Blog 3

Pelvic Floor Disorders (women): incontinence, prolapse, overactive bladder, emptying disorders

Let’s first understand what the pelvic floor is. The pelvic floor is a group of muscles, fascia and ligaments between the tailbone (behind) and the pubic bone (infront) in the pelvis. Pelvic floor and its muscles are responsible for closing the lower pelvis and supporting the pelvic organs i.e. urethra, urinary bladder, anus, rectum, vagina and uterus (in females). They help with controlling the urination and bowel movements and are voluntary muscles, meaning, we can control them just like an arm or leg. When a person is unable to control the muscles of their pelvic floor, this is known as pelvic floor disorder or dysfunction (PFD).

A pelvic floor disorder is when one is unable to properly relax and coordinate the muscles in their pelvic floor. Some of the symptoms of a PFD

  • An urgent need urinate
  • Painful urination
  • Incomplete emptying of their bladder
  • Urine or stool (faeces) leaking
  • Constipation, straining or pain during bowel movements
  • Pain or pressure in the vagina or rectum
  • Pain during sex
  • Erectile dysfunction in men
  • A heavy feeling in the pelvis or a bulge in the vagina
  • Pain in the lower rectum
  • Muscle spasms in the pelvis

PFDs are more commonly seen in women and often, in older

  • One in five people will suffer from a pelvic floor disorder during their lifetime.
  • One-third of all women and 50 percent of women over the age of 55 are currently affected by a pelvic floor disorder.

Shifts in hormones may lead to weaker or stiffer muscles in the pelvic floor. Connective tissues become more rigid and provide less support. Women also experience a lot of stress and changes to the pelvic region throughout their life during pregnancy, childbirth and menopause, and therefore become more susceptible to pelvic floor issues. Though ageing is associated with pelvic floor dysfunction, it is not a direct cause of this condition.

The exact cause of a PFD is not known but there are many factors known to weaken the muscles of the pelvic floor. Increasing age is already known to cause generalised weakening of the muscles. Aging may either add to the deterioration of pre-existing pelvic floor dysfunction during one’s lifespan or interact with other potential predisposing factors, such

  • Obesity
  • Pregnancy and childbirth
  • Overuse of pelvic muscles (common in those with constipation)
  • Heavy lifting and straining
  • Menopause
  • Injury to the pelvic region
  • Prior surgery or pelvic radiation
  • Smoking, caffeine ingestion and other lifestyle factors
  • Congenitally (by birth) weak connective tissue (or inherited)

A PFD includes urinary incontinence (UI), pelvic organ prolapse (POP), and bowel dysfunction [anal incontinence (AI) and difficult defecation]. Incontinence means the inability to control the flow of urine from the bladder or exit of faeces from the rectum. Prolapse means when a body part has displaced from its normal position in the body, usually downwards or outwards, protruding from a body opening. It usually indicates that the muscles supporting the body part have weakened or deteriorated.

Apart from ageing, menopause and other factors leading to weak pelvic floor muscles, urinary incontinence in females can also happen due to: Damage to nerves that control the bladder from diseases such as multiple sclerosis, diabetes, or Parkinson’s disease Diseases such as arthritis that may make it difficult to get to the bathroom in time. In men, it can happen due to prostatitis, a painful inflammation of the prostate gland or an enlarged prostate gland, which can lead to benign prostate hyperplasia, a condition in which the prostate grows as men age.

  • Damage to nerves that control the bladder from diseases such as multiple sclerosis, diabetes, or Parkinson’s disease
  • Diseases such as arthritis that may make it difficult to get to the bathroom in time.
  • In men, it can happen due to prostatitis, a painful inflammation of the prostate gland or an enlarged prostate gland, which can lead to benign prostate hyperplasia, a condition in which the prostate grows as men age.

Thus, there are different types of incontinence:

  • Stress incontinence occurs when urine leaks as pressure is put on the bladder, such as during exercise, coughing, sneezing, laughing, or lifting heavy objects. It’s the most common type of bladder control problem in older adults.
  • Urge incontinence happens when people have a sudden need to urinate and cannot hold their urine long enough to get to the toilet. It may be a problem for people who have diabetes, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, or stroke.
  • Overflow incontinence happens when small amounts of urine leak from a bladder that is always full. A man can have trouble emptying his bladder if an enlarged prostate is blocking the urethra. Diabetes and spinal cord injuries can also cause this type of incontinence.
  • Functional incontinence occurs in many older people who have normal bladder control. They just have a problem getting to the toilet because of arthritis or other disorders that make it hard to move quickly. Eg: cognitive impairment, physical frailty, environmental barriers, or immobility.

Stress and urge incontinence also known as mixed incontinence is prevalent than urge type apart from stress incontinence. Prevalence of urinary incontinence (UI) peaks around menopause, with a steady rise thereafter into later life.
Overactive bladder includes urgency to urinate, increased frequency to urinate especially at night and sometimes, incontinence (urge incontinence as mentioned above). It is usually caused due to unhealthy lifestyle habits, medical conditions or both.

Emptying disorders include incontinence, overactive bladder and urinary retention as well. Urinary Retention is the inability to completely empty the bladder. It's more common in men, especially as they get older, and can be caused by an enlarged prostate.

Any type of PFD or emptying disorder has a significant impact on one’s quality of life. It causes significant morbidity that consequently affects the costs related to health care leading to decreased productivity. It negatively impacts the physical and emotional wellbeing of clients.
It causes:

  • Limitations and deficits in task performance, social interactions, and personal relationships
  • Anxiety
  • Emotional distress or depression.
  • Sexual problems.
  • Sleep disturbances and interrupted sleep cycles
  • Decrease in physical activity, which can lead to further muscle weakness, atrophy (reduction in muscle mass), and joint stiffness.
  • Daily living dysfunction
  • Impaired skin integrity
  • Urinary tract infections and urosepsis
  • Injuries from falls (due to urgency)

Having symptomatic Pelvic Organ Prolapse (POP) is associated with a greater likelihood of either or both - Urinary Incontinence (UI) or Faecal Incontinence (FI). Older adults often underreport PFD due to embarrassment, lack of knowledge regarding appropriate healthcare provider and treatment options, belief these disorders are physiologic or normal part of ageing, or prioritising other medical conditions. But we don't need to make it a normal part of ageing or underestimate it and must seek treatment and prevention.

Maintaining a healthy lifestyle as one ages can help reduce the risk of developing a pelvic floor disorder. It is recommended eating a healthy diet high in fibre, getting regular exercise and stopping smoking.
Kegel exercises (also called pelvic floor exercises) strengthen the pelvic floor muscles and can also be helpful to prevent dysfunction. To perform a Kegel exercise:

  • Make sure the bladder is empty, then sit or lie down.
  • Tighten the pelvic floor muscles. Hold tight and count 3 to 5 seconds.
  • Relax the muscles and count 3 to 5 seconds.
  • Repeat 10 times, 3 times a day (morning, afternoon, and night).

Treatment of the condition can greatly improve the overall health. Non-surgical treatments can cure pelvic floor disorders. This usually involves:

  • Behaviour changes, such as avoiding pushing or straining when urinating and having a bowel movement and drinking appropriate types and amounts of liquid.
  • Prescription Medicines, such as low doses of muscle relaxants like diazepam
  • Physical therapy and biofeedback, which can help the older adult learn how to relax and coordinate the movement of their pelvic floor muscles

Depending on the individual case, the treatment options may include advanced and noninvasive surgeries.

Pelvic floor muscle therapy (PFMT) is beneficial in improving incontinence in healthy and/or non-frail older adults, and biofeedback-assisted PFMT improved incontinence in homebound older adults. Multicomponent interventions appear to hold the greatest potential for benefit in urinary incontinence. Those consisting of PFMT combined with lifestyle, mobility and nutritional interventions appear to be effective.
For frail older women with prolapse, PFMT and intravaginal pessaries remain viable treatment options for women wishing to avoid, or who are unfit for, surgical intervention. Special attention needs to be given to women with dementia for the management of pessaries w.r.t removal and retention.

Pelvic Floor Exercise

Pelvic floor muscle exercise (PFME) or PFMT is particularly beneficial in the treatment of stress UI in older women. Studies have shown up to 70% improvement in symptoms of stress UI following an appropriately performed pelvic floor exercise program. This improvement is evident across all age groups. There is evidence that women perform better with exercise regimes supervised by clinicians specialising in PFD as opposed to unsupervised or leaflet-based care. There is evidence for the widespread recommendation that PFME helps women with all types of UI. However, the treatment is most beneficial in women with stress UI and who participate in a supervised pelvic floor muscle training program for at least 3 months.

Electrical Stimulation

Electrical stimulation (ES) is a therapeutic option for patients with UI. It includes the suprapubic, transvaginal, sacral, and tibial nerves (lower body nerves). The electrodes can be implantable or not, and the ES can be of long or short duration. Transvaginal ES causes contractions of the pelvic floor, increasing the number of muscle fibres with rapid contraction, which are responsible for continence in situations of stress. Tibial nerve ES is a peripheral non-implantable method that can be applied percutaneously with a needle or transcutaneously with a stick-on ECG-type electrode.
Some clinical trials suggest using 50 Hz for stress UI and 10-20 Hz for urge UI, and that mixed symptoms should be treated according to the predominant symptom. Pelvic floor ES, with a non-implantable stimulator, is covered for the treatment of stress and/or urge UI in cognitively intact clients who have failed a documented trial of pelvic muscle exercise (PFME) training. A failed trial of PFME training is defined as no clinically significant improvement in UI after completing 4 weeks of an ordered plan of PFMEs designed to increase periurethral (around the urethra) muscle strength.

Behaviour Modification

Behaviour modification consists of scheduled toileting with a systematic delay, education, and positive reinforcement. The information gathered with the initial evaluation bladder diary allows the healthcare provider to identify patterns that better facilitate behaviour modification. Bladder diary-based interventions should be based on the devised schedule for the first week. However, if the urge to urinate is too strong, voiding is permitted but should then resume on the established schedule. This facilitates an increased time of 15–30 min between voids.

Bladder Retraining

Bladder retraining aims to lengthen the amount of time between bathroom visits. The older adult is encouraged to void on a schedule. The voiding schedule starts at a short interval, as per the frequency from the bladder diary. A typical program takes several weeks with the goal of progressively increasing the time between voids. Women with urge UI or mixed UI may benefit from bladder retraining and pelvic floor exercise as well as physiological quieting. Bladder retraining focuses on instruction to resist the urge to void in-between scheduled voids; using distraction, relaxation and inhibition techniques and/or strengthening, and the intervals are progressively increased. Positive reinforcement for remaining dry between scheduled voids is used to strengthen the behaviour. This approach is most appropriate for improving the symptoms related to urge UI and may improve stress UI. Bladder retraining also facilitates an increased amount of urine the bladder can comfortably retain. This will reduce the number of incontinent episodes and improve self-control.

Prompted Voiding

Prompted voiding is a technique that can be used in older adults with cognitive impairments. This intervention involves recognizing some degree of bladder fullness and responding when prompted. Prompted voiding is similar to scheduled toileting and adds verbal prompting and reinforcement. This technique is often preferred as it reduces passivity and facilitates more independence. Once the initial training is complete, prompted voiding requires the same amount of time as scheduled toileting. Prompted voiding consists of monitoring the older adult on a regular schedule (hourly or more frequently initially) depending on the frequency of incontinence episodes on the bladder diary. A decrease in UI frequency typically occurs within the first 3–6 days. Prompted voiding involves five steps. They are: check, talk, prompt, praise, and correct.

  • Check : The Change the client’s position and do a physical check for wetness.
  • Talk : Ask the client “are you wet or dry?” Ask up to 3 times and give accurate feedback.
  • Prompt : Ask the client if they will try to use the toilet or other device. The question should be repeated up to 3 times in a persuasive manner. The client is not toileted unless they answer in the affirmative.
  • Praise : Give positive feedback for making an effort to use the toilet or other device and for being dry.
  • Correct : This means making an appropriate corrective statement if the client is wet. For example, “You are wet, please try and tell me before you have to go next time.” If the client is wet but tries to use the toilet or other device, give praise but no correction.

Scheduled Toileting

The goal of scheduled toileting is to anticipate wetness and “void to avoid” an accident. Toileting is performed at regular intervals based on current individualised toileting habits obtained from the bladder diary. There are no attempts to delay voiding or to resist urges with this approach. The goal is for regular voiding to become a routine, reducing incontinent episodes with typical voiding occurring every 3 to 4 hr. An example of a scheduled toileting regime is listed below.

  • Client’s bladder diary indicates that she is wet ~ 2 hr after meals.
  • Schedule created for the client to void within 1.5 hr of meals.

Environmental Modification

Impaired mobility, low vision, and fine motor deficits can impact an older adult’s ability to successfully execute toileting tasks. Many restrooms have light coloured flooring and white toilets. For a person with low vision, this creates a barrier where the toilet is no longer discernible from the walls or floor. The addition of a black toilet seat creates visual contrast and minimises the impact of low vision on functional UI. Impaired functional mobility is another contributing factor to functional UI. Limiting obstacles and proper lighting are imperative to ensure a clear path to the restroom. The addition of an elevated toilet or grab bars enable clients with functional transfer deficits to increase safety and independence during the toileting process. Clients with nocturia (increased frequency of urination at night) could benefit from the use of a bedside commode since the level of urgency is typically greater at night. Clothing management plays a significant role in the bladder management process. Clothing that is restrictive can increase pressure on the lower abdomen resulting in elevated urgency sensation. Restrictive clothing also creates a barrier to efficiently and effectively lowering lower extremity garments. Clothing modifications that are beneficial include properly fitting lower extremity garments and elastic waist pants instead of zippers.

Diet Modification

Some foods and beverages are known to promote diuresis (increased urine flow) or bladder irritability, which in some people, can exacerbate incontinence

  • Caffeine has been shown to have a diuretic effect and is a constituent of a variety of beverages and foods. Many foods, beverages, and medications contain significant amounts of caffeine.
  • Caffeine-containing products may increase UI symptoms by increasing detrusor pressure and by promoting detrusor muscle excitability (outer layer of bladder muscle).
  • Based on the amount of caffeine consumed, the older adult may be advised to replace caffeinated dietary intake with non-caffeinated alternatives and to note any changes in bladder symptoms.
  • If bladder symptoms persist and the client wishes to continue to consume caffeine, they should be advised to restrict this to less than 200 mg/day (or two cups of coffee) to decrease urgency and frequency.
  • Other dietary factors that may contribute to UI symptoms include carbonated drinks.
  • There is also evidence to suggest that aspartame and other artificial sweeteners induce detrusor contraction and thus may contribute to UI symptoms.
  • Excessive fluid intake can exacerbate UI symptoms.
  • Fluid restrictions may result in an increase in urine concentration that can cause bladder irritation, promote urgency, frequency, and UTI.
  • An appropriate level of fluid intake is particularly important for older adults, for whom a strong relationship between evening fluid intake and nocturia has been reported. The daily volume of fluid intake should be approximately six 8-oz glasses (6 235ml glasses) per 24-hr period.
  • To reduce nocturia, clients are advised to reduce fluid intake after 6pm (or approximately 3–4 hr before bedtime) and shift their intake to the morning and afternoon, which anecdotally appears to have good results.

Surgical Therapies

Prolapse surgery may be reconstructive or obliterative, depending upon the choice of the woman. Frail women experience increased lengths of hospital stay and 30-day complications compared to non-frail women. Women with frailty are at greater risk of procedure and non-procedure related complications (mostly cardio-respiratory) and impaired outcomes compared to non-frail women but are satisfied and experience improved quality of life, given that there is improvement in continence. Studies showed that frail older women did not experience greater rates of procedure-related complications than non-frail women.
Obstructive surgeries are associated with satisfactory results for prolapse but complication rates were higher in women undergoing reconstructive surgery. For frail older women with prolapse, intravaginal pessaries remain viable options for women wishing to avoid, or who are unfit for, surgical intervention.

Continuing and maintaining the progress made during an older adult’s plan of care is imperative for wellness and prevention. Client education should consist of a home exercise program and compensatory strategies. Clients involved with the development and return demonstration of the overall home program are more likely to carryover the information into her daily routine. Practising the home exercise program and creating clear expectations throughout the course of treatment allow for the client to seek clarification in a timely manner. The use of visual aids and handouts can be beneficial references to assist the client in internalising the information and foster improved carryover.

With the increasing life expectancy of people, especially women, knowledge of the prevalence, and the risk factors for pelvic floor disorders, is of public health importance. Although these conditions become more common as women age, they do not have to be a normal part of ageing. Pelvic floor dysfunction also often goes unaddressed by health care professionals. Pelvic Floor Disorders must be screened during primary care consultations, especially in older and obese women with a focus to improve modifiable risk factors that will eventually help prevent or reduce the impact of these conditions on daily life.