Urinary Function, Dysfunction and
PT Assessment and Management
• Continence:
– Normal ability of a person to store urine and faeces
temporarily, with conscious control over the time and
place of micturition and defaecation.
– Continence of urine and faeces is fundamental to:
• Sociological
• Psychological
• Physical well-being
– Infants do not have such control, but develop the
neurological maturity and form the habits necessary,
usually by 3 or 4 years of age.
• Incontinence:
– Involuntary or inappropriate passing of urine or faeces, or both.
– Incontinence is a symptom or a sign with a cause, not a
condition or a specific disease
– May be a temporary state associated with a transient cause:
• Transient unconsciousness
• Infection
• Drug side-effects
– May be persistent resulting from longer-lasting or even
permanent causes:
• Trauma in childbirth
• Stroke
Normal Lower Urinary Tract Function
• The Micturition Cycle:
– Consists of two phases:
• Bladder filling
– The detrusor muscle is
compliant
– The first mild desire to void
is commonly felt at volume
of 150–200mL
• Bladder emptying
Normal Lower Urinary Tract Function
• Storage Of Urine:
– The normal bladder’s compliance accommodates and
stores the incoming urine without a significant rise in
pressure within the bladder.
– The effective pressure in the bladder is produced by
the bladder wall and is usually less than 15cm H2O.
– Elastic ability of the bladder to accommodate an
increasing volume of fluid without a rise of pressure is
called Compliance.
– Reflux of urine up the ureters is prevented by
peristaltic waves of muscular contraction that pass
down the walls of the ureters.
• Voiding Of Urine:
– Normally achieved by voluntary, cortically
mediated relaxation of:
• External urethral sphincter
• Levator ani muscles
– Followed by a detrusor contraction
Neurological Control of Continence
• Continence is controlled neurologically at
three levels:
– Spinal
– Pontine
– Cerebral
• A combination of somatic and autonomic
pathways
Mild Desire to Void
Decision to Void
Desire to Void But Environment Not
Conducive
Factors – Normal Urinary Function
• The bladder and urethra are structurally sound
and healthy.
• The nerve supply to the bladder, urethra, external
sphincter and PFM is intact.
• The bladder is positioned and tethered so the
neck is well supported and able to close, and the
urethra is not kinked.
• The bladder is positioned and supported high
enough in the abdominal cavity that intraabdominal pressure is transmitted both to it and
to the proximal portion of the urethra.
Factors – Normal Urinary Function
• Bladder size and capacity are normal.
• There are no pathological changes in
surrounding structures.
• The woman has the ability to move sufficiently
quickly and freely to a socially acceptable site
in order to void.
• The woman is able to adjust clothing and
position herself for voiding unaided.
Factors – Normal Urinary Function
• The woman does not suffer from faecal
impaction, for this can cause urinary
incontinence.
• The woman is in good general physical health,
alert, and free from confusion, depression or
serious stress.
• There is a fluid intake of about 11⁄2 litres per
day, and avoidance of excess alcohol or
caffeine.
Lower Urinary Tract Dysfunction
• Storage symptoms:
– Experienced during the storage phase
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Abnormal bladder sensations
Frequency
Urgency
Leakage of urine etc.
Lower Urinary Tract Dysfunction
• Voiding symptoms:
– Experienced during the voiding phase
– Include any description or deviation from a
speedy and continuous flow of urine
• A slow or intermittent stream
• Hesitancy at the start of micturition
• Terminal dribble etc.
Lower Urinary Tract Dysfunction
• Postmicturition symptoms:
– Experienced immediately after micturition
• A feeling of incomplete emptying
• Postmicturition dribble etc.
Lower Urinary Tract Dysfunction
• Some Useful Definitions:
– Enuresis:
• Involuntary loss of urine.
– Nocturnal enuresis:
• Involuntary loss of urine during sleep.
– Nocturia:
• Individual has to wake at night one or more times to
void.
• It is different from a habit of always waking at a certain
time to void
Lower Urinary Tract Dysfunction
– Increased daytime frequency (pollakisuria):
• The complaint by patients who consider that they void too
often during the day.
• Frequency as the passage of urine seven or more times
during the day, or the need to wake more than twice at night
to void.
– Urgency:
• A compelling desire to pass urine which is difficult to defer.
– A normal desire to void:
• The feeling that leads a person to pass urine at the next
convenient moment, but voiding can be delayed if necessary.
Lower Urinary Tract Dysfunction
– The urinary voiding stream:
• Slow, spitting or spraying, or intermittent
• Stops and starts.
– Hesitancy:
• Difficulty in initiating flow.
– Dysuria:
• Pain on passing urine.
– A postvoid residual (PVR):
• The volume of urine left in the bladder at the end of
micturition.
Incontinence Of Urine
• Groups of patients referred to the
physiotherapist are those with storage
symptoms resulting in urine leakage.
• Involuntary urinary leakage may be a
symptom of which the patient complains or a
sign seen on examination, which may be
urethral or extraurethral leakage.
Common Types Of Urinary
Incontinence
• Extraurethral incontinence
– Loss of urine through channels other than the
urethra is called extraurethral incontinence.
– Fistulae between the bladder or urethra
– vagina trauma at pelvic surgery such as
hysterectomy
– endometriosis
– Infection
– carcinoma.
Detrusor overactivity
incontinence
• Patient with detrusor overactivity complains
of urge incontinence, which is involuntary
leakage of urine accompanied by or
immediately preceded by urgency. (symptom)
• Detrusor overactivity is confirmed as a sign
and observed at urodynamic assessment as
spontaneous or provoked detrusor
contractions during the filling phase.(Sign)
• Detrusor overactivity may be further qualified
as neurogenic,where there is a relevant
neurological condition, or as idiopathic, when
there is no known cause. (Condition)
Urodynamic stress
incontinence
• (The symptom). The patient complains of
incontinence on stress, that is,when the intraabdominal pressure is raised by exertion or
effort (e.g.sneezing, coughing or walking).
• (The sign). An involuntary spurt, dribble or
droplet of urine is observed to leave the
urethra immediately on an increase in intraabdominal pressure (e.g. when coughing).
• (The condition). Urodynamic stress
incontinence (USI) is the name coined to
denote the condition in which there is
involuntary loss of urine when, in the absence
of a detrusor contraction, the intravesical
pressure (pressure in the bladder) exceeds the
maximum urethral pressure.
• Mixed urinary incontinence is the complaint of
involuntary leakage associated with urgency
and also with exertion, effort, sneezing or
coughing.
• Weakness and sagging of the pelvic floor are
the factors on which physiotherapists have
concentrated their attention.
• Trauma to muscle or adjacent tissues (e.g.
from abuse, surgery or childbirth)
• Damage to the nerve supply to the sphincter
or levator ani muscle (e.g. from surgery,
stretching or tearing at childbirth)
• Weakness from underuse (the patient may sit
around all day, perhaps suffering from
depression)
• Stretching from overuse (e.g. repeated
coughing, straining at the stool because of
constipation, heavy lifting or obesity).
Nocturnal enuresis
• Nocturnal enuresis is urinary incontinence
during sleep, or ‘bed wetting’ at an age when
a person could be expected to be dry – usually
agreed to be the developmental age of 5
years.
• The vast majority of children who suffer from
nocturnal enuresis are dry by puberty but the
condition causes great psychological suffering
and social deprivation.
Giggle incontinence
• Girls in particular go through a giggling phase
around puberty, if not before.
• It is thought that giggle incontinence is caused
by detrusor overactivity induced by laughter.
Incontinence associated
with sexual activity
• The urethra and bladder lie in close proximity
to the vagina; thus sexualactivity can cause
urinary symptoms and lower urinary tract
dysfunction, and this in term may give rise to
sexual problems.
Voiding Difficulties
• Urine is stored in the bladder and may have
difficulty in escaping.
• Large cystocoele kinking the urethra.
• The detrusor is so stretched by virtue of the
volume of urine, caused by the urethra being
obstructed, that it cannot contract effectively.
Assessment
• Assessment should first be by uroflowmetry to
assess the flow rate, if any, and a bladder scan
will give an indication of the volume of urine
in the bladder following voiding.
• Weak detrusor activity may sometimes be
enhanced by drugs such as bethanechol
chloride.
Physiotherapy Assessment Methods
• A short, simple explanatory leaflet may be
appropriate give an outline of the structure
and purpose of the initial session.
• Patients feel disappointed that they have not
immediately been offered surgery, and often
have low expectations of physiotherapy.
• Patients start with misconceptions, for
example that ‘pelvic floor muscle exercises’
are exercises done on the floor, and this
prospect may be unappealing!
• Patient with urinary problems should be
interviewed and examined in a quiet, private
room, in an unhurried manner.
• From the chart it is possible to determine:
– the actual frequency of micturition compared with
the patient’s subjective impression
– the precise degree of nocturia
– whether the patient has an altered diurnal voiding
rhythm and is voiding more by night than by day
– the total and individual volumes being voided per
24 hours
– the incidence of urinary accidents; and possible
causes or triggers
– the total volume and what is being drunk per 24
hours
– the volume of liquids being drunk containing
caffeine.
PAD TEST
• Takes1 hour and comprises the following sequence:
1. The test is started without the patient voiding.
2. Apreweighed absorbent perineal pad is put on and the timing begins.
The patient is asked not to void until the end of the test.
3. The patient drinks 500mL of sodium-free liquid (e.g. distilled water)
within 15 minutes, then sits or rests to the end of the first half hour.
4. In the following half hour the patient walks around, climbs up and
down one flight of stairs, and performs the following exercises: standing
up from sitting (10); coughing vigorously (10); running on the
spot for 1 minute; bending down to pick up a small object (5); washing
the hands under cold running water for 1 minute
Paper Towel Test
• In standing, the patient holds a coloured
paper towel against the perineum and coughs
strongly three times. Any leakage is absorbed
by the paper towel, which, where damp,
changes colour.
Manual Grading of the Strength of a
PFM Contraction
• Proposed by Laycock & Chiarelli in 1989.
• Six-point scale
–0
–1
–2
–3
–4
–5
nil contraction
flicker
weak
moderate
good
strong
Manual Grading of the Strength of a
PFM Contraction
• The PERFECT scheme:
– P power – which is more correctly the ‘strength’ of the
PFM determined on the six-point scale; both the left and
right sides of the levator ani muscles are graded
– E endurance – i.e. the time measured in seconds (up to
10) that a maximum voluntary contraction (MVC) can be
held before fatigue sets in.
– R repetitions – i.e. the number of MVCs which can be
performed (up to 10) interspersed with rests of 4 seconds
– F fast – i.e. the number of 1-second contractions (up to
10) performed, contracting/relaxing as quickly as possible,
up to 10 or until fatigue sets in
– ECT – every contraction timed – to complete the acronym.
Confirming a Contraction of the PFM
• Thirteen ways of confirming a contraction of the PFM:
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Vaginal examination by the physiotherapist
Self-examination by the patient
Hand on perineum by the physiotherapist
Hand on perineum by the patient
Observation of perineum by the physiotherapist
Observation of perineum by the patient – using a mirror
Perineometer
Stop and start midstream – only occasionally for suitable patients
Using the Neen Healthcare Educator
Using a cone in the vagina and applying traction to the string while trying to
grip the cone
– Asking the partner at intercourse
– Manometric and EMG biofeedback
– Transperineal or labial ultrasound.
Biofeedback
• The technique by which information about a
normally unconscious physiological process is
presented to the patient or therapist, or both
as:
– Visual
– Auditory
– Tactile signal
The Perineometer
• Record changes in
activity in the region of
the vagina
• Two types:
– One records pressure
changes
– Other monitors
electromyographic
activity (EMG)
The Educator
• A simple device called the Educator
• Inserted into the vagina with the patient in
crook half lying
• A voluntary contraction of the PFM will cause
the indicator to move downwards and is one
way of confirming a contraction
• An upward movement of the indicator
indicates valsalva manoeuvre
Computerized Manometric and
Electromyographic Equipment
• Equipment which provide a visual display; some
also have facilities for electrical stimulation.
• The probe is introduced into the vagina with the
woman in a comfortable supported crook halflying position, but could equally well be used in
standing.
• Once the machine is switched on and adjusted,
thewoman is asked to contract the PFM.
• Screened of varying contraction intensity,
duration and rest periods, for the patient to
try to follow.
• Serve to motivate the patient not only to
practise but also to work for longer, stronger
contractions.
Quality of life and Symptoms
Questionnaires
• Two main groups of questionnaire:
– generic
– disease specific
• International Consultation on Incontinence
Questionnaire (ICIQ), in its short form
(ICIQSF), has been rigorously pruned down to
just 6 questions and will take a patient only a
few minutes, and is scored in moments
Visual Analogue
Scale
• The patient is asked to place a cross at the
appropriate point on a 10 cm line, one end of
which is marked
– for example, ‘no leakage',' no incontinence’ or ‘no
problem’, and at the other end ‘always wet','
totally incontinent’ or ‘massive problem’.
• Before and after a course of treatment to
measure ability to participate in a variety of
social activities without leaking
Imaging –Ultrasound Scanning of the
Bladder
• A small portable ultrasound scanner designed
to scan the bladder and calculate the volume
of urine in the bladder.
• It is possible to use ultrasonography to
visualise the lower urinary and intestinal tracts
including the bladder, urethra, external
urethra sphincter, rectum and anus, PFMs and
associated connective tissues.
Urodynamic, Radiological and
Electromyographical Assessment
• Urinary tract infection is commonly associated
with dysfunction.
CYSTOMETRY
• The relationship between the volume of fluid and
the pressure in the bladder, during both filling
and voiding.
• The test has its own morbidity in that
occasionally patients develop urinary infections
afterwards and its reliability is not 100%.
Urethral Pressure
Profilometry
• Micro transducer mounted on the tip of a fine
catheter or by a fluid-filled or gas-filled
catheter attached to an external transducer.
The catheter is drawn down the urethra from
the bladder neck to the external meatus.
• Carried out during voiding (VUPP) to detect
obstruction.
Uroflowmetry
• Reliable indicator of normal detrusor
contraction and urethral relaxation.
• Patient is asked to void, in private, into a toilet
in which a flow meter has been fitted.
• This device measures the quantity of fluid
passed per unit of time.
Distal Urethral Electric
Conductance
• Accurate detection of leakage of urine is
obtained by inserting a short probe with two
ring electrodes into the distal part of the
urethra.
• Passage of urine past the electrodes increases
conductivity between them, and this can be
recorded electronically.
Electrophysiological
Tests
Electromyography
• Single needle EMG has been used to examine
the puborectalis and external anal sphincter.
• Fine EMG needle is inserted and the motor
unit action potentials.
• Duration, amplitude and the number of
phases of the action potentials of individual
motor units can be measured.
Stress Incontinence
• Increase the strength and endurance of their
PFM.
• Biofeedback.
• Electrical stimulation.
– Pulse duration of 250s with a frequency of 30–40
Hz.
– Once or twice a day for 10–20 minutes,
Urgency Incontinence
• Electrical stimulation.
– 5–10 Hz in continuous mode with a 500s pulse
duration.
– Once or twice a day for 20–30 minutes.
• Deferment techniques increase the period
between voids.
– Series of repeated strong PFM contractions
– Distraction
– Perineal pressure etc.
Mixed Incontinence
• A combination of stress and urge
incontinence.
Continence Promoting Advice
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An adult should drink 1000–1500mLper day.
Urine output of about 1500mL is a better guide.
Concentrated urine may irritate the bladder.
Drinking large volumes will cause frequency.
Restrict caffeine and alcohol intake.
– Diuretics effect
– Heighten the activity of the detrusor muscle
– Reduce tension in the external urethral sphincter
• Activity causes leakage the patient should
discontinue it.
Teaching PFM Contractions
• Visualisation:
– A large, simple diagram or a model (or both) of
the pelvis, pelvic organs and the levator ani
muscles is helpful.
• Language:
– Chose specifically for each individual patient.
– Easily understand.
• Stopping passing water/urine
• Stopping passing/breaking wind etc
Teaching PFM Contractions
• Starting Position:
– PFM contractions can be performed in any
position.
– A useful initial position is:
• Sitting on a hard chair leaning forward with support
from the forearms on the thighs, with knees and feet
apart.
Teaching PFM Contractions
• Duration and Repetition of Contractions:
– Perform long, strong contractions one after the other
with a rest of about 4 seconds between.
– Hold for as long as possible.
• Changing the Starting Positions:
– Start in sitting.
– Try to contract in other positions.
– Exercise the PFM in a variety of situations while:
• Telephoning
• On the bus or train
• Watching television etc.
Teaching PFM Contractions
• General Advice:
– Contract the PFM before and during any of the events,
which normally trigger leakage:
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Coughing
Sneezing
Laughing
Nose blowing
Lifting
Running
Jumping etc
– This technique is called the Knack or Counter-bracing.
Biofeedback
• May be used in:
– Assessment
– Treatment as a challenge and motivator
• Manometry:
– Used with a vaginal pressure probe
– Give biofeedback by means of a manometer or a
visual display.
Vaginal Cones
• Increased reflex activity of the PFM to support
and retain the cone against gravity, and to
counteract downward slippage.
• Sets of five to nine small, progressively
weighted cylinders, ranging from 10 to 100g
Electrical Stimulation
• Interferential Therapy:
– 4000 Hz (4 kHz) or 2000 Hz (2 kHz) used
extensively therapeutically in the treatment of
urinary incontinence
• Low- Frequency Muscle Stimulation:
– 250s pulse duration
– Frequency of 35–40 Hz
– Duty cycle of 2 seconds on and 4 off would be
appropriate, for 5 minutes
Bladder Retraining
• The main aims are to:
– Correct faulty habits
– Control urgency
– Prolong periods between voids
– Reduce incontinence episodes
– Reduce the daily number of voids and increase
voided volumes
– Build up the patient’s confidence
Bladder Retraining
• Deferment techniques are taught such as:
– Repeated maximal pelvic floor contractions at times
when urgency is felt
– Perineal pressure
• Sitting on a rolled towel
• Arm of a chair
– Standing on tip toes
– Distraction
• Companionship
• Games
• Television or music etc
Timed and Prompted Voiding
• The patient is taken to the toilet or sat on a
commode whether or not they express a
desire to void.