Physiotherapy

Chartered Physiotherapists in Women's Health and Continence work with all aspects of physiotherapy relating to women's health and continence, but also treat men and children who present to them with issues of bladder, bowel and other pelvic floor problems.

At your first visit, your Chartered Physiotherapist will ask you questions about your presenting problem. They will then carry out a detailed physical assessment, before agreeing a rehabilitation programme with you. You will then work with your physiotherapist to achieve and maintain optimum functioning of your continence systems.

The aim of pelvic floor rehabilitation is "To restore control over the pelvic floor musculature when it has been lost, and to teach correct methods of control over bladder and bowel, which some individuals never learnt as children, or learnt incorrectly. (Schussler 2000).

Chartered Physiotherapists in Women's Health and Continence work in different settings including Maternity and General Hospitals, Private Practices, and Community Care. When you choose a Chartered Physiotherapist in Women's Health and Continence you can have the peace of mind of knowing that you are being treated by a physiotherapist who has a university degree qualification and is committed to the highest standards of ethical and clinical excellence.

For more information on Physiotherapy for Bladder Control, Physiotherapy for Bowel Control and Physiotherapy for Male Bladder Control please click on the tab links below.

Chartered Physiotherapists

continence Foundation Ireland physiotherapy photo

The Irish Society of Chartered Physiotherapists
123 St Stephen's Green,
Dublin 2.
Tel : (01) 402 2148.

To find your nearest Chartered Physiotherapist, visit:
www.iscp.ie

Physiotherapy for Bladder Control

The Bladder

The bladder is a balloon like muscle, which stores urine. It can hold around 500mls or 1 pint. As it fills to capacity, it gives a sensation to pass urine. By tightening your pelvic floor muscles you should be able to delay the urge and postpone emptying the bladder until it is convenient. It is normal to empty your bladder 4-7 times in the day and once at night.

PDF Infographic Download

What Every Women Should Know About Here Bladder

Where are the Pelvic Floor Muscles?

The pelvic floor muscles support the bladder, vagina, womb and rectum, holding them in the correct place. These muscles should react automatically to close the bladder outlet when you cough or sneeze. During childbirth, these muscles can be damaged and the muscles are no longer as effective at controlling the bladder outlet. It may be that the pelvic floor muscles are ineffective for other reasons even you haven't given birth.

continence Foundation Ireland pelvic Floor Muscles illustration

The Abdominal Muscles

The deep muscles of your abdomen support your spine and pelvic floor. These supporting muscles provide a "girdle of strength" around your pelvis and work for long periods of time. They work most effectively when the pelvis is held in the natural 'neutral'position.

To be more effective in doing your exercises AIM to find this neutral position. Imagine a compass on your lower abdomen, the navel is north and pubic bone is south. Your pelvic bones are east and west. In neutral, the line between the pubic and pelvic bones remains horizontal. Start your exercise with your pelvis in this position whether you are lying, sitting or standing.

The abdominal muscles are easiest to find in side lying with the tummy relaxed. Check your pelvis is in neutral whether in lying, sitting or standing. Slowly and gently draw in the lower abdominal muscles as if bringing your tummy towards your spine (and your hip bones together). Don't move the spine or pelvis. Keep breathing and hold the muscle for at least 10 seconds. When you can do 10 x 10 second holds, introduce the hold while walking with a good posture. Make sure your technique is correct. Using this abdominal muscle can help you find your pelvic floor muscle. It is not easy to find the pelvic floor muscles and it can take a lot of time and concentration.

NB Bracing the tummy is incorrect; this technique is gentle and slow and the tummy should not bulge out. This slow contraction of the deep abdominal (Transversus Abdominis ) muscle will help a pelvic floor contraction but bracing and forcing will not. It is important to know that over-holding of the abdominal muscles can be part of the problem with bladder overactivity. It is important to release the abdominal muscles as well to ensure correct activation.

Posture

When your posture is correct you will look and feel better. It also enables you to improve the control over the pelvic floor for longer periods of time e.g. when out for a walk.

  • Hold your head up but not your chin.
  • Lift your breast bone and keep your neck long.
  • Breathe down low.
  • Pelvis in neutral.
  • Knees straight not locked.
  • Weight between the big toe, little toe and heel.

The Pelvic Floor Exercise (Pelvic Floor Elevator)

Every one is different and needs an exercise programme to suit their individual needs. However, this is a good way to activate your mucles as you imagine your pelvic floor is like a lift and try to take the lift up and down to different floors.

  • Sit comfortably on an upright chair, knees slightly apart.
  • Breathe in deeply and then all the way out.
  • Take the lift to the first floor by gently drawing in the lower abdominals and by tightening your back passage (be careful not to brace your tummy; you can try tightening the back passage first and then lower abdominals).
  • As soon as you have tightened - resume normal breathing while you hold.
  • Keep holding for 5 secs and build up to 10 secs.
  • Release the muscle completely.
  • Breathe in deeply and then all the way out.
  • Take the lift to the second floor by drawing in the lower abdominals and by tightening your back passage as above.
  • As soon as you have tightened - resume normal breathing while you hold.
  • Next time contract the muscles and take the lift to the third floor.
  • Repeat to each floor holding each repetition up to 10 seconds.
  • Correct breathing and the ability to release the muscle COMPLETELY to the basement during the programme is very important.

Pelvic Floor Muscle Training

  • In order to control the bladder and stop accidents you must increase the strength and endurance of the muscles.
  • To train the muscles you need to spend time every day doing the exercise .
  • Aim to squeeze harder to take the lift higher.
  • Aim to squeeze longer to hold the lift longer at each floor.
  • Count how long you can hold for and how many times you can repeat the squeezes. This will enable you to know that you are increasing your exercise programme and improving your strength.
  • Aim to hold for 10 seconds and do 10 repetitions as a guide.
  • Include a set of fast squeezes in each set of exercises; tighten quickly and release quickly and repeat 10 times.
  • Record your programme to see your progress.
  • Do your exercises 3 times per day.

Once you have mastered these exercises use them when you need them. As you breathe in to cough or sneeze, quickly take the muscle to the third floor and hold it there while you cough/ sneeze. Practice holding the muscle and coughing to prevent a leak. This is called "The Knack".

Test

When passing urine, try to stop or slow mid stream. This is a test only and NOT an exercise. (You should not do this test more than once per week).

Points to Remember

  • Don't go to the toilet "just in case". Learn to take control of your bladder and have confidence.
  • Most women only leak when doing activities. To prevent accidents when out walking or doing exercise, learn to hold your posture and abdominal control. Holding the lift at the first floor gives you similar control.
  • The more control you need, the harder you must squeeze the muscles.
  • Use your muscles when you need them and exercise them regularly.
  • Drink normally: 1.5 litres of water a day.
  • Avoid tea, coffee, fizzy drinks and alcohol.
  • Watch your weight, being over weight can put a further strain on your muscles.
  • Avoid constipation and straining by taking extra fibre in your diet.
  • It may take up to 3-5 months to train the muscles.
  • Improvements can happen much sooner and can continue for up to a year.
  • When in the bath, try putting one or two fingers into the vagina and see if you can feel the squeeze.
  • KEEP THEM UP FOR LIFE.

Bladder Retraining

For people who have problems making it to the toilet in time (urgency or urge incontinence), simple bladder training can improve your symptoms. Urge incontinence is due to over-activity of the bladder muscle or nerves. It gives a sensation of urgency to pass urine and you may not reach the toilet in time. Having to get up more than once a night is common.

An average person can hold 400 to 500mls of fluid and passes urine six to eight times in a 24 hour period. When you have a problem with urgency it is usually due to a disturbance in the reflexes of the bladder or reduced bladder size. The bladder gives off strong messages that it wants to empty and you find it difficult to stop the reflex, the bladder squeezes and the pelvic floor is not strong enough to resist it.

To retrain your bladder, when you feel the urge to go to the toilet during the day try and hold on for a few minutes longer than you normally would before passing urine. Try not to rush to the toilet at the point when your urge is strongest (see diagram). Use the techniques below to practice holding. It can be very difficult at first and seem impossible.

Urge Curve

continence Foundation Ireland urge curve chart illustration

Your retraining programme

If the urge is too severe then talk to your doctor about medication, but then you should practice these techniques in conjunction with the drug therapy. Bladder retraining may also be used for someone who has an over stretched bladder.

When the urge starts stand still, as the urge rises squeeze your pelvic floor, as the urge peaks distract yourself, as it subsides wait and walk calmly to the toilet.

Helpful hints for holding on:

  • Stand still or sit down. Sitting and leaning forward is best.
  • Practice regular breathing.
  • Don't brace your stomach.
  • Tighten your pelvic floor muscles.
  • Press on your pelvic floor muscles and hold the pressure for as long as it takes for the urge to subside.
  • If you can't sit - Stand up on your toes for a long as it takes the contraction to subside (this helps settle the reflexes).
  • Think of something else other than the toilet - distract yourself, give your self a small task to do e.g. check your text messages.
  • Avoid large quantities of alcohol, avoid tea and coffee.
  • Drink at least a litre of water daily.

Bladder Diary

Your doctor, physiotherapist or nurse continence advisor may ask you to fill out a bladder record chart or bladder diary. This is a record of your fluid intake, the amount of fluid passed and episodes of leakage daily. This gives a lot of information about the minimum and the maximum amount of fluid the bladder can hold, types of fluids you are drinking, whether they are irritating the bladder, the number of times you are going to the toilet daily and the different patterns that you have established. This chart will be used to help you and your advisor understand and retrain your bladder.

continence Foundation Ireland physiotherapy bladder control photo

Physiotherapy for Bowel Control

Food that we eat enters the mouth, passes through the stomach and is digested in the small intestine. Here, nutrients are absorbed and any waste remaining forms a loose bowel motion or faeces (stool). This travels to the colon where water is absorbed and the faeces should become more solid.

When faeces reach the lower part of the bowel - the rectum, there should be a feeling of fullness in the bowel and the urge to pass a bowel motion. This feeling is reliant on the nerves in the rectal area sending message to the brain.

Our pelvic floor muscles, and sphincter muscles surrounding the back passage, allow us to control where and when we empty our bowels. We would all like to feel 'in control of 'our bowels rather than our bowels in control of us'. Normal bowel control depends on many factors including the integrity and strength of the internal and external sphincter muscles.

Loss of bowel control is called anal incontinence and is described as the involuntary loss of faeces (faecal incontinence) or flatus (flatus incontinence). It is not uncommon for people with anal incontinence to experience some symptoms of urinary incontinence also (ie. leakage of urine).

Approximately 1 in 20 people have a problem controlling their bowel. This can affect both men and women and does tend to increase with age. Causes of anal incontinence can be due to:

  • Damage to the pelvic floor muscles, nerves and connective tissue during childbirth.
  • Having a third or fourth degree tear during childbirth.
  • Spontaneous relaxation of the internal anal sphincter.
  • Spinal lesions.
  • Neurological disease eg. multiple sclerosis.
  • Irritable rectum.
  • If the rectum is blocked with severe constipationâ€?this can cause a stretch on the rectum and impaction leading to overflow incontinence.
  • Environmental factors such as limited mobility, reduced access to toilet.

Other symptoms that may be related to anal incontinence are:

  • Passive faecal soiling without a sensation of needing to empty the bowel.
  • Faecal or flatal urgency ( ie. not able to hold on / having to immediately pass a bowel motion).
  • Feeling of incomplete bowel evacuation.
  • Rectal prolapse (often a feeling of something coming through the back passage).

What to do if you are not in control of your bowel?

Management of anal incontinence is a team approach and may involve the GP in the first place, a colorectal surgeon, a dietician, a physiotherapist and most importantly, the patient. The initial physiotherapy visit should involve a detailed history of the nature of the symptoms and possibly completion of a bowel diary.

A bowel diary gives the team an idea of the pattern of your bowels over a period of time. A thorough physical examination should include evaluaton of the muscles of the pelvic floor as well as assessment of alignment of the spine and pelvis. A specialist clinic may also use anorectal manometry, pudendal nerve testing, defaecating protograms, colonic transit studies or MRI.

Physiotherapy management includes:

  • Education in reasons for anal incontinence.
  • Evaluation of the way you currently use your muscles to empty your bowel and correction if necessary.
  • Specific pelvic floor exercise program.
  • Manual therapy on the pelvic floor muscles or surrounding joints.
  • Biofeedback - to show you how you are currently using your muscles and allow you to improve your technique.
  • Electrical stimulation - to make the muscle work if it is extremely weak.
  • Sensation - improving your awareness of both the contents of your rectum and what your muscles are doing.

Goals in bowel management are to:

  • Hold on for a short time after you feel the first urge to go to the toilet.
  • Allow time to get there and remove clothing without any accidental loss of faeces.
  • Pass a bowel motion within about a minute of sitting down on the toilet.
  • Pass a bowel motion easily and without pain - ideally, you shouldn't be straining on the toilet or struggling to pass a bowel motion which is hard and dry.
  • Completely empty your bowel when you pass a motion.

Where are the sphincter muscles ?

The back passage, or anus, consists of two rings of muscles �the internal and external sphincter muscles. The internal sphincter muscle should be closed at all times except when you are trying to pass a bowel motion. At this point, it relaxes and allows faeces to enter the top part of the anal canal.

The external anal sphincter muscle is a band of muscle that is under voluntary control ie. we should be able to tighten the external sphincter band to control gas and faeces. The external sphincter muscle must be strong enough to push the bowel motion back up into the rectum to hold until in an appropriate place to defaecate. Control and timing are important. Like any other muscle in the body, it we don't use it, we lose it!

Sphincter muscle exercises

  • Sit or lie with your knees hip width apart. Think of the circle of the sphincter muscle and try to tighten the circle inwards and upwards as if you were trying to stop yourself passing wind. Do not let your buttocks, thighs, abdominals or even your shoulders move or lift.
  • Count how many seconds you can hold it for (aim for 5-10 secs) and then release the muscle fully. Keep breathing as you hold the muscle tight.
  • Repeat this 10 times, 3 times during your day.
  • Gradually increase how many seconds you can hold the muscle.
  • It is also important to recruit the fast muscle fibres.
  • Pull up the whole circle as tight as possible. Remember to not bring in your thighs or abdominals and do not hold your breath. Tighten and then release COMPLETELY.
  • Repeat 10 times 3 times / day.

Any pelvic floor muscles can take time to strengthen. It is important to do exercises regularly to build on muscle strength and endurance. It can take 3-5 months before you see results.

It is possible to check if this muscle is working or not by 1. using your finger to feel the sphincter muscle lift or 2. Sitting on a rolled up face cloth or small towel. If you feel a bowel motion coming, try to hold for a few seconds with your sphincter muscle and then go to the toilet when you are in control and not your bowels!! If you are uncertain about your exercises or how to do them, please consult a chartered physiotherapist specialised in faecal incontinence.

continence Foundation Ireland physiotherapy bowel control photo

Physiotherapy for Male Bladder Control

Where are the Pelvic Floor Muscles?

The pelvic floor is a sheet of muscle and connective tissue (fascia) stretched across the floor of the pelvis. On the outside this is known as the perineum which is the area between the base of the penis and the back passage (anus). The pelvic floor muscles stretch from the pubic bone at the front to the coccyx behind, and out to the bones that you sit on. There is an extra ring of muscle around the back passage (anal sphincter), which is important for bowel control. Men also have two other sphincters that help to prevent urine leakage. One is at the base of the bladder and the other just underneath the prostate gland.

Why do the exercises?

After surgery, whether prostatectomy or TURP (transurethral resection of prostate) the pelvic floor musculature and nerve supply can be affected. Men may suffer from stress incontinence i.e. leaking urine on coughing, lifting, rising from a chair etc. Other symptoms after surgery may include urge incontinence, an urgent need to pass urine, with leaking on the way to the toilet and/or erectile dysfunction (difficulty achieving and maintaining an erection).

Symptoms may include:

  • Urinary leakage during activities such as coughing, laughing, sneezing or during sporting activity.
  • Urinary leakage from sitting to standing.
  • A sudden feeling that you need to rush to the toilet, or leaking on the way to the toilet.
  • Anal incontinence which is leakage of stool (faeces) or difficulty in controlling wind.
  • Post-micturition dribble (leakage of a few drops of urine after you have finished passing urine).
  • Erectile dysfunction.
  • Premature ejaculation.

How to do the exercises?

Pelvic floor exercises may help these symptoms after interventions for prostate cancer but ideally the exercises should be started before you have surgery and resumed after your operation, once the urinary catheter has been removed. You should not attempt to perform the exercises while your catheter is still in place.

Pelvic floor muscle exercises can be done lying on your back with your knees bent and apart and your feet flat on the ground. They can also be done while you are sitting or standing.

To perform pelvic floor muscle exercises:

  • Squeeze the muscles around the anus as though you are trying to stop your self passing wind.
  • Squeeze the muscles around your urethra as though you are trying to stop your self passing urine; and lift these muscles up inside.
  • If you are doing the exercises correctly, you should be able to see the anus contracting and lifting.
  • The area around the base of your penis dips in towards the abdomen.
  • The scrotum lifts.
  • Both testicles draw up,

All of the above areas should be contracting at the same time, and there should be no movement or tilt of your pelvis when you are performing the exercises. Do not brace or harden your abdominal (tummy) muscles. Pelvic floor muscle exercises should not include active contraction of your buttock muscles or the muscles of your inner thighs. You can assess whether you are doing the exercises correctly by looking at the movement of the pelvic floor muscles. This is best done with a hand mirror while reclining on the bed.

How many and how often?

A health professional working in the area of incontinence can provide you with an individualised bladder control programme based on your symptoms:

  • Build up to 10 long squeezes holding for 5 secs at first and then up to 10 secs each.
  • Then do 10 short squeezes done rapidly to improve speed and strength.
  • For some this will be too easy, for others this may be too difficult. Start with what you feel is a comfortable length of time for you to squeeze. Gradually increase it over the next few weeks.
  • Do your exercises 3 times per day.
  • Tighten your pelvic floor muscles before and during any activity that makes you leak e.g. coughing, sneezing, lifting, rising from sitting, so that with practice this will become an automatic reaction.
  • After urinating, tighten your pelvic floor muscles strongly to empty the last drops out. This may help to stop "after dribble."
  • If you are sexually active, tighten your pelvic floor muscles during intercourse to maintain the quality of your erection.
  • Urge control techniques - you learn to suppress the urge to urinate by doing the pelvic floor muscle contractions as well as using a number of distraction techniques (see urge curve).
  • Postural awareness and control - pelvic muscles work more effectively when you are sitting upright as opposed to slumping or slouching.

If you practise your pelvic floor muscle exercises as above, you should notice an improvement in 3-5 months. It is important that you continue with your exercises even if they do not seem to be helping. Further advice is available from a chartered physiotherapist.

continence Foundation Ireland physiotherapy male Bladder Control
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