, that doesn’t mean we’re supposed to go to the bathroom then.  It’s kind of like hunger which waxes and wanes.  Just because I’m hungry for lunch at 11:00 doesn’t mean I’m going to eat then.  Continence is a learned behavior and we’re not supposed to go immediately upon getting the first urge to void.  In fact we should wait 2 to 5 hours between voids and we should void 5-7 times/day.  Nocturia is nighttime voiding;  people under 65 should only void 1time per night or preferably not at all, for those over 65, 1-2 voids per night is normal.

Bladder function is controlled by an intricate feedback loop between the bladder and the brain.  The bladder is a muscle much like a water balloon.  When it is empty it collapses on itself and is flat, as it fills it rounds out like a balloon being filled with water.  Stretch receptors in the muscular lining of the bladder send a signal to the brain to start looking around for a toilet as the bladder fills.  Many of us have developed bad habits over the years of going to the bathroom “just in case” there won’t be a toilet available at a later time when we really have to go.  This switches the control over urination from the bladder to the brain being in control.  Frequent voiding when the bladder is not full leads to less bladder tolerance for storing urine, which is the ultimate job of the bladder.

Pelvic organ prolapse is a condition where the organs of the pelvic cavity (uterus, bladder and rectum) can start to fall into and actually out of the vagina.  According to Hagen (2005) it is seen in 50% of women who have given birth.  Hendrix (2002) found it was one of the three most common reasons for hysterectomy in women following endometriosis and cancer.  Symptoms of pelvic organ prolapse can include a feeling of heaviness, falling out, may be worse in the evening due to the affects of gravity.  It is associated with urge urinary incontinence, frequency, straining at the stool, incomplete evacuation or dribbling after urination.  Causes may be nerve damage or muscle or ligament laxity often occurring many years following delivery.

Physical Therapy can be very affective in the treatment of urinary incontinence and pelvic organ prolapse by teaching women and men to strengthen the pelvic floor muscles.  Think of your trunk as a canister.  We know we should have strong abdominals to support our back, but what do you think is at the bottom of the can — the pelvic floor muscles whose strength is critical.  In fact, the same nerves control the pelvic floor as the transverse abdominal, the stomach muscle just inside your hip bone and the posterior tibialis, the muscle that makes your toes squeeze and fan.  Every time you raise your arms over your head in standing, your abdominals contract together with your pelvic floor muscles to stabilize your trunk.   Physical Therapists can evaluate the strength of the pelvic floor muscles just like any other muscle in the body and teach patients how to perform a quick as well as a sustained contraction.  Often a Biofeedback machine is used to train patients to correctly perform this contraction.  Bump (1991) demonstrated that 40% of women were unable to perform a proper pelvic floor muscle contraction with verbal instruction alone.  Additionally, Electric stimulation is used for urge and stress incontinence to calm aberrant muscle contractions of the bladder.

Although physicians often treat urinary incontinence with medication, Brubaker (1997) found that Electric stimulation was considerably safer and more cost effective than the use of life long medication. Estrogen was commonly used for the treatment of urinary incontinence in the past; however studies now clearly show (Hendrix 2005, Shamliyan 2008) that oral estrogen leads to increases in urinary incontinence in randomized controlled trials compared to placebo.  In studies comparing medication vs. pelvic floor exercises, Wells (1991) reported outcomes were equally satisfactory and muscle strength was significantly higher in the exercise group vs. the medication group.  Bugio (1998) demonstrated that the exercise group had significantly less leakage and at the end of the trial, the medication group wanted another form of treatment.  Burgio (2000) later went on to demonstrate that a combination of pelvic floor muscle exercise and medication to be more effective than either treatment alone.

Now for the crappy information on fecal incontinence:  the involuntary loss of fecal material through the anal canal.  This is under reported and one of the leading causes of nursing home placement.  Caushaj P (1992) found the community prevalence in the UK was 4.2 men and 1.7 women per 1000 between ages of 15 and 64; 10.9 men and 13.3 women per 1000 over the age of 65.  Shamiliyan’s (2008) systematic review found that the prevalence of fecal incontinence was twice that of urinary incontinence and increased with age.  Risk factors for females included: number of births, anal trauma, vaginal prolapse.  Risk factors for men included urological surgery and radiation for prostate cancer.

Bowel dysfunctions such as constipation and obstructed defecation can be difficult to measure as people differ in their opinion of what constipation is.  Normal bowel function includes 2 to 3 bowel movements/day to 3x/week.  Constipation is less than 3 BMs/week.  Helovsek (2008) found a high prevalence of constipation in women with pelvic organ prolapse and urinary incontinence: of 302 women presenting to the Cleveland Clinic 36% had constipation.  Varma (2008) found 12.3% of women had weekly episodes of obstructive defecation.

Physical Therapy intervention for constipation includes pelvic floor muscle rehabilitation much like that mentioned above for urinary incontinence and pelvic organ prolapse.  Again, Biofeedback and Electric stimulation may be used.  A home exercise program is important.  Joint mobilization or scar mobilization may be indicated for painful presentations.  Treatments to stimulate the bowels may include abdominal muscle training (Massery 2006) or abdominal massage (Harrington 2006; Brown 2006).  Bowel training via patient education may also be indicated ie: defecation mechanics such as the passive way we sit on the toilet (as well as gender differences of men going to the bathroom with a magazine and women who are expected to rush) vs. the active posture of squatting as they do in India and certain parts of Europe.

As you can see, there are effective interventions for these conditions, and you should not have to suffer or be marooned in your home if you have either one of these incontinence experiences.

Mary Boyd, MS, PT is the owner of Mountain View Physical Therapy and is a member of the Sandpoint Wellness Council.  She can be reached at 290-5575 or on the web at www.mtnviewpt.com.

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