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Treatment

The easiest treatment for a patient with pelvic floor dysfunction is to educate and give advice. Knowing that they are not alone, that their condition is a common problem and that there is something that can be done about it can make a significant impact for a patient's self-efficacy, motivation, mental health and quality of life.

Stress Urinary Incontinence

Advice

  • Acknowledge the condition, let your patient know that this is common and they are not the only one. It is not something to just put up with. It can improve.

  • Consider using a continence pad - the fear of leaking may be preventing your patient from doing things such as going out to lunch or doing the groceries. Advising your patient on the use of continence pads (not sanitary pads - these hold far less liquid than continence pads are designed to) may be a great management strategy that allows them to continue doing the things they want to do.

Techniques

  • Pelvic floor engagement each time the patient coughs/sneezes/lifts. Also known as the 'knack', a short strong pelvic floor contraction just prior to doing the activity that causes leakage is a good way to decrease urine leakage and strengthen the pelvic floor. 

  • Pelvic floor muscle training - not many people can correctly perform pelvic floor muscle contractions. A referral to a continence clinic to correctly teach this might be the most appropriate management. However, to give the patient an understanding of a pelvic floor contraction, consider these strategies:

    • Easiest in crook lie, hardest in standing​

    • Needs to be individualised dosage just like a gym program

    • Should feel like holding in a wee or a fart

    • Make sure you rest between each contraction for at least double the time of contraction

    • Can be fast-twitch or slow-twitch: 

      • Fast-twitch - can you squeeze and let go?

      • Slow-twitch - can you squeeze, breathe in, breathe out and then let go?

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Urge Urinary Incontinence

Advice

  • Acknowledge the condition, let your patient know that this is common and they are not the only one. It is not something to just put up with. It can improve.

  • Education should include the importance of fluid intake. Many people with urinary urge limit their fluid intake. This in turn exacerbates the problem as the bladder can become irritated with the higher concentration of uric acid and other waste products in the urine. Use a urine chart like this one to assess whether they are hydrated. 

  • Adjust caffeine intake and other known bladder irritants such as artificial sweeteners.

  • Consider using a continence aid - see above. 

Techniques

  • Try putting off going to the toilet for 10-30seconds when the urge comes. This is the first step of bladder retraining.

  • Use a distraction method; if the urge comes, finish the task you were doing  before WALKING not rushing to the toilet.

  • Pelvic floor muscle training - see above.

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Functional Incontinence

Advice

  • Family/carer education - if a patient is unable to dress or undress they may need assistance from their family or carers. The family or carers are just as important if there is a cognitive barrier to getting to the toilet in time.

  • Engage OT services - a patient may need bathroom modifications such as a wider entrance for a frame, or grab rails.

  • Functional rehab - improve the patient's ability to sit to stand and their safe walking speed. Do they need a gait aid?

  • Use of continence aids - just because a patient is using a pull-up or pad does not mean that they can't try to use the toilet when they identify the need. The continence aid can be in place as a back-up option.

Faecal Incontinence

Advice

  • Increase fluid intake - use the bladder chart to determine hydration

  • Defecation dynamics - this is how to sit on the toilet properly. Feet should be placed up on a stool so the knees are below the hips; elbows should rest on the knees so they are sitting forward; 'blow' the tummy out instead of bracing and sucking it in; have a straight back. This ensures that the ano-rectal angle is at its widest, allowing the optimal angle for a bowel movement with the least effort.

Techniques

  • Sits - this is helpful if a patient is having lots of accidents or struggles to identify the need to use the toilet. It is a good way of establishing or identifying bowel routine. A 'sit' is introducing set times to go and sit on the toilet to try for a bowel movement. There should be no forcing or pushing . The optimal timing for this is 20-30 minutes after a meal. 

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Prolapse

Advice

  • Acknowledge their condition.

  • Introduce periods of horizontal rest to relieve the heaviness/dragging sensation. This takes the pressure of both gravity and the abdominal contents off from sitting on the pelvic organs and pelvic floor.

  • Avoid straining or bearing down - particularly when emptying the bladder and bowels DO NOT STRAIN. Use defecation dynamics to reduce this. By straining or bearing down, there is increased pressure going through the pelvic floor.

Techniques

  • Pelvic floor muscle training - as above

  • Teach defecation dynamics - as above

Increased Pelvic Floor Tone

Advice

  • Acknowledge their condition.

  • Identify any lifestyle factors that may be contributing - is psychological intervention appropriate to assist in anxiety/stress/trauma?

Techniques

  • Relaxation techniques - even simple meditations can be effective to allow relaxation of the pelvic floor muscles. 

  • Good bladder and bowel habits - no straining or bearing down, use defecation dynamics, ensure the bowels are regular and ensure fluid intake is enough to maintain hydration.

More Specialised Treatments

  • Oestrogen therapy - there are oestrogen receptors in the bladder, anal sphincter and pelvic floor muscles. Use of topical oestrogen can reduce severity and frequency of incontinence in women who are post-menopausal [14].

  • For people with fluid restrictions due to cardiac problems, introduction of a horizontal rest time during the day can be helpful. Many people with cardiac problems can have urge incontinence or nocturia, as when lying in bed all the fluid has returned from their extremities. Having horizontal rest periods during the day can stop this from happening. 

  • Other medications:

    • Anticholinergics can be used for reducing severity of urge urinary incontinence ​

    • There are many different laxatives that can be used for constipation

    • Bulking agents such as Metamucil can be useful for diarrhoea once it is known that the patient is not constipated and has an adequate fluid intake.

  • For prolapse:

    • A pessary can be used which is a device that sits in the vagina to provide support to the pelvic organs. This can reduce pain and the heaviness or pressure felt from the prolapse.​

    • Surgery can be performed to repair the prolapse. This involves fixating or suspending the prolapsed tissue to its original position.

  • Pelvic floor down-training

    • This is to allow the pelvic floor muscles to relax. Internal or external massage can be used; self-massage (perineal massage) may be taught and prescribed; biofeedback may be used.​

    • The use of dilators is another technique to reduce pelvic floor tone and vaginismus.

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