Is there an implied "don't ask don't tell" policy when patients have a co-morbidity of incontinence? Are patients too embarrassed to discuss this?

We have all seen patients come in with stained clothing accompanied by a very distinct odor on a regular basis. Yet there's nothing in their medical history you can attribute to the current situation. Maybe there's something simple we can do without going beyond individual skill sets and level of expertise. Integrating pelvic muscle strengthening into the patient's exercise program may be one solution.

You may be doing your patients a disservice by considering your treating diagnosis unrelated to incontinence. Many patients with low-back, hip and pelvic pain also have incontinence. By incorporating exercise modifications and pelvic strengthening exercises into the treatment program, you can provide patients a safe place to voice concerns. This article will provide basic incontinence information and integrative exercise modifications for those not specialized in incontinence. When incorporated into a patient's current exercise program, pelvic floor strengthening can improve incontinence or maintain continence.

Start at the Eval

Address incontinence in the evaluation. Many patients may be coming for another diagnosis, but this is a good time to include questions about incontinence in the history of their evaluation. Developing a questionnaire for patients to complete is another way to capture necessary information about a patient's experience with incontinence. Let your patients know which providers can assist them. Family practitioners, general practitioners, internists, geriatricians, physician assistants, nurse practitioners, physical therapists and urologists are providers who can treat incontinence.

There are two types of incontinence, stress incontinence and urge incontinence. Stress incontinence is defined as small leaks occurring with a forceful contraction or impact, such as a cough, laugh, bend or lift, or with running or jumping. Urge incontinence is characterized by continuous leaking or delayed leaking of large amounts of urine when the bladder contracts after the removal or end of a provocation. This bladder contraction overpowers contraction of the pelvic and urogenital diaphragm and sphincter muscles.

The pelvic region is innervated by nerves, which may affect low-back or hip pain. Patients who have a diastasis recti or piriformis spasm may benefit from pelvic muscle strengthening while re-educating the pelvic muscles at the same time to reduce or eliminate incontinence. Progressive neuromuscular re-education and therapeutic exercise increase pelvic muscle function and restore continence.

According to a 2005 study of stress urinary incontinence treated with pelvic floor muscle exercises, 60 percent of women who performed intensive pelvic floor muscle exercise led by an instructor reported to be continent to almost continent at the conclusion of the study. The exercise program length lasted six months. Researchers concluded that successful treatment of stress urinary incontinence relied upon the intensity, duration and frequency of pelvic muscle exercise led by a therapist. Common muscles involved in urinary incontinence are the urogenital/perineum and pelvic diaphragm/levator ani muscles. Muscles affecting bladder control include the internal and external sphincters, obturator internus, abdominal, gluteal and adductor muscle groups. Both the gluteal and abdominal muscle groups provide accessory muscle function with pelvic muscle contractions.

In the Diaphragm

When inhaling, the diaphragm pulls down and compresses abdominal organs increasing pressure on the bladder and bowel. This causes an increase in intra-abdominal pressure. The diaphragm recoils to its original shape and decreases intra-abdominal pressure during exhalation.

The pelvic diaphragm is also known as the levator ani muscles. The pelvic diaphragm supports and stabilizes the bladder, uterus and bowel structures. Contraction of the pelvic diaphragm supports and stabilizes the bladder and bowel. The pelvic diaphragm is comprised of the pubococcygeal, iliococcygeal and ischiococcygeal or puborectalis muscles.

All three muscles form a sling to keep a constant low-grade contraction for postural support of internal organs. The pubococcygeal muscle is as an accessory muscle for the urinary sphincter. The iliococcygeal muscle is an accessory muscle for the vagina. The ischiococcygeal/puborectalis serves as an accessory for the anal sphincter.

The urogenital diaphragm is a superficial structure made of three muscles, the transverse perineal, bulbospongeosus or bulbocavernus and the ischiocavernus. The muscles forming the urogenital diaphragm primarily help with sexual function and urethral sphincter action.

The pelvic and urogenital diaphragm skeletal muscles associated with continence have mostly slow-twitch fibers (65 percent) and 35 percent fast-twitch fibers. Slow-twitch fibers are low force, slow to fatigue and provide constant contractions providing postural support in optimal position to maintain continence. Fast-twitch fibers provide high force contraction, quick explosive actions and fatigue quickly. These fibers are active with forceful contractions such as a cough or sneeze increases intra-abdominal pressure and pressure on the bladder and urethra. The urogenital and sphincter muscles are mostly made of fast-twitch fibers as they quickly and forcefully contract and relax to regulate urine flow. Consider the role of both fiber types when establishing therapeutic exercise. The hammock formed by pelvic and urogenital diaphragm muscles assists with leakage control. At rest, they support internal organs. When active, they tighten and lift to control the flow of urine.

The Sphincter Muscles

Sphincter muscles include external and internal urinary and anal sphincters. External sphincters are voluntary circular muscles, which regulate urine flow or bowel contents. Internal urinary sphincters in males and internal anal sphincters in males and females provide the same function but involuntarily.

The obturator internus creates a pulley effect, lifting the bladder and urethra into correct alignment for the best function. Adductors facilitate pelvic muscle function due to close attachment to the urogenital and pelvic diaphragm muscles and by hip adduction.

Abdominal contraction increases intra-abdominal pressure, placing increased pressure on the bladder, pelvic and urogenital diaphragm muscles. Chronic abdominal contraction inhibits the pelvic diaphragm from descending during inhalation and maintaining pressure on the bladder. This can cause bladder irritability and urge incontinence.Gluteal muscles are often recruited when attempting to contract pelvic and urogenital diaphragm muscles for leakage control. The gluteal muscles can dominate the pelvic muscles due to their large size. Relax the gluteal muscles with most incontinence therapeutic exercise to prevent this from happening.

Exercise Tips

Avoid forceful bearing down or pushing so as not to encourage further prolapsing. The force of bearing down or pushing may worsen a prolapsed uterus, cystocele or rectocele. Uterine prolapse occurs when the uterus descends into the vaginal canal. A cystocele occurs when the bladder bulges into the vaginal wall. A rectocele occurs when the rectum bulges into the vaginal wall. An enterocele develops when the pouch of Douglas protrudes into the vaginal wall. Suggest patients wear an absorbent pad in case leakage occurs. Encourage patients to take toilet breaks to empty their bladder and prevent leakage. Have patients plan ahead during activities that may cause leakage so they can easily access restrooms.

Encourage exercise and lifestyle modifications for continuing physical activity and strengthening of the pelvic floor musculature. Sometimes people avoid exercising to prevent leakage. The avoidance prevents patients from strengthening the musculature that improves incontinence or maintains continence. The Valsalva maneuver, holding your breath during exertion, increases intra-abdominal pressure causing more bladder pressure and leakage.

The Beyond Kegels exercise protocol by Janet Hulme, PT, gives a more detailed direction in establishing an incontinence exercise treatment program. Apply the same training principles like any other training program, such as overload, specificity, maintenance and reversibility. To strengthen pelvic muscles, avoid exercising to failure to prevent recruitment of the abdominals and glutes when pelvic muscles fatigue. Maintenance programs involve performing the same exercises at a lower volume and intensity versus training programs, which are performed at higher levels to reach the desired result. By reviewing the basics and incorporating the integrative exercises, you can add more value to your patient's care.

Trish Muse is a staff physical therapist with Inova Physical Therapy Center in Alexandria, VA, and owner of Body Productions Inc. She is a Polestar Pilates practitioner, NSCA certified strength and conditioning specialist, wellness coach and writer with more than 20 years of experience in the fitness industry.