Understanding Different Types of Urinary Incontinence

By Kim Buonomo, DPT, PHRC Lexington

We often see patients who report urinary incontinence as a symptom of their pelvic floor dysfunction. Incontinence is defined as the lack of voluntary control over one’s urination or defecation. Sometimes this is not the reason they seek treatment, but rather a secondary finding. I can’t tell you how many times I’ve heard something along the lines of “I leak urine, but that’s just the way it is, because I’ve had kids.” Urinary incontinence is not considered a normal part of the aging process, and while very common, can often be resolved or improved with appropriate medical interventions including pelvic floor physical therapy (PFPT). I wanted to perform a review with information I think everyone should know about urinary incontinence and the pelvic floor. The best way to know if pelvic floor PT could help in your specific circumstances is to see a pelvic floor physical therapist. Many of us here at PHRC (including me!) are currently offering digital healthcare appointments!

The prevalence of incontinence has been widely studied, but as some patients may not report it to their doctors, the true occurrence may be even higher than we think. In general, incontinence affects 20-30% of young adults, 30-40% of middle aged individuals, and 30-50% of elderly individuals and affects both men and women. Large studies have indicated that there is a 3% to 11% overall prevalence rate of incontinence in men, but some studies report that may actually be as high as 39%.

Types of urinary incontinence include:

Stress
Urge
Mixed
Overflow
Functional

Let’s delve into each of these.

Stress Urinary Incontinence (SUI)

What happens: Urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy.

AKA: stress incontinence, stress urinary incontinence, SUI, “Don’t make me laugh, I’ll pee my pants,” “I can’t jump on a trampoline or I‘ll leak.”

Risk factors include, but are not limited to: pregnancy, menopause, obesity, low physical activity, professional sport, gynaecological operations, prostatectomy, athletes (especially young female athletes), and other pelvic injuries.

Prevalence: Stress urinary incontinence affects an average of 48% of women and less than 10% of men as a primary symptom.

Effects of PT: Pelvic floor muscle training (PFMT) and pelvic floor physical therapy are recommended as a first line treatment for stress urinary incontinence. A Cochrane review of 21 trials involving 1281 women showed that women with SUI who received pelvic floor muscle training were eight times more likely than controls to report that they were cured, and 17 times more likely to report cure or improvement. Women treated with PFMT leaked urine less often, lost smaller amounts, and emptied their bladders less often during the day. Another study which interviewed 263 women who had undergone PFPT for stress incontinence showed that five years after PT, up to 41.7% of women were still adherent to training and reported that their quality of life was “very high.”

For more information, check out the following from the PHRC Blog:

Urge Urinary Incontinence (UUI)

What happens: You have a sudden, intense urge to urinate followed by an involuntary loss of urine. You may need to urinate often, including throughout the night.

AKA: urge incontinence, urge urinary incontinence, UUI, “gotta go right now,” “I put my key in the door and suddenly I’m running to the bathroom” “I can’t hear running water without needing to pee.”

Risk factors include, but are not limited to: infection, neurologic disorder, diabetes, bladder overactivity or hypersensitivity, lifestyle habits such as holding your bladder for extended periods.

Prevalence: An average of 17-22% of female patients with incontinence report urge incontinence is the primary symptom. UUI is reported in 40% to 80% of male patients with incontinence.

Effects of PT: PT can improve pelvic floor function and bladder function control. We often talk about improving the coordination between the pelvic floor and the bladder. Some thoughts about how PT improves urge incontinence include improving patient’s understanding of their lower urinary tract, changing pelvic floor muscle activity during exercises to inhibit detrusor overactivity, and increasing pelvic floor muscle strength.

Clinical experience has shown that different physical therapy treatment modalities generally will provide progress in most individuals with bladder overactivity. The bladder training that we do in PT emphasizes the neurological (cognitive) control over your bladder and often uses a voiding schedule to inhibit the sensation of urgency and postpone voiding. The goal is to attain a longer interval between consecutive voids with larger voided volumes.

For more information, check out the following from the PHRC Blog:

Mixed Urinary Incontinence

You experience more than one type of urinary incontinence.

AKA: “My bladder has a mind of its own.”

Risk factors include, but are not limited to: any of the above

Prevalence: Some sources say up to half of women who report urinary incontinence have mixed incontinence and 10-30% of men with incontinence have mixed incontinence.

Effects of PT: Mixed incontinence includes symptoms of both stress incontinence and urge incontinence. Since PT can help with either stress or urge incontinence, it should help with mixed incontinence as well. However, mixed incontinence is often considered more severe because it is more challenging to manage than either urinary condition alone. First-line treatment can include behavioral and pelvic floor muscle training, followed by overactive bladder medication. Sometimes combination therapy (conservative treatment like PT, as well as surgery such as a midurethral sling) can be used, but the effectiveness of this approach is unclear, and surgery is thought to have some risk of making the urgency component worse.

Overflow Urinary Incontinence

What happens: You experience frequent or constant dribbling of urine due to a bladder that doesn’t empty completely. In this situation, the intra-vesical pressure eventually equals the urethral resistance. This includes the involuntary release of urine due to a weak bladder muscle or due to blockage, where the bladder becomes overly full, even though the person feels no urge to urinate.

AKA: OI, OFI

Risk factors include, but are not limited to: neurological conditions such as diabetes or multiple sclerosis, impaired ability to sense bladder fullness or reduced bladder muscle contractility, neurogenic bladder, a blockage in the urinary tract, such as a bladder stone or a urinary tract tumor that constricts the urethra. When blockage occurs in men, it is usually caused by an enlarged prostate gland (benign prostatic hyperplasia, or BPH), cancer of the prostate, or a narrowing of the urethra.

Prevalence: unclear

Effects of PT: Since these patients have a medical cause of these symptoms apart from pelvic floor muscle dysfunction, their treatment focuses on addressing the underlying cause, so PT is often not a first-line treatment. Treatment can include self-catheterization (a tube is inserted into the bladder through the urethra, allowing urine to drain) or surgery to address the obstruction or abnormal growth. Medications are rarely used to treat overflow incontinence in women, but medications that make the prostate smaller may decrease pressure on the urethra in men. Physical therapy may be helpful for training the patient to self-catheterize, to provide education, and may help if the patient has symptoms of stress or urge incontinence after the underlying cause of the overflow incontinence has been addressed.

Functional Urinary Incontinence

What happens: A physical or mental impairment keeps you from making it to the toilet in time. For example, if you have severe arthritis in your hands, you may not be able to unbutton and remove your pants quickly enough. If you recently had surgery such as a hip replacement, you may not be able to walk quickly enough to get to the bathroom in time.

AKA: functional incontinence

Risk factors include, but are not limited to: poor vision, psychological issues, environmental barriers to using the restroom, cognitive issues (including forms of dementia, delirium, and intellectual disabilities), neurological or muscular limitations, such as arthritis.

Prevalence: unknown

Effects of PT: Functional incontinence doesn’t necessarily involve the pelvic floor muscles, but that doesn’t mean that PT can’t help. In cases where incontinence is caused by a physical impairment, PT can often address that to improve function and ability to get to the bathroom. For example, working on fine motor tasks for the patient with arthritis in the hands, or improving functional mobility for the patient who had a recent hip or knee surgery. PTs can also provide education and help with home planning. Modifying the home environment can make a big change in symptoms, such as putting a commode by your bed so you don’t have to walk as far to the bathroom in the middle of the night.

In summary, urinary incontinence is not as straightforward as one might think. There are many different causes with symptoms of leakage and different treatment ideas. Urinary incontinence affects people of all ages and there are many treatment options. Working with a PT can help you find the right solution for you, so you can stay happy and dry!

References

Schröder, P. Abrams, K.E. Andersson, et al. Guidelines on urinary incontinence. A.G. Arnheim (Ed.), EAU guidelines, European Association of Urology, Arnheim, the Netherlands (2010), pp. 11-28

Beyar, N. and Groutz, A., 2015. Pelvic floor physical therapy for female stress urinary incontinence: five years outcome. Physiotherapy, 101, pp.e146-e147.

Demaagd, G. A., & Davenport, T. C. (2012). Management of urinary incontinence. P & T : a peer-reviewed journal for formulary management, 37(6), 345–361H.

Dumoulin C, Hay‐Smith EJC, Mac Habée‐Séguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD005654. DOI: 10.1002/14651858.CD005654.pub3.

Krzysztoszek, K. and Truszczyńska-Baszak, A., 2018. Physical therapy in stress urinary incontinence among women – a review of the literature and a suggested treatment protocol. Rehabilitacja Medyczna, 21(4), pp.60-67.

Mayo Clinic. 2020. Urinary Incontinence – Symptoms And Causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/symptoms-causes/syc-20352808> [Accessed 7 May 2020].

Nitti V. W. (2001). The prevalence of urinary incontinence. Reviews in urology, 3 Suppl 1(Suppl 1), S2–S6.

Sung, V., Borello-France, D., Newman, D., Richter, H., Lukacz, E., Moalli, P., Weidner, A., Smith, A., Dunivan, G., Ridgeway, B., Nguyen, J., Mazloomdoost, D., Carper, B. and Gantz, M., 2019. Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence. JAMA, 322(11), p.1066.

Tak, E.C., van Hespen, A., van Dommelen, P. et al. Does improved functional performance help to reduce urinary incontinence in institutionalized older women? a multicenter randomized clinical trial. BMC Geriatr 12, 51 (2012). https://doi.org/10.1186/1471-2318-12-51

Uofmhealth.org. 2020. Overflow Incontinence | Michigan Medicine. [online] Available at: <https://www.uofmhealth.org/health-library/uh1227> [Accessed 7 May 2020].

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.