Stress urinary incontinence (SUI) can affect up to 1 in 3 women between the ages of 16 to 65 years of age (Fantl, 1996) making it not an uncommon illness which often goes untreated due to embarrassment and low consultation rates. There are a range of causes of SUI although it is usually related back to a general weakening of the pelvic floor muscles. However main types of women affected are the elderly (Maggi, Minicuci, Langlois, Parvan, Enzi & Crepaldi, 2001) and mothers that have delivered via a natural child birth.
Differences in pressure:
In a normal balance between bladder and urethral pressure, the urethra pressure normally wins, resulting in the muscles remaining tight and closed, holding in urine. However, activities such as coughing, laughing, sneezing or physical activity, such as lifting heavy objects, will raise intraabdominal pressure which will in turn change bladder pressure causing incontinence (Abrams, Stanton, Griffiths, Rosier, Ulmsten, Van Kerrebroeck, Victor & Wein, 2002). Normal voiding of the bladder is due to this pressure shift also; however in SUI the force is involuntary. In SUI there is simply a lack of strength holding these muscles closed which is why sudden changes in intraabdominal pressure can cause the release of urine.
Diagnosis:
Initial diagnosis is simple with this illness and there is only one major and obvious symptom (with other minor symptoms that are secondary to the urinary incontinence). Diagnosis can only occur if the patent is to present the symptom to a doctor or medical practitioner, otherwise the issue can go largely untreated.
Physicians will need to go through range of patient testing to get a conclusive diagnosis. An accurate patient history will be required for things such as diet (drinks high in diuretics) or previous pregnancy (weakening of the pelvic muscles) will need to be noted (Long, Giri & Flood, 2008). Patients may need to be referred onto specialists such as Urologists or Gynaecologists for urinalysis and physical examinations respectively.
History:
Arnold Kegel (1894-1981) was a gynaecologist and the inventor of the Kegel Perineometer (an instrument applied to measuring vaginal air pressure) and the Kegel exercises which he developed after he recognised the strength deficiency in SUI sufferers. The term "Kegels" has become synonymous with pelvic floor strengthening. In 1948 he published a paper titled "The nonsurgical treatment of genital relaxation; use of the perineometer as an aid in restoring anatomic and functional structure". His initial research used cadavers, which proved to be useless after muscle atrophy had set in. After attempting to diagnose using only internal palpation directly onto the affected muscles, he created the Perineometer apparatus - designed to measure from zero to 100mmHg of pressure. After 30 designs and 18 years of Kegel's research and case studies, the original device has lead the way for more modern electromyography perineometers which measure electrical activity across the muscle instead of pressure exerted over the pubococcygeus. His groundbreaking research allowed women who previously were not aware, to understand that the hammock of muscles could be contracted voluntarily (Kegel 1948).
Physiology & Tissues injured
The affects of Pregnancy:
Day & Goad (2010) describe the pelvic floor as the "hammock of muscles, beginning at the pubic bone at the front of the pelvis and passing between the legs to the base of the spine". This large group of muscles (known as the Pubococcygeus) work together to support the direct internal organs, control the bowel and bladder from releasing, play a role in sexual activity and of course, childbirth (Haslam, 2004). There are a multitude of hormones being created and released during pregnancy, one in particular is Relaxin. Relaxin is a peptide hormone that is produced by the corpus luteum of the ovaries that encourages the ligaments and soft tissue to become more elastic to promote an easier birth (Day 2010).
There is no doubt that pregnancy is a traumatic experience on a woman's body. The violent birth process can cause tearing of the vagina and the anal sphincter which can take anywhere from weeks or months to heal. The mechanics of childbirth are consistent with the pattern of injury of SUI. The main muscles affected in SUI are the levator ani and coccygeus muscles which together form the pelvic diaphragm. Herschorn (2004) writes that it is important to note that a combination of effective smooth, striated and connective tissue are essential for a urethral sphincter to be functional and watertight. All of these muscles and tissues together are responsible for compensating and tightening further when intraabdominal pressures change. While the uterus can take anywhere from 6 to 8 weeks to go return to its original size, often the pelvic floor never fully regains its initial strength and tightness (Barton, 2004).
Prognosis
What does this mean for our patient?
Ideally, preventative strengthening is the ideal to promote the best recovery for this injury. However, because Lucy has already had 3 natural childbirths, we can look to re-strengthening the pelvic floor muscles with exercise. In the most severe cases, surgery is recommended to repair the loss of tension and pressure. The most common form of surgery is the insertion of a sling, which can be inserted laparoscopically or with minimal invasion via the vagina (Daneshgari, Paraiso, Kaouk, Govier, Kozlowski & Kobashi, 2006). The sling is a narrow strap designed to sit under the urethra and can be made from man-made mesh or the patients own tissues, donated from another area of the body. Another temporary measure is the use of Bulking injections (Day & Goad, 2010). It's classified as temporary because the procedure needs to be re-done approximately every 18 months. It involves the injection of substances that help keep the urethra closed. The substances range from natural collagen, which can produce an allergic reaction in some patients, through to coaptite which is completely synthetic and more durable.
Suggested exercise suitable to lifestyle, injury, recovery
Technique:
With correct and regular daily exercise from the patient, we can expect to see results within 6 weeks (Choi, Palmer & Park, 2007). The Kegel exercise required can be described as tightening your pelvic muscles as if you are trying to hold back from passing wind whilst tensing around a tampon in your vagina simultaneously. Because the hammock of muscles runs from the anal sphincter laterally to meet with the front of the pubic bone, isolating only the vaginal muscles of the pelvic floor is extremely difficult in new patients therefore incorporating the anal sphincter contraction is part of the learning process and is still found to be quite effective. Patients can check correct technique by sitting on a firm chair and performing a set of Kegel exercises - If they feel themselves move upward from the surface of the chair due to pressure exerted, then the action has been achieved correctly.
Biofeedback:
This is where Biofeedback comes in to play. Peterson (2008) writes that biofeedback allows women to identify, isolate, contract, and relax the pelvic floor muscles either on their own or whilst utilising equipment. It is a type of behavioural therapy that creates feedback or awareness about a physiological body movement or action. Because there is such a concentration of muscle groups in a small area, patients may have issues with identification and isolation. One suggestion would be for the patient to self-palpate their vagina during a contraction, normally whist bathing and reclining. One of the most effective methods of providing biofeedback is the use of a stimulation probe. The probe is inserted into the vagina and displays lights or graphs when the correct muscles are being tightened. Tiny electrodes are attached to both the inside and out of the pelvic region, measuring where and when pressure & electricity are activated during a muscle contraction. Optimal biofeedback therapy uses a reward and recognition type system to educate the patient with correct and incorrect muscle visualisations (Abdelghany, Hughes, Lammers, Wellbrock, Buffington & Shank, 2001). The patients see the right colours lighting up when correct muscles are engaged which provides positive reinforcement and furthermore, muscle memory. The natural re-training of the muscles, coupled with a computerised visual and audio feedback system shows the patient the direct relation to the physical control mechanism. Further methods are designed to regain optimisation and the upper-hand in bladder control and release. The technique requires the patient to edit how the pelvic floor muscles react when the bladder begins to fill, re-training it to "hold" for longer periods of time. This is designed to encourage the bladder to fill to its normal capacity before sending signals to the brain to empty or spill the urine. The treatment enhances the correct muscles required to lock-down the bladder successfully via the correct amounts of pressure needed.
Exercise and bladder diaries:
It would be advisable for Lucy to keep a diary of her Kegel exercises and any instances of urinary incontinence, so she can monitor her own improvements and advances which will sustain personal motivation. If she wishes to keep a more advanced diary she can choose to record frequency of urination, decrease of incontinence episodes & type, volume and frequency of fluid intake. Initially they are helpful in establishing the severity of the urinary incontinence; as time goes on it will record and display for the patient the incremental positive changes that may otherwise go missed.
