Management of the Pelvic Floor in Older Men and Women

Management of the Pelvic Floor in Older Men and Women

CHAPTER 22 Management of the Pelvic Floor in Older Men and Women Cynthia E. Neville OUTLINE Introduction Normal Bladder Function Neural Control of t...

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CHAPTER

22 Management of the Pelvic Floor in Older Men and Women Cynthia E. Neville

OUTLINE Introduction Normal Bladder Function Neural Control of the Lower Urinary Tract The Pelvic Floor Bladder Control as a Geriatric Syndrome Polypharmacy Caregiver Burden Impact on Rehabilitation Falls Aging of the Genitourinary System Lower Urinary Tract Symptoms and Bladder Control Problems Stress Urinary Incontinence Urge Urinary Incontinence

Urinary Tract Infections and Urinary Retention Identification, Screening, and Assessment of Bladder Control Problems Screening Patient Interview and History Taking Taking a Bladder History Physical Examination Pelvic Floor Muscle Palpation and Testing Outcome Measures Interventions Pelvic Floor Muscle Training Feedback and Biofeedback

INTRODUCTION Pelvic floor disorders are a group of conditions that affect the pelvic floor and include bladder control problems and urinary incontinence (UI), pelvic organ prolapse (POP), bowel control problems, and pelvic pain conditions. Bladder control problems, including urinary incontinence and other lower urinary tract symptoms (LUTS) (e.g., urinary urgency and frequency, nocturia), are prevalent in older adults, affecting around 50% of older women and 25% or more of older men.1 Urinary urgency and incontinence increase risk of falling in older adults.2 Functional decline is directly correlated with bladder control problems.3 Other negative consequences of bladder control problems include decreased work productivity, decreased sexual function,4 psychosocial problems,5 decreased quality of life,6 and negative rehabilitation outcomes, such as increased risk of admission to long-term care.7 The annual direct and indirect costs of bladder control problems such as overactive bladder in the United States is estimated to exceed $100 billion.8 Perhaps because of the changes with age, older adults have the highest prevalence of UI and other LUTS (UI/LUTS) of any group, except for those with specific neurologic 502

Electrical Stimulation Education Fluid Management Strategies Bladder Training Strategies for Deferral and Inhibition of Urinary Urgency and Nocturia Nocturia Management Bladder Emptying The Frail Elder and Cognitively Impaired Summary References

diseases.1 Older women are at greater risk for and have twice the rate of UI and LUTS as men, perhaps because of the effects of vaginal delivery.9 Vaginal delivery leads to alterations of the anatomy and support structures of the urethra and pelvic organs. UI /LUTS rates are different by setting. For example, upward of 52% of community-dwelling and/or homebound persons over the age of 60 have UI or other LUTS.10 In long-term care settings, however, 50% to 70% of residents experience UI.11 UI/LUTS are a common reason for older adults to require long-term care. UI and LUTS are negative prognostic indicators for rehabilitation outcomes. Therefore, rehabilitation professionals should identify these problems and seek and/or implement appropriate interventions. The prevalence of UI and LUTS indicates that routine screening questions should be included in every history of an older adult. As direct access and primary care professionals, physical therapists have a fiduciary responsibility to provide direct care for the whole person, rather than for a single condition or diagnosis for which the patient seeks care or is referred. Once UI or other LUTS are identified, physical therapists are well qualified to manage this condition and provide education and treatment or to refer the patient with UI or LUTS to another qualified practitioner.

Copyright © 2020, Elsevier Inc.

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Management of the Pelvic Floor in Older Men and Women

This chapter aims to systematically describe the assessment and intervention options for bladder control problems in older adults that can and should be implemented by all physical therapists. It will discuss the aging of the lower urinary tract (LUT) and the negative impact of bladder control problems on older adults. A review of the normal functions and common dysfunctions of the bladder, lower urinary tract, and pelvic floor muscles is included, as well as a review of the neural control of the LUT and pelvic floor. Explanation and instructions for screening, assessment, and interventions for bladder control problems including UI and other LUTS will prepare the practicing physical therapist to optimize rehabilitation outcomes through the provision of effective evidence-based interventions and/or referral to an appropriate provider for care.

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Normal adult bladder function is characterized by cycles of filling with urine, storing of urine, and emptying of urine.13 The urinary system is made up of the upper and lower tracts. The kidneys and ureters make up the upper urinary tract. The kidneys filter 200 quarts of blood daily to remove excess water and waste products and produce approximately 2 quarts of urine. Urine travels from the kidneys to the bladder through the ureters fairly consistently throughout the day, at about 15 drops per minute. Urine production normally decreases at night but may increase in the aging adult, considered a normal aspect of aging. The LUT consists of the bladder and urethra (Fig. 22.1). The bladder is a hollow muscular organ, the detrusor muscle, which is lined by mucosa (urothelium) and is sensitive to the volume of urine and its chemical composition. Urine is stored in the bladder until it is emptied through the urethra. During storage, the pressure in the bladder is less than the pressure of the urinary sphincters, which maintain closure of the bladder outlet. Normal functional bladder capacity is 300 to 400 mL of urine.13 Adults typically store urine for 2 to 5 hours during the day based on the volume and composition of liquid consumed. Adults who are adequately hydrated empty their bladders approximately five to eight times per day and one time or fewer at night.12 When the bladder is approximately two-thirds full, a person normally experiences an urge to void. Individuals should be able to defer voiding as needed.12 The process of emptying the bladder, called urination, is initiated by relaxation of the pelvic floor muscles and the bladder neck. Relaxation of the internal urinary sphincter at the bladder neck and the external urinary sphincter and pelvic floor muscles is promptly

NORMAL BLADDER FUNCTION Most people take normal bladder function for granted. Normal bladder function means that the bladder will fill, store, and empty on a regular basis. A healthy bladder is pain-free. A healthy bladder does not cause a person to have an overwhelming sensation of the need to urinate, and a healthy bladder never leaks. Adults of any age should be able to sleep through the night without the frequent need to urinate causing waking (nocturia). Bladders should be free of infection and painless during filling, storing, and emptying.12 The bladder should normally store urine long enough for a person to sit through a concert or a movie for a few hours without having to move to a toilet to empty the bladder. During urination, the healthy bladder will empty completely or normally retain a small postvoid residual volume. Ureter Female

Male Peritoneal coat Detrusor smooth muscle Transitional cell lining/mucosa Trigone Bladder neck

Prostate Membranous urethra Distal urethral mechanism Longer urethra in the male

Pelvic floor Urethral sphincter mechanism affecting the length of the urethra Ovary Uterus

Pubic bone

Cervix

Urethra

Bladder Pubic bone

Bladder

Urethra Penis

Rectum Vagina

Glans

Anus

Testis

Prostate gland Rectum Anus

FIG. 22.1 Anatomy of the lower urinary tract in both sexes. (From Chapple CR. Urodynamics Made Easy. 4th ed. St Louis: Elsevier; 2019.)

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followed by contraction of the detrusor muscle, causing a strong continuous flow of urine and emptying of the bladder called elimination. Bladder emptying is characterized by bladder pressure higher than bladder outlet pressure. The bladder may empty completely, or there may be a residual volume of urine of up to 100 to 200 mL, which may be considered normal.14

Neural Control of the Lower Urinary Tract Bladder control and continence depend on the neural coordination between the bladder, urethra, and pelvic floor muscles (PFMs). Filling and storage of the bladder are mediated by the sympathetic and central nervous systems. As more urine is stored, bladder outlet resistance must increase to maintain continence. For this to occur, bladder afferent nerve endings send information regarding bladder fullness to the dorsal horn of the spinal cord. This information is relayed onto spinal interneurons that activate somatic pudendal and sympathetic hypogastric efferents. Somatic pudendal efferent activation causes contraction of the striated urethral sphincter and increased pelvic diaphragm muscle tone. Coincidentally, activation of sympathetic hypogastric efferents via the hypogastric nerve inhibits detrusor contractions and promotes urethral smooth muscle contraction.13 Information from bladder stretch receptors is also sent to the pontine continence center, the periaqueductal gray (PAG) matter, and the right anterior cingulate cortex. These areas promote continence by increasing sympathetic efferent activity, bladder compliance, and external urethral sphincter tone; inhibiting parasympathetic activity (activated during voiding); and facilitating pudendal motoneurons.13 Once a person determines an appropriate time and place to void, afferent signals from the bladder are sent to the PAG matter. The PAG matter coordinates voiding by activating the pontine micturition center (PMC). The PMC activates parasympathetic pelvic efferents to the detrusor via the pelvic nerve, causing the bladder to contract. Coincidentally, sympathetic and somatic efferents to the urethra are inhibited, allowing urethral relaxation and urine flow.13

THE PELVIC FLOOR Bladder control and continence depend on the function of the PFMs, as well as the integrity of anatomic structures that support the pelvic organs and affect urethral pressure. The PFMs include the perineal membrane and levator ani muscles (Fig. 22.2).15 The perineal membrane is the superficial layer of the PFMs and includes the ischiocavernosus, bulbospongiosus, and superficial transverse perineal muscles. The levator ani group is the deep layer of the PFMs, also known as the pelvic diaphragm. The posterior region consists of the iliococcygeus and coccygeus muscles, which originate from a fibrous band on the pelvic wall called the arcus tendineus levator ani and insert into the central perineal body. Together, they form a relatively

FIG. 22.2 Pelvic floor muscles. (From Hagen-Ansert SL. Textbook of Diagnostic Sonography. 8th ed. St. Louis, MO: Elsevier; 2018.)

flat, horizontal shelf from the pelvic sidewalls on which the pelvic organs rest. The anterior region of the levator ani muscle includes the pubococcygeus and puborectalis muscles. They originate from the pubic bone on either side and form a sling around and behind the rectum. The pubococcygeus muscle attaches to the coccyx via the anococcygeal ligament. It is further delineated into the puboperinealis, pubovaginalis or puboprostaticus/ levator prostate, and puboanalis portions. Both the superficial and deep layers of muscle function as a unit during a PFM contraction. The three levator ani muscles are tonically active, providing constant support to the pelvic organs.15 In women, they narrow the urogenital hiatus and draw the urethra, vagina, and rectum toward the pubic bone. In this situation, the supporting connective tissues experience minimal tension. If muscular support is lost, such as denervation from childbirth, deconditioning, or just age, connective tissues can stretch or tear, providing a mechanism for pelvic organ prolapse and/or stress UI. The levator ani muscles can also be contracted voluntarily during abrupt rises in abdominal pressure (as occurs with a cough or sneeze) to stop urine leakage by compressing the urethra against the symphysis pubis or by preventing urethral descent. In both men and women, the striated urethral sphincter plays an important role in continence. It is composed predominately of slow-twitch (type I) muscle fibers. This muscle is constantly active and assists continence during prolonged periods of bladder filling and urine storage.13 The anatomic structures of the pelvic ligaments (urethral, cardinal, and uterosacral), endopelvic fascia, and urethral smooth muscle and vascular plexus are important to continence. They maintain anatomic position, which influences organ function. Ligamentous support is integral to the effective functioning of the bladder neck and urethra, as well as the PFMs. Optimal function of the PFMs requires anatomic integrity, motor control, coordination, endurance, power, and mobility of the connective tissue.16 The pelvic floor muscles have several vital and musculoskeletal functions that are listed in Box 22.1. The PFMs are composed of approximately 30% fasttwitch type II muscle fibers and about 70% slow-twitch type I muscle fibers13,16 and typically act as a functional unit.17 The quality of contraction and relative contribution of the different muscle layers may impact voluntary

CHAPTER 22 BOX 22.1 • • • • • • •

Management of the Pelvic Floor in Older Men and Women

Functions of the Pelvic Floor20,32,54

Bladder control Bowel control Support of pelvic organs Respiration Lumbopelvic stability Sexual function Childbirth 13

20

BOX 22.2

• • • • • 54

(Livingston ; Sapsford et al ; Memon and Handa )

• • • •

control of the pelvic floor. The PFMs contract voluntarily, described as a “squeeze and lift” around the urethra and anus, and the vagina in woman. Magnetic resonance imaging (MRI) studies show approximately 30 degrees of coccyx movement with a maximal concentric contraction of the pelvic floor muscles.18,19 No other movement of the pelvis or contraction of other muscles (abdominals, gluteal, or adductors) is necessary for the squeeze-and-lift contraction of the pelvic floor muscles. Verbal cueing to engage the contraction around both the anterior (urethral) and posterior (anal) aspects of the PFMs is more effective than cueing only the anterior aspect.17 In other words, instructing a patient to “squeeze and lift your internal pelvic muscles as if stopping both urine and gas” is most effective at eliciting an effective PFM contraction. Voluntary relaxation occurs after a person stops performing the voluntary contraction. Table 22.1 describes these muscle contractile functions under normal and symptomatic conditions. Anticipatory control of the pelvic floor involving the involuntary contraction of the PFMs precedes most or all body movement as an automatic co-contraction to increase trunk stability.20 This should occur automatically in anticipation of increases in intra-abdominal pressure, such as laughing, jumping, coughing, or sneezing. The PFMs maintain position of the bladder neck during

• •

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Bladder and Bowel Control Problems Associated with Pelvic Floor Dysfunction

Urinary incontinence Urinary urgency and frequency Nocturia Incomplete bladder emptying Painful urination Pelvic organ prolapse Fecal incontinence Constipation Obstructed defecation Incomplete bowel emptying Painful defecation

increased intra-abdominal pressure.21 Bladder neck descent may occur if PFM activation is lacking or if anatomic support is compromised. Descent and decompression of the urethra are associated with urine leakage and stress urinary incontinence, and with the eventual development of mixed urinary incontinence. The PFMs must relax to initiate urination. Involuntary relaxation of the PFMs occurs during normal urination, defecation, and vaginal childbirth. Bladder (and bowel) control problems are associated with PFM dysfunctions and are listed in Box 22.2.

BLADDER CONTROL AS A GERIATRIC SYNDROME Health care providers are often not aware of the individual psychological and social impact of UI/LUTS. Bladder control problems are not similar to having hypertension, which could lead directly to a stroke or heart attack, and death. Instead, UI/LUTS are considered to be a “geriatric syndrome” because many of its risk factors are not directly related to the genitourinary tract. Geriatric

TABLE 22.1

Pelvic Floor Muscle (PFM) Function and Dysfunction

Name of Condition

Description

Symptoms/Diagnosis (Patient Complaints)

Signs/Impairments (Tests, Measures, Observations)

PFMs are able to contract and relax on command and in response to increased intra-abdominal pressure as appropriate PFMs are unable to contract when needed

Normal urinary, bowel, and sexual functioning

Overactive PFM

PFMs are unable to relax and may contract during functions such as defecation or micturition

Nonfunctioning PFM

No PFM action palpable

Obstructive voiding or defecation (constipation), dyspareunia, pelvic pain Any PFM symptom may be present

Strong or normal voluntary and involuntary contraction Complete relaxation Absent or weak voluntary and involuntary PFM contraction Noncontracting PFM Absent or partial voluntary PFM relaxation Nonrelaxing PFM Noncontracting, nonrelaxing PFM

Normal PFM

Underactive PFM

(© Cynthia E. Neville. Reproduced with permission.)

Urinary or fecal incontinence, pelvic organ prolapse

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syndromes have been defined as “multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older person vulnerable to situational challenges.”22,23 As such, UI and other LUTS are strongly associated with functional decline.24 The insidious sequalae of bladder control problems are evident in the psychosocial ramifications of fear of an embarrassing incident. As the older person begins to have symptoms that require the use of pads or special garments to avoid embarrassing incidents, the older adult may gradually limit his or her physical and social activities. This limitation may promote deconditioning, a risk for frailty, and a risk for increased infections and falls. It is not uncommon for the older adult to become homebound because of effects of untreated bladder control problems. Elders with UI are twice as likely to feel depressed than those without incontinence.25 They have higher levels of anxiety and lower scores on quality-of-life measures.26 Thus, LUTS are associated with embarrassment, stigmatization, social isolation, and depression.5,27

Polypharmacy Another geriatric challenge is polypharmacy that directly and indirectly affects bladder control problems. Medical providers who prescribe pharmaceuticals often prioritize the treatment of other conditions over addressing UI/ LUTS, which alters management of LUTS.28 For example, therapeutic pharmaceutical competition exists such that the treatment for one condition, such as heart failure, may adversely affect a coexisting condition, such as UI.29 An example of therapeutic competition is when a patient who has heart failure must take a diuretic that iatrogenically contributes to LUTS of urinary urgency, frequency, and incontinence. The presence of certain comorbid conditions and functional impairments listed in Box 22.3 can lead the health care provider to overlook UI/LUTS.28 Additionally, many pharmaceutical interventions for common comorbid conditions existing in older adults can adversely affect bladder control problems. These drugs are also listed in Box 22.3.

Caregiver Burden Bladder control problems also can cause a considerable burden on the elder’s caregivers.30 The burden of toileting, dealing with changing and washing clothing and linens, cleaning furniture, and managing irritated skin exposed to urine may become overwhelming. Exposure of the skin and perineum to urine may lead to the development of infections and wounds, requiring further care.31 All of these factors can lead to incontinence being the “last straw” before a caregiver decides to place his or her loved one or client in a skilled nursing environment, which may explain the relationship between incontinence and institutionalization.30

BOX 22.3

Medical Conditions and Drugs That Directly Affect Bladder Function

Medical Conditions • Congestive heart failure • Peripheral venous insufficiency • Renal disease • Urinary tract infection • Bladder tumor • Bladder stones • Bladder outlet obstruction (prostatic or bladder neck in men; pelvic organ prolapse, bladder neck, or urethra in women) • Diabetes • Neurologic conditions • Radiation therapy Conditions That Can Precipitate Urinary Incontinence (UI) by Increasing IntraAbdominal Pressure • Chronic cough (chronic obstructive lung disease, smoking, asthma, allergies, emphysema) • Constipation • Obesity • Occupation (involving heavy lifting) and/or recreational activities (weight lifting, jogging) Obstetric History • Number of pregnancies and deliveries • Mode of delivery (vaginal vs. cesarean delivery; forceps- or vacuum-assisted vaginal delivery) • Episiotomy and/or anal sphincter laceration during delivery • Infant birth weight • UI/fecal incontinence during or following pregnancy Gynecologic History • Menopausal status (including hormone replacement therapy) • Surgery (hysterectomy, pelvic organ prolapse, and antiincontinence procedures)

Drugs Adversely Affecting Bladder Control α-Adrenergic antagonists (αblockers) for hypertension contract the bladder neck, causing urinary retention and thus overflow urinary incontinence. In men with benign prostatic hyperplasia, these drugs can be used to relax the bladder neck muscles to allow urine to flow more easily. Angiotensin-converting enzyme (ACE) inhibitors decrease detrusor overactivity and urethral sphincter tone, leading to reduced urge incontinence and increased stress incontinence. A dry cough can occur with the use of an ACE inhibitor, provoking stress incontinence. Diuretics increase urinary frequency and may cause urinary urgency and incontinence through overwhelming the bladder’s capacity. Antidepressants result in urinary retention and eventually overflow incontinence. Antipsychotics can cause urinary incontinence through complex pathways that may not occur for weeks after initiation. Sedative-hypnotics may cause sedation and immobility, leading to functional incontinence. Anti-Parkinson medications Estrogen (oral and transdermal) Antihistamines relax the bladder, causing it to retain urine and cause overflow incontinence.

(Data from https://www.uspharmacist.com/article/druginduced-urinaryincontinence)

Impact on Rehabilitation UI and LUTS negatively impact rehabilitation outcomes across all levels of care. Patients who have UI and any

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Management of the Pelvic Floor in Older Men and Women

other orthopedic or neurologic diagnosis in inpatient rehabilitation have lower Functional Independence Measure scores.7 The presence of UI/LUTS is a negative predictor of functional improvement in home health care.24 Urinary incontinence predicts disability, rehospitalization, and institutionalization.32,33 Importantly, the most relevant admission factor related to posthospital physical function at 3, 6, 9, and 12 months was UI.34

Falls The compelling evidence of a positive relationship between UI/LUTS and falls should alert physical therapists to the need for screening and intervention in both institutionalized and community-dwelling adults.2,23 The relationship between UI and falls may be explained by the fact that people experiencing urinary urgency and urge urinary incontinence feel the need to rush to the toilet/commode.35 If mobility is impaired, as indicated by slower Timed Up and Go (TUG) scores36 (or other standardized measures), then the risk of falls increases. Concern about not being able to get to the toilet in time combined with the cognitive demands of multitasking to get to the toilet quickly may negatively affect balance in older people.37,38 For example, an elder may report having no sense of urge to urinate while sitting, but when he or she stands up, he or she is overwhelmed by the urge to urinate. Multiple tasks must be executed successfully to avoid leaking, including walking to the bathroom, concentrating on not allowing urine flow to start, negotiating household obstacles, undressing before initiating urination, and negotiating the transfer to the commode. As a result, elders commonly fall in the bathroom.39 Both moderate to severe overactive bladder (OAB) and mild OAB were associated with any falls in a large (n ¼ 2505) cross-sectional study of male adults.40 Overactive bladder symptoms were found to have a greater impact on falls than mobility problems and depressive symptoms. Additionally, two or more incidents of nocturia increased risk of falls and fractures.41,42 Nocturia in men was consistently shown to be associated with increased risk of any fall in a 2016 systematic review.43

AGING OF THE GENITOURINARY SYSTEM The LUT and genitourinary system undergo predictable changes with aging in both men and women.44 Decreased circulating estrogen and decreased arterial blood flow associated with menopause are directly responsible for age-related changes in the LUT in women. As a result, thinning of the vaginal mucosa and vaginal wall increases the potential for perineal skin breakdown and contributes to weakening of the connective tissue structures supporting the bladder neck. Decreased bladder neck support may contribute to its hypermobility and result in stress incontinence. Decreased arterial blood flow to the

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submucosal vasculature and a decrease in the number of striated muscle fibers results in decreased mucosal coaptation of the urethra and a decrease in urethral closure pressure, which may allow the escape of urine, resulting in leakage. Decreased urethral closure pressure may also allow bacteria to enter the urethra. Retrograde movement of bacteria may then be a cause of increased urinary tract infections (UTIs) in aging women.45 All older adults experience age-related changes that may impact bladder control. The pelvic floor muscles are subject to sarcopenia and thus muscle weakness.46 Bladder sensation diminishes significantly with age, so that an older adult may better manage LUTS by urinating at a scheduled time rather than waiting to feel the urge to urinate. Bladder capacity does not change as a result of aging; however, the strength and effectiveness of the detrusor muscle contraction decline with age, and the rate of urine flow may be diminished. The clinical significance of postvoid residual volume and whether it is expected to change with age is not clear.47 The circadian rhythm impacting the sleep cycle changes with age. Secretion of the diuretic hormone vasopressin decreases, leading to an increase in nighttime urine production. For this reason, some consider waking up two times per night to be an age-related change and within normal limits,42 whereas others question whether any amount of nocturia, or waking to urinate, is normal.48 Though common, nocturia should not be considered normal as two or more episodes of nocturia followed by sleep are associated with poor sleep quality, daytime dizziness, drowsiness, decreased function,49 and cardiovascular events in addition to falls as mentioned earlier.42 In middle-aged men the prostate gland may begin to enlarge, a condition called benign prostatic hyperplasia (BPH).50 Around half of men over the age of 65 report symptoms related to BPH, in which growth of prostatic tissue begins to encroach on the prostatic urethra. Typical symptoms include increased urgency and frequency of urination and difficulty emptying the bladder or initiating urine flow. BPH can lead to the development of a wide range of LUTS51; however, not all LUTS in aging men are a result of BPH.52

Lower Urinary Tract Symptoms and Bladder Control Problems The most common LUTS in older adults are urinary incontinence, urgency and frequency, nocturia, and feeling of incomplete emptying.1 Urinary urgency is the complaint of a sudden, compelling desire to pass urine that is difficult to defer and often leads to a frequency of urination of more than eight times in a day. Urinary urgency may be caused by an OAB, expressed by the complaint that the bladder does not feel empty after micturition. A patient with this complaint may require a referral for measurement for postvoid residual (PVR). The symptom of

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T AB L E 2 2 . 2

Types of Urinary Incontinence, Definition, and Cause

Type of Urinary Incontinence (UI) Urgency UI Stress UI

Mixed UI Postural UI

UI associated with chronic retention of urine Functional UI

Insensible incontinence

Management of the Pelvic Floor in Older Men and Women

International Continence Society Definition62

Cause: Storage Versus Emptying?

Complaint of involuntary loss of urine associated with urgency Complaint of involuntary loss of urine on effort or physical exertion (e.g., sporting activities) or on sneezing or coughing

Storage problem due to overactivity of the bladder detrusor muscle contracting Storage problem due to decreased outlet resistance such as decreased activation, atrophy, or functional impairment of pelvic floor muscles and/or decreased closure of urinary sphincters Storage problem (see Urgency UI and Stress UI)

Complaint of involuntary loss of urine associated with both stress and urgency UI Complaint of involuntary loss of urine associated with change in body position, e.g., rising from a seated or lying position Complaint of involuntary loss of urine, which occurs in conditions where the bladder does not empty completely (formerly known by the term overflow UI) Complaint of involuntary loss of urine that results from an inability to reach the toilet due to cognitive, functional, or mobility impairments in the presence of an intact lower urinary tract system Complaint of urinary incontinence where the person has been unaware of how it occurred

Storage problem due to decreased outlet resistance during postural change Emptying problem

Storage problem

Further investigation is warranted

(© Cynthia E. Neville. Reproduced with permission.)

incomplete emptying may or may not be indicative of an elevated PVR volume or other pathology.53 The basics of screening for medical causes of UI/LUTS listed in Box 22.3 are discussed in a later section. Table 22.2 describes the types of UI and their causes and are further explored next. Stress Urinary Incontinence. Stress UI can also be referred to as activity-related incontinence. A small amount of urine leaks during an increase in intraabdominal pressure. As mentioned earlier, a history of having a vaginal delivery is one factor that predisposes women to stress UI.54 Although the exact relationship between pregnancy/childbirth and stress UI is unclear, it is typically attributed to pudendal nerve injury, stretching/tearing of the pelvic ligaments and/or levator ani muscles, or damage to the urethra.55 Trauma caused by the passage of the fetal head and body through the vaginal canal may lead to a loss of anatomic support (levator ani muscles, endopelvic fascia, and pelvic ligaments) to the proximal urethra. This loss of anatomic support is one mechanism of female stress UI. Without support, the bladder neck and/or urethra descend and decompress during increases in intra-abdominal pressure. The urethra then cannot be sufficiently compressed or closed, abdominal pressure exceeds urethral pressure, and leakage of urine occurs.56 After the age of 60 years, other stress UI risk factors and/or age-related physiological changes in muscle and connective tissue, such as the changes in the

quality of collagen and loss of elasticity, play a greater role in the development of stress UI in older women.10 Reported risk factors for female stress UI include age, estrogen loss, Caucasian race, family history of stress UI, obesity, smoking, chronic cough/respiratory disease, pelvic surgery, chronic constipation, and neurologic disorders.57 Men with prostate cancer who undergo radical prostatectomy (RP) are at great risk of developing some form of UI. At least 50% of men experience UI immediately following this procedure.58 Following RP, the proximal urethral sphincter, consisting of the bladder neck, prostate, and prostatic (proximal) urethra, is removed. Consequently, continence depends on the integrity of the rhabdosphincter, the distal urethral sphincter. Stress UI following RP is largely attributed to incompetence of the rhabdosphincter. Surgery-related scar tissue, pudendal nerve injury, reduced sphincter mobility secondary to scar tissues, an underdeveloped/weak distal sphincter, and/or weak PFMs are considered possible causes of rhabdosphincter incompetence following RP. Although the incidence of UI decreases over time, those men who remain incontinent report a negative impact on their quality of life.51 Urge Urinary Incontinence. An estimated one-third of persons with OAB,59 characterized by feelings of urinary urgency and frequency of urination, also suffer from urge UI. OAB is defined as urgency, with or without urge UI,

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Management of the Pelvic Floor in Older Men and Women

usually with frequency and nocturia. People with OAB experience a sudden strong urge to urinate and may leak a moderate to large volume of urine before reaching the toilet. Overactive bladder symptoms can be caused by low bladder compliance (a high rise in bladder pressure during bladder filling) and/or detrusor overactivity (the presence of involuntary bladder contractions during the filling phase). The exact cause of urge UI in many cases is unknown.60 Detrusor overactivity can occur owing to idiopathic, neurogenic (associated with a neurologic condition, such as stroke, Parkinson disease, multiple sclerosis, brain injury or tumor, spinal cord injury or tumor, or diabetes mellitus), or nonneurogenic (bladder infection, bladder outlet obstruction, bladder tumors, bladder stones, and aging) causes. In women with a history of stress UI, chronic decompression of the proximal urethra may lead to a decrease in detrusor muscle inhibition and urge UI, resulting in “mixed UI”—a combination of stress and urge UI symptoms. Urethral obstruction secondary to POP may lead to detrusor muscle changes and subsequently detrusor overactivity. Other factors associated with female OAB and/or urge UI include advancing age, hysterectomy, caffeine intake >400 mg/day (about 2.5 cups),61 consumption of carbonated drinks, obesity, arthritis, and impaired mobility and/or impaired activities of daily living.62 In men, obstruction caused by benign or malignant prostatic enlargement can result in OAB by altering bladder physiology or neural regulation, restricting bladder emptying, and/or affecting PFM strength. Following surgical removal of the obstruction (as in RP), the bladder may continue to be overactive, potentially causing postsurgical urge UI.63

URINARY TRACT INFECTIONS AND URINARY RETENTION UTIs are a common medical condition in the older adult population affecting 20% in the community and over 50% of institutionalized elders.64 They are more common in women because the female urethra is shorter and bacteria from the vagina and rectum may contaminate the distal third of the urethra. A simple preventative measure is to wipe from front to back and then drop the toilet paper after urination to avoid contamination of the urethra. Another contributing factor to UTIs is urinary retention allowing residual urine to colonize bacteria. During intercourse, bacteria are introduced into the urethra and bladder. Additionally, changes in the vaginal flora secondary to estrogen depletion lead to bacterial colonization of the urethra and bladder. Younger women may experience acute UTI symptoms of dysuria (painful urination), urinary urgency and frequency, suprapubic pain, and hematuria (red blood cells in the urine). However, UTIs in older adults may present atypically with symptoms such as confusion, delirium, and falls.65 They may not experience the discomfort of a UTI common to younger women. Therefore, UTI in an older woman should be suspected with any

TABLE 22.3

509

Clinical Presentation and Severity of Urinary Tract Infection (UTI)67

Clinical Features

Type of UTI

No urinary symptoms in the presence of bacteria Dysuria, urinary urgency, urinary frequency, nocturia, suprapubic pain Flank pain, unilateral costovertebral tenderness, ipsilateral shoulder pain, fever and chills, skin hypersensitivity (hyperesthesia of dermatomes)

Asymptomatic bacteriuria Acute UTI Acute pyelonephritis

sudden change in cognition or urinary frequency. Clinical features of UTIs are listed in Table 22.3. The onset of a UTI may be more difficult to recognize in a patient who already has other LUTS, such as urinary urgency and frequency, because UTIs share similar symptoms.1 Questions that should raise suspicion of a UTI requiring referral to a physician are listed in Table 22.4. Older women are at increased risk for recurrent UTIs, defined as three or more episodes of UTI in 12 months. Medical management of UTIs is complex and controversial because UTIs are often misdiagnosed and medically mistreated.66 Asymptomatic bacteriuria is common on older women and may not always need to be treated with antibiotics.65 Symptomatic UTIs are diagnosed with urine dipstick testing for nitrites and leukocytes, and by urine culture to isolate the causative organism. Recurrent UTIs may need to be treated with prophylactic antibiotics. TABLE 22.4

Red Flag Questions for Medical Screening for Urinary Incontinence (Positive response indicates the need for physician referral)

Questions

Possible Medical Concern

Was there a sudden onset of incontinence? Did leaking occur after surgery or with a medication change?

Infection

Is there burning/blood with urine/ stool? Is there a change in vaginal discharge? Odor? Is there difficulty initiating the stream? Are there moderate/large amounts of incontinence without warning? Is there an acute change in mental status?

Incontinence as unexpected side effect of surgery or medication Infection Infection, atrophic vaginitis Acute urinary retention Diabetes, heart failure, venous insufficiency, hypercalcemia, hyperglycemia Infection

(© Cynthia E. Neville. Reproduced with permission.)

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Intravaginal estrogen may be prescribed for women with recurrent UTIs to decrease vaginal pH and reverse microbiological changes in the vagina following menopause.67 Urinary retention is the inability to empty the bladder completely and can be acute or chronic. Acute urinary retention happens suddenly. People with acute urinary retention cannot urinate at all, even though they have a full bladder. Acute urinary retention can cause great discomfort or severe suprapubic pain and is a potentially life-threatening medical condition requiring immediate emergency treatment. Urinary retention is diagnosed by bladder ultrasound or catheterization to determine the postvoid residual volume left in the bladder after an attempt to urinate. Incomplete bladder emptying can be caused by a chronic condition. Remarkably, a postvoid residual volume of urine of up to 100 to 200 mL in older adults may be considered normal.14 Often people are not even aware they have this condition until they develop another problem, such as UI or a UTI.

IDENTIFICATION, SCREENING, AND ASSESSMENT OF BLADDER CONTROL PROBLEMS Screening In health care and rehabilitation settings, screening for UI/ LUTS in older adults should be a routine component of every physical therapy evaluation. In the absence of a verbal patient history, a variety of indicators of bladder control problems are often readily identifiable in the course of routine review of the patient’s medical record and history. Patients may have a documented preexisting diagnosis of urinary incontinence. The patient may be taking medications for UI/LUTS (see http://emedicine.medscape.com/ article/452289-medication#showall for more information). The observant clinician may also be able to detect that a patient is experiencing bladder control problems by noticing environmental and contextual cues. For example, the person may choose to wear dark polyester pants to hide wet spots and stains. The physical therapist may notice pads or garment products in the person’s home or room, and the therapist may notice that he or she is wearing a garment or pad. Sometimes, there may be an odor about a person who is experiencing incontinence.

Patient Interview and History Taking When evaluating a patient for UI/LUTS, a thorough medical history should be taken from the patient and/or primary caregiver. The history should review medical conditions that influence bladder function directly and conditions and/or lifestyle factors that precipitate UI (see Box 22.3). Surgical history, including urethral, bladder, bowel, rectal, obstetric and gynecological (female), and prostate (males), should be obtained. Conditions that may limit physical activity, such as arthritis or pain,

should be discussed, as impaired mobility and activities of daily living are risk factors for UI. Medications should be reviewed, including those that alter cognition, fluid balance, and bladder and/or sphincter function. Through various mechanisms, medications can directly affect urinary function. For example, antihypertensive medication, neuroleptics, and benzodiazepines can reduce urethral pressure. Diuretics are known to increase the production of urine. Anticholinergic medications and β-blockers may affect one’s ability to empty the bladder completely. Other medications can affect urinary function indirectly via their side effects. Constipation, a risk factor for stress UI, is a side effect associated with narcotic analgesic and iron use. Another risk factor for stress UI, a dry cough, is a side effect of angiotensin-converting enzyme (ACE) inhibitors.68 A bladder symptom history identifies onset, type, frequency, and severity of symptoms; precipitating factors; and need for further medical evaluation. Key questions of a bladder symptom history are found in Table 22.5. The International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence Short Form (ICIQUI SF) found in Fig. 22.3 is a 4-item questionnaire that can be used to identify, quantify, and characterize UI/ LUTS. Further information about the ICIQ-UI SF is shared in the section on Outcome Measures later in this chapter. Red flag conditions described in Table 22.4 should also be obtained. Patients should be asked whether or not they experience regular constipation, as it is a known risk factor for stress UI.57 Double incontinence, when a person experiences both UI and fecal incontinence at least once a month, has been reported to occur in about 8% of women and 5% of men with UI.69 Patients should be asked about their daily fluid intake. Adults should drink at least six to eight 8-oz drinks per day, or half an ounce of fluids per pound of body weight.70 A bladder diary can be used to quantify bladder function, including voiding frequency, volume of each void, number of UI episodes per day, sensations such as the intensity of urgency leading to leakage or to voiding, the size or severity of each UI episode, and daily pad usage.53 A 3-day bladder diary has been shown to be superior to 7-day recording.71 For someone with UI/LUTS, drinking enough water to make up half of the daily fluid intake may serve to dilute and reduce irritability of other fluids, such as coffee. Restricting fluids is a common coping strategy used by elders with UI/LUTS to reduce urinary frequency, urgency, and incontinence. Yet, reducing fluids may lead to dehydration, increased concentration of bladder irritants in the bladder, and/or constipation or urinary tract infection, and paradoxically make symptoms worse. Conversely, a patient may report excessive fluid intake, which may increase urinary urgency, frequency, and UI. Patient and caregiver education is critical to optimize fluid management for continence and bladder health. A patient education sheet about bladder health prepared by the author for general use that describes

CHAPTER 22 TABLE 22.5

Management of the Pelvic Floor in Older Men and Women

Key Questions to Include in the Initial Assessment of UI/LUTS53

Circumstances Surrounding UI/LUTS Symptoms *Never—urine does not leak Leaks before you can get to the toilet? Feel an urge to urinate that is so sudden and strong that you don’t make it to the bathroom in time? Leaks when you cough or sneeze? Leaks when you are asleep? Urge to urinate wakes you up from sleep to urinate during the night? If yes, how many times? Leaks when you are physically active/exercising? Leaks when you have finished urinating and are dressed? Leaks for no obvious reason? Leaks all the time? Are you wearing pads or garments? How many do you use in a day? What type of fluids do you drink? How much? Do you drink any water? Pain with urination? Need to strain to empty?

(Female) Feeling of bulging in the vagina?

Implications No incontinence; consider asking about other LUTS Urgency UI, increased risk for falls

Stress UI Enuresis—bladder contracts during sleep OAB, increased fall risk for waking more than one time per night Stress UI Stress UI or urge UI Needs further investigation Needs further investigation Severity of leakage, risk for UTI and skin breakdown Lifestyle factors contributing to symptoms, risk for dehydration Possible UTI Possible urethral obstruction, incomplete emptying, or urinary retention Possible pelvic organ prolapse

LUTS, lower urinary tract symptoms; OAB, overactive bladder; UI, urinary incontinence; UTI, urinary tract infection. (Copyright Cynthia E. Neville)

the kind of information valuable to the patient and caregiver is located in Box 22.4. Taking a Bladder History. Discussing the sensitive topic of bladder control problems can be uncomfortable for physical therapists not accustomed to the types of questions inherent in a bladder history. Incorporating routine questions, asked in a sensitive manner of every older adult, will quickly develop confidence and comfort in formally screening patients for the presence of UI/LUTS. Patients often do not disclose their LUT symptoms without being specifically asked because UI/LUTS are associated with embarrassment. By phrasing questions in ways that avoid embarrassment and preserve the patient’s

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dignity, the physical therapist may more effectively gain important information. For example, the word incontinent may be frightening or offensive to the patient. He or she may think that incontinence means a complete lack of bowel and bladder control. Instead of asking if a person is incontinent, the therapist might ask, “Do you ever leak urine when you cough or sneeze or during exercise?” Leakage is a very common symptom and the patient may be more likely to answer yes and engage in further discussion about symptoms. Key questions and their possible implications to include in the initial assessment of UI/LUTS are listed in Table 22.5. Although it is true that symptoms alone cannot be used to make a definitive medical diagnosis of specific lower urinary tract condition, internationally agreed-upon guidelines support the fact that conservative therapies may be started for urgency, stress, and mixed incontinence53 and for bothersome LUTS such as urinary frequency without a formal diagnosis. Physical therapists can and should confidently develop an assessment of the type and severity of bladder control problem. Further medical testing for definitive diagnosis is not necessary or required to begin basic treatments, unless there is a suspicion of a UTI.

Physical Examination Box 22.5 summarizes the components of the physical therapist examination of persons with UI/LUTS and suspected pelvic floor muscle dysfunction. All licensed physical therapists can perform external examination procedures to evaluate pelvic floor and abdominal muscle function. This includes external observation of pelvic floor muscle contraction and external palpation of pelvic floor muscle contraction (Fig. 22.4). However, not all physical therapists have undergone specific training in the internal examination and evaluation of pelvic floor muscle function and dysfunction. Internal (vaginal and rectal) examination of the pelvic floor is consistent with description of physical therapist practice in all 50 states in the United States but is generally regarded as an advanced practitioner skill and is not taught in entry-level education programs. It is strongly recommended that physical therapists undergo specific training in the internal vaginal and anorectal examination of the pelvic floor prior to performing these examinations on patients/clients. For clients with pelvic pain and/or additional musculoskeletal complaints or conditions, a comprehensive examination of the spine, pelvis, and hips is warranted.

Pelvic Floor Muscle Palpation and Testing The purpose of pelvic floor muscle palpation is to assess the ability of the patient to contract and relax the PFMs correctly, to assess other elements of PFMs such as tone and pain, and to measure both the power of the contraction and the elevation of the pelvic floor muscles. Two

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FIG. 22.3 International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Diagnostic questions of the ICIQ-UI SF Question #4: When does urine leak? scales, the Brink scale72 and Modified Oxford Grading Scale,73 have been described for grading PFM function through digital palpation. The Brink scale is based on three muscle contraction variables: intensity of the “squeeze” generated by the muscle contraction, vertical displacement of the examiner’s two fingers as the muscles lateral to the vagina contract, and muscle contraction duration. Each variable is rated separately on a 4-point categorical scale. The three subscale scores are summed to obtain a

composite score. The Brink scale does not discriminate between right and left pelvic floor muscle contraction. The Modified Oxford Scale uses a 6-point numerical scale to grade PFM contraction. Vaginal or rectal digital palpation is performed and muscle strength is graded on the right and the left using this scale. The Modified Oxford Grading Scale may be applied to digital rectal PFM examination; however, this scale has not been validated when performed via the anorectum. Studies reporting

CHAPTER 22 BOX 22.4

Management of the Pelvic Floor in Older Men and Women

513

Patient and Caregiver Information About Bladder Health

What Is Considered Normal? • The bladder’s job is to fill with urine, store it, and then empty on a regular basis. • The normal range of voiding urine is six to eight times during a 24-hour period. As we get older, we may need to pass urine more frequently but usually not more than every 2 hours. • The average bladder can hold about 2 cups of urine before it needs to be emptied. • Urine should flow easily without discomfort in a good, steady stream until the bladder is fully or almost completely empty. • No pushing or straining is necessary to empty the bladder. • An “urge” is a signal that you feel as the bladder stretches to fill with urine. Urges can be felt even if the bladder is not full. Urges are NOT commands to go to the toilet. An urge is merely a signal and can be controlled. What Are Good Bladder Habits? • Take your time when emptying your bladder. Don’t strain or push to empty your bladder. • Allow your bladder to empty completely each time you urinate. Do not rush the process or stop before emptying is finished. (Note: It is normal for many people to have some urine left in the bladder after urination.) • Try not to ignore your bladder. Do not wait for more than 4 hours between toileting during the day. • Try not to urinate too frequently. Avoid going to the toilet more often than every 2 hours and avoid going “just in case.” Try to go only when your bladder is full.







It is usually not necessary to go when you feel the first urge to urinate. Urgency and frequency of urination can be improved by retraining the bladder and spacing your fluid intake throughout the day. After urinating, women should wipe from front to back and then drop the tissue in the toilet to decrease the chance of getting a urinary tract infection. Maintain good bladder habits, and don’t let your bladder control your life!

Tips to Maintain Good Bladder Habits • Stay hydrated and maintain a good fluid intake starting early in the day. Depending on your body size and environment, drink 4 to 8 cups (8 oz each) of fluid per day unless otherwise advised by your doctor. Half of the fluids that you drink should be water or water-like. Not drinking enough fluid concentrates urine, making it more irritating, and may create a foul odor and dark color of the urine. • Limit the amount of caffeine (coffee, cola, chocolate, or tea) and citrus fruit juices and fruits that you consume as these drinks and foods can irritate the bladder and be associated with increased sensation of urinary urgency and frequency. • Limit the amount of alcohol you drink. Alcohol increases urine production and also makes it difficult for the brain to coordinate bladder control. • Stop drinking 2 to 3 hours before going to sleep to decrease the chance that bladder urges will wake you up and disrupt your sleep. • Avoid constipation by maintaining a balanced diet of dietary fiber, drinking enough water, and getting regular cardiovascular exercise.

(© Cynthia E. Neville. Reproduced with permission.)

BOX 22.5

Components of a Basic Physical Examination for Persons with Urinary Incontinence

General Examination • Observation for lower extremity edema • Lower extremity functional strength and joint mobility • Lower extremity neurological screening examination: reflexes, myotome and dermatome testing • Functional mobility



Specific Examination of Female Clients Perineal Observation • Perineal skin for inflammation, excessive vaginal discharge, lesions, scars • Demonstration of pelvic floor muscle voluntary and involuntary contraction and relaxation

Specific Examination of Male Clients Genital Observation • Irritation of skin or skin breakdown on penis from urine exposure, genital lesions • Demonstration of pelvic floor muscle voluntary and involuntary contraction and relaxation contraction

External Examination • Sensation around the perineum • Palpation to identify painful tissues • Sacral reflexes: anal wink, bulbocavernosal reflex Internal Examination (After Medical Clearance Postsurgery) • Sensation within the vagina • Palpation to identify painful tissues

• • • • •

Pelvic floor muscle bulk right and left Pelvic floor muscle contraction right and left Pelvic floor muscle function testing Pelvic floor muscle manual muscle test or Brink score Examine rectally if no contraction palpable vaginally Presence and quantification of pelvic organ prolapse

External Examination Perineal and perianal sensation • Sacral reflexes: anal wink, bulbocavernosal reflex •

Rectal Examination (After Medical Clearance Postsurgery) • Pelvic floor muscle contraction right and left • Pelvic floor muscle function testing • Pelvic floor muscle manual muscle test

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FIG. 22.4 External palpation of the pelvic floor muscle (PFM): Palpation of the levator ani externally placing fingertips between the external anal sphincter and ischial tuberosity (ischiorectal fossa). During levator ani muscle contraction the muscle elevates and pushes fingertips out of the ischiorectal fossa space. A, Palpation through clothing. B, External perineal palpation. © Cynthia E. Neville. inter- and intrarater reliability for the Modified Oxford Grading Scale for vaginal palpation are conflicting74 and therefore this method may not be robust enough to be used for scientific purposes to measure muscle strength. However, this method is recommended as a good technique for physical therapists to understand, teach, and give feedback to patients about their ability to perform PFM contraction correctly.

Outcome Measures LUTS and health-related quality of life (HRQOL) can be measured with condition-specific standardized assessment tools. These tools can also be used to measure change in symptoms and quality of life before and after intervention and to demonstrate the outcome or efficacy of the physical therapy interventions for UI/LUTS. Therefore, they are optimally administered pre- and postintervention. A review of studies using outcome measures after surgery for incontinence found over 42 different measures used, indicating a lack of uniformity in outcome reporting in the research.75 The validated tools described to follow are clinically useful and are commonly used in PT practice. The International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) is a 4-item self-report measure used to assess the impact of UI symptoms on quality of life as well as symptom severity. This measure assesses frequency of UI, amount of leakage, and overall impact of UI. The fourth question of the ICIQ-UI SF provides a specific symptoms checklist, which can be of use to the evaluating clinician to develop an understanding of the circumstances surrounding bladder symptoms (Fig. 22.3). The total score of the ICIQ-UI SF ranges from 0 to 21, with greater scores indicative of increased symptom severity and impact.76 The ICIQ-UI SF demonstrates good construct validity and reliability.77 The minimum clinical important difference (MCID) for a population of adult women with stress incontinence is a decrease of 2.52 points

at 4 months,77 a decrease of 5 points at 12 months, and a decrease of 4 points at 24 months.78 The Pelvic Floor Distress Inventory (PFDI) measures urinary, colorectal (bowel), and pelvic organ prolapse symptoms.79 Its companion measure, the Pelvic Floor Impact Questionnaire (PFIQ), measures the impact of these symptoms on HRQOL. Both the PFDI and PFIQ were found to be internally consistent, reliable, and valid and to demonstrate responsiveness in women undergoing surgery for a variety of pelvic floor disorders.79 As the PFDI and PFIQ are quite lengthy, shorter versions (PFDI-20 and PFIQ-7) were developed and also found to have good reliability, validity, and responsiveness.80 In addition, based on global ratings of improvement defined as at least “a little better” after surgery for pelvic floor disorders, a change of 45 points on the PFDI-20 summary score (summary of the three scale scores) and a change of 36 points on the PFIQ-7 summary score were found to be clinically important.81 The American Urological Association Symptom Index (AUA-SI) is a 7-item self-report measure used to assess urinary urgency, frequency, and voiding symptoms.82,83 The total score of 0 to 35 is used to assess symptom severity, where <8 indicates mild symptoms, 8 to 19 indicates moderate symptoms, and 19 + indicates severe symptoms. There is no established MCID.

INTERVENTIONS Physical therapists can initiate conservative therapies immediately for urgency incontinence, stress incontinence, mixed incontinence,53 and bothersome LUTS such as nocturia and urinary frequency, even in the absence of a definitive medical diagnosis or specific referral to physical therapy for treatment of symptoms as mentioned earlier. Interventions can be initiated based on patient report of LUTS and/or assessment of pelvic floor muscle impairments of an inability to contract and relax, endurance, and coordination. Interventions should be initiated immediately if there is a suspicion that UI/LUTS

CHAPTER 22

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and/or pelvic floor dysfunction are causing or contributing to fall risk or other neuromusculoskeletal impairments. Medical testing for definitive diagnosis of UI/LUTS such as urodynamic evaluation by a urologist or urogynecologist is not necessary or required to begin basic treatment interventions for UI/LUTS. The role of regular physical activity cannot be emphasized enough, for general health and well-being as well as for pelvic floor health. The recommendations of a minimum of 150 minutes/week of moderate-intense aerobic activity and resistive exercises that allow 8 to 13 repetitions to volitional fatigue on 2 or more days per week are widely accepted. Because skeletal muscle requires an adequate supply of oxygen, adenosine triphosphate (ATP), and nutrients for contractile function, it stands to reason that general fitness will enhance pelvic floor health and have a positive effect on stress UI.16 Core muscle training such as Pilates or yoga are encouraged to enhance PFM health and optimal function.16 The primary physical therapy interventions for UI/LUTS aimed toward improving PFM function include PFM training, biofeedback, and electrical stimulation. Those interventions aimed toward improving behaviors affecting the bladder include education, fluid management, bladder management, and nocturnal management.74 Each is discussed next.

Pelvic Floor Muscle Training Poor pelvic floor strength is associated with pelvic organ prolapse and urinary or fecal incontinence. Therefore, pelvic floor muscle training (PFMT) is the first-line intervention for stress and mixed UI.84,85 PFMT is a program of repeated PFM contraction focusing on the repetitive, selective, voluntary contraction and relaxation of the PFMs.16 The aim of PFMT is to change the morphology of the PFMs by achieving exercise-induced hypertrophy of the levator ani muscle group, to improve the tone of the PFMs, and to increase motor unit recruitment and activation during PFM contraction.74 Increasing the PFMs’ thickness and responsiveness is thought to improve BOX 22.6 •



• •

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urethral pressure and structural support of the pelvic organs, thus preventing urethral descent during abrupt rises in intra-abdominal pressure.86 Patients can also be taught to purposefully contract the PFMs prior to abrupt increases in intra-abdominal pressure as an effective strategy to stop leakage.87 All trials in one systematic review reported that women who performed PFMT were statistically significantly more likely to report symptom improvement or cure.88 PFMT is believed to reduce stress UI by improving urethral closure and pelvic organ support. A properly timed PFM contraction can stop stress UI by compressing the urethra against the symphysis pubis. PFMT is thought to reduce urge UI in the short term by compressing the urethra, which in turn neurologically inhibits the detrusor (bladder) muscle contraction89 and, in the long term, stabilizes the inhibitory neurogenic activity with changes in muscle morphology. As with any other skeletal muscle, correct performance of PFM contraction and relaxation requires precise training with appropriate monitoring and feedback.90 However, many people do not know how to contract and relax the PFM for effective exercise training and functional use. Specific verbal cueing to “squeeze and lift your muscles as if stopping both gas and/or urine” may be the most effective verbal cue for instructing a person to perform a PFM contraction.17 Many elders are unable to perform a proper PFM contraction with verbal instructions alone. Patients benefit from education regarding the anatomy of the PFMs,91 specific instructions, demonstration, and palpation when appropriate to learn the correct contraction. General instructions for how to contract PFMs are included in Box 22.6. For specificity and motor learning, PFM contractions can be initially integrated into other movements and exercises often prescribed by physical therapists, such as the bridge exercise performed when a patient is lying supine with hips and knees flexed and then lifts the pelvis and the hips off of the floor. Activation of both the pelvic floor muscles and hip rotator muscles92 or the PFM and gluteals93 has a faciliatory effect to PFM exercises.

General Instructions for How to Contract Pelvic Floor Muscles

The pelvic floor muscles attach from the pubic bone in the front of the pelvis to the tailbone or coccyx and to the side walls of the pelvis at the hip joints. The pelvic floor muscles are those that you would use to stop the flow of urine and to prevent the passage of stool or gas from the rectum. You should feel a tightening around the urethra, where urine passes; the vagina (for females); and the anus, where gas and stool passes. The muscle contraction should combine both a squeeze around the openings and a lift of the muscles upward toward your head. Squeeze and lift the muscles and hold the contraction for 3 to 5 seconds and repeat at least 8 to 10 times. Practice these exercises 2 to 3 times per day.

• • • • •

Once this becomes easy to do, try to hold the contraction for 8 to 10 seconds and repeat 8 to 10 times, 2 to 3 times per day. Never hold your breath when you are doing these exercises. Try counting out loud to avoid breath holding. Never strain or bear down, like you are trying to produce a bowel movement. Always fully relax these muscles after each contraction for at least 5 seconds. Try to relax your abdominal, buttocks, and thigh muscles during exercise. Concentrate on the pelvic floor muscles only.

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Coactivation of these muscles stimulates PFM activation even when they are too weak to contract effectively and/or independently. Rehabilitation should progressively be targeted at training the patient to perform relatively isolated contractions of the PFMs, with minimal to no co-contraction of the abdominals, gluteals, adductors, or hip rotators. This specificity will then allow for the performance of intense maximum contractions of the PFMs. Isolated PFM contractions satisfy the American College of Sports Medicine (ACSM) “overload” principle requirement, because rarely do people perform maximal contractions of the PFMs during daily functional activity. PFMT should be performed for a duration of 8 weeks minimum.74 In geriatric rehabilitation, this may be best accomplished by incorporating PFMT into therapeutic exercise routines and regular physical activity. Hypertrophy of the PFMs will take at least 6 weeks and may not be fully achieved for up to 4 to 6 months, so even after a rehabilitation intervention is completed, a patient should be encouraged to continue the PFM training program. The physical therapist who does not perform an internal palpation exam of the PFMs can estimate the capacity of the PFMs to perform and sustain a quality contraction. Progression of PFMT begins with attention to training both slow-twitch and fast-twitch PFM fibers. In general, most elders can start with a 3-second contraction followed by a 6- to 10-second relaxation. Physical therapists should verbally emphasize the feeling of the muscle “squeezing and lifting.” The imagery of an elevator going up and down can be effective. The levator ani’s name is indicative of this elevator-like action. “Squeeze” means the elevator doors are closing (sphincters close) and “lift” means the PFMs elevate toward the head. “Hold” is staying on the top floor, then the elevator “drops” or descends, and the “doors open” when the sphincters relax. Establishing the coordination of PFM contraction and relaxation is a key initial component of PFMT. PFMT has been extensively studied and is well supported in the literature.85 Protocols in the literature vary widely; however, a meta-analysis of PFMT supports the prescription of 24 daily contractions.94 This translates into two sessions of 12 repetitions or three sessions of 8 repetitions of both sustained and fast-twitch contractions on a daily basis. Muscle training exercises should be performed at least 2 days per week, with 5 days/week the most prescribed.95 Contraction intensity should be both maximal and submaximal with both sustained and rapid types (1 to 20 seconds).95 Rest periods between sets can be 1 to 20 seconds and the number of sets from 2 to 40.95 Training positions have been described most often as supine followed by standing, seated, and in the lateral decubitus position.95 Duration was 12 weeks in most studies.95 Effective muscle training requires several exercise principles that are applicable to PFMT.16 The principle of exercise specificity enhances effectiveness. Appropriate cueing to target the desired type of contraction is

described later. A good knowledge of the anatomy of the pelvic floor is necessary to prescribe the correct movements and exercises. The techniques of motor learning to facilitate neural recruitment and control are also necessary. Motor learning techniques include relevance (aligned with specific patient goals), repetition to fatigue, and random practice. Random practice can include PFMT in different situations and positions. Feedback (described later) is an additional element of motor learning. External feedback may be required initially, during the early training period, but should be gradually withdrawn to enhance the patient’s internal feedback mechanism. The principle of overload is critical to achieve gains in muscle strength and hypertrophy in any skeletal muscle, and the pelvic floor is no different.16 Overload can be achieved by using a rate of perceived effort (RPE) of 6 to 8 on a 10-point scale to fatigue (a 10% drop in force, which generally occurs in approximately 10.5 seconds).16 However, some authors postulate that fatigue is a reason pelvic floor muscles fail and therefore hypothesize that failure during a training program is probably contraindicated.16 A 60% effort is necessary to achieve sufficient overload to promote changes in muscle morphology. Finally, progression of the program should be included. Progression includes exercises in different settings and positions, harder contractions, and the use of quick contractions (power). The principle of reversibility means that any gains achieved with a training program will be lost if the program is terminated. Therefore, the patient should be educated that when symptoms are under control, the program can be reduced to a maintenance level but not terminated. Expected results of PFMT include decreasing episodes of incontinence and symptoms of urgency and frequency, which can be tracked using a bladder diary. Symptoms of nocturia are decreased as well, thus improving sleep, including all the benefits associated with improved sleep. By decreasing UI and LUTS, PFMT decreases the risk of adverse events such as falls and infections. Ultimately, both the outcomes of rehabilitation and the patient’s quality of life are improved. Pelvic floor muscle training should continue for at least 6 weeks and up to 4 to 6 months to achieve hypertrophy and optimum results. Once a person knows how to perform PFM exercise, the exercises can be done anytime and anywhere. Patients should be encouraged to incorporate PFMT into routine activities, such as while sitting and before rising after a meal. After 4 to 6 months, a patient may continue with a maintenance program. The minimum number of contractions required to maintain normal PFM function has not been determined; however, there is some evidence that as few as 10 repetitions per week are enough to maintain PFM function and reduced symptoms of UI.74

Feedback and Biofeedback Gaining skill in correct performance of PFM contraction and relaxation is often difficult for people with pelvic

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floor disorders. Individuals often report that they cannot feel the muscle contracting and relaxing. Visualization might be advantageous, but obviously individuals cannot easily observe pelvic floor muscle contraction and relaxation. Therefore, perineal biofeedback may be an effective component to promote awareness of pelvic floor muscle activation, coordination, and motor learning. Women who received biofeedback during PFMT were significantly more likely to report that their incontinence was improved compared to women who received PFMT alone.96 Some systematic reviews provide support for PFMT and biofeedback for pelvic floor rehabilitation in women with UI,97 people with fecal incontinence,98 and men with UI following RP (limited support).99 Simple feedback can be provided by physical therapists who palpate the levator ani muscles externally (Fig. 22.4) or intravaginally or intrarectally and provide verbal and manual kinesthetic feedback and cueing for contraction and relaxation of the muscles. Asking the patient to sit on a small, inflated ball is a technique to assist patients in obtaining kinesthetic awareness and feedback of the PFMs contraction and relaxation. The patient will feel the ball between the ischial tuberosities where the PFMs reside. As the patient contracts the PFMs, he or she can feel the muscles lift off of the ball, and as he or she relaxes, the PFMs move back down onto the ball. This type of feedback can also be accomplished by having the patient sit on a folded or rolled-up towel placed between the ischial tuberosities. Pressure biofeedback uses devices that are placed inside the vagina or anus to detect squeeze pressure. When the

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person contracts the muscles, the device measures the amount of pressure produced by the squeeze component of the contraction and provides information and feedback to the patient about the amount of pressure generated. The feedback information may be as simple as a pressure gauge reading or a sound when a certain pressure is achieved. The feedback may be in the form of both an auditory cue and a visual display on a cell phone application. There are a variety of relatively low-cost pressure feedback devices available for patients to purchase and use at home. The drawback of pressure feedback devices is that they cannot distinguish whether the patient is generating squeeze pressure with facilitation using the abdominal or gluteal muscles or if he or she is able to generate squeeze pressure by contracting the PFMs independently. Surface electromyography (sEMG) perineal biofeedback (Fig. 22.5) is the gold standard for biofeedback during PFMT. sEMG can be recorded from internal vaginal or rectal sensors or from surface electrodes placed externally near the anus. The abdominal, adductor, and gluteal muscles can also be monitored to determine if the patient is correctly isolating the PFMs. Patients with bladder control problems, especially symptoms of urgency and frequency, may initially benefit from sEMG feedback to learn how to relax the PFMs prior to initiating strengthening exercises. sEMG is an effective tool to increase patients’ understanding of both the contraction and the relaxation activity of their PFMs. Advanced training is required for physical therapists to become competent in the performance and analysis of sEMG perineal biofeedback for the treatment of pelvic floor disorders.

FIG. 22.5 Surface electromyography (sEMG) biofeedback. Channel 1 top graph: pelvic floor muscle (PFM) performance. Channel 2 middle graph: abdominal muscles; note heartbeat artifact. Channel 3 bottom graph: gluteal muscles; note gluteal muscle co-contraction during PFM contraction. © Cynthia E. Neville.

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Electrical Stimulation Electrical stimulation (ES) for the treatment of bladder control problems is a noninvasive low-cost treatment well tolerated by most individuals. Compelling, but limited, evidence supports the use of ES for bladder control in pelvic floor muscle rehabilitation as an intervention for symptoms of urinary urgency and overactive bladder100,101 as well as for facilitating pelvic floor and urinary sphincter muscle contraction.102 Sacral nerve, tibial nerve,101 and intravaginal stimulation have effectiveness in treating urge urinary incontinence in some studies.100,101 Intravaginal ES can improve quality of life, urine leakage, pelvic floor muscle strength, and the squeeze pressure of a PFM contraction.103 Electric stimulation improved incontinence symptoms and enhanced the quality of life in patients with urinary incontinence following stroke.104 Improved urethral closure and improved neuromotor function of the PFMs have been repeatedly demonstrated with electrical stimulation with nonimplanted surface or internal electrodes.103,105,106 However, a recent systematic review indicates that it is currently not known if ES is as effective as, or more effective than, PFMT for the treatment of incontinence.107 Electric stimulation should be performed as a component of multimodal physical therapy intervention for pelvic floor disorders and not as a stand-alone treatment. The objectives of ES treatment include neuromodulation of pelvic nerves to regulate the diverse population of nerves related to bladder control and pelvic floor muscle function, to facilitate sensory awareness of pelvic floor muscles, to inhibit reflex bladder contractions and decrease urinary urgency, and to facilitate the contraction of the PFM. Theoretically, neuromodulation by ES reflexively influences the neural activity to the pelvic parasympathetic nerve and the hypogastric sympathetic nerves of the bladder, as well as the sensory and motor inputs to the pelvic floor. A variety of ES electrode placement options are available (Fig. 22.6). Two or four electrodes placed over the sacrum at the levels of S2–4 nerve roots, two electrodes

placed suprapubically over the bladder 2 to 3 inches apart, or two electrodes placed on either side of the anus on the perineum in the S2–3 dermatome provide neuromodulation to the pudendal nerve S2–4. Surface electrodes placed above the medial malleolus and at the medial aspect of the calcaneus stimulate the distal tibial nerve, which shares the S3 nerve to the bladder and pelvic floor. Physical therapists trained in pelvic floor rehabilitation may also recommend internal vaginal or internal rectal electrodes for appropriate patients; however, internal electrodes are not necessary to provide ES treatment for improving bladder and pelvic floor muscle control. For example, a systematic review indicates that transcutaneous tibial nerve stimulation for adults with OAB was effective.108 Table 22.6 provides suggested parameters for ES treatment.

Education Community-dwelling elders have poor knowledge of normal bladder function and UI.109 It is doubtful that education alone can improve symptoms of incontinence and improve bladder control110; however, some research shows that education and training including Internetbased education111 can result in improvements in symptoms when included in a pelvic floor training program. Education about normal bladder control should include the topics listed in Box 22.7.

Fluid Management Strategies Individuals with UI will often self-initiate fluid restriction to better manage their urinary symptoms.112 However, there are conflicting results in the effects of decreasing fluid intake on incontinence113 and overactive bladder,114 with concerns that dehydration must be avoided. Fluid intake over 2,400 mL (80 oz) or under 1,500 mL (50 oz) can contribute to UI.115 Thus, leeway exists in making recommendations for changes in fluid intake, which may be to either increase fluids or decrease fluids depending on the patient’s fluid intake behaviors.

FIG. 22.6 Surface transcutaneous electric nerve stimulation (TENS)/neuromuscular electrical nerve stimulation (NMES) electrode placement for stimulation and neuromodulation. A, Tibial nerve. B, S2–4 sacral 3 nerve root. © Cynthia E. Neville.

CHAPTER 22 TABLE 22.6

Management of the Pelvic Floor in Older Men and Women

519

Parameters for TENS/NMES for Bladder Control Typical Protocol for Urinary Urgency and Urge Urinary Incontinence, Overactive Bladder, Nocturia

Typical Protocol for Stress Urinary Incontinence and Underactive Pelvic Floor

Possible Parameters

Two electrodes: options • Medial ankle over distal tibial nerve • Suprapubic over bladder 2 inches apart • Over S2–4 nerve roots on sacrum 10–30 Hz

Two electrodes next to the anal sphincter, perform active PFM contraction during stimulation “on” time

Internal vaginal or internal rectal electrodes for appropriate patients provided by trained PT can also be used for either protocol

35–50 Hz

Pulse duration (width)

100–350 μsec

100–350 μsec

Waveform Amplitude (intensity) Duty cycle

Asymmetrical biphasic To patient tolerance

Asymmetrical biphasic To patient tolerance or anal wink

5–50 Hz (underactive PFM) 5–20 Hz (urgency) 100–200 Hz (pain) 100–1000 μsec Note: Wider pulse duration requires less amplitude to depolarize nerves and so is more comfortable Symmetrical or asymmetrical biphasic To patient tolerance or anal wink

5–10 seconds on 5–10 seconds off

Duration Frequency of prescription Length of prescription Comments

10–20 minutes 1 to 7/week BID if possible 8–12 weeks May decrease to 1 /week for long term Can be done in sitting or lying position Consider treatment before bedtime if patient has nocturia

Correlate with PFM training program Start: 5 seconds on, 10 seconds off Progress to: 10 seconds on, 4 seconds off 10–20 minutes BID to 3/week

Equal rest Double rest If combining with active PFM training, then work up to less than half of on time as rest time 5–30 minutes BID to 1 /week

8–16 weeks

Once to ongoing

Progress to a standing position, performing active contractions with stimulation

Both protocols can be used for a patient who has mixed urinary incontinence or who has both PFM weakness and urinary urgency

Electrode placement

Frequency

BID, two times per day; NMES, neuromuscular electrical nerve stimulation; PFM, pelvic floor muscle; PT, physical therapist; TENS, transcutaneous electric nerve stimulation.

BOX 22.7

Education About Normal Bladder Function

Education about normal bladder function should include: Role of the normal bladder and its function: • Bladder typically fills at a fairly constant rate • Bladder stores urine 2 to 4 hours during the day and longer, 6 to 8 hours, at night • Bladder empties but not always completely: Normal postvoid residual may be 100 to 200 mL (3 to 7 oz) Definition of incontinence: what it means, signs, symptoms, risk factors, self-care, and prevention Relationship between fluid intake and bladder function and symptoms Relationship between bladder muscle and pelvic floor muscles (© Cynthia E. Neville. Reproduced with permission.)

Role of pelvic floor muscles in controlling urine flow How to perform pelvic floor muscle exercises • Pelvic floor muscle contractions can inhibit bladder urgency Avoid urinating when there is not an urge to do so (except when on a schedule for voiding) Frequently emptying bladder to avoid leaking contributes to urinary urgency and frequency and decreased perceived bladder capacity Normally we can override the urge to urinate. We may need to retrain the brain and bladder, and re-learn bladder control: • “Mind over bladder” • •

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The physical therapist and patient/caregiver can assess fluid intake behaviors and formulate fluid management strategies by discussing fluid intake habits or by evaluating a bladder diary. The goal of fluid management is symptom reduction, not deprivation or forced fluid intake. Changes in fluid intake can initially be made in small increments of 2 to 8 oz at a time and gradually progress over 2 to 4 weeks. The physical therapist can often identify bladder irritants on the bladder diary or hypothesize which fluids in the patient’s diet may be contributing to symptoms. Common bladder irritants often contain caffeine and include coffee, tea, soda, and alcohol.116 Other bladder irritants include some medications and chocolate.61 Daily consumption of >204 g (2 to 3 cups) of caffeine per day was significantly associated with any UI.117,118 Awareness of the effects of certain fluids on UI/LUTS may lead to behavior that will reduce or eliminate the problematic fluid. A person may not want to give up coffee but may be willing to decrease the amount of coffee intake, or can be aware of impending symptoms when he or she drinks coffee so that he or she can manage those symptoms. The gradual normalization of water and fluid intake to recommended guidelines to maintain hydration and to minimize the negative effects of bladder irritants on LUTS is a key goal. The patient can be advised how to dilute bladder irritants with water. For example, drinking an ounce or two of water before or after drinking coffee may minimize the effects of the coffee. Optimally, fluids should be evenly spaced throughout the day, with most hydration coming in the morning and afternoon hours. Thirst and fluid intake are often impaired, even in the healthy older individual,119,120 so the individual may need to initiate adequate fluid intake rather than waiting until feeling thirsty. The total fluid intake should be about six to eight 8-oz glasses/day or 48 to 64 oz total. The U.S. Food Science Board–recommended guidelines for older adults are half an ounce of fluids per pound of body weight.70

patient the opportunity to urinate in the bathroom.122 Bladder management has conflicting evidence as to its effectiveness, owing in part to the variability of individuals’ abilities and type of bladder control problems included in studies.123,124

Bladder Training

Nocturia Management

Bladder training is a behavioral exercise used to improve bladder control in all treatment settings. Bladder training is also called timed voiding, habit training, or promoted voiding. A key component of bladder training is education about the function of the bladder to fill, store, and empty. Timed voiding is a program of mandatory scheduled voiding, whether there is an urge to urinate or not, with progressive increases or decreases in the intervals between voiding.121 Habit training is a program of identifying the patient’s typical voiding habits and then scheduling voiding based on those habits, whether there is an urge to urinate or not.121 Prompted voiding is used with cognitively impaired patients. The caregiver is responsible for verbally cueing the patient to identify the need to urinate and identify if leakage has occurred and then offer the

Waking from sleep with the urge to urinate (nocturia) is a common scenario leading to falls in older people. The more a person drinks in the evening, the more likely he or she is to have to get up to urinate. Fluid management strategies, as described previously, are recommended for nocturia management. Stopping fluids 2 to 3 hours before sleep and avoiding drinking fluids in the evening and during the night are recommended for patients with nocturia. When a person does wake with the need to void, he or she can use urgency inhibition strategies as described earlier. Physical therapists can advise patients to perform PFM contractions while lying in bed, while sitting on the edge of the bed, or before standing up to reduce urinary urgency. Pelvic floor muscle contractions potentially inhibit urgency and concurrent bladder contractions

Strategies for Deferral and Inhibition of Urinary Urgency and Nocturia The urge to urinate resulting in urinary urgency and urinary leakage can be deferred or inhibited with a number of different strategies. PFM contractions, mental distraction, and calf muscle exercises may inhibit or decrease the feeling of the strong urge to urinate so that the urge will dissipate. A reciprocal inhibition relationship exists between the bladder detrusor muscle and the pelvic floor muscles. When the bladder muscle contracts to empty, the pelvic floor muscles must be relaxed. Conversely, when the pelvic floor muscles contract, the bladder muscle is reflexively inhibited. Performing 8 to 12 strong quick pelvic floor muscle contractions can work to inhibit detrusor/ bladder contractions and decrease associated feelings of urgency. The PFM contractions inhibit the bladder by closing the external urinary sphincter, elevating the bladder neck and thus closing the internal urinary sphincter, and activating a detrusor inhibition reflex.125 Another technique shown to reduce bladder contractions is to perform heel raises, or “self-induced plantar flexion.”126 Active plantar flexion movements and heel raises can be done in the sitting, lying, or standing position for 10 to 20 repetitions to decrease the sensation of urgency. Diaphragmatic breathing to decrease sympathetic output may be effective. Mental distraction techniques including meditation, visualization of a calming scene, concentration on a poem or song, and keeping the mind busy with a task (such as counting in another language) are all strategies that may be effective. Sitting down and putting pressure on the perineum between the legs, such as sitting on the arm of a couch, can also decrease the urge and inhibit the bladder.

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and reduce the risk of leaking urine on the way to the bathroom. This may potentially prevent a fall on the way to the bathroom. For men, providing a urinal near the bed may be a reasonable management strategy for nighttime voiding. For both men and women, a bedside commode may be beneficial to reduce the risk of falling while trying to ambulate to a bathroom. Finally, if a person has lower extremity swelling, it may be helpful to elevate the feet 2 to 3 hours before sleep to encourage processing of fluids before going to bed to reduce nocturia.

Bladder Emptying Older adults may report that they feel as if they are not emptying the bladder completely. Physical therapists should provide education that there can be a normal postvoid residual volume of urine left in the bladder after emptying. For the bladder to initiate emptying, and to empty efficiently, the pelvic floor muscles must be relaxed. Physical therapists can teach the patient to contract and relax the PFMs and to feel the difference between the contraction and the relaxation. The patient should then be more aware of the tone of the PFMs and actively relax the PFMs when initiating urination. Position and posture during urination may impact the ability to empty the bladder. Sitting in what is referred to as the “potty posture” or the “defecation posture”127 (Fig. 22.7) with the hips flexed to >100 degrees facilitates relaxation of the PFMs and may also improve emptying of the bowels. This posture should be used every time a person urinates or defecates. For some, sitting on a public toilet seat is not acceptable. Some women may hover over the toilet seat. This position may lead to contraction of the hip and pelvic floor muscles and make it more difficult to initiate urination and to fully empty. The PFMs also must be relaxed in males to initiate urination in the standing position.

521

The Frail Elder and Cognitively Impaired Multiple integrating risk factors such as age-related changes in physiology, cognitive changes, polypharmacy, and comorbidities may lead to UI/LUTS in the elder with frailty.1 A comprehensive, multicomponent, and multidisciplinary approach is optimal because of this multifactorial nature of UI. A lack of clinical trials to guide practice in the treatment of UI in this population makes clinical decision making a challenge.1 The most common strategy for management of UI in the frail elder is the use of pads and garments; however, they may be misused and potentially increase the risk of developing UI and associated conditions such as UTIs. Conservative interventions may be effective so that pad usage can possibly be decreased or potentially eliminated. The health care team’s assessment, choice of interventions, and timing of interventions for incontinence must take into consideration the patient’s multisystem involvement and the service delivery processes that are involved in the care of the patient or resident in his or her environment. Rehabilitation providers typically focus on promoting strength, safety, mobility, and dexterity relating to toileting. Physical therapists should also actively collaborate with nursing care providers to promote regular or scheduled voiding intervals. Elders with cognitive impairments or sensory impairments may not recognize the need to urinate, so therapists can reinforce and promote scheduled voiding as a strategy for the elder to regularly empty the bladder, even during therapy sessions. One study successfully used PFMT for older women with mild cognitive impairment or Alzheimer disease (mean Mini-Mental State Examination score ¼ 23) and UI. The intervention group received six sessions of training for 12 weeks. The primary outcome was change in UI episodes measured with a frequency volume chart. After 12 weeks of training, the mean number of UI episodes per 24 hours decreased from 3.3 to 1.7 in the intervention group and by 0.5 in the control group.128 The International Continence Society Committee on Incontinence in the Frail Elderly provides evidence-based recommendations for practice in caring for frail elders with incontinence, listed in Box 22.8. Health care providers are more likely to succeed in supporting bladder control in frail elder people when the health care team is knowledgeable about conservative evidence-based interventions, and members collaborate to support each other to provide all interventions as much as possible.

SUMMARY

FIG. 22.7 Squatting or defecation posture for bladder and bowel evacuation.

Bladder control problems such as urinary incontinence negatively impact rehabilitation outcomes and patient quality of life. Health professionals caring for elders must identify and assess incontinence and other LUTS, even while other conditions and diagnoses take precedence in the plan of care. Bladder control problems should be identified during the initial patient assessment. Baseline

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BOX 22.8

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Management of the Pelvic Floor in Older Men and Women

Summary of International Continence Society Recommendations for Practice for Frail Elders with Incontinence

Environmental cues—toilet visibility, signs, color differentiation, images, arrows, and directions should be used to compensate for visual-perceptual deficits in frail older adults with urinary incontinence (UI). Each component of the toileting process requires skill dexterity and physical strength. Individual strength and dexterity impairments relating to toileting should be identified and treatment provided in frail individuals and those with cognitive impairments Day-to-day continence care processes (such as scheduled voiding) in health care settings should be promoted by awareness-raising activities for the patient, family and caregivers, and clinical staff.

Planning for services for frail elders should ensure that time, resources, knowledge, and skill required to conduct an assessment are provided to health care providers, including active, effective, conservative management of UI episodes and promotion of bladder control. Gaps in health care practitioner knowledge about preventing, managing, and treating incontinence should be continually addressed with training and education. Evidence-based guidelines for the use of continence aids, such as pads and garments, should be implemented to promote an active approach to diagnosis, treatment, and prevention of UI.

Fonda D, DuBeau CE, Harari D, et al. Incontinence in the Frail Elderly. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.), Incontinence: Proceedings of the Fourth International Consultation on Incontinence, July 5–8, 2008, 1165–1240. Health Publications Limited Paris. https://www.ics.org/Publications/ICI3/v2.pdf/ chap18.pdf.

measurement of the severity of symptoms, types of symptoms, and impact of UI/LUTS on quality of life can be obtained early in the rehabilitation episode of care using standardized validated outcome measures such as the ICIQ-UI SF. Therapists should consider the potential negative impact of symptoms on achievement of rehabilitationrelated goals, such as reducing fall risk and preventing rehospitalization. Improvement in bladder control and reduction of UI/LUTS should be stated goals of rehabilitation. If a patient is leaking urine, it can be inferred that he or she likely has a pelvic floor disorder. The patient ideally should complete a 3-day bladder diary to further assess symptoms and behaviors relating to symptoms; however, the therapist can obtain valuable information about a patient’s fluid intake and voiding habits simply by asking questions and engaging in a conversation about them. Even in elder patients with multiple impairments and comorbidities, basic interventions to improve bladder control can be initiated immediately and are best reinforced by all members of the rehabilitation and nursing care team. External examination of pelvic floor muscle contraction can be performed, and patients can begin to perform pelvic floor muscle exercises to improve the function of this critical muscle group. Bladder training and timed voiding are simple and effective enough strategies to influence and improve bladder storage and emptying patterns. Small and/or gradual changes in fluid intake volumes, timing of fluid intake, and identification of bladder irritants can lead to symptom improvement in a short period of time. Techniques to defer urinary urgency, such as heel raises and fast-twitch pelvic floor muscle contractions, are often easy to incorporate into a daily schedule and are often immediately effective. Being able to control urgency may not only return some feeling of control to the patient with symptoms of urinary urgency, frequency, and UI but also ultimately reduce the risk of a fall occurring while rushing to the bathroom. Electrical stimulation applied externally to the distal ankle or sacral spine can be effective at reducing urgency and urgency incontinence, with little to no side effects. Every therapist should be proficient in teaching PFMT because of its effectiveness for

bladder control problems. If an individual has UI/LUTS, then PFMT should be incorporated into the therapeutic exercise prescription. Many elders require additional strengthening of the hip and gluteal muscles, and PFM contractions can be performed at the same time as these exercises to promote improved PFM function and strength. Conservative interventions are all well tolerated and may yield satisfying results in the form of symptom reduction, improved patient satisfaction and self-efficacy, reduced fall risk, and improved overall outcomes of rehabilitation. Although UI/LUTS are highly prevalent in the aging population, prevention of PFM disorders leading to UI/ LUTS is being intensively investigated.129 Prevention of incontinence is not yet an integral part of the present health care paradigm but may be achievable in the future. Physical therapists can identify bladder control problems in the evaluation of patients and during any episode of care. Physical therapists can provide basic interventions described in this chapter, which may improve health and rehabilitation outcomes. When basic interventions are not effective, physical therapists can refer to a physical therapist with advanced training in pelvic health rehabilitation. Elders with UI/LUTS are at risk for poor rehabilitation outcomes. Physical therapists should identify and coordinate management, just as they would do for osteoporosis, hypertension, or diabetes. Because pelvic floor rehabilitation is strongly supported in the literature, physical therapists should confidently incorporate PFMT and rehabilitation of the PFMs into clinical care.

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