You Have More Incontinent Patients Than You Realize

The wonders of the pelvic floor and the science of continence are a whole lot more absorbing (baboom, tsssh) than I’d ever imagined before I specialized in pelvic health.

1:3 women leak.¹ If it was an infectious condition, we’d be talking in pandemic terms. But, as it’s not catching, is usually pain-free, and is taboo, we don’t talk about incontinence at all. Not even if we notice a pad when we’re assessing someone’s hip function. We don’t ask. And, they don’t tell.²

Which is a shame because a third of your female clients are affected by a condition which is highly responsive to treatment. There’s up to an 84% cure rate.³ Read that and weep, MSK colleagues.

The problem with incontinence is that it impacts other areas of your patients’ lives.

• A third of people who leak are also clinically depressed; in fact, being incontinent doubles a woman’s risk of postnatal depression.⁴
• An unknown number of fractured femoral necks in the elderly population are associated with rushing to the toilet in the night.
• Chronically disrupted sleep is linked to heart disease, blood-pressure problems, and obesity.⁵

So, it’s important we address these issues, even if our patients are too embarrassed to raise them.

What Should I Do If My Client Admits Her Bladder Problem?

Advise her to cut down caffeine (very slowly, or she’ll suffer headaches), which can be found in green tea as well as the more obvious coffee, tea, and chocolate. Avoid citrus, tomato, soda, and alcohol. Drink 1.5-2l of water a day. Milk is bladder-friendly, as are peppermint or chamomile teas.

Constipation is associated with urinary incontinence, so eating well and good toileting positions can be helpful.⁶

These basic lifestyle and dietary changes can be curative for some people.⁷

Send your patient away with a 3-day bladder diary. This does two things – gives you 3 days to read up and watch courses on pelvic floors and continence on MedBridge, so you know what to do when they come back, and gives you a reliable diagnostic tool for assessing bladder disorders.⁷

What Is Normal Bladder Function?

Normal bladder function is voiding fewer than 8 times a day and once at night.

You should be able to hold on for 2-4 hours between first feeling the urge to pee and actually having to do so.

Any leaking at all is abnormal, even when it’s only a few drops with laughing, coughing, or sneezing. It’s common, but that does not make it normal.

A normal void is 300-500ml, which is somewhere between a Venti and Grande coffee, assuming you buy your decaf from popular coffee chains.

How to Interpret a Bladder Diary

When your client returns, you are looking for patterns that might differentiate between stress incontinence, overactive bladder, or mixed presentations.

Consider the following:

• Is your client drinking enough volume? (1.5-2l fluid)
• Is she drinking too much volume? ( >2.5l fluid, taking into account exercise and weather variables)
• What is she drinking – is it bladder friendly?
• When is she drinking – if she’s up at night, is she drinking large volumes after 6pm?
• When is she leaking – is it at a particular time or associated with a particular activity?

Assess the total input and output for each 24-hour period

Calculate the night-time urine production by adding the volumes from first going to bed until (and including) the first morning void. If the night-time urine production is more than one third of the total production, then this is nocturnal polyuria and best treated with a medication like desmopressin – refer to general practitioner.

What is the functional bladder capacity – the largest volume passed at one time? If it is less than 300-500ml, consider overactive bladder, which will be worse with concentrated urine or caffeinated drinks. Other causes of irritable bladder are a tumor or stone in the bladder. Refer to this article for differential diagnoses.

Is the leaking linked to an activity, such as emptying the washing machine, running, lifting heavy loads? Consider stress incontinence as a diagnosis.

Pelvic Floor Exercises

A properly functioning pelvic floor goes a long way to solving most cases of stress incontinence and urgency problems. Overactive bladder and frequency will need behavioral and diet changes, and possibly medication.

The pelvic floor muscles support the internal organs. If they are weak or poorly coordinated, leaking can occur when the intra-abdominal pressure exceeds the contraction force they can generate.

A too rigid pelvic floor cannot react to the stresses from above (intra-abdominal pressure) or below (impact force) and so, leaking can occur.

Examples of Pelvic Floor Exercises

Compliance can be an issue. Pain is a great motivator and often these conditions are pain-free, so people forget to do their exercises. Happily, the digital age means you have 24:7 access to your patients – get them to set an alarm or direct them to the excellent apps available.⁹

Pelvic floor disorders are associated with hip pain, pelvic pain and low back pain. So, ask, in detail, about their continence. It may be the missing part of the jigsaw you need to help them and restore their long-term wellbeing.