Urinary Incontinence
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Clinically Relevant Anatomy
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Pelvic Floor[edit | edit source]
The pelvic floor is made up of the muscles, ligaments, and fascial structures that act together to support the pelvic organs and to provide compressive forces to the urethra during increased intra-abdominal pressure.
The pelvic floor muscles refers to the muscular layer of the pelvic floor. It includes the levator ani, striated urogenital sphincter, external anal sphincter, ischiocavernosus, and bulbospongiosus.[1]
The urethra, vagina, and rectum pass through the pelvic floor and are surrounded by the pelvic floor muscles. During increased intra-abdominal pressure, the pelvic floor muscles must contract to provide support. When the pelvic floor muscles contract the urethra, anus, and vagina close. The contraction is important in preventing involuntary loss of urine or rectal contents. The pelvic floor muscles must also relax in order to void.[1]
Mechanism of Injury / Pathological Process
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Definitions: [edit | edit source]
- Urinary incontinence (symptom): Complaint of involuntary loss of urine.
- Stress (urinary) incontinence: Complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing.
- Urgency (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency.
- Mixed (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency and also effort or physical exertion or on sneezing or coughing.
- Urgency: Complaint of a sudden, compelling desire to pass urine which is difficult to defer.
- Overactive bladder (OAB, Urgency) syndrome: Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.[2]
Clinical Presentation[edit | edit source]
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Diagnostic Procedures[edit | edit source]
A large portion of women with urinary stress incontinence can be diagnosed from clinical history alone. In this systematic review, little evidence was found on the performance of urinary diaries, and pad-tests although they are common diagnostic assessments used in physical therapy.[3]
Clinical history[edit | edit source]
Clinical history taking compared with multi-channel urodynamics was found to have 0.92 sensitivity and 0.56 specificity for the diagnosis of urinary stress incontinence based on the presence of stress incontinence symptoms.[3]
Pelvic Floor Muscle Function and Strength[edit | edit source]
Pelvic Floor Muscle Strength
Modified Oxford grading system: [edit | edit source]
0 - no contraction
1 - flicker
2 - weak squeeze, no lift
3 - fair squeeze, definite lift
4 - good squeeze with lift
5 - strong squeeze with a lift
Palpation of the pelvic floor muscles per the vagina in females and per the rectum in male patients.[4]
PERFECT mnemonic assessment, described by Jo Laycock:[edit | edit source]
P - power, may use the Modified Oxford grading scale
E - endurance, the time (in seconds) that a maximum contraction can be sustained
R - repetition, the number of repetitions of a maximum voluntary contraction
F - fast contractions, the number of fast (one second) maximum contractions
ECT - every contraction timed, reminds the therapist to continually overload the muscle activity for strengthening[4]
Pad Test[edit | edit source]
The 1 hour pad test was found to have 0.94 sensitivity and 0.44 specificity for diagnosing any leakage compared with multi-channel urodynamics.
The 48 hour pad-test was found to have 0.92 sensitivity and 0.72 specificity for the diagnosis of urinary stress incontinence.[3]
Urinary (Voiding) Diary[edit | edit source]
One study found a scale derived from a 7 day diary was 0.88 sensitive and 0.83 specific for the diagnosis of detrusor overactivity in women.[3]
Outcome Measures[edit | edit source]
- Incontinence Quality of Life Instrument (I-QOL)
- Male Urogenital Distress Inventory (MUDI)
- Male Urinary Symptom Impact Questionnaire (MUSIQ)
- Patient Global Impression of Improvement (PGI-I)
- Patient Global Impression of Severity (PGI-S)
- Pelvic Floor Distress Inventory - 20 (PFDI - 20)
- Pelvic Floor Impact Questionnaire - 7 (PFIQ - 7)
Management / Interventions
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The Knack maneuver:[edit | edit source]
The Knack maneuver essentially is a voluntary contraction performed in response to a specific situation. Teach a voluntary contraction of the pelvic floor muscles with appropriate timing, for example, just prior to a cough or sneeze. It is a useful strategy in patients with stress urinary incontinence.[5]
Differential Diagnosis
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Multi-channel urodynamics testing is the gold standard for making a condition-specific diagnosis. This testing is typically done in secondary care, not in primary care or physical therapy.[3]
Key Evidence[edit | edit source]
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Resources
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Case Studies[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ 1.0 1.1 Messelink B, Benson T, Berghmans B, Bo K, Corcos J, Fowler C, Laycck J, Huat-Chye Lim P, van Lunsen R, Lycklama a Nijeholt G, Pemberton J, Wang A, Watier A, Van Kerrebrocck P. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn 2005;24:374-380.
- ↑ Abrams P, Cardozo L, Fall M, et al. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology 2003;61:37-49.
- ↑ 3.0 3.1 3.2 3.3 3.4 Martin JL, Williams KS, Sutton AJ, Abrams KR, Assassa RP. Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence. Neurourol Dynam 2006;25:674-683.
- ↑ 4.0 4.1 Laycock J. Pelvic muscle exercises: physiotherapy for the pelvic floor. Urologic Nursing 1994;14:136-40.
- ↑ Miller JM, Sampselle C, Ashton-Miller J, Son Hong G-R, De Lancey JOL. Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence. Int Urogynecol J 2008;19:773-782.
