REHABILITATION OF PELVIC FLOOR

Introduction

Urinary incontinence (UI) is, according to the International Continence Society, the objectively demonstrable involuntary loss of urine that causes a social or hygienic problem.

UI is a dysfunction which occurs in healthy people as well as being associated with various illnesses. It responds to a number of different aetiologies.

Pelvi-perineal rehabilitation can be defined as ‘a set of specific non-surgical and non-pharmacological techniques whose purpose is the treatment of pelvic static disorders, sexual dysfunctions, and the last portion of the urinary and digestive tract.

Types of incontinence

  1. Stress (Stress incontinence), loss of urine associated with any physical activity of movement. Not associated with desire to urinate.
  2. Urge (unstable bladder), involuntary loss of urine associated with a strong and sudden desire to urinate.
  3. Mixed, a combination of both and the most frequent.

Rehabilitation treatment

Given that the main purpose of the treatment of UI is improving the quality of life of the patients, it is important to know the patient’s preferences, the type of life they lead and their personal circumstances.

3.1. Information: The established treatment and its characteristics should be explained to the patient. It should be made clear what is expected of it. The patient will also be informed that physical therapy does not exclude other therapeutic possibilities.

3.2. Perineal Kegel exercises (active assisted digitally or instrumentally)

3.3. Biofeedback, this is a feedback system that collects information from a process that occurs unconsciously for the individual, processing it and amplifying it so that it is returned in the form of a visual or sound signal so that it can be understood by the patient.

Biofeedback sessions should be fully supervised by the physiotherapist, who will modify the characteristics of the work done according to the progress achieved.

3.4. Functional electrical stimulation (FES), this is nerve stimulation that seeks to act on sacral roots, so that the placement of the electrodes is in accordance with the location of the roots. That is, a full reflex arc is required for the use of FES.

3.5. Intravaginal devices (spheres, vaginal cones), exert a retrocontrol that allows for the proper strengthening of the perineum.

3.6. Pharmacological treatment

 

Types of urinary incontinence

  1. UI during the menopause
  2. UI during pregnancy and childbirth
  3. UI in men

1. UI during the menopause

Urinary incontinence is a frequent problem that can affect women of all ages. It can sometimes be associated with a loss of self-esteem, shame, depression and even social isolation. Its appearance in later years is not uncommon, following many years of childbirth. Also, it can be accompanied by faecal incontinence and/or gas, but it is especially common after the menopause.

The menopause is the final stage of menstrual bleeding, confirmed by a period of at least 6 months of amenorrhoea (lack of menstruation). It is caused by the cessation of ovarian function. In Spain, the average age for the beginning of the menopause is 48 ± 3 years old. It is deemed physiological between 45 and 55 years old.

Pathological menopause occurs before the age of 40 or following surgery (like the removal of ovaries) or treatments such as chemotherapy or radiotherapy.

In addition to the symptoms that may appear during the menopause (hot flushes, insomnia, tingling, fatigue, weight gain, sadness, pain during intercourse…), urinary incontinence can also appear. It can happen even as a result of stresses such a coughing or sneezing, and the patient does not think it matters. It should be remembered that UI is generally caused by muscle weakness in the pelvic floor and that this weakness can encourage the descent of the pelvic organs (prolapse) through it. It is therefore essential to seek medical attention in all cases of involuntary loss of urine in order to rule out serious illness, assess the early beginning of rehabilitation and avoid prolapses.

The management of menopausal women should be coordinated by a gynaecologist. If hypotonia (weakness) of the pelvic floor (with or without incontinence) and/or sexual dysfunction (pain, vaginismus, anorgasmia) is suspected, it is recommended to refer the patient to assessment at rehabilitation services that have a pelvic floor unit to treat this pathology, with therapeutic methods backed by scientific evidence.

  1. UI linked to pregnancy and childbirth

Urinary incontinence (UI) affects women of all ages and the nature and severity of its symptoms vary. The prevalence of UI varies according to the type of study, the definition of UI and the characteristics of the population studied (predominantly age). Figures have been published which range between 5% and 72% and, in Spain, the available data falls between 15% and 42%.

Pregnancy is associated with an increase in incidences of loss of urine (UI) in a third of women, and even faecal incontinence (FI) in one in ten pregnant women. In addition, it is estimated that approximately 70% of women suffer from some sexual dysfunction at 3 months postpartum, a figure which is reduced to 34% of women at 6 months, although it is elevated by the physical disturbance that it causes, especially worrying due to the associated emotional disturbance.

A pelvic floor rehabilitation programme before childbirth protects against UI and FI at the end of pregnancy, a benefit that is maintained up to six months after childbirth. The more intensive the pelvic floor rehabilitation programme, the more beneficial the treatment and the lower the incidence of UI and FI, as suggested in the available scientific evidence (Cochrane 2008).

Comprehensive care for postpartum women, which includes treatment of a weakened pelvic floor, possibly injured from childbirth trauma, is performed by coordinated gynaecology-obstetrics and rehabilitation services in order to achieve the most effective and earliest possible recovery in patients. This will allow women to enjoy this exciting stage in their lives.

3. UI in men

The appearance of urinary incontinence in elderly men is not uncommon, especially after prostate surgery, which accounts for up to 87% of cases.

The main factors determining treatment are:

  • Time passed following prostate surgery. Given that there is a progressive recovery capacity during the first few months.
  • Severity of urine loss. This is determined by the number of pads or diapers used by the patient and by the “pad test”.
  • Findings from the cystoscopy and urodynamic study.
  • Ages and associated illnesses of the patient

After a complete medical evaluation an individualised physiotherapy treatment will be applied to each patient, which will then be regularly reviewed. Among the therapeutic methods of pelvic floor rehabilitation, in our service we apply the most clinically effective techniques backed by scientific evidence. The most frequently used are biofeed-back, electric muscle stimulation, Kegel exercises (perineal contraction exercises), as well as the teaching of techniques for blocking perineal stress.

Pelvic floor rehabilitation in men improves symptoms and especially improves the patient’s quality of life. It is advisable to do it early or treat it in the event that it appears.

Additional bibliography

  1. Manual Sociedad Española de Medicina Física y Rehabilitación (Handbook Spanish Society of Physical Medicine and Rehabilitation) (SERMEF) 2006

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